Summary: Mr X complained about the quality of care provided to his late relative Mrs Y at the care home. There was no fault in the way the care home supported Mrs Y’s eating and drinking or with her mobility. We cannot achieve any worthwhile outcome by further investigation of Mr X’s concerns about the delay in getting her a suitable chair or regarding what he was told about whether Mrs Y was at the end of her life.

The complaint

1. Mr X complained about the quality of care provided to his late relative, Mrs Y at the care home. In particular he complained the care provider:
1. gave the family conflicting information around whether Mrs Y was on an ‘end of life’ pathway;
2. failed to provide appropriate support to Mrs Y with her eating and drinking;
3. failed to provide appropriate support to enable Mrs Y to walk again after a hospital stay; and
4. delayed providing a suitable chair to enable Mrs Y to get out of bed.
2. Mr X says this caused the family distress and frustration.

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The Ombudsman’s role and powers

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 future we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
4. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
5. We provide a free service, but must use public money carefully. We may decide not to continue with an investigation if we believe:
• it is unlikely we could add to any previous investigation by the care provider, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants. (Local Government Act 1974, sections 34B(8) and (9)
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)

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How I considered this complaint

7. I have considered the information provided by Mr X and discussed the complaint with him. I have considered the care home’s response to my enquiries and the information provided by the Council in response to my third party enquiries.
8. I gave Mr X and the care provider the opportunity to comment on a draft of this decision. I considered any comments I received before making a final decision.

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What I found

Safeguarding

9. Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.

CQC fundamental standards

10. CQC is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of the fundamental standards and prosecute offences.

Lasting power of attorney

11. The Mental Capacity Act 2005 introduced the “Lasting Power of Attorney (LPA)”. This replaced the Enduring Power of Attorney (EPA). An LPA is a legal document, which allows a person (‘the donor’) to choose one or more persons to make decisions for them, when they become unable to do so themselves. The 'attorney' is the person chosen to make a decision on the donor’s behalf. Any decision has to be in the donor’s best interests.
12. There are two types of LPA:
• Property and Finance LPA – this gives the attorney(s) the power to make decisions about the person's financial and property matters, such as selling a house or managing a bank account.
• Health and Welfare LPA – this gives the attorney(s) the power to make decisions about the person's health and personal welfare, such as day-to-day care, medical treatment, or where they should live.

