Summary: Mrs X complains about the care provided to her deceased mother Mrs Y at Newbury Manor Nursing Home (the Care Provider). We find fault with the Care Provider for failing to follow Mrs Y’s drink chart, poor communication with Mrs X, failing to keep the family updated, and poor service to the family when Mrs Y died. We have agreed remedies with the Care Provider for the injustice caused.

The complaint

1. Mrs X complains about the care her mother Mrs Y received at Newbury Manor Nursing Home (the Care Provider) before her death.
2. Mrs X complains the Care Provider did not give her family the opportunity to be with her when she died.
3. This caused the family significant distress. Mrs X would like the Care Provider to make service improvements so another family do not have to go through the same.

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The Ombudsman’s role and powers

4. 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)
5. 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)
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 our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. I spoke with Mrs X and considered the information she provided.
9. I made enquiries with the Care Provider and considered the information it provided.
10. I considered relevant law and guidance, as set out below and our guidance on remedies, published on our website.
11. 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

Legal and administrative background

Relevant CQC Guidance

12. 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. We take account of the standards and accompanying guidance when deciding if a Care Provider has acted with fault.
13. I consider the following fundamental standards relevant to this complaint:
14. Regulation 9 “Person Centred Care” says care providers should enable and support relevant people to make or participate in making, decisions relating to the service user's care or treatment to the maximum extent possible…”.
15. Regulation 10, which covers ‘dignity and respect’. This includes ensuring staff treat all those using care services in a caring and compassionate way.
16. Regulation 12 “Safe care and treatment” says care providers must assess risks to people's health and safety during any care and make sure that staff have the qualifications, competence, skills and experience to keep people safe. Staff must also respond appropriately if there is a medical emergency. And there must be suitable systems in place for administering medications accurately as prescribed.
17. Regulation 14, ‘meeting nutritional and hydration needs’. This says providers must meet the nutrition and hydration needs of service users. This includes recording those needs in care plans and reviewing them on an ongoing basis.
18. Regulation 16 says care providers must make sure that people can make a complaint about their care and treatment. All complaints must be investigated thoroughly and any necessary action taken where failures have been identified.
19. Regulation 20, which requires care providers to have a ‘duty of candour’ to act in open and transparent way when delivering care. It places an expectation on care providers to say sorry when poor care has caused harm.

What happened

20. Mrs X is Mrs Y’s daughter. She had many hospital admissions in 2023 for various health needs and had Vascular Dementia.
21. Newbury Manor Nursing Home is registered with the Care Quality Commission (CQC) as a nursing care home. I will refer to it as the Care Provider in this complaint.
22. Mrs X says the family came to the difficult and reluctant decision to place Mrs Y in a nursing home, but went with the advice of the hospital and Mrs Y’s GP, as she needed 24 hour nursing care.
23. Mrs Y’s GP was also the visiting GP of the Care Provider so the family went with his recommendation.
24. The hospital discharged Mrs Y at the end of October 2023, and she moved into the nursing home. Her family chose a room next to the day room where residents ate their meals and did activities, as Mrs Y was sociable and liked to be around other people.
25. Mrs X visited her mother regularly. Her brother was the first point of call as he lived nearby whereas Mrs X lived an hour away.
26. Mrs X said Mrs Y told her the staff never asked if she wanted to eat in the day room, and spent her time permanently in her pyjamas and in bed. Mrs X said they chose the bedroom they did so Mrs Y could walk the short distance to the day room with her walker. Mrs Y was only taken to the day room once in her wheelchair.
27. Mrs X visited Mrs Y at lunch times to see if staff would take Mrs Y to the day room to eat. She said no one asked Mrs Y if she wanted lunch in the day room. Mrs X noted Mrs Y getting lunch in her room two hours late, and it was cold.
28. On a further visit in November Mrs X says she found Mrs Y distressed and needing various creams and dressings to be applied. Mrs X asked the care staff who said only nurses could do this. She went to the nurses station who came and cleaned Mrs Y but did not give any medication. Mrs X was there for over an hour and asked the staff to give her a call once they had attended to Mrs Y but she says she never got a call.
29. Mrs X emailed the manager with her concerns who said she would get a response within seven days. She did not hear back so she chased ten days later and had a phone call with the manager, who arranged a meeting a few days later.
30. Mrs X said the manager told her at the meeting:
• All Mrs Y’s medications had been sorted;
• Carers would ask Mrs Y if she wanted to eat in the day room every mealtime;
• Mrs Y would get hourly drink visits to keep her hydrated;
• Mrs X would get weekly calls to keep her updated, and
• A physiotherapist saw Mrs Y and said she could walk to the day room with her walker.
31. On Christmas eve Mrs X’s brother visited Mrs Y. He was concerned as Mrs Y had been sick and was agitated and hot. He called Mrs X as he was worried Mrs Y’s internal bleed had retuned.
32. Mrs X called the Care Provider and said the nurse did not know Mrs Y had been sick. The nurse returned her call and said she thought Mrs Y should go to hospital in case her chest infection had returned and she needed antibiotics. Mrs X did not agree to this.
33. The paramedics arrived and Mrs X asked him to call her after he had seen Mrs Y.
34. The paramedic told Mrs X Mrs Y was nearing end of life and she should come and see her. He agreed it would not be worthwhile to move her to hospital as she was too frail. He said he would contact palliative care and out of hours doctor to give her morphine. He promised to stay with Mrs Y until Mrs X arrived.
35. Mrs X arrived at 2am on Christmas day. The paramedic explained Mrs Y’s body was shutting down and it could be a few hours or a few days, but the nurses would give her a better idea.
36. Mrs X says no nurses attended after the paramedics left and she had to ask them to chase the out-of-hours doctor to give Mrs Y pain relief. The doctor came at 9am but without morphine, so the nurses had to find a chemist which was open. It was administered to Mrs Y at 11am.
37. Mrs X was told the staff would check Mrs Y every 15 minutes and went home to get some rest. The Care Provider called her just past midnight on Boxing Day when Mrs Y had passed away.
38. In March 2024 Mrs X made a complaint to the Care Provider. She said:
• Mrs Y did not have food from the menu. Nor was she invited to play bingo, or get her hair and nails done.
• Staff only took Mrs Y to the day room once in her wheelchair, when she could have gone in her walker.
• The Care Provider did not have the correct contact details of her and her brother. The staff could also not find the Power of Attorney when the paramedics came to see to Mrs Y.
• Staff did not manage Mrs Y’s medication properly.
• Mrs X had to chase for a meeting with the manager who said at the meeting the medication had been sorted, carers would ask Mrs Y each mealtime if she wanted to eat in the day room, she would get hourly drink visits and Mrs X would get a weekly update on the telephone. Mrs X said none of this happened.
• The manager said a dietician would visit Mrs Y to advise on her eating and drinking. There was also a Short and Long Term (SALT) referral. The Care Provider did not update the family about this.
• The nurses and staff did not treat the family well when Mrs Y was at end of life. Mrs X had to chase the nurses for medication for Mrs Y, staff asked the family to pick up the morphine prescription from the chemist on Christmas day. The Care Provider failed to call Mrs Y before Mrs Y died, and there were no condolences from any staff at the care home.
39. The Care Provider response went through Mrs Y’s food and fluid charts to show it offered food from the menu but her appetite was poor from admission to the care home. It said:
• The GP prescribed Juice supplements as Mrs Y was only eating around half of each meal offered, and staff gave these to Mrs Y.
• Mrs Y refused the hairdressers. Staff did offer activities to Mrs Y during her stay as noted in her daily care records. Sometimes she was asleep, sometimes she refused, but she did take part at times.
• On Christmas day the staff could not find the hard copy of the Power of Attorney as it was locked in the managers office. Now the Care Provider scan important documents onto their system and keep hard copies in a secure area that all nurses can access.
• The manager told Mrs X in the meeting that staff would offer drinks to Mrs Y every hour. There is no evidence of this. This point is upheld.
• The hospital gave Mrs Y two weeks worth of medication on discharge. The Care Provider called Mrs Y’s GP when Mrs X told it some general items were missing. The care charts show creams and medications given according to doctors instructions.
• There is no evidence that a dietician visited Mrs Y, or the Care Provider told Mrs X of the SALT consultation. This point is upheld.
• From the daily notes there is evidence that Mrs Y was cared for at least hourly over night on Christmas eve. The nurse on duty recorded she chased 111 to see when an out-of-hours doctor would attend.
• “Whilst I appreciate the nursing team were busy, I would expect a member of the nursing team to ensure the welfare of the family was being met and to be available to answer any questions they may have. I would not expect a member of the family in this situation, to be asked to collect morphine. Mrs Y’s condition was deteriorating, and the family would naturally wish to be with her.”
• The nurse in charge should have made the family aware that she was going to locate a pharmacy to get the morphine, and this may take some time. This point is upheld and I apologise for any distress caused.
• There is no evidence in the notes that Mrs Y declined before she passed away. The family wanted a call at signs of deterioration and had not told staff they would be back to visit that day. However there would be an expectation that once Mrs Y had morphine, her symptoms of pain and agitation would reduce, and she would gradually become unresponsive. There is no evidence nurses explained this to the family, which may have changed their visiting plans had they known. There is no evidence that Mrs Y had 15 minute checks, and this point is upheld.
• We would expect the manager to contact the family to offer their condolences personally, and for the Care Provider to send a sympathy card to the grieving family. I apologise this did not happen and uphold this point.
40. The Care Provider investigated the complaint and the report shows the actions taken because of the complaint:
• The service to continue to follow the new process for storing Power of Attorney that has been put into place following this incident. These are now scanned onto the system and hard copies are kept in a secure area that all nurses can access. This will be monitored by regional manager on her weekly visits.
• Management team to ensure that any information given to the family is recorded in the care plan, shared at handover, carried out by staff, and checked by nursing team such as the implementation of 15 minutes checks on a resident. To be monitored by home manager.
• Nursing and management teams to ensure that family members are informed of all professional visits/ consultations and prescribed treatments. This is to be recorded in electronic records. To be shared at daily meetings and handover by the management team. This will be monitored by regional manager on her weekly visit.
• Nurses to ensure and evidence that families of residents referred to the palliative team have the information they need, and their welfare is monitored while they are sitting with their loved one. The updated company end of life policy and supplementary booklet to be introduced into all services by 25 March 2024. Implemented by home manager, monitored by regional manager.
• Any medication that needs collection from a local pharmacy to be collected by a member of staff and not a grieving family member. To be shared at daily meetings and handover by the management team.
• Home manager to ensure all the next of kin of residents who have passed away are contacted personally and a sympathy card is sent via post, according to updated end of life policy. To be monitored by regional manager.
• Home and deputy manager have received formal counselling as part of the company’s disciplinary procedure.
41. Mrs X remained dissatisfied with the complaint response so she brought her complaint to the Ombudsman.
42. As part of my enquiries the Care Provider sent me the care plans, medication and food charts for Mrs Y.

Analysis

43. Having reviewed the food and medication charts for Mrs Y I can see that staff did offer food from the menu. However it is clear staff failed to carry out the drink checks as promised and did not give Mrs Y the prescribed juice drinks as often as they should have been. This is fault by the Care Provider causing distress for Mrs Y by not having her hydration needs met, and causing distress for Mrs X.
44. The Care Provider should have kept the family updated about the SALT consultation and result. This is fault causing frustration and distress to Mrs X.
45. The nursing staff could not find the Power of Attorney when paramedics attended the care home on Christmas day. The Care Provider have admitted fault for this and set up service improvements so this does not reoccur. This caused Mrs X distress and frustration.
46. The care provided to the family of Mrs X on Christmas day when Mrs Y was at end of life failed to follow the rules of good administrative practice and was insensitive. This caused frustration and distress to Mrs X.
47. I have put forward an apology and symbolic payment for Mrs X as a result of the faults identified. I am satisfied the service improvements the Care Provider have now set up address the issues from this complaint, and the Ombudsman will monitor the impact of these changes through our complaints.

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Agreed action

48. I have found fault in the actions of the Care Provider which has caused Mrs X and Mrs Y injustice. As Mrs Y has now died, I cannot remedy her personal injustice. The recommendations below are therefore to remedy Mrs X’s injustice and to improve future practice.
49. Within one month of the final decision the Care Provider will:
1. provide an apology to Mrs X accepting the findings of this investigation and in line with our guidance on remedies (section 3.2); Guidance on remedies - Local Government and Social Care Ombudsman
2. pay Mrs X £500 a symbolic payment in recognition of her distress.
50. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

51. I find fault with the Care Provider for failing to provide a good service, follow the drink plan, poor communication and failing to keep the family updated, and poor service to the family when Mrs Y died.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman