Summary: Mr Z, on behalf of his father Mr X, complained that the quality of care at Woodland Grove Care Home, Loughton fell below acceptable standards and that there was a lack of communication. There is no evidence of fault in how the care provider dealt with end of life issues, falls and hydration for Mr X.

The complaint

1. Mr Z complains, on behalf of his father Mr X (deceased), that the quality of care fell below acceptable standards and that there was a lack of communication.
2. Mr Z says it was distressing to see his father ill in hospital and suffering from an untreated infection.

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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. (Local Government Act 1974, sections 34B and 34C)
4. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
5. 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

6. I considered evidence provided by Mr Z and the care provider as well as relevant law, policy and guidance.
7. Mr Z and the care provider had an opportunity to comment on my draft decision. I considered all comments before making a final decision.

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What I found

Key facts

8. This section sets out the key events in this case and is not intended to be a detailed chronology.
9. Mr X was a resident at Woodland Grove Care Home which is part of Oakland Primecare Limited. Following his death in May 2024, Mr Z made a formal complaint to the care home about the care his father had received shortly before his death. He also raised concerns about a serious fall that occurred about six months before his death and the lack of end of life care planning.
10. The care home responded detailing the actions it had taken to try to check if Mr X had an infection but saying it had not been able to obtain a urine sample. It explained it had spoken to Mr X’s GP who sent a paramedic to examine Mr X.
11. The paramedic examined Mr X and found no concerns and also gave advice on how to get a urine sample. It said that five days later a senior member of staff, whilst administering Mr X’s medication noticed signs that resulted in an ambulance being called. On arrival the paramedic established Mr X had a compacted chest infection and needed to go to hospital. The care home said Mr X had not presented previously with any signs of a chest infection.
12. It also said that it had not kept a fluid chart because Mr X was considered to be independent with his fluid intake. It also said his care notes showed he was encouraged throughout the day to drink. It considered he was receiving adequate fluids because staff helped him to change incontinence products.
13. In the complaint Mr Z said the family had not received a satisfactory response in respect of a serious fall Mr X had suffered in November 2023. The care home said it had sent details of the safeguarding procedure and a detailed report about the procedures followed.

Analysis

14. I have looked at the information held by the care home in respect of the issues raised and will deal with each in turn.

Dehydration

15. Mr Z says that when Mr X was admitted to hospital in April 2024 he was told by doctors that Mr X was severely dehydrated and that this was a case of neglect. As I wasn’t party to that conversation I cannot comment on what the doctor said. However, I have reviewed the actions of the care home prior to Mr X’s admission.
16. The daily case notes show Mr X was eating and drinking normally in the days prior to his hospital admission on 30 April. The notes also show care home staff assisting him to the toilet and to change continence pads which it was noted were wet. On the day of his admittance to hospital, staff helped Mr X to change a wet pad at 7:26 am.
17. While I cannot comment on what the doctors told the family about Mr X’s condition, the information provided in the care notes does not indicate any significant issues with dehydration. Mr X was drinking and eating every day and passing urine. Mr Z told me the family visited his father regularly and so assuming the family visited Mr X in the days before 30 April, there is nothing to suggest they alerted the care home to any concerns about Mr X in relation to these issues.
18. There is no evidence to suggest the problems reported by the doctors are as a result of any faut by the care home.

End of life care plan

19. The care home says that it takes a proactive approach to advance care planning and therefore discussed this with Mrs X in June 2023. The notes made at that time state Mrs X was not ready to record her wishes and requested extra time to consider this. The care home says that it attempted to engage Mrs X on this matter in regular monthly follow ups but she was not willing to proceed with a more in-depth conversation.
20. In February 2024, Mr Z contacted the care home after speaking to his father’s GP. He confirmed the family did not want Mr X to be hospitalised unless medical attention for something like a fracture was required. The care home noted that further information about advanced care planning would be sought from Mr Z when he next visited. This discussion did not take place before Mr X was hospitalised in April.
21. On 1 May, Mr Z telephoned the care home saying Mr X was responding to the antibiotics and he was at end of life. The care home confirmed Mr X could return to the care home once he was stable enough to be transported. It said it had anticipatory medications in place. Mr X did not return to the care home as he died in hospital four days later.
22. I am satisfied there were discussions between the care home and the family about end-of-life care. The evidence I have seen shows the care home initiated conversations in 2023 but the family did not wish to proceed at that time. By 2024, when Mr X was approaching end of life, there is evidence of contact between the care home and the family and a willingness to discuss wishes with the family. I have not seen any evidence to suggest the care home failed to respond to the family or that it refused to meet their wishes. I am aware the family did not want Mr X to die in hospital but there is nothing to suggest this was due to any failings by the care home. I therefore find no fault on this point.

Falls

23. Mr X was prone to falling and had a zimmer frame to help him mobilise. However, due to his condition, he regularly forgot to use it. In November 2023, Mr X had a fall that caused significant injuries and required hospital treatment. The care home responded appropriately including making a safeguarding referral to the local authority. I have not investigated whether the local authority carried out a safeguarding investigation but I assume if it had it would have been in contact with the family. There is no information to suggest the fall was due to fault by the care home.
24. The care home made a second safeguarding referral to the local authority in 2024 after Mr X suffered further falls. These falls were unwitnessed and happened when Mr X was mobilising independently. The fall clinic at the hospital had discharged Mr X because his dementia diagnosis meant they could not work with him.
25. I appreciate this was a concern for the family but it appears the care home did take measures to try to limit the risk of falls. When I spoke to Mr Z on the telephone he said that care home staff did intervene if Mr X was moving around without his zimmer frame. I am satisfied the care home responded appropriately including making safeguarding referrals.

Communication

26. Mr Z told me the care provided was generally good but he felt the communication was poor. I have been provided with details of the communication between the family and the care home from February 2024 onwards. As the family were regular visitors, there will also have been unrecorded contact between staff and the family.
27. The information I have seen shows the care home notified the family when Mr X had falls in February and March. The home provided updates when family members telephoned. In April, contact was made to inform the family of medical updates. On 30 April when Mr X was found very unwell, the family were called and they were at the care home when the ambulance arrived. It was then the family’s decision for Mr X to be taken to hospital. While Mr X was in hospital, and after he died, the care home contacted the family for updates and to check how the family, particularly Mrs X, were doing.
28. Based on this evidence, I cannot conclude there was a lack of communication between the family and the care home. The family may have wanted more regular or detailed communication but I am not persuaded the level of communication in this case would amount to fault.

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Final decision

29. I have completed my investigation and do not uphold the complaint.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman