Summary: We did not uphold complaints about the late Mrs Y’s care at the end of her life. We were satisfied the Care Provider offered appropriate care around eating and drinking, obtaining health care and communicated well with the family.

The complaint

1. Ms X complained about her late grandmother Mrs Y’s care in Chase House Care Home (the Care Home) run by Chase House Limited (the Care Provider). She complained about:
1. The Care Home’s communication with the family about Mrs Y’s care at the end of her life
2. A failure to obtain appropriate health care – chiropody, dietician and audiology (hearing)
3. Removal of the buzzer.

Back to top

What I have investigated

2. I investigated the complaints in paragraph one. Ms X made other complaints which I have summarised at the end of this statement along with my reasons for not investigating them.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers. We provide a free service, but we use public money carefully. We may decide not to start or continue with an investigation if we believe:

• the action has not caused injustice to the person who complained, or
• the injustice is not significant enough to justify our involvement, or
• it is unlikely further investigation will lead to a different outcome.

(Local Government Act 1974, sections 34B(8) and (9))

4. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
5. If we are satisfied with a care provider’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

Back to top

How I considered this complaint

6. I considered Ms X’s complaint to us, the Care Provider’s response and documents in this statement. I discussed the complaint with Ms X.
7. Ms X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

Relevant law and guidance

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
9. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
10. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents
11. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.
12. NICE (National Institute of Health and Care Excellence) Quality Standard 13 on End-of life care for adults says:
• Adults who are likely to be approaching the end of their life are identified using a systematic approach (Quality Statement 1)
• Adults approaching the end of their life have chances to discuss advance care planning (Quality Statement 2) (Advance care planning is a discussion about future care between a person and their care provider, including their wishes, concerns, goals and preferences)
• Care is co-ordinated across health and social care (Quality Statement 3)

What happened

13. Mrs Y had a long-term health condition causing frailty and lived in the Care Home in 2021. She died in September.
14. The Care Home kept care plans describing Mrs Y’s needs and preferences and her desired outcomes. The care plans explained how to meet her needs. Mrs Y’s care plans said:
• She had mental capacity to make decisions about her care and support and could instruct staff about how she wanted her care given. She had good insight but sometimes made unwise decisions
• She regularly expressed the wish to die and was reluctant to eat, drink or take medicines and declined care. Staff would leave and return later to see if she had changed her mind. She ate and drank what she chose and when she wanted to
• She would ring her family with concerns and nursing staff would reassure family
• Her body mass index was 28.8 in August (this meant Mrs Y was classed as overweight). She had lost 12 per cent in weight over the last 6 months and so was at risk of malnutrition
• She needed a fortified diet to try and reduce weight loss. She was currently declining food but if she wanted anything, pureed or liquidised meals may be easier for her to swallow and she may enjoy ice cream or jellies.
• She sometimes needed support to eat and drink. She needed prompts and encouragement.
15. Staff kept records of contact with Mrs Y’s relatives. These indicate staff spoke to Mrs Y’s family regularly about her care and updated them about her condition, including discussing end of life care on 10 June.
16. A letter from the NHS offered Mrs Y a telephone appointment with the audiology clinic in June. The deputy manager told me this took place and Mrs Y was given headphones and an amplifier which she refused to use. The deputy manager went on to tell me that staff considered Mrs Y could hear them well enough.
17. The deputy manager told me a chiropodist visited in July 2021. An email from the chiropodist said they saw Mrs Y for a routine appointment in July, her nails were long and were cut and filed and her feet were creamed.
18. Relatives were also visiting Mrs Y. Mrs Y’s daughter spoke to the deputy manager on 7 July and explained Mrs Y was refusing to be repositioned. Mrs Y’s daughter said her mum expressed a wish to die and was declining care. Mrs Y’s daughter went on to say the family did not want staff forcing her mum to eat if she did not want to. The deputy manager reassured Mrs Y’s daughter that staff were respecting her mum’s wishes as well as trying to promote her wellbeing.
19. On 28 July, staff spoke to Mrs Y’s daughter about Mrs Y’s condition and said she had been given end of life pain relief, she was not breathless and staff could cope with the symptoms at the moment without needing a doctor.
20. On 2 August, staff phoned Mrs Y’s daughter to explain Mrs Y was not well enough to be hoisted for a shower and so they would not shower or bathe her at present.
21. On 23 August, staff spoke to family and said Mrs Y had been declining most medicine, would then ring the bell complaining of pain but then decline medicine when offered. The records indicate Mrs Y continued to refuse medication.
22. Mrs Y saw her GP on 9 September (the day before she died), staff asked the GP if her regular medicine could be stopped.
23. Mrs Y’s end of life care plan in September said:
• The aim was to ensure Mrs Y was comfortable and free of pain
• The GP implemented the end-of-life pathway
• She had end-of-life medicine available
• She and the family wanted her to stay at the Care Home
• Staff would ensure regular visits took place from family
• Mrs Y would have hourly checks at night and at least every two hours on the day
• The GP was aware she was refusing her medicines and advised to respect this
• Mrs Y’s needs and wishes around food and drink fluctuated, staff should offer her sips of water and mouthcare if appropriate
• The nurse would assess her for pain, nausea, secretions and agitation regularly.
• Family were to be updated of changes, regardless of time.
24. One of the Care Home’s registered nurses said in a statement in October 2021 that Mrs Y had access to a call bell, could use it and did so regularly. The nurse also said Mrs Y could express her needs to staff and she also called her family regularly on her mobile phone. The records support this as there are entries saying Mrs Y had been using the mobile to call her daughter.
25. The Care Provider has no evidence staff referred Mrs Y to a dietician. The deputy manager told me it was not usual procedure to involve a dietician when a resident was at the end-of-life stage.
26. The Care Provider responded to Ms X’s complaint. Ms X was unhappy with the response and complained to us.

