Summary: There is no evidence the care provider failed in its management of Mrs X’s care and treatment.

The complaint

1. Mr and Mrs A (as I shall call them) complain the care provider did not manage Mrs X’s conditions properly, in particular her poor appetite and diabetes.

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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 injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)

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What I have and have not investigated

3. I have investigated the complaint set out in paragraph 1 above. Mr and Mrs A also complain that the GP rarely visited the care home but that is not a matter within the jurisdiction of the Ombudsman.

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How I considered this complaint

4. I considered all the information provided by the care provider and by Mr A. Both parties had an opportunity to comment on an earlier draft of this statement before I reached a final decision.

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What I found

Relevant law and guidance

5. 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.
6. Regulation 9 says “The care and treatment of service users must be appropriate, meet their needs, and reflect their preferences.”
7. Regulation 14 says the nutritional and hydration needs of service users must be met.
8. ‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a care plan.

What happened

9. Mrs X had dementia and several physical health problems, including Type II diabetes. Her care plan noted that she could be non-compliant with dietary and hygiene needs.
10. The care plan for Mrs X says her blood glucose levels should be monitored monthly although in fact the monitoring charts from the home show the blood glucose levels were being monitored on a weekly basis. The care provider says the blood sugar readings were taken by “trained and competent Registered RNs and Senior Lead Carers”.
11. The nutrition and hydration section of Mrs X’s care plan says she was on a diabetic diet, had a poor appetite and was weighed on a weekly basis. After a weight loss of 2kg in August 2021, the goals were defined as “To promote a well-balanced diet; Fortified drink in place; Food and Fluid chart Monitoring; Encouraging her to have small frequent diet along with main meal; Complan is given to maintain the Nutrition level; Chef /Cook to visit the resident to monitor the progress and provide help and advise the food choices; Eating and drinking when necessary; Offer extra calories and proteins in dietary plan”. Daily care records regularly note when Mrs X declined her meals. The care provider used the MUST process to determine Mrs X’s risk. Her risk score was a level 1 (medium risk).
12. In March 2023 the care provider referred Mrs X to a dietitian because of her poor appetite. The dietitian visited her at the care home and advised staff to offer snacks and drinks throughout the day; offer nutrient dense/fortified meals; weigh at least monthly; ensure regular mouth care. The dietitian also gave examples of fingers food to tempt Mrs X.
13. Mrs X died in May 2023.

The complaint

14. On 26 May Mr A wrote to the care provider and said they believed shortcomings in care had hastened her death. He said Mrs A had emailed many times in the previous months about the decline in Mrs X’s health. He said despite promises a dietitian was never engaged and so Mrs X had not received proper nutrition when it could have made a difference. He said the doctor rarely visited. He complained that on one occasion a family member who also had diabetes checked Mrs X’s blood glucose level which was extremely high. He asked why this was not being monitored and managed by the care provider.
15. The care provider responded. He said Mrs X did not have any undiagnosed conditions and was suffering from the frailty of old age: he said “A part of this condition is loss of appetite and as a result losing weight. Our records clearly show that her weight was closely monitored and appropriate steps were taken within the normal guidelines for care of the elderly: none of these suggest feeding by tube or other intrusive methods.” He said the GP was involved in discussions about Mrs X’s care management on a regular basis.
16. In respect of Mrs X’s diabetic management, he said he had seen the weekly blood sugar monitoring for January 2022 to May 2023 and all the results were in the range of 5.5 to 14.0mM which represented “excellent diabetic control”.
17. Mr A complained to the Ombudsman.
18. The care provider says Mrs X never suffered any hypo or hyperglycaemic episodes at any time during her 3-year stay at the care home. He adds, “(Mrs X) had Type II diabetes, her blood sugar levels were monitored at least once weekly and at other times when (Mrs X) appeared unwell, her blood sugars were monitored as a precaution to ensure her unwell self was not due to her diabetes. In the event (Mrs X’s) blood sugar levels were high, then she was referred to the GP and a monitoring plan was implemented to ensure the interventions were effective in bringing the blood sugar levels down. A combination of the weekly monitoring of blood sugar levels and the blood sugar levels taken while (she) was unwell, ensured (her)Type II diabetes was monitored and treated timely.”
19. The care provider adds that as Mrs X’s diabetes was well managed, she did not have a specialist diabetic nurse. Any such referral would have been made by her GP. He says in response to the complaint about diabetic management, a GP member of the Board of Trustees was asked to review her care. The detail of his report does not suggest any shortcoming in the provision of Mrs X’s diabetic care.

Analysis

20. There is no evidence the care provider failed to take necessary steps to maintain adequate nutrition and hydration for Mrs X. MUST charts were completed as appropriate and regular weight monitoring was undertaken. Contrary to Mr A’s complaint, a referral was made to a dietitian who made some recommendations but did not suggest a follow-up review.
21. There is no evidence the management of Mrs X’s diabetes was at fault. Her blood glucose levels were taken regularly. A review of the diabetic care in place did not reveal any shortcomings. In any event, Mrs X’s diabetic care was also the responsibility of her GP who did not make any referrals for more specialist care.

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Final decision

22. I have completed this investigation. I find that the actions of the care provider did not cause injustice to Mrs X.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman