Summary: Ms Y complains about the care her mother, Ms C, received at a care home commissioned by the Council. Ms Y says the Home did not isolate Ms C from other residents when there was a Covid-19 outbreak. She says Ms C caught the virus, following which her health deteriorated. Ms Y complains about how the Home managed Ms C’s food and fluids after it identified she was near end of life and that it applied its visitation policy inconsistently. We find fault in how the Home managed Ms C’s care during the Covid-19 outbreak. We do not find fault in the Home’s decisions around food and fluids but have found fault in the records for four days. We have not found fault in how the Home applied its visitation policy.

The complaint

1. The complainant, who I refer to as Ms Y, complains about the care Ms C received at Westergate House Care Home (“the Home”). The Council funded Ms C’s placement at the Home.
2. Ms Y complains the Home allowed Ms C into communal areas, alongside other residents, when there was an outbreak of Covid-19 on her unit. She says Ms C was immobile so could not have accessed the communal areas without the support of staff. Ms Y says that Ms C then caught Covid-19, following which her health deteriorated.
3. Ms Y also complains about how the Home managed Ms C’s food and fluids when it identified she was near end of life. Ms Y says the Home restricted her food and fluids on the basis Ms C might aspirate. She says the amount of food and fluids given was not enough to sustain Ms C.
4. Ms Y says she was allowed to visit during the time Ms C was considered near end of life and gave Ms C food and drink without the knowledge of staff. She says Ms C could was able to eat and drink and her condition recovered as a result. She says that due to improvement, the Home stopped visits again in line with its Covid-19 policy. Shortly afterwards Ms C declined again. Ms Y says the Home then took the same approach to food and fluids but would not allow her to visit as before. Ms C passed away several days later.

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The Ombudsman’s role and powers

5. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the council or care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
6. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
7. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
8. If we are satisfied with an organisation’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)
9. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
10. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

11. I considered the information the Ms Y provided and spoke to her about the complaint, then made enquiries of the Home, through the Council. I sent a copy of my draft decision to Ms Y and the Council, to be shared with the Home, for their comments, before making a final decision.

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What I found

Law, Guidance and Local Policies

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (“CQC”) has guidance on how to meet the fundamental standards. The fundamental standards include:
• ‘Person-centred care: You must have care or treatment that is tailored to you and meets your needs and preferences.
• Consent: You (or anybody legally acting on your behalf) must give your consent before any care or treatment is given to you.
• Safety: You must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Providers must assess the risks to your health and safety during any care or treatment and make sure their staff have the qualifications, competence, skills and experience to keep you safe.
• Food and drink: You must have enough to eat and drink to keep you in good health while you receive care and treatment.’
13. The Department of Health and Social Care (“DHSC”) published guidance on the ‘Admission and care of residents in a care home during Covid-19’. The guidance changed over time. In January 2021 the guidance said an outbreak is defined as two or more confirmed cases of Covid-19. It said care home providers should, wherever possible, implement social distancing measures and support individuals to following shielding guidance for the clinically extremely vulnerable group. It said residents who are known to have been exposed to a person with possible or confirmed Covid-19 should be isolated with other similarly exposed residents.
14. The DHSC also published guidance on ‘The Mental Capacity Act (2005) and deprivation of liberty safeguards (“DoLS”) during the Covid-19 pandemic’. At the relevant time, it said that during the pandemic it may be necessary to change a person’s usual care and treatment arrangements to, for example, protect them from becoming infected with Covid-19, including support for them to self-isolate or to be isolated for their own protection. It said, many changes to arrangements around a person’s care linked to the pandemic, will not constitute a deprivation of liberty. In many cases it will be sufficient to make a best interests decision to put in place the necessary arrangements for a person who lacks capacity, during this emergency period. Where a person has an existing DoLS, it will often be possible to put in place new arrangements to protect the person within the parameters of the existing authorisation. In some cases, a new DoLS authorisation may be needed. In such cases an urgent authorisation can come into effect instantly when the application is completed and last for up to a maximum of 7 days, with the possibility of extending for a further 7 days.
15. The Social Care Institute for Excellence (“SCIE”) published guidance on ‘Best interest decisions: A Covid-19 quick guide’. It says that in some cases someone who lacks capacity may not understand or adhere to social distancing rules. If this is the case the person supporting them will need to use a combination of kindness, vigilance and knowledge of the individual to address each circumstance as it arises. Ongoing efforts to help the person understand the rules should be maintained.
16. The Liverpool Care Pathway for the Dying Patient was a care pathway addressing palliative care options for patients in the final days and hours of life. In 2014, following a review, the pathway was phased out. A guidance document, ‘One Chance to Get it Right’ was published in 2014 by the Leadership Alliance for the Care of Dying People, comprised of multiple health and care organisations.
17. The One Chance to Get it Right guidance sets out five priorities of care for the dying person:
• Priority 1 – The possibility that a person may die within the next few days or hours is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly.
• Priority 2 – Sensitive communication takes place between staff and the dying person, and those identified as important to them.
• Priority 3 – The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants.
• Priority 4 – The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible.
• Priority 5 – An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, coordinated and delivered with compassion.
18. One Chance to Get it Right refers to the General Medical Council (“GMC”) guidance on ‘Treatment and care towards the end of life: good practice in decision making’. This guidance says the offer of food and drink by mouth is a part of basic care and must always be offered to patients who are able to swallow without serious risk of choking or aspirating food or drink.
19. The Home has a Nutrition and Hydration Policy. It says adequate fluid intake is a major contributor to preventable dehydration. It says the recommended daily intake for the older person is between 1,200 and 1,600ml in 24 hours. It says changes in eating and drinking are common in people living with terminal illness and most people lose interest in eating and drinking in the last few days of their life. Staff should be aware of swallowing difficulties during this period and seek advice if concerned.
20. The policy lists strategies to increase fluid intake, which may include an individualised daily fluid intake goal. It says staff should identify when a person is at risk of dehydration. Those identified as at risk should have their fluid intake monitored by using fluid charts.
21. The Home had a policy for visitation during the Covid-19 pandemic. It said that to maintain necessary infection control, visiting was limited to certain circumstances. This included:
• Where a resident is close to death and the Home Manager permits end of life visits in line with the guidance.
22. The policy said that indoor end of life visits were allowed for up to two people for 60 minutes per day, for a period of seven days. Following this period the Home Manager would review the visiting arrangements.

Background

23. Ms C was a resident of the Home from mid-2019 to February 2021. She had a diagnosis of Alzheimer’s alongside a range of other health concerns. Ms C was assessed as lacking capacity to make decisions about her day-to-day care. A DoLS was in place, which restricted Ms C from leaving the Home.

Care plans

24. Ms C had the following care plans in place which are relevant to this investigation:
• Covid 19 Pandemic
• Communication
• Mobility/Moving and Handling
• Nutrition/Hydration
• Hopes and Concerns for the Future

Covid 19 Pandemic

25. The care plan was completed in October 2020. It said Ms C had not retained or processed information about the pandemic. It said staff would encourage zoom calls and facetime with family.

Communication

26. The care plan was completed in November 2020. It said Ms C could not understand isolation and did not adhere to social distancing. It said Ms C had a sensor mat in her bedroom and staff needed to monitor her hourly to ensure her safety.

Mobility/Moving and Handling

27. The care plan was completed in November 2020. It said Ms C required assistance of one to two staff members when mobilising. It said Ms C had been very weak and unsteady with her gait which put her at high risk of falls. Ms C had a sensor mat which is used when she is in her room. It said Ms C required assistance with transfers and was unable to walk from place to place.
28. The plan was updated in early February 2021 to say Ms C had deteriorated and was bed bound.

Nutrition/Hydration

29. The care plan was completed in November 2020. It said staff were to encourage Ms C to take small mouthfuls of food and sips of flood. It said Ms C could eat and drink independently, but staff needed to encourage her to maintain independence. It said staff should encourage Ms C to eat a varied diet and encourage effective hydration.
30. The plan was updated in early February 2021. The updated plan said Ms C was not eating and having small amounts of fluids. It said staff would check every 15 minutes and offer food and fluids as needed. It said Ms C was holding her food in her mouth and was at high risk of choking.
31. The Home completed fluid charts for Ms C. Most of the fluid charts indicated Ms C had a low fluid intake. The target intake each day on the charts sometimes varied but most charts suggested a target of 800-1200ml.

Hopes and Concerns for the Future

32. The care plan was completed in November 2020. It said Ms C would like her family involved at her end-of-life stage. It said Ms C does not wish for hydration to be stopped when end of life happens. It said any decisions around end-of-life must be discussed with her next of kin.

