Summary: Mr X complained about the standard of care provided to his late mother, Mrs Y, at Cloverleaf Tanglewood Care Home. On the evidence considered the care provider was at fault for a delay in obtaining pain relief medication for Mrs Y and for failing to respond to the call bell in a timely manner. It should apologise to Mr X and make a symbolic payment. It has already reviewed its procedure for end of life care. It should also provide evidence of how it is monitoring call bell records to prevent recurrence of the fault.

The complaint

1. Mr X complained about the standard of care provided to his late mother, Mrs Y, at Cloverleaf Tanglewood Care Home. In particular he complained it delayed obtaining appropriate pain relief medication, failed to manage her pain correctly and delayed responding to the call bell. This caused Mrs Y and the family significant distress. Mr X also says the care provider failed to properly explain the complaints procedure, causing him frustration and time and trouble.

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The Ombudsman’s role and powers

2. 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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. 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)

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How I considered this complaint

4. I considered the information provided by Mr X and spoke to him on the telephone. I considered the care provider’s response to my enquiries.
5. I gave Mr X and the care provider the opportunity to comment on a draft of this decision. I considered any comments I received in reaching a final decision.
6. 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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What I found

What happened

7. Mrs Y was in her eighties. She had health conditions. She had previously lived at another care home but moved to Cloverleaf Tanglewood Care Home (the care provider) in late January 2022 when the previous home could no longer manage her care needs.
8. The care provider’s pre-admission assessment noted Mrs Y had a small appetite and was not eating and drinking well, she required assistance with personal care and was not compliant with taking medication. She required a wheelchair or frame for mobility and could be verbally abusive. She was intolerant to pain relief other than paracetamol.
9. The care records show the care provider monitored Mrs X’s food and fluid intake. There were occasions when Mrs Y would eat a proportion of a meal and other days when she would refuse to eat. She also had a poor fluid intake. The care provider sought to provide personal care and change Mrs Y’s clothes daily, but the notes show she could be resistant to this.
10. In early February the care provider spoke with two relatives and explained Mrs Y was deteriorating. It said Mrs Y had not eaten that day but had taken her medication and some fluid.
11. The care provider noted Mrs Y was extremely distressed and agitated the following day, she refused her medication and would only accept a small amount of food and fluids. It contacted the GP and Community Mental Health Team (CMHT). The care provider noted the CMHT refused to assess Mrs Y as it considered she may be dehydrated. The GP called an ambulance. The notes record the paramedics assessed Mrs Y and decided not to take her to hospital. Mrs Y had accepted some pain relief and a moderate amount of fluid.
12. On 8 February Mr X visited Mrs Y. He said Mrs Y was distressed and in pain. He says he pressed the call bell, but no-one attended so he found a staff member to administer pain relief. The records show a call at 16:27 on that date was not responded to for over two hours. However, the records also show Mrs Y drank a small amount of juice and ate a quarter of her sandwiches at 17:40 and had paracetamol administered at 17:44 for general pain. Further paracetamol was given on two of the next three days.
13. The records show Mrs Y’s daughter spoke with the care provider on 11 February. The notes recorded ‘feel [Mrs Y] is in discomfort but chews paracetamol therefore requested liquid from the GP’. The records show the care provider received the paracetamol suspension on 15 February. The following day the records noted Mrs Y lashed out during personal care. She was regularly distressed and medications were given with great difficulty.
14. Mrs Y’s food and fluid intake deteriorated further. She required full assistance from two care staff with all aspects of her care including continence care. At times she refused care and support. The care provider placed Mrs Y on two hourly checks.
15. Mrs Y’s daughter spoke with the care provider on 20 February. In the notes the care provider said Mrs Y’s daughter wanted Mrs Y to be pain free mentally and physically and did not want further investigations but support for Mrs Y with food and fluid. She felt Mrs Y was now at end of life and wanted this discussed urgently with the GP. The records show the care provider administered oral paracetamol to Mrs Y twice that day and noted it was ‘effective’.
16. The records show the GP visited at 1pm on 21 February and discontinued most of Mrs Y’s medication. The GP prescribed oral morphine for breakthrough pain relief. The care provider updated Mrs Y’s care plan to reflect that she would like to be treated at the care home and not admitted to hospital and she was to be made comfortable and pain free.
17. The records show the care provider administered oral paracetamol to Mrs Y that day and noted it was ‘effective’. Mrs Y’s daughter visited her the following day. Mr X says she found Mrs Y in a pyjama top and pants and Mrs Y’s pain relief had not yet arrived. The medication records show the morphine was first administered to Mrs Y at 10.45pm in the evening on 22 February the day after the GP visited and was ‘effective’.
18. The care provider administered morphine again the following morning but noted it was ‘not effective’ and so requested a GP review. The GP carried out an end of life review on 23 February and advised the care home to increase the frequency of the morphine. However, the records note Mrs Y spat the oral morphine when it was administered so the GP prescribed an additional medication to treat agitation (levomepromazine) and advised the care home if the medication had no effect it should commence using a syringe driver (to deliver 24 hour medication). The records show Mrs Y received morphine orally, by injection and by a syringe driver over the following days.
19. Mr X said when he visited Mrs Y on the night before she died he pressed the call bell and had to go and find help as no-one responded. The records show a call that evening was not responded to for 32 minutes.
20. Mrs Y died in late February 2022.
21. In late August 2022 Mr X complained to the care provider. He complained about the quality of care provided to Mrs Y. In particular, he complained:
• Mrs Y was in pain in the days leading to her death. He considered her pain management was non-existent. He said the end of life pain relief was late to get to her and inadequately supplied. Mr X said staff tried to give her dry paracetamol when she was not taking liquids and failed to consider getting liquid paracetamol prescribed until it was suggested by the family.
• Delay in responding to Mrs Y’s call bell, stating family pressed the alarm one Friday and no-one came for one hour.
22. He did not receive a response and sent a further letter in October 2022. The care provider responded two days later and apologised. It accepted that in error it had failed to respond to his complaint.
23. In its response the care provider said Mrs Y was sensitive to all pain relief but paracetamol. When trying to support or offer her she regularly refused it and her health declined significantly from 21 February. Her GP was heavily involved and the CMHT were also involved due to her refusal of care and intervention, food and fluid intake and deteriorating mental health. It noted seven GP visits and two CMHT visits during Mrs Y’s stay. It said records showed Mrs Y was settled apart from minimal discomfort in her last few days and provided details of the medication it administered to Mrs Y. It said it had looked at its call bell records for Fridays and could not identify a time and date when there was an hour delay.
24. Mr X remained unhappy and complained to us. He considered the care provider did not act quickly enough to obtain pain relief for Mrs Y and Mrs Y’s call bell was not always answered.

The care provider’s response to our enquiries

25. In response to our enquiries the care home provided a copy of the call bell records for Mrs Y’s room. The records show the call bell was activated 175 times during Mrs Y’s stay at the care home. Of these, there were 19 occasions when the records show the call bell rang for over 30 minutes duration with three of these being over an hour.
26. The care provider said it was not able to identify from the care notes that care was delayed. It said Mrs Y spent a lot of time out of her room in communal areas at the start of her stay. Mrs Y had a floor alarm mat and so this could have been caught whilst she was in the room. It also said around that time it had identified an issue with the alarm call point which was not sounding and alerting staff in the lounge area. This was fixed having been noticed during an inspection.
27. I have compared the care notes with the call bell records. On eight of the 19 times, there were care entries within a short time of the call bell ringing and on one there was an entry just before the call bell rang.

Findings

28. Mrs Y lived at the care home for just over one month. During that time, the records show the care provider supported Mrs Y with eating and drinking and personal care although she regularly declined support. The records show she had reviews with the GP and Community Mental Health Team and advice and assistance was sought from medical professionals.
29. When Mrs Y’s condition deteriorated the care provider arranged for a GP visit, following discussion with Mrs Y’s daughter. The records show the GP visited at 1pm and prescribed morphine which was not administered until 10.45pm the following day. Mrs Y’s daughter visited Mrs Y during that day and Mr X says his sister reported Mrs Y was in pain. I am concerned at the delay in obtaining and administering the morphine. During that day the records show staff administered oral paracetamol but given Mrs Y’s condition had deteriorated to the extent the GP prescribed morphine I would have expected the care provider to prioritise getting it. This delay is fault and meant Mrs Y was likely to have been in pain or discomfort which could have been relieved during this period.
30. In response to a draft of this decision the care provider has advised it followed its agreed procedure at the time whereby the prescription was sent to the pharmacy who delivered as per the agreed process. Since this complaint it says there have been ongoing reviews of procedures for end of life care. This has included earlier planning for end of life care. It now has an enhanced agreement with the GP’s surgery and pharmacy so that it can collect prescriptions direct from them during operating hours and can use the out of hours service at night. It is now also has a procedure whereby patients admitted for end of life care are prescribed medications on admission. Pre-emptive medication is by printed prescription form so the care provider can collect these locally from the pharmacy. I am satisfied this revised procedure will prevent a recurrence of the fault identified in this case.
31. It was for the GP to determine what medication to prescribe and in what dosage. The records show Mrs Y received pain medication over the following days, orally, through injection and latterly by syringe driver. The administration of medication is a decision for professionals to make and I cannot take a view on whether or not this was sufficient. I have seen the care provider’s staff training records and am satisfied staff were appropriately trained in end of life care.
32. The call bell records show there were 19 occasions when the call bell rang for over 30 minutes. As I have explained above, on nine of these occasions Mrs Y received support shortly before or after the bell rang. However, that leaves 10 occasions when the call bell rang for over 30 minutes without a response. This is fault. I cannot know what triggered the call bell on these occasions and whether Mrs Y was in her room or elsewhere. However, there were at least two occasions where the records support Mr X’s claim that he rang the call bell, it was not answered and he had to go and ask for help. This delay in answering the call bell is fault and caused Mr X frustration. It also meant there was a delay in Mrs Y receiving the support she needed.
33. In response to a draft of this decision, the care provider has advised it now has live oversight of call bell data and a data analyst dedicated to reviewing all call bell reports across the company. It says it conducts a weekly review of call bell data results which are analysed by the data analyst and form part of the ongoing risk management process. I am satisfied this action will prevent a recurrence of the fault identified.
34. The care provider was at fault for not responding to Mr X’s initial complaint. It says this was an administrative error and has already apologised to Mr X for this. That was an appropriate remedy.
35. Mrs Y has died so the injustice caused to her by the faults identified cannot be remedied. However, these faults have caused Mr X distress and have left him with a sense of uncertainty over whether Mrs Y received appropriate care. The injustice of distress cannot generally be remedied by a payment, so we seek a symbolic amount to acknowledge the impact of the fault.

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Recommended action

36. Within one month of the final decision the care provider should apologise to Mr X and pay him £300 to acknowledge the distress caused by the delay in obtaining morphine and in answering Mrs Y’s call bell.
37. Within one month of the final decision the care provider should provide evidence of how it is reviewing the call bell data and using this to prevent similar fault occurring.
38. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

39. I have completed my investigation. The care provider was at fault causing injustice for which I have recommended a remedy.

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Investigator's decision on behalf of the Ombudsman