Summary: There was fault in the way the care home provided care to Mrs C. This has caused distress to Mrs C and her daughter. The Council has agreed to apologise, pay a financial remedy and carry out a service improvement to address the injustice.

The complaint

1. Mrs B complains on behalf of her mother, Ms C, who has died. Mrs B complains about the poor care that Ms C received at Westbourne Care Home, Holmes Chapel, Cheshire.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. 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)

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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What I have and have not investigated

5. Mrs B has also complained about the actions of the doctors involved with Ms C and the speech and language therapist. I have not investigated these complaints as the Parliamentary and Health Ombudsman investigates complaints relating to the NHS.

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How I considered this complaint

6. I have discussed the complaint with Mrs B and I have considered the information that she has sent.
7. The care package was funded by Trafford Council under a deferred payment agreement. As the Home was located in Cheshire East, the safeguarding enquiry was carried out by Cheshire East Council. I have considered the information sent by both councils, the Home and the relevant law, guidance and policies.
8. I have also considered all sides’ comments on the draft decision.

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What I found

Law, guidance and policies

Care Quality Commissiion

9. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards.
11. This says that:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).
• The nutritional and hydration needs of the service user must be met. Where a person is assessed as needing a specific diet, this must be provided in line with that assessment (regulation 14).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The Home must, as far as is reasonably practicable, ensure that service users are able to make decisions about their care or treatment (regulation 11).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

What happened

Chronology

12. This is a chronology of Mrs B’s complaints and the investigations that have taken place into the complaints.
• 12 January 2022: Ms C moved into the Home.
• 20 January 2022: Mrs B complained to Trafford Council about the Home and Ms C’s GP. She had made complaints and safeguarding referrals about the two previous care homes where Ms C had resided.
• 30 March 2022: Mrs B made a safeguarding referral regarding the Home to Trafford Council. Trafford Council emailed the referral to Cheshire East Council as the Home was located there.
• 27 May 2022: Mrs B made a safeguarding referral to Trafford Council and Trafford Council sent it to Cheshire East Council. Cheshire East Council decided that the referral did not meet the threshold for a safeguarding enquiry and closed the matter.
• 15 June 2022: Ms C was diagnosed with a terminal illness.
• 17 June 2022: Mrs B made a safeguarding referral to Cheshire East Council.
• 22 June 2022: Mrs B complained to the Home.
• 6 July 2022: The Home responded to Mrs B’s complaint.
• 6 July 2022. Ms C was taken to hospital but returned later that day. The hospital made a safeguarding referral based on Mrs B’s referral.
• 10 July 2022: Ms C died.
• 11 July 2022: The Home responded to Mrs B’s complaint.
• 13 July 2022: Mrs B called the police about the Home’s alleged failures. The police took no further action and closed the matter.
• 3 August 2022. Cheshire East Council started a safeguarding enquiry.
• 13 December 2022: Cheshire East Council completed the safeguarding enquiry and emailed the outcome to Mrs B. The allegations were partially substantiated.
• 20 January 2023: Cheshire East Council made a referral to the Safeguarding Adult Board (SAB) to consider whether a Safeguarding Adult Review (SAR) should be held.
• 26 January 2023: The SAB decided that the threshold for an SAR was not met.
• 9 March 2023: Mrs B contacted her MP about her complaints.
• 13 March 2023: Cheshire East Council responded to the MP’s referral by organising a meeting between Mrs B, the Chair of the SAB and the Council’s Chair of Safeguarding to go through the decision of the SAB.
• 20 March 2023: The Chair of the SAB wrote to Mrs B with a list of actions agreed at the meeting.
• 26 March 2023: Mrs B complained to Cheshire East Council about the safeguarding enquiry and made a complaint to the CCQ about the Home.
• 3 April 2023: The CQC carried out an inspection of the Home as a result of Mrs B’s complaint.
• 18 April 2023: Cheshire East Council provided a stage 1 response to Mrs B’s complaint about the safeguarding enquiry.
• 24 April 2023: Mrs B escalated her complaint about the safeguarding enquiry to stage 2.
• 9 May 2023: Cheshire East Council provided its stage 2 response to the complaint.
• 18 June 2023: The Chair of the SAB wrote a 7-page letter to Mrs B reviewing the actions that had been taken following the meeting on 13 March.
• 20 October 2023: The Home completed its 45-page investigation report into Mrs B’s complaints and upheld most of the complaints.
• 21 February 2024: Both councils sent a final joint response to Mrs B’s complaints as she had continued to make complaints.