Covid-19 outbreak

33. In early January 2021 two residents and staff members on a different unit of the Home tested positive for Covid-19. The Home informed Ms Y. On the same day, Ms Y spoke to Ms C and facetime and took a screenshot, which showed Ms Y sitting in the lounge on her unit.
34. Two days later, several residents on Ms C’s unit tested positive for Covid-19. The Home informed Ms Y. Ms Y says a senior care worker told her that Ms C was being kept away from other residents, in her bedroom. However, she spoke to Ms C on facetime that day and took another screenshot, which showed Ms C in the lounge. She took another screenshot the following day and Ms C was in the lounge again.
35. The Home says it tried to keep residents in their rooms but could not lock them in or restrict their movement against their will without a DoLS.
36. Six days later, the Home had several further positive tests on Ms C’s unit. Four days after that, Ms C tested positive for Covid-19. At this point almost all the residents on the unit tested positive for Covid-19. The Home says that, for this reason, it inverted its normal protocol for keeping residents that had tested positive in their rooms. Instead, it let everyone who had tested positive walk around normally.
37. On the same day Ms Y spoke to Ms C on facetime and took another screenshot. This showed Ms C in the lounge with other residents in close proximity.

End of life care - Nutrition and Hydration

38. Ms C passed away around three weeks after her positive Covid-19 test. Ms Y complains about how the Home managed Ms C’s food and fluids during this period of time. I have looked through the Home’s records, and records from Ms C’s GP. To set things out in the clearest possible way, I have included below a summary of what happened each day, starting the day Ms Y tested positive.
39. Day 1 – The Home records show that Ms C was eating and drinking well.
40. Day 2 – Ms C had 530ml of fluids. The fluid chart shows Ms C refused one drink of 150ml. The food charts show Ms C declined all food offered to her that day. The daily records said Ms C had a poor appetite and fluids as she was very sleepy.
41. Day 3 – A care worker from the Home contacted Ms Y, to say Ms C’s nutrition and hydration over the past day had been very poor. Ms Y says the care worker told her staff would only give Ms C fluid as mouth care of 5ml every 30 minutes and would not give food. Ms Y emailed the Home Manager and said Ms C was only dehydrated and asked staff to hydrate her.
42. The fluid charts show Ms C had 340ml of fluids and refused one drink of 100ml. The food chart said Ms C was sleeping all day and not swallowing, and that she declined all her food. The daily records said Ms C was unwell and not tolerating any oral diet or fluids. The GP records show the Home contacted the GP, who carried out a video consultation. The GP advised the Home to keep Ms C comfortable and they would speak to Ms Y to establish the family’s view.
43. Day 4 – Ms Y spoke to the GP. She relayed that the Home told her they would only give 5ml fluids to Ms C for mouthcare. The GP arranged for a community nurse to assess Ms C for subcutaneous (“s/c”) fluid administration. The assessment approved the request and s/c fluids were started that afternoon. Alongside this, the fluid charts show Ms C had 540ml of fluids through regular drinks.
44. Day 5 – The s/c fluids were stopped at the end of the course as the nurse did not believe s/c fluids were improving Ms C’s situation. Staff told Ms Y of the decision.
45. Day 6 – Ms Y was allowed to visit the Home as staff felt Ms C was at end of life. Ms Y says she begged care workers to feed Ms C and give fluids. The fluid charts show Ms C had 460ml fluids. They do not show that Ms C was offered or declined further fluids. However, the daily records say staff offered drinks throughout the day. The food charts show Ms C ate relatively well that day. The GP advised the Home to watch and wait. Ms Y says Ms C was alert and responsive.
46. Day 7 – The daily notes said staff offered drinks regularly. The fluid charts show Ms Y had 975ml and ate during the day.
47. Day 8 – The daily notes said staff encouraged fluids and Ms C was brighter and more alert. The fluid charts show Ms C had 1380ml fluids and ate during the day. Ms Y says she visited and gave Ms C food and fluids too. She says Ms C was hungry and drank everything.
48. Day 9 – The daily notes said food and fluids were given, that Ms C was well and there were no new concerns. The fluid charts show Ms C had 460ml of fluids. There are no records of her refusing fluids. The nutrition charts show she ate well.
49. Day 10 – The daily notes say Ms C was more alert and ate well at breakfast. The Home has not provided the fluid chart for this date so there is no evidence of Ms C’s fluid intake. The nutrition chart shows Ms C ate well. Ms Y says she visited on this day and gave Ms C food and drink.
