Summary: Ms X complained the care provider failed to provide appropriate care and support to her father, Mr Y. The care provider was at fault for trying to take a blood sample from Mr Y without raising this with the GP, despite it being expressly stated that this should not happen in the care plan. In addition, there is no evidence Mr Y received appropriate mouth care on five days which may have caused him discomfort and which caused Ms X distress and uncertainty over whether proper mouthcare was provided. The care home should apologise for this and take action to prevent a recurrence of the fault. I have not made a finding on the cleanliness of Mr Y’s room or that Mrs Y was required to take washing home.

The complaint

1. Ms X complained the care provider failed to provide appropriate care and support to her late father, Mr Y. In particular, Ms X complained:
1. Mr Y was not checked regularly enough or routinely offered drinks;
2. he was not given enough pain medication towards the end of his life;
3. the care provider failed to liaise with Mrs Y who had lasting power of attorney (LPA) for Mr Y regarding GP referrals and medical decisions; and
4. the family were not contacted soon enough on the day Mr Y died so were unable to be with him.
2. Ms X says Mr Y did not receive the care he should have and this caused the family distress.

Back to top

What I have and have not investigated

3. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide we could not add to any previous investigation by the organisation, or there is another body better placed to consider this complaint. (Local Government Act 1974, section 24A(6))
4. I have not investigated point b) above. The Council is currently investigating Mr Y’s pain management under its safeguarding procedures. Where there is an ongoing safeguarding enquiry we will not normally investigate the same issue. That is because the Council has a statutory responsibility for safeguarding to prevent abuse and neglect. It will be looking at the same evidence we would consider so it is unlikely any investigation by me would reach a different outcome, and the Council is better placed to take action against the care home should it identify failings.

Back to top

The Ombudsman’s role and powers

5. 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)
6. 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)
7. 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.

Back to top

How I considered this complaint

8. I have considered information provided by Ms X and discussed the complaint with her on the telephone.
9. I have considered the care provider’s response to my enquiries and the relevant law and guidance.
10. I gave Ms X and the care provider the opportunity to comment on this draft decision. I considered any comments I received in reaching a final decision.

Back to top

What I found

11. 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 standards include person-centred care. Care providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences.

What happened

12. Mr Y transferred to the care home from hospital in late July 2022. His condition was deteriorating, and it was expected that he had weeks to live. He was prescribed anticipatory medication to support his end of life care. Mr Y’s ability to communicate was limited and he was unable to express his needs. Mr Y’s wife, Mrs Y, had lasting power of attorney (LPA) for Mr Y’s finances and health and welfare. An LPA is a legal document that allows a person to choose one or more persons to makes decisions for them when they become unable to do so themselves.
13. The care home assessed Mr Y was at high risk of a pressure injury and so required three hourly repositioning. He was cared for in bed and required full assistance with food and fluid and personal care and had a ureteral catheter.
14. Mr Y’s care plan noted the GP and family had decided it was in Mr Y’s best interests not to be admitted to hospital for further investigations. The care plan noted the treatment escalation plan agreed in the hospital which included that Mr Y was not to receive further IV antibiotics and was not to have routine bloods taken and IV fluids (unless to relieve symptoms i.e. thirst).
15. The records show staff supported Mr Y with three hourly repositioning and assisted him with personal care and catheter care.
16. In late October a staff member noted Mr Y’s condition deteriorated. The care home contacted Mrs Y who visited the care home. The GP attended and the notes record they spoke with Mrs Y. The GP instructed the care home to remove Mr Y’s catheter and to keep it out unless Mr Y started to drink plenty again. The GP advised the care home to stop his regular medications, to keep him comfortable and to provide palliative medication as necessary.
17. The care home reviewed Mr Y’s care plan. It noted due to Mr Y’s deteriorating state which meant it was difficult for him to swallow, he was no longer taking food or fluids. It noted Mr Y was sleepy most of the day.
18. The records show the care home checked Mr Y at least every three hours during the day and every one to two hours during the night. The care home used the Abbey pain scale to monitor whether Mr Y was in pain. This is a standardised assessment tool for assessing pain in those who are non-verbal with dementia. Over the next 12 days the records show Mr Y received mouth care on seven of them.
19. Nine days later the care home recorded Mr Y’s condition was deteriorating. Mr Y appeared settled but was having some involuntary body movements, so the Nurse administered some medication which they noted had a good effect.
20. Three days later, in the handover notes from the night to day shift the care home recorded Mr Y appeared settled throughout the night, his care needs were met and mouth care was given. He did not require any medication and remained comfortable and settled.
21. Early that morning, the staff administered palliative medication as Mr Y was agitated and unsettled. Staff checked Mr Y twice more in the next hour, repositioning him on one visit and at the next they noted he appeared asleep and content. At 07:43 a staff member noted a change in Mr Y’s skin tone and his breathing. They notified the Nurse and Mrs Y was contacted. Mr Y died 30 minutes later with a staff member present, before Mrs Y arrived at the care home.
22. The care home manager spoke to Mr Y’s family. They recorded the family were upset they were not present when he died. They said they were advised they would be called before he passed away. The care home manager noted they explained this was not always possible.
23. Ms X complained to the care home. She raised concerns that staff had placed the call bell near Mr Y although he was unable to use it, that staff placed a jug of water on Mr Y’s table, but he could not pour a drink unaided and so water ended up on the bed or floor and that Mr Y was left for hours without being checked and was rarely offered drinks. She said it was up to family to give him drinks when they visited.
24. Ms X also complained that a few weeks after his stay began they noticed bruising as Mr Y had bloods taken and that he was given antibiotics twice although he did not have capacity to consent to this and Mrs Y had power of attorney.
25. Ms X said Mr Y was rarely given pain medication and was left alone for hours on the bed with the tv on and curtains open. She said on day 9 after Mr Y’s health deteriorated she reported Mrs Y told staff Mr Y required continence care. The staff member said they would be in within an hour. However, Mrs Y had to push the call bell and wait a further 25 minutes before someone attended. She complained Mrs Y had to take the laundry home on some occasions as there was no-one doing the laundry and staff had stopped cleaning Mr Y’s room.
26. The care home manager responded to Ms X’s complaint. They noted the discharge letter from the hospital stated no blood tests or antibiotics. They said they had attempted to take blood at the surgery’s request. They said the records showed antibiotics were discussed with Mrs Y and were given to make Mr Y more comfortable, not necessarily to prolong his life.
27. They advised Mr Y’s catheter was removed for comfort reasons as it was not working properly.
28. The manager advised that towards the end of his life Mr Y received mouth care involving cleaning his mouth or assisting with sips of thickened fluids. They acknowledged the Nurse should have called the family when he was given medication at around 5am. The care home manager said they had spoken to the Nurse who profusely apologised for this omission. They said that it was not always possible to predict when someone was going to pass away. They said they would arrange a staff meeting to discuss some of the concerns where improvements could be made and further training in end of life care. They added they were continuing to recruit ancillary staff and were fully aware of issues within certain departments of the home which were being addressed.
29. Ms X remained unhappy and complained to the Ombudsman. She also raised Mr Y’s room was not cleaned and that they had to take washing home during the last few weeks of his life.

Findings

30. At the time Mr Y was discharged to the care home his health was deteriorating and it was expected that he had a short time to live. The care provider completed appropriate care plans and risk assessments for Mr Y which were updated throughout his time at the care home. There was no evidence of fault in the initial care planning.
31. Ms X raised concerns about the cleanliness of Mr Y’s room and that the family had to take washing home. These specific issues were not addressed in the complaint response from the care home and it is very difficult for me to make a finding on them now. The manager of the care home has changed and so I cannot determine exactly what happened at the time. The manager has confirmed the care home operates a cleaning schedule, has an infection control lead and cleanliness has never been a concern raised through inspections. The home provides laundry facilities although it is open to relatives to do it themselves by arrangement. I do not see I can achieve anything more through investigating this issue further.

Checks and offer of drinks

32. I have examined the care notes from 1 October 2022 onwards and these show Mr Y was checked around every three hours for repositioning, in line with his care plan, and was checked more frequently at night. Staff documented his care interventions including personal care and toileting and the records show Mr Y received regular continence care. Overall, from my review of the records, the care home provided an appropriate level of care. However, there are no records to show Mr Y received mouth care on 5 of his last 12 days. Ms X said Mrs Y had to say something to staff before this was carried out. This was fault and meant Mr Y may have been in some discomfort. It also caused Ms X distress and uncertainty over whether Mr X received appropriate mouth care.
33. In her complaint to the care home Ms X referred to a specific incident when staff delayed attending to Mr Y’s continence needs. The care home’s complaint response made no specific reference to this incident but found the longest time the call bell was ringing was 5 minutes 44 seconds. It is difficult to reconcile when this incident occurred with the care home records. It was not appropriate for Mrs Y to have to wait for a prolonged period for Mr Y to receive support with his continence care but without further evidence of exactly when this happened, I cannot make any further comment or reach a finding on this specific incident and it would not be proportionate to investigate this further.
34. The care home did not complete fluid charts for Mr Y as Mr Y was receiving full support with food and fluids. The records show staff sought to encourage eating and drinking which is what I would expect. I have seen no evidence the family raised concerns about Mr Y’s fluid intake during his stay or that staff had any concerns that Mr Y was dehydrated. The records show the care plan was updated in September 2022 to thicken Mr Y’s liquids and to note that staff should monitor Mr Y at each meal time and to refer to the Speech and Language Therapy (SALT) Team if they had any concerns.
35. Staff monitored Mr Y’s catheter and the records show it was regularly emptied. As problems arose with the catheter in mid October 2022, professional advice was sought from the GP and District Nurse. Ms X says the catheter was inserted incorrectly, however the records show the catheter was inserted by trained nurses and when it was changed they recorded it was draining well. I have seen no evidence the care home was at fault in relation to Mr Y’s catheter care.

GP referrals and medical decisions

36. As Mr Y’s health deteriorated the care home involved the GP and District Nurse appropriately and on GP advice Mr Y’s catheter was removed. Ms X has raised concerns that an attempt was made to take blood and that Mr Y was given antibiotics. The care provider administered medication in line with the GP’s instructions. If Ms X has concerns about the GP’s actions it is open to her to raise those with the GP and then to the Parliamentary and Health Service Ombudsman. However, the care plan expressly stated Mr Y was not to have routine bloods taken. The care provider should have drawn this to the attention of the GP at the time and should not have attempted to take blood. To do so, without drawing the care plan to the GP’s attention, was fault. In addition, Mrs Y had LPA for Mr Y’s health and welfare and so should have been consulted before this action was taken. This caused Ms X distress when she became aware this had happened.

Delay in contacting family on the day Mr Y died

37. The records show Mr Y was agitated and unsettled when the staff administered anticipatory medication on the morning he died. Although it is very difficult to predict when someone may die, Mr Y’s condition had changed from earlier records. With hindsight, given his deteriorating condition and that he was approaching end of life, the care home should have called Mrs Y sooner. The care home has already apologised for the distress this may have caused which was appropriate.

Injustice

38. Mr Y has died so any injustice caused to him by the faults identified cannot be remedied. However the attempt to take blood and failure to record mouth care caused Ms X distress and uncertainty over whether appropriate care was provided.

Back to top

Recommended action

39. Within one month of the final decision I recommend the care provider:
• apologises to Ms X for the distress and uncertainty caused by not recording whether Mr Y’s mouth care was completed every day and for attempting to take bloods from Mr Y.
• reminds staff of the need to ensure mouth care is completed appropriately to prevent discomfort for those receiving end of life care and that mouth care is noted in the records.
• reminds staff of the importance of following a person’s care plan and ensuring those with LPA are consulted appropriately regarding health decisions.

Back to top

Final decision

40. I have completed my investigation. The care provider was at fault causing injustice for which I have recommended a remedy and service improvements to prevent recurrence of the fault.

Back to top

Investigator's decision on behalf of the Ombudsman