Safeguarding enquiry report – 3 August 2022

13. Cheshire East Council carried out a safeguarding enquiry into Mrs B’s concerns which were as follows.

Pain management / medication

• The Home did not give Ms C medication 1 four times a day, even though that was the prescription.
• Two pain patches were found on Ms C’s body when she was taken to hospital on 5 July 2022.

Dietary needs

• The speech and language therapist’s (SALT) assessment was done remotely, but should have been done in person.
• The Home did not meet Ms C’s nutritional needs and the food quality was poor. The Home gave Mrs B food she was unable to swallow.

Health care

• Ms C had a mouth infection and the Home failed to address this early enough.
• The GP prescribed a cream for Ms C’s haemorrhoids and staff continued to apply this for 12 weeks without asking for a review by the GP.
5. Cheshire East Council made the following findings in the safeguarding enquiry:

Pain management / medication

• The Council reviewed the MAR charts from 1 May to 15 June 2022. Medication 1 was prescribed on a PRN basis until 16 June when it was changed to four times a day. (Note: PRN medication means medication to be used ‘as and when required’.)The medication was administered as prescribed after 16 June so the Council had no concerns about the administration of medication 1.
• The Council upheld the complaint that two pain medication patches were applied at the same time and this should not have happened.

Dietary needs

• The Home had no control over the SALT’s visits and whether the assessment would take place in person or remotely.
• Ms C experienced a loss of appetite and weight loss and chose to eat very little. This was in line with her diagnosis of a terminal illness. Mrs B had mental capacity to make decisions about her health and care needs so the Home had to offer her some choice in what she ate.

Health care

• The Home applied the same cream for 12 weeks for the haemorrhoids without checking with the GP and this resulted in a sore on the area. The Home confirmed that this should not have happened.

Complaint and analysis

15. The Home carried out a thorough investigation into Mrs B’s complaints dated 20 October 2023 and upheld most of the complaints. I have explained to Mrs B that, where the Home upheld the complaint, I will not reinvestigate the complaint. I have based my analysis on the Council’s safeguarding enquiry, the Home’s own investigation and the records sent by the Home.
16. I have summarised Mrs B’s complaints and my analysis around common themes for clarity.

Nutrition and weight

17. Mrs B complained that:
• Ms C often did not receive her breakfast until 10:30.
• The Home did not properly meet Ms C’s nutritional needs and this led to Ms C’s weight loss.
• The Home did not weigh Ms C and did not communicate with the family about the weight.
• The Home did not give food in line with the recommendations of the SALT.

Analysis

18. I appreciate that Ms C’s terminal illness may have affected her appetite and may have contributed to her weight loss. However, the Home had a duty to follow Ms C’s care plan for nutrition and follow the advice of the speech and language therapist (SALT) so I have focussed the investigation on that aspect.
19. On the evidence I have seen, there was fault in the way the Home managed Ms C’s nutrition. The fault was as follows:
• Ms C’s care plan said that all food and fluids had to be recorded to know how much Ms C had accepted. The Home failed to keep adequate records. The Home sent me 19 nutrition records for June 2022 so 11 records were missing. Also, the records that were provided did not always say what the consistency of the food was or the amount Ms C had eaten.
• The food records did not say what time breakfast was served so I could not say whether it was served too late in the morning.
• When Ms C was admitted to the Home, she was prescribed a level 6 diet which was soft, tender and moist food, which needed chewing not biting. The food should be mashed or broken with a fork and should be in bite size pieces no larger than 1.5 cm. The daily records showed that Ms C was given food that was not of the correct consistency. There were also many days that the food records did not say what the consistency was.
• Ms C was prescribed a level 4 diet on 27 June 2022. However, the Home did not keep food records to see if the correct consistency of food was provided.
• Ms C’s weight was 50.5 kg when she entered the Home and was 46 kg in June 2022. Her MUST (Malnutrition Universal Screening Tool) score from April onwards meant that she should have been weighed every week but the Home failed to do this. The Home only weighed Ms C 6 times during her stay.
• There was regular communication with the family but there were no weekly updates to the family about Ms C’s wellbeing or weight.
• Nutritional supplements had been prescribed for Ms C when she entered the Home. One of the supplements ‘fell off the system’ on 9 February even though there was no note to say it had been discontinued.
• Ms C was prescribed a different nutritional supplement on 9 April 2022, but 12 doses were missed in April, 21 doses in May and 12 doses in June. Sometimes the doses were missed because Ms C was sleeping or unable to swallow, but there were several times when they were missed because the Home was waiting for a delivery of the supplement. The Home could not say why this was or whether the Home chased the supplier.