Findings

Complaint (a): The care home’s communication with the family about Mrs Y’s care at the end of her life

27. I have read all the records of the Care Home’s contacts with Mrs Y’s family. I am satisfied staff provided a good service with regular updates, including a detailed discussion about end-of-life care at the appropriate time. I do not uphold this complaint because care was in line with Regulation 9 of the 2014 Regulations and NICE Quality Statements 1 and 2 about end-of-life care: care was planned to meet Mrs Y’s needs and preferences and discussed with her family.

Complaint (b): There was a failure to obtain appropriate healthcare – chiropody, dietician and audiology (hearing)

28. Provisionally, I am satisfied care was in line with Regulation 12(i) of the 2014 Regulations and NICE Quality Statement 3. Mrs Y saw a chiropodist and had a telephone appointment with the hearing clinic in June and July respectively.
29. Although the Care Home could have referred Mrs Y to a dietician about her reduced food and fluid intake, it would appear likely that Mrs Y would have declined support around this. She was consistent about wanting to die and had capacity to refuse care. It would have been unacceptable practice to force the issue any further. I am satisfied the Care Home provided care in line with Mrs Y’s wishes and in line with Regulation 14 by encouraging eating and drinking in so far as Mrs Y was willing to accept what was offered. I do not uphold this complaint.

Complaint (c): Removal of the buzzer.

30. There is no evidence to support the allegation that staff removed the buzzer. The records indicate regular contact with staff and between Mrs Y and her family by phone and in person. I do not uphold this complaint.

Back to top

Final decision

31. I do not uphold complaints about the late Mrs Y’s care at the end of her life. I am satisfied the Care Provider offered appropriate care around eating and drinking, obtaining healthcare and communicated well with the family. There is no evidence staff removed the buzzer.
32. I completed the investigation and shared a copy with my final statement with the Care Quality Commission in line with our information sharing agreement.

Back to top

Parts of the complaint that I did not investigate

33. I did not investigate complaints about:
• The size of the room
• Failure to change bedding
• Staff use of electronic tablets
• Initial refusal to give the family care records
• Use of PPE
• Loss of items and mixing up clothing
• Comments by a staff member
• Confusion about visiting.
34. The reason I did not investigate these complaints are the injustice was minor or I could achieve nothing further by investigating them.

Back to top

Investigator's decision on behalf of the Ombudsman