50. Day 11 – The daily notes say Ms C ate and drank very well. The fluid charts show Ms C had 900ml of fluids. The nutrition chart shows Ms C ate during the day but did not finish all her meals and refused some food. Ms Y says that on this day the Home manager told her that, as Ms C was doing much better, she was no longer considered to be on end of life care so she could no longer visit. Ms Y expressed concerns to the manager that staff would not continue giving drinks and food to Ms C.
51. Day 12 – The daily records say Ms C ate well. The fluid chart shows Ms C had 600ml of fluids. It records that she refused one drink in the evening. There was a note under ‘action required’ that said ‘encourage fluids’. The nutrition charts show Ms C ate most of her food that day. Ms Y says she received an update from the carer that Ms C was eating and drinking well.
52. Day 13 – The daily records say Ms C ate well, that there were no new concerns and strict food and fluids would continue. The fluid charts show Ms C had 1000ml of fluids. The nutrition charts show Ms C ate well. GP records said Ms C had been near end of life but this was now not imminent. The record says it was probably a lack of hydration and she was on a strict fluid chart.
53. Day 14 – The daily records say Ms C was assisted with breakfast and fluids, which she took well. The fluid chart shows she had 1200ml of fluids. The nutrition chart shows Ms C ate well during the day but refused her evening food.
54. Day 15 – The daily records say Ms C was weak and tired but settled and no concerns. The fluid charts show Ms C had 1025ml of fluids. The nutrition chart said Ms C was unable to swallow at breakfast and declined her food at midday. It says Ms C was sleeping in the evening and it was difficult to wake her up, so she did not eat in the evening.
55. Day 16 – The daily records say staff called the GP as Ms C sounded ‘chesty/bubbly’. It says staff gave Ms C 1:1 care throughout the day and contacted the GP for a suspected chest infection. The GP prescribed antibiotics. The notes show Ms Y called and asked if Ms C was eating and drinking. The nurse said Ms C was having small amounts of fluids but not food as she was keeping the food in her mouth and was at risk of choking. Ms Y said if Ms C did not eat or drink, she would get worse. The care worker said she would not force Ms C to eat or drink as there was a risk of choking. The fluid charts show Ms C was given 170ml of fluids as mouth care. The nutrition charts show food was offered during the morning and afternoon, but Ms C was unable to eat.
56. Day 17 – The daily records say Ms Y spoke to the nurse who told her Ms C was no different to the day before, would keep food in her mouth and was drinking small amounts. It says food and fluids were offered but most of the day Ms C either declined, was not swallowing or was coughing. The fluid charts show regular mouthcare of 5-10ml. It recorded that Ms C was coughing and not able to tolerate drinks. The GP records said that further s/c fluids were not appropriate. It said it was essential for fluid intake to increase. The GP asked staff to offer Ms C drinks with a straw. The Home updated its nutrition and hydration care plan as outlined at Paragraph 30.
57. Day 18 – The daily records said staff assisted Ms C into an upright position to encourage fluids but that she was at increasing risk of aspiration. The Home comHome completed a choking risk assessment that found Ms C was at high risk of choking. The daily records said staff spoke to the GP who decided not to start s/c fluids and to keep offering drinks where possible. They said staff woke Ms C on occasions to encourage fluids, but she was coughing and sounding bubbly. Staff called the GP again as Ms C was not swallowing and indicated she appeared to be heading towards end of life. They say staff used a syringe to give 5ml fluids but Ms C did not drink and any fluid would be sitting in her lungs. The fluid charts showed actions every 15 minutes. On some occasions Ms C was asleep. On others she was not able to swallow or was coughing. In total Ms C had around 130ml of fluids.
58. Day 19 – The daily records said regular mouth care was given and that Ms Y visited Ms C. The fluid charts recorded that Ms C was sleeping for most of the day. There were occasional records of ‘mouthcare given’. A consultant and nurse from the local NHS Trust visited the Home and recorded that Ms C was not alert enough to have oral fluids. A meeting took place at the Home with the consultant, nurse, the deputy manager of the Home and Ms Y. The GP record says the process of end-of-life care was explained to Ms Y.
59. Day 20 – The daily records said regular mouthcare was given. The fluid charts again recorded that Ms C was sleeping for most of the day and mouth care was given on occasion. Ms Y spoke to the GP and requested they consider options to hydrate Ms C, including s/c fluids. The GP advised s/c fluids would be used to support a patient through a short-term illness when there was a good expectation of recovery. The GP advised Ms C was no longer in this position after the consultant assessment that identified Ms C was near end of life.
60. Day 21 – The daily records said regular mouthcare was given. The fluid charts indicate staff checked Ms C every 15 minutes and mouthcare was given. The following morning Ms C passed away.

Findings

61. I have separated my findings into the following areas of complaint:
• Covid-19 outbreak
• Nutrition and Hydration
• Visitation

Covid-19 outbreak

62. I find fault in how the Home managed Ms C’s care in the context of the Covid-19 outbreak.
63. Ms C had a Covid-19 care plan in place that set out the need for restrictions on visiting to reduce risk of infection. However, there was nothing in the care plan about how the Home would manage the risk of infection to Ms C during an outbreak. The care plan was not updated following an outbreak of Covid-19 on Ms C’s unit. The communication care plan said Ms C could not understand social distancing and had a sensor mat in her room.
64. The Home says it could not restrict Ms C’s movement around the Home without a DoLS. However, government guidance from the relevant time set out that in most cases a further DoLS was not necessary to make changes to a person’s care in the interests of social distancing. I cannot see evidence the Home considered changes to Ms C’s care plan or routine, to encourage social distancing during the outbreak.
65. I acknowledge there were significant challenges for the Home in keeping residents with dementia and Alzheimer’s socially distanced. Ms C was not bed bound at this time and could walk of her own accord. However, she was frail and at significant risk of falls. Her mobility care plan was clear that she should only mobilise with the assistance of one or two members of staff. A sensor mat was in place, to alert staff if Ms C tried to mobilise alone. This represented an opportunity to make changes to Ms C’s care, for example for staff to encourage Ms C not to leave her room, or not to assist her to an area where other residents were in proximity. It is unlikely the Home needed a DoLS to adopt an approach of this nature. Even if it did, it could have applied for an urgent DoLS, which would have been valid from the date of application.
66. There were 10 days between the outbreak on Ms C’s unit and Ms C testing positive. On eight out of 10 days there is a record that Ms C was in the lounge. The records do not say whether staff assisted Ms C to the lounge. But there is no record staff encouraged Ms C to stay in her room. And at least two of the records, plus the Home’s response to my enquiries, suggest Ms C would wander around the unit of her own accord. This raises concerns about whether the sensor mat was properly in place, and whether Ms C was frequently able to walk around the unit unattended, against the advice of the mobility care plan and despite the risk of falls or coming into close contact with other residents during an outbreak.
67. Another record, six days into the outbreak, said Ms C was sat in her bedroom for her protection as there were positive Covid-19 tests. However, it goes onto say her door was left open so she could get up and walk to the lounge whenever she wanted. This record appeared to acknowledge that Ms C should keep to her room for her safety, but then suggested Ms C could walk freely from her room to the lounge despite the risk from Covid-19 and falls.
68. The Home says staff tried their best to keep residents distanced from each other when in the communal areas. The screenshots do not show whether Ms C was close to any other residents when in the lounge, except the one on the day Ms C and most other residents of the Home tested positive so were allowed to mix. However, if Ms C was walking around the unit unattended there was a strong chance she came into close contact with other residents.
69. It is impossible to say whether Ms C would have avoided contracting Covid-19, had the Home taken more steps to encourage social distancing. There was an outbreak on the unit that affected residents and staff. The nature of the unit meant most residents would not understand social distancing. Even if the Home was able to encourage stringent social distancing, there was a considerable chance Ms C would still have caught the virus. However, I cannot see evidence staff reviewed Ms C’s care plan in response to the outbreak, encouraged her to stay away from communal areas, or ensured she was supported when mobilising in line with her care plan. I therefore find fault, and that this caused distress to Ms Y in respect of uncertainty about the impact it might have had, but for the fault.

Nutrition and Hydration

70. I do not find fault in how the Home made decisions about Ms C’s nutrition and hydration, overall, during the final three weeks of her life. I have noted four occasions on which there were issues with the records around Ms C’s fluid intake. I have found fault in relation to these issues but, for the reasons outlined in the following paragraphs, cannot find that these represented wider fault in the way the Home managed Ms C’s hydration.
71. Ms Y says Ms C made an advanced decision that she did not want food or fluids to be restricted in line with the Liverpool Pathway or any equivalent. I can see this advanced decision was represented in Ms C’s care plan on Hopes and Concerns for the Future.
72. The Home says it did not actively restrict food or fluids at any point. It says it could not force Ms C to eat or drink when she declined or was at risk of choking or aspirating.
73. The Liverpool Pathway has now been phased out. Instead, there is the One Chance to Get it Right guidance, referred to at paragraphs 16 to 18. This says that food and drink should always be offered to patients that are not at serious risk of choking or aspirating.
74. If staff at the Home reached the view Ms C was at high risk of choking or aspirating from eating and drinking, I would not be able to criticise their decision not to encourage food or fluids as normal.
75. I have considered the Home’s actions at three different stages of the timeline given at paragraphs 39 to 60:
• Days 2 to 6
• Days 7 to 15
• Days 16 to 21

Days 2 to 6

76. I do not find fault with how the Home made decisions about food and fluids during this period.
77. The Home’s records show Ms C had a poor food and fluid intake starting on Day 2, because she was unwell, sleepy, was not swallowing and declining food. The Home contacted the GP for advice and the GP arranged for s/c fluids. During the week before this, Ms C‘s fluid intake was in line with, and on some days above, the target amounts.
78. Ms Y says Ms C was only dehydrated and the Home should have given fluids but instead limited her to 5ml every 30 minutes for mouthcare. I cannot see evidence in the records that staff limited Ms C’s fluids to mouthcare at this in time. The fluid charts show staff offered and gave drinks. Ms C’s food and fluid intake was much lower than normal, but staff recorded reasons in the Home’s records. They contacted the GP and s/c fluids were given to address dehydration and there are records staff offered food.
79. The Home acted on the concerns about Ms C’s health by contacting the GP. A course of action followed that was agreed between the Home, the GP and NHS. Ms C was kept fully informed and gave her views to staff at the Home and the GP. Therefore, I cannot find fault in how the Home responded or made decisions.
80. I have one concern with the Home’s record keeping for Day 6. The daily records say staff offered drinks throughout the day, but this is not reflected in the fluid charts. The fluid charts only show 460ml offered, and none refused. Given the significant problems with Ms C’s hydration over the preceding days, there was added importance of clear record keeping. The difference between the daily records and the fluid charts means I cannot say for certain whether adequate fluids were offered to Ms C on that day. I have therefore found fault in the record keeping. However, I note that Ms C’s condition improved, and her fluid intake for the following two days was in line with the target amounts.

Days 7 to 15

81. On six of nine days in this period, the fluid charts show Ms C had a fluid intake in line with the target amounts.
82. I have concerns about the Home’s records for Days 9, 10 and 12.
83. The fluid charts for Day 9 only show Ms C had 460ml of fluids. There are no records that staff offered any other fluids or that Ms C refused. The daily notes say fluids were given but not how much or how often. Therefore, I cannot find evidence on this day that staff offered or encouraged Ms C to drink adequate fluids.
84. The Home has not provided the fluid chart for Day 10, following several requests. Therefore, there is no evidence staff offered adequate fluids to Ms C on this day.
85. The 600ml Ms C had on day 12 was below the target amount. There is one record that Ms C refused a drink. However, there are no other records that staff attempted to offer Ms C drinks. This suggests that, at the very most staff offered 800ml, which is the lowest end of the target, and did not make any further attempts after she declined one drink. Therefore, I cannot find evidence staff encouraged Ms C to drink adequate fluids on this day.
86. I cannot say what impact the above three days had. On the other six days Ms C received fluids in line the target amounts, including the three days before Ms C’s condition deteriorated again. However, the fault causes distress to Ms Y in terms of uncertainty about how the Home managed Ms C’s hydration on the days in question.

Days 16 to 21

87. I do not find fault in how the Home made decisions about Ms C’s food and fluids during this period. As already outlined, I cannot criticise the decision of staff not to continue attempting to give food and fluids to Ms C, if they believed there was a risk of choking or aspiration. Staff made clear records that Ms C was unable to swallow and was at risk of choking or aspirating. They contacted the GP, who considered further s/c fluids but decided this was not appropriate.
88. Ms Y indicated the Home only stopped giving food and fluids because staff suspected a chest infection. It later transpired Ms C did not have a chest infection. I cannot find fault on that basis. The reasons staff recorded were that Ms C was not tolerating food or fluids and was at risk of choking or aspirating. Staff followed the correct course of action by contacting the GP. The GP prescribed antibiotics for a suspected infection. However, whether or not the underlying cause was an infection does not change the risks to Ms C at the time from difficulty swallowing.
89. A range of healthcare professionals, including from the hospital, were involved in decision making and identified that Ms C was near the end of her life, was not alert enough to have oral fluids and that s/c fluids were not appropriate. The GP asked staff at the Home to offer Ms C fluids with a straw. However, they also noted that staff at the Home were qualified and experienced to properly assess the risk of choking and aspiration.

Visitation

90. Ms Y indicated the Home applied its visiting arrangements inconsistently, across the two periods of time at which it identified Ms C was near end of life. I do not find fault in how the Home applied its visiting arrangements. I can see that Ms Y was allowed to visit the Home in line with the visiting policy during both periods.
91. Ms Y visited on Day 19. I understand Ms C’s condition had deteriorated in the two to three days before this. However, in line with the Home’s policy it was for the Home manager to make a judgement about when to allow visits, after it had been identified the person was near end of life. It was recorded that Ms C was near end of life on Day 18, and the following day Ms Y was able to visit.
92. Ms Y says that, initially, the Home Manager only allowed her to visit and attend the meeting with healthcare professionals, not her husband. The Home’s policy says two visitors are allowed for end-of-life visits, so that decision does not appear to have been in line with the policy. However, when Ms Y arrived, her husband was allowed to join. Therefore, I have not found that this was fault causing significant injustice.

Consideration of Remedy

93. I have found fault on the following basis:
• I cannot find evidence the Home properly considered changes to Ms C’s care or encouraged social distancing during the Covid-19 outbreak
• The records indicate Ms C was able to walk around the unit unattended despite the risk of falls and from the Covid-19 outbreak
• On four days, over a period of 21 days, the Home’s records do not evidence that staff offered or encouraged adequate hydration for Ms C
94. For the reasons already outlined, I cannot make any findings about whether it is likely Ms C suffered harm as a result of the fault identified. I have found it causes an injustice to Ms Y, in terms of distress and uncertainty about the care Ms C received on those occasions. I recommend the Council pay Ms Y £300 to acknowledge the distress caused. This amount is in line with our guidance on remedies relating to distress payments. It recognises the fault was significant in of itself. However, I cannot recommend a payment that reflects Ms Y’s distress about decisions regarding food and fluid intake, or other factors on which I have not found fault.
95. I have recommended the Council complete this remedy as the Council was the body that commissioned Ms C’s care at Home, therefore is the body in jurisdiction.
96. I have considered whether to make recommendations for service improvements at the Home. However, government guidance on the care of residents during Covid-19 and rules on social distancing have now been withdrawn. Therefore, the situation has changed compared to when the fault occurred. I would not be able to base any recommendations on currently available guidance on social distancing procedures within Homes. It is for the Home to set its own procedures in this respect. Therefore, I have not made recommendations on this point.
97. In respect of the fluid charts, I have not found there was systemic fault in how the Home managed food and fluids, or with its policies and procedures, therefore have also not recommended service improvements. However, I recommend the Council ensure the Home sends a reminder to regarding fluid intake records, as outlined at Paragraph 98.

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Agreed action

98. The Council has agreed to, within one month of this decision:
• Apologise to Ms Y for the fault identified at Paragraph 94
• Pay Ms Y £300 to recognise the distress caused
• Provide evidence the Home has sent a reminder to its nursing and care staff of the need to ensure clear records, where a fluid intake chart is in use. The chart should record all occasions staff offered or encouraged fluids, and when this was refused. If the chart shows the person has not reached their target intake for the day, this should be recorded along with any reasons. Any interventions or medical advice should be recorded in the hydration care plan.

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Final decision

99. There was fault in how the Home managed Ms C’s care during the Covid-19 outbreak. I do not find fault in the Home’s decisions around food and fluids but have found fault in the records for four days. I have not found fault in how the Home applied its visitation policy.

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Investigator's decision on behalf of the Ombudsman