Summary: Miss C complained about the care and support provided to her late father by a Nursing Home which was funded by the Integrated Care Board and investigated by the Council under its safeguarding procedures. We will not investigate this complaint because it is unlikely we could add to the investigation already completed by the Council or achieve the outcome Miss C wants.

The complaint

1. Miss C complains about the care provided to her late father, Mr D, by Lower Bowshaw View Nursing Home (the Home) which was funded by NHS South Yorkshire Integrated Care Board (the ICB) under discharge to assess arrangements from December 2021. Miss C feels the ICB and Sheffield City Council (the Council) should have done more to ensure the Home provided better care to her father and that it properly explained the last 24 hours of events leading up to his death on 5 January 2022. Miss C would like answers to explain the Home's poor communication and why it misplaced documentation relating to her father’s care and support arrangements. She would like lessons to be learnt and improvements to be made which benefits other prospective residents.

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The Ombudsmen’s role and powers

2. The Ombudsmen have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA)
3. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe:
• it is unlikely they could add to any previous investigation by the bodies, or
• they cannot achieve the outcome someone wants. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

4. I have considered information provided by the complainant and the organisations complained about including the Council’s response to the complaint and its safeguarding investigation.
5. Miss C had an opportunity to respond to a draft of this decision.

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What I found

Background

6. Mr D was discharged from hospital to the Home in December 2021 and the placement was funded by the ICB in line with discharge to assess arrangements. Discharge to assess is about funding and supporting people to leave hospital when it is safe and appropriate to do so, and continuing their care and assessment out of hospital.
7. Miss C said when she and her mother spoke to her father on the telephone on different occasions on 4 January 2022, he complained about feeling unwell.
   Miss C said her father had put this down to something he had eaten for breakfast. She said he also told them he had vomited and soiled his bed but the Home’s staff had delayed attending to him and helping him get changed. She later complained to the Council about this.
8. Miss C said when her mother spoke to her father later the same evening, she felt his breathing had deteriorated. Miss C said she made several attempts to contact the Home by telephone but did not receive a response.
9. Miss C was contacted by the Home’s manager on the morning of 5 January who informed her that her father had died. She said there was a further delay in the Home’s manager contacting her mother to break the news.

The Council’s safeguarding investigation and response to the complaint

10. Following contact from Miss C in February 2022 the Council considered several issues relating to Mr D’s care and support in the Home and the allegation of neglect in line with its safeguarding procedures. The issues considered included:
• Food and fluid intake and continence records;
• Recordings of unwellness or discomfort between 4 – 5 January;
• Frequency of observations of blood pressure and oxygen levels;
• Staffing levels at the Home; and
• Staff’s understanding and alertness to Mr D’s condition when he became unwell.
11. Following the Council’s safeguarding enquiry it concluded its investigation and did not substantiate the allegation of neglect due to lack of evidence. It closed the safeguarding enquiry in May.
12. Miss C complained to the Council in September and it responded in October and confirmed the following:
• the Home had misplaced Mr D’s records relating to food and fluid intake between 4 – 5 January. The Home had reported this to the Care Quality Commission (CQC);
• the Home did not have any other records available apart from the daily notes;
• the Home’s manager had spoken to staff who said Mr D had not told them he was in pain or waiting for a continence pad change;
• the Home had observed Mr D’s blood pressure and oxygen levels and had confirmed these as normal; and
• the Council had reviewed the staffing levels in the Home and did not have any concerns.
13. Miss C did not agree with the Council’s findings as she said her mother had told staff over the telephone that Mr D was waiting for a continence pad change. She also said her father had not eaten after his breakfast so the Home should have been aware he was unwell.

Findings

14. Miss C remains concerned about the actions of the Home and continues to feel a sense of doubt about the events during the last 24 hours of her father’s life. She accepts the outcome may have been the same but says if the Home had acted differently, she and other family members may have been able to visit Mr D in his final hours. It is understandable why Miss C feels this way. For this reason, she asked the Ombudsmen to consider a complaint.
15. The Council considered matters under its safeguarding procedures and subsequently dealt with a complaint under its complaint procedures. Both procedures sought to provide Miss C and other family members with the answers they wanted about the final day of Mr D’s life.
16. The Home misplaced important documentation relating to Mr D’s care and support. The Home said the documents had been misplaced when sharing with other agencies. It accepted Mr D’s records should have been kept safe. It reported the matter to the regulator, CQC, due to the fundamental standards it has to meet. It is likely the CQC may have used this information to inform any future inspection of the Home relating to quality, safety and care. An investigation by the Ombudsmen is unlikely to achieve more or be able to say, on balance, what happened to the documentation.
17. During its investigation the Council found some of the Home’s records were inaccurate or incomplete and not personalised to Mr D. It said it would work with the Home to improve to make sure records were accurate. It is unlikely an investigation by the Ombudsmen could achieve more.
18. The Council also found that Mr D’s care plan was not detailed as he had only been in the Home for about one month. It said the care plan was due to be reviewed but did not happen before Mr D passed away. Despite this the Council’s safeguarding enquiry did not establish the allegation of neglect or establish concerns about the interventions staff completed at the time Mr D became unwell. Further investigation by the Ombudsmen is unlikely to come to a different view.
19. In her complaint to the Ombudsmen Miss C said the Home had provided conflicting information about what happened when its staff called the emergency services. The Home told the Council and Miss C there were two nurses in the Home at the time her father became acutely unwell. It said one nurse had called the emergency services while the other had stayed with Mr D. Investigation by the Ombudsmen is unlikely to be able to achieve any more than what the Council’s investigation has already established.
20. Miss C would like to be clearer about events, but it is unlikely the Ombudsmen could achieve this outcome or add to what has already been established. The Council investigated and found some faults and said it would work with the Home to improve. It also said it would monitor the Home and ensure it provided an apology letter to Miss C and her family.

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Final decision

21. We have not investigated Miss C’s complaint because an investigation is unlikely to add to the previous investigation already completed by the Council or achieve more.

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Investigator's decision on behalf of the Ombudsman