Medication

20. Mrs B said:
• Ms C was prescribed a new medication for pain on 15 June 2022 but the Home did not administer this.
• Ms C had not received pain medication 1 or any pain medication for 7 days before she was taken to hospital on 5 July 2022.
• The Home did not give Ms C medication 2 as prescribed.
• When Ms C arrived in hospital on 5 July 2022, it was discovered that she had two pain patches applied, which should not have happened.

Analysis

21. In terms of the prescription of the new pain medication on 15 June 2022, I cannot say there was fault as this new prescription was on a PRN basis. Ms C had already been prescribed a different type of pain medication on a PRN basis, and Ms C was given this medication on 15 June 2022. The GP then discontinued the new pain medication on 18 June 2022. So, as PRN medication really depends on the judgment of the medical staff at the time, I cannot say there was fault.
22. There was, however, continued fault in the administration of medication 1. Medication 1 was prescribed on a PRN basis when Ms C moved into the Home, but the GP changed the prescription on 17 March 2022 to 4 times a day. However, staff continued to give medication on a PRN basis which was fault. It was not until 15 June 2022 when the GP wrote another prescription for medication 1 to be administered 4 times a day that staff then finally administered the medication correctly.
23. In addition, doses of medication 1 were sometimes missed between 29 March and 10 April 2022 as staff said they were ‘awaiting delivery’ even though other staff were able to administer the medication.
24. I uphold the complaint regarding the administration of medication 2. Ms C was prescribed medication 2 on a PRN basis but this was noted to ‘drop off the system with no explanation' on 13 February 2022. However, I note that Ms C was prescribed a different medication for the same ailment at the time.
25. A pain patch was applied on 1 July 2022 and a different pain patch was applied on 4 July 2022. Staff should have removed the first pain patch, but did not do so. This failure was fault and put Ms C at risk of receiving too much medication.
26. I do not uphold the complaint that Ms C had not been given pain medication 1 or any pain medication on 5 July 2022 and I find no fault in that respect. On that day, Ms C had two pain patches in place (see previous paragraph) and was given pain medication 1 and another pain medication in the morning.
27. There was also fault in the general administration of medication as there were discrepancies with the Home being out of stock of certain medications which meant it could not administer the medication. The records showed several occasions where medication was not administered as staff were ‘awaiting delivery’' or medication ‘fell of the system’ with no note to say it had been discontinued.

Pain relief in the days before Ms C’s death

28. Mrs B said the Home did not administer pain relief in line with the advice of the palliative care nurses in the days before Ms C died.
29. The records showed that the palliative care nurses visited Ms C on 7 July 2022 and said Ms C could be given PRN medication 3 every 2 hours and PRN Medication 4 every 2 hours so the combination of these 2 drugs would mean that Ms C received pain relief medication every hour. This regime should only be used if Ms C appeared in pain or had expressed pain to her family and this regime was to be continued until she was settled.
30. The nurses recommended that a subcutaneous pump/syringe driver to deliver the medication should be put in.
31. The Home emailed the GP after the visit and said the Home only had stock of Ms C’s medication for 16 hours if the protocol recommended by the palliative care nurses was followed. The Home asked the GP to send an urgent prescription or to give permission to the Home to give Ms C medication from other residents, if required.
32. The palliative care nurse emailed the Home at 15:37 to confirm the advice that they had given earlier during their visit.
33. The palliative care nurse visited Ms C on the following day (8 July 2022) and sent an email to the Home following her visit. She said: ‘Ms C appeared to be very settled, with minimal response to touch, in the dying phase’. The nurse had reviewed the medication that Ms C had received since 10:00 on 7 July and noted that Ms C had been given 7.5 mg of medication 3 and 5 mg of Medication 4 and the nurse suggested that these would therefore be the appropriate doses to include in the syringe driver, when this arrived.
34. Ms C’s MAR chart for 7 July to 8 July 2022 showed that:
35. Ms C was given medication 3 on:
• 7 July 2022: 10:10, 12:25
• 8 July 2022: 01:25, 8:20, 12:10
36. Ms C was given medication 4 on
• 7 July 2022: 14:15
• 8 July 2022: 04:00, 10:22, 19:05
37. The Home started observations of Ms C every 15 minutes on 7 July 2022. These described Ms C as settled, with regular but shallow breathing. On the occasion that Ms C was described as ‘restless’, she was given medication.
38. The syringe driver containing both medications was started at 14:45 on 8 July 2022.

Analysis

39. Ms C was given pain medication 3 times on 7 July 2022 and there was a gap of around two hours between the administrations. There was a long gap from 14:15 on 7 July 2022 until 01:25 on 8 July 2022.
40. I was surprised that the Home did not administer medications 3 and 4 on an hourly basis after the palliative care nurses’ advice, but I cannot say that this was fault. My reasons are as follows:
• The hourly administration was recommended only if Ms C was showing signs of pain and until she was settled so it really depended on Ms C’s presentation. From the records I have seen, Ms C was given medication every time she showed signs of becoming restless or any time the family felt Ms C needed medication.
• The palliative care nurse visited Ms C on the following day (8 July 2022) and said Ms C was very settled. The nurse checked the Home’s administration of medication and did not raise any concerns. The palliative care nurse then based the dose of the medication to be provided by the syringe driver on the medication the Home had provided in the last 24 hours which suggests the nurse was satisfied with the medication the Home had provided.

Hygiene and haemorrhoids

41. Mrs B said:
• Ms C was not bathed or washed at the Home.
• Ms B had haemorrhoids when she was admitted to the Home on 13 January 2022 but was not seen by the GP until the next week and by then she was in a lot of pain.
• The GP prescribed a cream for Ms C’s haemorrhoids and staff continued to apply this cream for 12 weeks without seeking a review from the GP. She says the lack of hygiene and oversight of the haemorrhoids treatment caused a sore to Ms C’s bottom.
• The staff did not change Ms C’s bed frequently enough.
• The room was dirty and smelled and the bins which contained continence products were not emptied frequently enough.

Analysis

• Ms C’s care plan said Ms C should be offered a bath or shower every day. The offer and refusal of the bath/shower should be recorded in Ms C’s daily record. The record keeping in this respect was poor. The Home’s daily records for June 2022 said ‘personal care’ had been provided or refused but only specified whether this included a shower or bath on four occasions. This poor record keeping was fault.
• Ms C was seen by a doctor on 14 January 2022 in relation to the haemorrhoids so there was no fault in that respect.
• The continence plan dated 18 January 2022 said the GP had prescribed a cream for haemorrhoids which was for ‘short term use giving relief of inflammation, swelling, itching and soreness.’ Ms C was not seen by the doctor until 16 March 2022 to review her sacrum. The Home should have called the GP for a review of the haemorrhoids sooner and the failure to do so was fault.
• The Home said the room was cleaned and the bins were emptied frequently but apologised if it failed to meet expectations at times.
• The Home said the staff were not required to record when the bed linen was changed. Mrs B said that the staff had a duty to record when the bed linen was changed. She said this did not happen and, in the end, she resorted to taking Mrs B’s bed linen home to wash and she changed the bed linen. In my view, staff should keep a record of when the bed lined has been changed. If the Home’s staff were not keeping this record, it is impossible for the Home to monitor that this was happening and so there was fault.

Falls risk assessments

42. Mrs B said:
• Ms C was discharged from hospital on 6 July 2022 and returned to the Home. Mrs B said Ms C had been given stronger pain medication and Ms C was trying to get out of bed despite the fact she could not stand or walk. Mrs B said she asked for the Home to add a cot side to the bed as she was concerned that Ms C would fall out of bed but this was refused.
• Ms C had two falls during that night. Mrs B said one of the falls resulted in a fractured shoulder, although this was never diagnosed. Mrs B said the Home did not take the appropriate action to address the risk of falls.

Analysis

43. There was fault for the following reasons:
• There was a falls risk assessment in place but this was not reviewed when Ms C returned from hospital. It is my understanding that Ms C had been prescribed different pain drugs and may therefore be more drowsy which may have increased the risk of falls.
• The care plans contained conflicting information on falls.
• No measures were implemented to address the risk after the first fall other than a note stating ‘bed rails pending’. The falls risk assessment should have been updated and this was fault.
• It is impossible to say what the outcome would have been if a risk assessment had been carried out earlier but I note that bed rails were installed on 7 July 2024 so the Home agreed that the bed rails were needed to reduce the risk of falls. So the injustice is uncertainty of what would have happened if the falls risk assessments had been carried out earlier.

Miscellaneous complaints

44. Mrs B said:
• The initial room Ms C moved into did not meet Ms C’s needs as the space between the bed and the wall was too narrow for her walking frame which meant she could not use the bathroom.
• Ms C had developed a swelling on her tongue on 13 June and asked the GP to visit. She waited until 15:00 and the GP had not visited yet.
• The Home did not use the correct incontinence aids for Ms C.
• The Home failed to meet medical appointments for Ms C and this contributed to the delay in the diagnosis of her medical condition.

Analysis

• I uphold the complaint that Ms C was placed in a room that did not meet her needs when she first arrived at the Home. She was moved on the next day.
• The GP visited Ms C at 19:00 on 13 June to assess the swelling on her tongue and they prescribed medication. The medication was provided as prescribed so there was no fault in that respect.
• It was noted on Ms C’s admission assessment in January 2022 that she needed a particular continence aid and an incontinence assessment had to be done. The Home made a referral to the NHS for the continence assessment on 9 March 2022. So there was fault in this respect as the Home should have made this referral earlier.
• The Home said there had been a miscommunication from the GP regarding an appointment in May 2022 which was not the Home’s fault.

Further information

45. The Home concluded its investigation report into Mrs B’s complaints by apologising for its failings. The Home said it intended to take actions to remedy the failings that had been identified. The Home set out an improvement plan which identified 14 action points. These related to nutrition, medication, risk management, record keeping, oral health management, assessment and care planning and communication with family. The Home said the actions would be validated by the Council’s Quality Assurance Team and through the Home’s own internal audit process.
46. Cheshire East Council said on 18 June 2023 that its Quality Assurance Team visited the Home four times in 2022. The Quality Assurance Team’s last scheduled visit was on 20 April 2023 and the action plan was signed off on 21 April 2023 due to the improvements that had been made.
47. The CQC published its report on the Home on 23 July 2023 and downgraded the Home’s rating to ‘requires improvement.’ The CQC and set out a list of improvements the Home had to make.
48. Cheshire East said on 9 August 2023 that, in light of the CQC grading, the Home would be required to work with the CQC and complete an action plan. Cheshire East would work with the Home on this further action plan.

Injustice and remedy

49. To summarise, I have found fault in the Home’s provision of care, record keeping, nutrition, administration of medication, personal care, hygiene, falls risk assessments and some other areas.
50. The aim of the Ombudsman’s remedy is to put the person who suffered the injustice in the position they would have been if the fault had not happened. Sadly, Ms C is the person who suffered the most injustice from the fault I have identified, but any injustice to her cannot be remedied.
51. However, I do not underestimate the impact all this had on Mrs B. Mrs B said she witnessed Ms C’s suffering and this caused her great distress. The Ombudsman can sometimes agree a remedy for distress, which is a symbolic figure. In light of the number of faults and the severity of the faults I have found, I recommend a remedy of £2,000 to Mrs B.
52. I have also considered whether the Ombudsman should recommend a service improvement to the Home. I note that the CQC carried out an inspection of the Home in July 2023 as a result of Mrs B’s complaint and downgraded the Home to ‘requires improvement.’ The CQC is best placed to address any issues regarding the Home’s performance and I will send a copy of this decision to the CQC.
53. I also note that the Cheshire East’s Quality Assurance Team had been regularly involved with the Home from 2021 to 2023 and continues to be involved again after the CQC downgraded the Home. I will ask that Trafford Council shares this decision with the Home and its Quality Assurance Team so that the relevant people can learn from the decision.

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Agreed action

54. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise in writing to Mrs B for the fault I have identified.
• Pay Mrs B £2,000.
• Share a copy of the decision with the relevant staff at the Home and the Council’s Quality Assurance Team.

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Final decision

55. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman