Summary: Mrs X complains about the quality of care her late father, Mr Y, received from the Care Provider for just over six days before he died. There was no fault in the quality of care or the Care Provider’s handling of Mrs X’s complaints.

The complaint

1. Mrs X complains about the quality of care her late father, Mr Y, received from the Care Provider from 27 January to 3 February 2023, when he passed away. Mrs X is unhappy with the Care Provider:

• failing to properly empty or unblock Mr Y’s catheter causing discomfort;
• forcing Mr Y to take two large tablets at once despite him having difficulties with swallowing;
• leaving medication with someone else’s name in Mr Y’s room;
• not completing hourly checks on Mr Y as promised;
• leaving Mr Y undressed, dirty and clinging to his bed rails on 30 January.

Mrs X says the Care Provider’s actions caused Mr Y and his family significant distress and Mrs X wants to ensure other residents are not treated in the same way.

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The Ombudsman’s role and powers

2. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

3. 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 a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
4. 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

5. I have spoken to Mrs X and considered the information she has provided in support of her concerns.
6. I have considered the information the Care Provider has sent in response to my enquiries. This includes copies of daily care records for Mr Y, the Care Provider’s medicines policy and procedure for catheterisation and catheter care.
7. Mrs X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant legislation

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
9. Regulation 9: Person-centred care says people using a service have care or treatment that is personalised specifically for them. This regulation describes the action that providers must take to make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences.
10. Regulation 12: Safe care and treatment says people must not be given unsafe care or treatment or be put at risk of harm that could be avoided.
11. The International Dysphagia Diet Standardisation Initiative (IDDSI) provides guidance to speech and language therapists and other healthcare professionals on the diet and fluid textures best suited for people with dysphagia (difficulties swallowing). Levels 7 to 3 describe the textures of food as follows:

• 7 – Regular
• 7* - Regular easy chew
• 6 – soft and bite sized
• 5 – minced and moist
• 4 – pureed
• 3 – liquidized

(Fluids are described from levels 4 to 0).

What happened

12. This is an overview of key events and does not cover everything that happened.
13. Mr Y had diagnoses of mixed dementia, diabetes, a heart condition and conditions relating to his kidneys, prostate and bladder. He had been admitted to hospital with urosepsis – a serious complication of a urinary tract infection.
14. Mr Y was discharged from hospital into a residential placement with the Care Provider on 27 January 2023. The Care Provider completed a moving in assessment of Mr Y’s care needs a few days before he was discharged from hospital. Mr Y’s care was funded through the NHS Discharge to Access scheme. Mr Y’s family, including Mrs X, had selected this residential placement as there were no restrictions on visiting times.
15. The Care Provider’s moving in assessment of Mr Y noted his care needs based on his hospital discharge notes. This included that Mr Y had a long-term catheter, had refused the recommended level 6 diet in favour of level 7 and did not like clothing that was too restrictive. The Care Provider put in place a care plan to complete hourly observations and repositioning to prevent pressure sores every two hours during the day and every four hours at night. The Care Provider also planned to make a referral for a Speech and Language Therapy (SALT) review of Mr Y’s diet.
16. Mr Y seemed to settle well for the first three days at the care home and his family spent considerable time with him. On 30 January 2023, Mr Y started to deteriorate rapidly and by the morning of 3 February he had sadly passed away. By this point, Mr Y had spent just over six days at the care home.
17. In late March 2023, Mr Y’s granddaughter made a complaint to the Care Provider about the quality of care Mr Y received. The Care Provider met with Mr Y’s granddaughter and four other close relatives, including Mrs X, to discuss the concerns they had. These concerns broadly mirror those Mrs X has now brought to us.
18. The Care Provider completed its complaint investigation in April 2023 and issued a response on 19 April 2023. The Care Provider’s response gave details of its investigation and analysis of the daily care records completed by care home staff. The Care Provider apologised it could not provide a definitive explanation for Mr Y being found undressed and clinging to his bed rails by a relative on the morning of 30 January 2023. The Care Provider confirmed it had taken action following Mr Y’s experience and his family’s concerns.
19. On 10 May 2023, Mrs X replied to the Care Provider’s complaint response. She disagreed with its findings but accepted it had completed a thorough investigation. The Care Provider offered to discuss Mrs X’s further queries about Mr Y’s care and this discussion took place on 18 May 2023. The Care Provider followed up this discussion with an email to Mrs X which explained it would be closing its complaint investigation.

Analysis

20. In response to my enquiries, the Care Provider has sent copies of daily care records, hospital discharge records and care plan for Mr Y. The Care Provider has also shared its procedures for catheter care and medication, together with its complaint investigation records in respect of the complaint made by Mr Y’s family (including Mrs X) since he passed away.
21. I am satisfied the Care Provider completed a thorough investigation of Mrs X and her family’s concerns. It has taken the care to meet with and discuss at length the family’s concerns. Mrs X has also confirmed she considered the Care Provider’s handling of her family’s complaints to be ‘very good’.
22. Having had the opportunity to examine the same records as the Care Provider, the conclusions and findings it reached in Mr Y’s case reflect the evidence I have seen.
23. The Care Provider acted promptly following Mr Y’s rapid decline in health and to the requests made by his family.
24. From my review of the evidence provided, I have not identified any issues in the Care Provider’s handling that would suggest it had acted with fault which caused injustice to Mr Y.
25. The Care Provider has confirmed it completed a lessons learnt meeting with this care home and others in the area following Mrs X’s complaint. This included:

• better communication and support for families during end of life care;
• ensuring residents have access to drinks and belongings to promote independence;
• improving staff deployment;
• doing all it can to minimise delays in obtaining medication; and,
• supporting residents to always look presentable.

These actions are an appropriate and reasonable response to the concerns raised by Mrs X and her family.

26. Mrs X says she and her family raised concerns about the difficulties Mr X experienced swallowing tablets. She says they suggested care home staff broke larger tablets in half to make these easier for Mr X to swallow until liquid versions of medication were received.
27. The Care Provider’s medicines policy advises against altering the formulation of medicines from their original state, such as crushing tablets, opening capsules and cutting patches as this negates the product licence of the medication. The Care Provider’s policy states it should only alter the original formulation of medication under the prescribing GP’s advice, where there is no alternative formulation (such as dispersible or liquid) available and a pharmacist has confirmed the appropriateness of the change in formulation.
28. It therefore appears the care home was acting in accordance with its medicines policy by not splitting Mr X’s tablets in half. It may have been helpful if the Care Provider had explained this to Mrs X and her family at the time.
29. Mr X’s death has clearly been very distressing for everyone involved. I can appreciate Mrs X and her family’s desire to know more about what happened and the Care Provider’s actions. It is however not part of our role to determine the cause of Mr X’s death or whether the Care Provider’s quality of care contributed to this.
30. I have examined all the evidence the Care Provider has about Mr X’s short time in its care. I am satisfied it acted promptly in response to issues with Mr X’s declining health and appears to have provided appropriate care in line with his needs. I also consider the Care Provider’s handling of Mrs X and her family’s complaint was thorough and sensitive given the circumstances.
31. While I realise none of this alleviates the grief and distress Mrs X and her family have and are still experiencing, I hope my independent review gives some reassurance the Care Provider’s handling and learning from this complaint was appropriate and reasonable.

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Final decision

32. I have completed my investigation with a finding of no fault.

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Investigator's decision on behalf of the Ombudsman