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Beverley Grange Nursing Home (21 005 234a)

Category : Health > Community hospital services

Decision : Upheld

Decision date : 19 Apr 2022

The Ombudsman's final decision:

Summary: We investigated a complaint about the care the Nursing Home provided to Mrs Y and the Council’s safeguarding investigation. We found fault with the record keeping and complaint handling by the Nursing Home and that the Council’s safeguarding investigation was not completed on time. These faults caused avoidable frustration to Mr X. We recommended an apology and service improvements to address this injustice.

The complaint

  1. Mr X complains about the care provided to his mother, Mrs Y, by staff at Beverley Grange Nursing Home (the Nursing Home) between 16 March and 1 April 2020. Mr X also complains about the handling of his safeguarding concerns by East Riding of Yorkshire Council (the Council).
  2. Specifically, Mr X complains:
    • The Nursing Home did not offer Mrs Y enough food or drink in the two days before her death despite knowing she was at risk of dehydration because of previous hospital admissions;
    • The Nursing Home falsified fluid charts and there were multiple charts for each day, all recording different figures;
    • The Nursing Home response to his complaints talked in generalities and did not provide a satisfactory response to his concerns;
    • The Council’s safeguarding investigation has taken the Nursing Home’s version of events without investigation, and it has not reviewed key evidence.
  3. Mr X believes the Nursing Home did not properly care for Mrs Y despite her frailty. He says the Nursing Home did not provide him with honest answers in response to his complaint. This caused him distress and frustration.
  4. Mr X would like the Nursing Home to admit it failed to provide his mother with suitable care. He would like the Nursing Home to apologise for this and make service improvements to ensure similar problems do not happen again. He would like the Council to admit they did not complete a robust safeguarding investigation and apologise for this.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
  2. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  3. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
  4. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
  5. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
  6. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.

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How I considered this complaint

  1. I considered the complaint Mr X made to the Ombudsmen and information he provided on the telephone and by email. I also considered the information the Council and Nursing Home provided in response to my enquiries.
  2. I shared a confidential draft with Mr X, the Council and the Nursing Home to explain my provisional findings and invited their comments. I considered their comments before making a final decision.

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What I found


  1. Mrs Y needed 24-hour support. She went into the Nursing Home in 2014 and stayed there until her death in early April 2020. Mrs Y had advanced dementia and difficulty swallowing which meant there was a high-risk she might choke. This led to her not always drinking enough. The amount she took each day varied from 600ml to 1500ml. Her GP was aware and recommended Mrs Y just have liquidised food. She had previously been in hospital with dehydration. Mr X visited Mrs Y daily and during these visits he encouraged her to eat and drink. On 16 March 2020, the Nursing Home went into lockdown because of the COVID-19 pandemic. Mr X was present in the Nursing Home, and they told him of the decision. This was the last time he saw Mrs Y alive.
  2. Mr X telephoned the Nursing Home daily to check on Mrs Y, he worried about her not drinking enough and the risk of dehydration. On 24 March 2020 staff told him there was some concern as his mother’s intake over the previous days was low and they were encouraging her to drink more. Over the next few days staff told Mr X her intake remained low, but she was doing fine. Mr X expressed the importance of ensuring she had over 1000ml a day. On 28 March staff told Mr X he should stop calling as much because there was not enough staff to handle his queries and provide effective care. On 30 March the Nursing Home told Mr X Mrs Y had developed oral thrush and it sought a prescription. It said Mrs Y was drowsy, and her intake remained low. On 1 April Mr X received a call from the Nursing Home advising him his mother was not well and he should get to the home as quickly as possible. His mother died before he arrived.
  3. After her death, Mr X made a complaint to Mrs Y’s GP and to the coroner as he did not believe his mother had died of dementia as recorded on the death certificate. The coroner refused to investigate and advised Mr X to raise a safeguarding concern with the Council. He emailed his concern on 9 April 2020 and the Council assigned the safeguarding review to the Nursing Home manager to complete. They returned it on 4 June and the Council closed the enquiry on 18 June 2020.

Relevant Guidance and Legislation

  1. I have considered the following legislation and guidance as part of this investigation:
  • Care Act 2014
  • The Social Care Institute for Excellence (SCIE) Dementia; Advanced dementia and end of life care
  • Beverley Grange Nursing Home CC14 Nutrition and Hydration Policy and procedure
  • Care Quality Commission – The Fundamental Standards
  • Care and Support Statutory Guidance
  • East Riding of Yorkshire Safeguarding Adults Board: Procedure for completing Safeguarding Adult Reviews, November 2019
  • SCIE: Safeguarding Adults Reviews under the Care Act, March 2015


The Nursing Home failed to provide enough nutrition and fluid to Mrs Y between 16 March – 1 April 2020

  1. Mr X complains between 16 March and 1 April 2020 the Nursing Home did not provide enough fluids to Mrs Y even though she was at risk of dehydration. He thinks the carers did not encourage his mother to intake fluid in his absence.
  2. I have reviewed copies of Mrs Y’s fluid charts for the period 16 March to 1 April 2020 and her care plan. I have considered the explanation provided by the Nursing Home in its letter of 4 May and the following response from the Council on 20 August 2021. I considered the information provided by Mr X in his letter to the coroner dated 7 April 2020 and all correspondence with the Ombudsmen.
  3. Mrs Y received continuing healthcare funding for her placement in the Nursing Home. The East Riding of Yorkshire Clinical Commissioning Group reviewed her needs in January 2020. In this review, it recommended the Nursing Home contact Mrs Y’s GP to ask for an ‘optimal daily fluid’ amount for her. There is no evidence in her records the Nursing Home did this.
  4. Mrs Y’s care plan does not show a minimum fluid intake amount but does explain she had had varying intake since 2014. It was not unusual for her intake to be low. The records also state she spat out and clamped her mouth closed. The care plan advised staff to “document accurately food and fluid intake on charts provided.” It added “any deficits in food and fluid intake to be brought to the floor manager/nurses attention”. Mrs Y was doubly incontinent, and it was not possible to record her fluid output or record a fluid balance. Carers were aware and used a urine colour chart to note signs of dehydration.
  5. Mrs Y’s intake showed a decrease from 20 March, with 790ml recorded and then 650ml on 21 March. On 22 March a higher intake of 1310ml was recorded. From 23 March to 1 April, the values were low, with the highest being 845ml on 25 March. Mrs Y’s care notes state on 26 March carers suspected she had oral thrush as her mouth was swollen. Her intake remained low over the next few days and the Nursing Home asked for a prescription for an antifungal medication to treat the thrush on 30 March.
  6. Mrs Y care notes show she sharply declined from 28 March. Before this, the notes say she was “settled and well” despite her low fluid intake. On 28 March it noted her mouth was “very dirty”. On 31 March Mrs Y was noted as “reluctant to eat and drink” and the Nursing Home called the Primary Care Trust paramedic for advice. They explained the low fluid intake and said she seemed unwell and was sleepy. They provided observations taken by a Nurse. The paramedic advised staff to keep her comfortable and encourage fluids. She took 640ml of fluid that day, which was up from the day before. Staff noted Mrs Y continued to have difficulty swallowing.
  7. On 1 April the Nursing Home called the Primary Care Trust paramedic again who said to keep her comfortable, encourage fluids and note any bowel movements. The charts show staff offered fluids which she refused. Mrs Y died that evening.
  8. SCIE guidance explains “people with dementia can develop problems with eating, drinking and their ability to swallow at any stage of their illness, although it is most common to see this at the more advanced stages.” It explains “it may seem that the person is being starved or dehydrated to death, but they are not. In the end stages of dementia (in the last few months or weeks of life), the person’s food and fluid intake tends to decrease slowly over time. The body adjusts to this slowing down process and the reduced intake. It is thought that by this stage the hunger and thirst part of the brain has now stopped functioning for most people.” Although distressing to witness, it is not unusual for those reaching the end of life with dementia to take in less.
  9. Nursing Home staff could not force Mrs Y to take in fluids, they could only encourage her by offering. The Nursing Home has guidance in place to help its carers. Its CC14 Nutrition and Hydration Policy and Procedure states “staff must encourage fluid intake for all Service Users and to offer a selection of hot and cold drinks throughout the day, when awake at night and whenever people requested.” It accepts recommended fluid intakes vary and therefore “it is important for staff to establish what is normal for the service user. This information will be recorded in the Care Plan.” As mentioned in paragraph 20, Mrs Y’s care plan records no minimum fluid intake. This is fault.
  10. In summary, we do not have enough information to decide whether the Nursing Home provided Mrs Y with enough nutrition and fluid. We do not have a minimal intake amount and do not know a fluid balance because of her double incontinence. The records show carers offered Mrs Y fluids and encouraged her to drink. They also sought and followed the advice given. Staff could not force Mrs Y to take in fluids if she refused but they suitably recorded what they did offer. The next section of this statement will consider how the Nursing Home staff recorded these amounts.
  11. We understand Mr X does not think the amounts offered were enough and he would have given his mother more if he had visited her. As explained, we do not have enough information to determine if Mrs Y was given sufficient fluids.

The Nursing Home falsified fluid charts and used multiple charts for the same day

  1. Mr X complains the Nursing Home falsified fluid charts to hide that it had not offered Mrs Y enough fluids in the days preceding her death.
  2. During the Council’s investigation, the Nursing Home explained if staff could not find the daily chart when giving fluids to a resident, they started a new chart to ensure they recorded the information somewhere. The Nursing Home admitted this was not best practice. The Council accepted this explanation and asked the Nursing Home to stop this practice. It also recommended the Nursing Home set up a new diet and fluid sheet to ensure accurate recording.
  3. The Care Quality Commission Fundamental Standards Regulation 17 provides guidance on record keeping. It states at 17 (2)(c) “records relating to the care and treatment of each person using the service must be kept and be fit for purpose. Fit for purpose means they must: Be complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable. This includes results of diagnostic tests, correspondence and changes to care plans following medical advice.”
  4. As mentioned in paragraph 20, Mrs Y’s Care Plan did not record her minimal fluid intake. Other sections of Mrs Y’s records were incomplete; the 'total fluids consumed in 24 hours’ was not filled in. This caused problems during investigation as some records are difficult to read. The record for 20 March is an example of this. The use of multiple charts, such as on 29 and 30 March, caused further problems and the Nursing Home knew this was not good practice.
  5. The Council said because all copies of the charts were on file, this showed openness and transparency. It did not see any indication the Nursing Home had tried to conceal or falsify records.
  6. During this investigation, I asked the Nursing Home if it had carried out the recommendations made by the Council on 12 August 2021. It confirmed all staff are aware not to use multiple sheets and it has introduced an in-depth diet and fluid recording sheet which will enable it to monitor those who show signs of concern.
  7. In summary, the Nursing Home failed to keep adequate records. This is fault which caused confusion to Mr X. He felt he had no choice but to make a complaint if he wanted to understand what happened to Mrs Y in the days before her death. This is an injustice to him. The Nursing Home made changes following the Council’s recommendations and confirmed multiple charts are no longer in use. Therefore, this fault is remedied.

The Council did not conduct a fair safeguarding investigation

  1. Mr X complains the Council did not conduct a fair safeguarding investigation. He thinks it took the view of the Nursing Home without asking for evidence he held or considering the facts. He feels it did not have enough understanding of dehydration and should have spoken to a specialist.
  2. Under the Care Act 2014 section 44, the Council’s Safeguarding Adults Board must arrange a Safeguarding Adult Review when an adult in the area dies because of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult. A Safeguarding Adult Review is a process used to help organisations learn lessons for the future.
  3. Mr X sent an email to the Council on 9 April 2020. He was worried others in the Nursing Home may be at risk of dehydration or malnutrition. The Council started a safeguarding enquiry the same day. On 17 April 2020 a Safeguarding Specialist from the Council spoke to Mr X and they agreed what the enquiry would look at. This was the multiple fluid charts, access for Mrs Y to her GP and hospital, and contact between Mr X and the Nursing Home when he could not visit. The Safeguarding Specialist told Mr X they could not open the charts he sent and asked him to send them in a different format. The Safeguarding Specialist sent the enquiry to the Nursing Home Manager to complete after speaking to Mr X. The enquiry was returned to the Council on 4 June and closed on 18 June with no further action.
  4. The Council told us that it made a mistake and did not send the findings and recommendations to Mr X or the Nursing Home on 18 June. The Council noticed the mistake after an internal audit and it sent the report on 10 February 2021.
  5. SCIE guidance on Safeguarding Adult Reviews states the enquiry should consider what happened, any errors or problematic practice found and what could have been done differently. It should also look at why those errors occurred and if there are any explanations unique to the case and how these may be applied to future cases. Finally, it should decide if it needs to take action to prevent similar harm in future cases. The Council has a detailed adult safeguarding policy that advises how a Safeguarding Adult Review should be conducted.
  6. Mr X feels the Council did not involve him in the process because it did not request information from him. The contact notes show a Safeguarding Specialist from the Council spoke to Mr X on 17 April and discussed what would be investigated. They asked for copies of the charts they could not open. We do not know if the Council asked Mr X if he had any other evidence or if they discussed further contact. The Council’s policy says it should consider how the person who raised the enquiry will be involved. It says the process should be open and transparent. It does not say how much contact the Council should make, and it does not say what information it should ask for.
  7. The Council contacted Mr X to talk about his concerns, but we see from Mr X’s complaint that he was unclear on the process and expected more. We do not have detailed notes of the contact between Mr X and the Safeguarding Specialist, but it seems they could have better explained the safeguarding process to Mr X. This is a missed opportunity by the Council to engage with Mr X.
  8. The Council’s policy states that enquiries should be complete within six months. We can see the investigation part of the process was completed by 18 June, in time, but the Council did not complete the process because it did not share its findings with Mr X or the Nursing Home. The Council did not complete its safeguarding enquiry in six months, and it did not complete the process correctly. This is fault.
  9. Mr X was caused frustration because he felt the Council did not give weight to his evidence about Mrs Y’s care. He was caused further frustration when the Council did not share its safeguarding enquiry findings in a timely manner. This is an avoidable injustice to him.

The Nursing Home did not provide a full response to Mr X’s complaint

  1. Mr X complains the Nursing Home did not provide a full response to his complaint and this left him with more questions than it answered.
  2. I have reviewed the complaint from Mr X of 7 April 2020 and the Nursing Home response of 4 May. Mr X explains his concerns and asks for explanations about the multiple fluid charts and why his letter of 31 March went unanswered. The Nursing Home response does not address these points, instead repeating the information Mr X provided. It does not provide reassurances to Mr X that Mrs Y received the care she needed.
  3. The Parliamentary and Health Service Ombudsmen (PHSO) Principles of Good Complaint Handling states organisations should be open and accountable. It states they should “be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decision. When things have gone wrong, public bodies should explain fully and say what they will do to put matters right as quickly as possible.” The response does not do this.
  4. The guidance also says “providing fair and proportionate remedies is an integral part of good complaint handling. Where a public body has failed to get it right and this has led to injustice or hardship, it should take steps to put things right.” The Nursing Home did not take any steps after it received the complaint.
  5. Paragraphs 19 and 25 find fault by the Nursing Home which it did not identify in its own complaint consideration. It did not provide any reassurance to Mr X that similar fault could not happen again. This is fault in complaint handling and is not in line with guidance.
  6. In its report of 20 August 2021, the Council found the Nursing Home had failed to log Mr X’s complaint. The Nursing Home did not realise it had not acknowledged his complaint until Mr X contacted them. This is further fault in the Nursing Home’s handling of Mr X’s complaint.
  7. Mr X was already frustrated when he made his complaint and having to chase his complaint to make sure it was receiving attention caused further frustration to him. This is an injustice to him which could have been avoided if the Nursing Home had an effective complaint handling process in place.

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Agreed actions

  1. The Ombudsmen recommended, and the organisations agreed the following actions.
  2. Within one month of the date of the final decision, the Council will write to Mr X to acknowledge it did not complete the safeguarding enquiry on time and share the findings with him when it should have and apologise for the avoidable frustration this caused him.
  3. Within one month of the date of the final decision, the Nursing Home will write to Mr X to:
    • Acknowledge its responsibility for the faults identified in paragraphs 19 and 25 and apologise for the confusion and frustration caused to Mr X
    • Provide evidence that management and staff have received training in complaint handling in line with Ombudsmen guidance
  4. The Council and Nursing Home will provide evidence to the Ombudsmen that they have completed these recommendations.

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Final decision

  1. I partly uphold Mr X’s complaint. I found fault which led to an avoidable injustice to Mr X. The agreed actions will provide a suitable remedy.

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Investigator's decision on behalf of the Ombudsman

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