What happened

13. Mrs Y had dementia. She moved into the care home in September 2021. At the time she was able to move around independently. She needed prompting with personal care and support with maintaining her continence. She ate and drank independently. Mrs Y’s daughter, Mrs Z, had lasting power of attorney for Mrs Y’s health and welfare and finances.
14. In late October 2021 Mrs Y had a fall at the care home. Mrs Y was admitted to hospital where it was found she had broken her hip.
15. Mrs Y returned to the care home in late November 2021. At the time the care home says Mrs Y was referred to an OT by the hospital but was too frail to undertake an OT assessment. Staff noted she still had a lot of pain in her hip, and pressure damage to the skin on a heel. The care home noted Mrs Y had lost a significant amount of weight in hospital and had a Malnutrition Universal Screening Tool (MUST) score showing she was at very high risk of malnutrition. The care home manager referred Mrs Y to the GP and requested fortified drinks/desserts to supplement her diet.
16. The care home reviewed Mrs Y’s care plan. It noted Mrs Y was now moving towards the end of her life and had a prognosis of months to live. It noted Mrs Y now needed her personal care in bed, assisted by two staff members. Mrs Y now had a special bed and mattress to protect her skin from pressure sores. The care plan noted staff should record what Mrs Y ate and drank and she was to be re-positioned every two hours. The care plan noted staff were to support her at mealtimes. Her meals and drinks were to be fortified with cream or milk powder. It noted she had a high risk of developing pressure sores.
17. In mid-December the care home noted in the care plan Mrs Y had continued to lose weight and it was still waiting for the GP to prescribe her fortified drinks. It noted staff should continue to support Mrs Y with her meals and she would be reviewed by the GP in mid-December. It noted the pressure sore on her heel was healing well. The GP reviewed Mrs Y in mid December and considered Mrs Y may be moving towards the end of her life.
18. The care home’s records show staff supported Mrs Y with eating and drinking. The care home weighed her regularly and Mrs Y’s weight continued to decrease until Spring 2022 when it started increasing slightly. The staff completed fluid charts which show Mrs Y generally drank well, including regular fortified drinks. The food charts showed she generally ate smaller meals.
19. In May 2022 the Council carried out a mental capacity assessment of Mrs Y. It found Mrs Y did not have capacity to decide where she lived. It made a best interests’ decision that Mrs Y should remain in the care home. Mrs Z (Mrs Y’s daughter and LPA) was consulted on and agreed with the decision.
20. In June 2022 the care home requested an occupational therapy assessment to see if Mrs Y could be seated safely in a chair as she had a lack of flexibility in her legs. An OT carried out an assessment in July 2022 and recommended a specialist chair for Mrs Y. The OT advised the care home it should pay for the chair. The care home had a spare chair Mrs Y could potentially use, but the OT said this was too wide for Mrs Y. The care home did not agree to pay for the chair as it believed the family should fund it. The OT agreed to investigate who would need to fund the chair. Mrs Y’s skin continued to be fragile.
21. In late August 2022 the OT sent their chair recommendations to the care home and that Mrs Y be hoisted into a chair for 15 minute periods, to be built up over time. The family contacted the OT as the care home told them they would need to pay for the chair as it would not be able to purchase it. The OT agreed to speak to the care home.
22. In mid September 2022 the care home noted at a care plan review that Mrs Z was happy with the care Mrs Y was receiving.
23. The OT spoke with Mr X in late September 2022 during which Mr X raised his concerns about the care Mrs Y was receiving at the care home. He said the family were unsure about whether to buy the chair. The OT said it was for the care home to buy it. The OT spoke to the care home about Mr X’s concerns about the care Mrs Y was receiving and the chair. The care home manager said Mr X had not raised any concerns directly with them. The manager reported there were three other chairs at the care home which were not in use which may be suitable for Mrs Y. The OT agreed to revisit the care home in mid October to assess the other chairs.
24. In early October Mr X contacted the Council with his safeguarding concerns. In summary these included that:
• after Mrs Y’s fall she was returned to the care home.
• Mrs Y was starved and neglected, had lost weight and was not assisted with eating.
• Mrs Y’s bed was facing the wall not the window and he had to move the bed himself,
• Specialist seating may not be provided due to its cost.
• Property was missing from Mrs Y’s room.
25. Around this time the care home asked the Council to speak to Mrs Z (Mrs Y’s daughter and LPA) as she was concerned transferring Mrs Y to a chair may distress her or injure her fragile skin. The OT’s notes recorded Mrs Z had no concerns with Mrs Y’s care at the care home. Mrs Z was aware Mrs Y was moving towards the end of her life and wanted her to be comfortable. Mrs Z agreed to attend the OT’s assessment in mid October so they could assess Mrs Y’s reaction to being hoisted.
26. A Council social worker spoke with Mr X about his safeguarding concerns and then contacted the care provider and requested a response to the issues Mr X had raised. The care home manager spoke to the Council and advised that Mr X had not made a formal complaint with them but could do so.
27. The care home emailed the Council in mid October with its response to Mr X’s concerns. In summary it said:
• Mrs Z, who held LPA, had agreed with Mrs Y’s return to the care home after her fall.
• Mrs Y had lost a lot of weight in hospital. She received support from one staff member with eating and when her weight continued to drop was referred to a dietician and prescribed fortified drinks. She was gaining weight.
• The bed faced the door so staff could see and interact with Mrs Y when walking past. It was now facing the window as Mr X had requested.
• The OT was visiting that month to assess whether any of the care home’s existing specialist chairs would be appropriate for Mrs Y. However, Mrs Z had raised concerns about whether hoisting would distress Mrs Y.
• In relation to property going missing, Mrs Y lived on a dementia unit and some people would go into another’s room and move items without realising what they were doing. The manager had explained this to Mrs Z who had no concerns after this was explained.
28. The Council considered the care home’s response and that Mrs Z had not raised any concerns and she had LPA for Mrs Y. It decided Mr X’s concerns were not safeguarding matters. It had informed CQC of the outcome; that it had decided it would take no further action.
29. The OT reassessed Mrs Y in mid October 2022 in a chair provided by the care home. Mrs Z attended. The notes record Mrs Y appeared to cope well with the hoist and the chair was considered appropriate. The OT noted Mrs Z did not like other residents entering Mrs Y’s room but she understood why this happened. The OT contacted the District Nurse who provided advice on taking care not to damage Mrs Y’s skin while in the chair.
30. In late October 2022 CQC contacted the care home about Mr X’s concerns. The care home advised the CQC Mr X had raised the issues as safeguarding concerns with the Council. The care home said it would log Mr X’s concerns as a complaint and respond to him.
31. In late October 2022 Mrs Y died.
32. The care home responded to Mr X’s complaint in November 2022. It explained:
• it had some adjustable chairs and was not obligated to buy a new chair if a current chair met the OT’s recommendations.
• the bed faced the door so Mrs Y could see staff walking by. Mr X requested the bed face the window and this was arranged.
• due to it being a dementia unit some residents would go into another’s room and relocate items. It said it believed all missing items were returned to Mrs Y’s room. It was looking to find ways to minimise the risk of people entering others’ rooms moving forward.
• Mrs Y had lost a large amount of weight after her hospital admission and was placed on an end of life pathway. She was assisted by staff at meal times and referred to the dietician.
• Mrs Y was referred to the occupational therapy team and the first step was to get her comfortable in a seating position. It relied on the support of trained professionals to ensure plans regarding moving were carried out safely.
• The special bed was in good working condition and was inspected regularly.
• It requested an OT assessment in June 2022. This took place in August 2022 and recommended a special chair. As the care home already had some which were not in use it requested another assessment.
33. Mr X remained unhappy, and the care home responded at the second stage of its complaints procedure in December 2022. It reiterated some of its previous comments. In relation to eating and drinking it said it had reviewed Mrs Y’s care plan which noted there were days Mrs Y could eat without assistance and other days when she needed support. It had noted Mrs Y’s appetite was small and despite input from the dietician her weight gain was slow. Mr X said he had visited and found Mrs Y with an uneaten dessert. The care home apologised for this and said if Mrs Y could not eat it herself, staff should have supported her. It said it would carry out additional spot checks as part of its lessons learned. Mr X had also said other items were missing which the care home had managed to locate and which were available for collection. Mr X remained unhappy and complained to us.

Findings

Complaint the care home gave the family conflicting information around whether Mrs Y was on an end of life pathway

34. The NHS considers end of life care as support for those in the last months or year to live. It says people are considered to be approaching end of life when they are likely to die within the next 12 months although this is not always possible to predict. The records show when Mrs Y was discharged from hospital the care home recorded on Mrs Y’s care plan that she had months to live. Mr X said staff members told him otherwise. I do not know exactly what Mr X and the family were told. However, when Mrs Z spoke with the OT in October 2022 she was aware Mrs Y was approaching the end of her life. I have seen no evidence they were informed otherwise and without further evidence there is nothing I could achieve by investigating this issue further.

Complaint the care home failed to provide appropriate support to Mrs Y with eating and drinking

35. Mrs Y lost a significant amount of weight during her hospital stay. When she returned to the care home, the records show the care home reviewed the care plan and noted Mrs Y required assistance with eating and drinking. It completed the MUST screening tool and acted accordingly. It sought support from the GP and a dietician referral and weighed Mrs Y regularly. It completed food and fluid charts to monitor Mrs Y’s intake. The daily care records show Mrs Y food intake was variable, but she drank well. There were occasions when she refused assistance or did not want to eat. The records show the care provider acted appropriately in response to Mrs Y’s weight loss.
36. Mr X has photographs which showed Mrs Y was left with food on some occasions. The care provider has apologised for this. Without specific dates it is difficult for me to reconcile this with the care home’s records as to whether staff had tried to assist her or not before Mr X visited. On balance, I am satisfied the care home acted appropriately in response to Mrs Y’s weight loss.

Complaint the care home failed to provide appropriate support to enable Mrs Y to walk again after a hospital stay

37. Mrs Y’s mobility had significantly deteriorated following her fall and hospital admission. On her return to the care home the flexibility in her legs had reduced and Mrs Y could not weight bear and needed the support of two staff members with personal care. The hospital referred Mrs Y to occupational therapy after her hospital stay. It was for occupational therapy to determine what, if any, action should be taken regarding Mrs Y’s mobility. The care home reviewed Mrs Y’s care plan and supported her in bed. It also requested an OT assessment to enable Mrs Y to sit out of bed. The care provider was not at fault.

Complaint the care home delayed providing a suitable chair to enable Mrs Y to get out of bed.

38. The care home requested an assessment to see if Mrs Y could safely be moved from her bed to sit in a chair. This was completed in August 2022. There was then a delay in getting the chair. This was for several reasons: the care home was unwilling to pay for a new chair because it felt it had suitable chairs in stock; Mrs Z had concerns about Mrs Y being distressed by being hoisted and moved for relatively short periods of sitting out; the need for a fresh assessment when the care home identified a chair that may be suitable and the need for District Nurse input given the vulnerability of Mrs Y’s skin.
39. The care home was entitled to re-use a chair it already had, once an OT was satisfied the chair was appropriate to meet Mrs Y’s needs. Even if I was to say there was a delay in organising the chair, any injustice caused by the delay was caused to Mrs Y. I cannot now know the extent to which she would have been able to sit out in the chair or for how long. I therefore do not intend to investigate this issue further as there is no worthwhile outcome I could achieve.
40. Mr X’s concerns were also considered by the Council through its safeguarding procedures, and it was satisfied these were not safeguarding concerns and that no further action was required. There is nothing else I could achieve by investigating Mr X’s concerns further.

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Final decision

41. I have completed my investigation. On the evidence considered there was no evidence of injustice caused by fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman