Decision Date: 19 August 2024
Summary
Both the Council and local Care Home (High Peak Lodge) were found to be at fault regarding the continence and end-of-life care of Mrs X. A complaint was brought by her granddaughter, Mrs Y, due to Mrs X not having received adequate care at times, causing emotional distress. There was also an investigation into the Council’s processing of a complaint the family had made about financial and emotional abuse of Mrs X by another family member.
What happened
Mrs X was an elderly woman with dementia, who did not have the capacity to make decisions for herself. She had previously lived with her daughter Ms A.
Wider family members had previously raised concerns about possible abuse by Ms A towards Mrs X.
The Council funded Mrs X’s move into the Care Home and FNC was paid for the nursing element.
Mrs Z (one of Mrs X’s daughters) and Mrs Y (Mrs Z’s daughter) both expressed concerns about the accommodation’s suitability.
Mrs X’s family also fell into disagreement on the specifics of her care and visitation, which ended up in the Court of Protection (the Court).
In March 2023, the Court upheld that Mrs X’s residency at the Care Home was in her best interests, but ordered that there should be full visitation rights from all her family. A visiting schedule was also ordered to be put in place. The Care Home produced this draft visiting schedule but faced conflicts with some family members of Mrs X.
Mrs Y complained that the schedule was changed to suit Ms A’s preferences alone, without further consultation. The schedule records showed both sides of the family to be dissatisfied with the visiting plan.
In late 2023, Mrs X’s health worsened. A Statement of Intent outlining end-of-life care plans was established.
After Mrs X moved to end-of-life care, Mrs Y was of the view that the Care Home’s changes to her visitation schedule (eg. increasing visiting times) did not allow Mrs X enough rest.
The Council’s letter on 4th December 2023 explained how the Care Home deemed a 15-minute rest period adequate on the basis of her needs and desire to have her family with her as much as possible.
Daily care records showed Mrs X went to bed around 9-10 pm, later than the end of visitation times. No records showed Mrs X to be unhappy with any visitors.
In January 2024, the Council carried out a mental capacity assessment and made a Best Interests decision around visiting. It was recorded that Mrs X was likely in the last days of her life. All time-related visitation restrictions were lifted.
Records showed that the Care Home updated both Mrs Z and Mrs A about Mrs X’s care, albeit inconsistently. The Care Home did not notify Mrs Z that a hospice was coming to assess Mrs X.
Mrs Y requested a joint meeting between the Council and Care Home to discuss Mrs X’s care. The Council claimed the Care Home manager was unable to facilitate a joint meeting. In contrast, the Care Home claimed it was attempting to arrange this meeting. This was a communication issue.
In June 2023, the social worker noted Mrs Y’s request for a joint meeting to discuss Mr X’s care but felt it was “not necessary”.
In July 2023, the Care Home held an individual meeting with Mrs Y and Mrs X after being unable to secure a joint meeting.
In November 2023, the Care Home contacted the Council again about a joint meeting. This never actually happened.
Mrs X had a Fast Track assessment for CHC funding that was backdated to November 2023. From then on her care was funded by the local Integrated Care Board (ICB), and the Council was no longer responsible for Mrs X’s care. Regardless, the Council remained involved with the arrangements due to the complexity of the situation.
Mrs Y claimed that Mrs X’s catheter regularly leaked, alongside recurring UTIs. The care staff took action to support Mrs X. The nurses acted promptly when contacted, and the GP referred her to a urology specialist for an alternative catheter as she kept pulling hers out.
The urology team did not suggest an alternative catheter type but recommended a leg strap to reduce the risk of it being pulled out again.
Mrs X’s catheter and continence pads should have been checked every 4 hours, yet the majority of the time were not. Some checks were found to be up to 2 hours late. Gaps between checks were several hours without explanation.
In one instance, it was recorded by the care staff that there was a significant gap between the checks. Mrs X was later found with dried faeces on her skin.
In July 2023, the Care Home told Mrs Y they would take steps to improve the management of Mrs X’s catheter care records. Yet, by January 2024 these issues remained. No clear records confirmed that Mrs X received 4 hourly continence checks.
Mrs X was said to have complained to Mrs Y and Mrs Z about her end-of-life care, yet there was no formal record of this. No formal complaints by Mrs X were recorded in the Care Home records, and the rest of the family were pleased with her care at the Care Home.
Mrs X was visited by social workers, the safeguarding team and her Relevant Person’s Representative (RPR). They all determined Mrs X to be happy and receiving adequate care, which was also reflected in her daily care records from the Care Home.
Records showed Mrs X generally ate well, despite Mrs Y’s complaints about her nutrition and weight. Her Malnutrition Universal Screening Tool (MUST) score, which determines malnourishment, had improved after arriving at the care home.
In October 2023, it was confirmed that Mrs X no longer needed dietetic input.
In November and December 2023, Mrs X’s food intake began to reduce and she lost weight. Care Staff records showed they weighed Mrs X regularly, encouraged eating, and referred her to a dietician. However, Mrs X died in late January 2024 before she could be seen by the dietician.
These records did not show Mrs X’s food intake between November 2023 and January 2024, despite the weight loss.
Similar care was recorded regarding hydration; she hit target levels until a decline in November 2023. The care staff frequently encouraged Mrs X to drink, but she declined most drinks in her last week of life. There was no record of the Care Home discussing with Mrs Z or Ms A about alternative hydration eg. a drip.
Mrs Y complained about Mrs X’s pressure care and stated the care workers did not encourage Mrs X to take regular bed rest to alleviate back issues. The Care Home alternatively stated that they did encourage Mrs X, but she declined.
Mrs Y did raise concerns about Mrs X’s capacity to make decisions. Yet, it was noted by the Council’s social worker that Mrs X was sociable and her happiness was balanced with safeguarding.
In December 2023, Mrs X’s lower back became red. The Care Home implemented periods of bed rest, which swiftly resolved the issue. She also received an airflow mattress.
But by 15th January 2024, Mrs X had developed a Grade 2 pressure ulcer on her lower back. Mrs X was moved to bed rest and had the area dressed. However, there were later gaps in Mrs X’s repositioning records. Whilst she could reposition herself, she was weak. In some instances, records showed 7-hour gaps in repositioning, while her daily care records showed Mrs X needed repositioning every 3 hours.
In one of Mrs X’s final days alive, her care was interrupted due to no available syringe drivers in the Care Home. Both were in use, and Mrs Y had to borrow one from her place of work as a substitute.
In reference to risk assessments for Mrs X’s trips out of the Care Home with relatives, it was noted that any trips out were recommended to be within 30 minutes of the Home due to her continence needs. The plan also noted how staff could recommend Mrs X not to go out if she was feeling unwell. Body maps also had to be completed on return from trips to account for possible bruising.
Care records showed Mrs X received several bruises and small cuts whilst at the Care Home.
In May 2023, a safeguarding enquiry had determined Mrs X was not at significant risk of harm as blood thinning medication made it easy for her to bruise. The enquiry did conclude that the Care Home had not been consistent with completing the body maps.
In August 2023, Mrs X’s RPR also noted inconsistent recording of body maps. The Care Home as a result issued a reminder to staff to adequately complete documents. Body maps continued to be inconsistent after this point, as seen through daily care records.
What was found
Overall, both the Council and the Care Home were found by the Ombudsman to be at fault, in various respects.
In response to the complaint made by Mrs Y regarding Mrs X’s catheter, the Ombudsman determined that there was an inappropriately long time between checks on occasion. There were no clear records to confirm Mrs X received the regular 4 hourly continence checks set out in her care plan. Hence, the Care Home was at fault, which contributed to Mrs X’s physical ailments (her UTIs) and Mrs Y’s distress.
In terms of Mrs X’s weight and nutritional management care, no fault was found. Yet, gaps in the nutritional records that were meant to detail the amount Mrs X ate (between November 2023 and January 2024) amounted to fault.
The Care Home’s failure to discuss alternative hydration options with Mrs Z or Ms A was also considered to be a fault.
Mrs X’s pressure care by the Home, balancing her capacity to make decisions and autonomy against the risk, was not deemed a fault by the Ombudsman. The Ombudsman declared it was reasonable to allow her to decide where she wanted to be (whether in bed or socialising), and it was unlikely this had any negative impact on Mrs X.
The January pressure care issue, however, where records showed infrequent repositioning after the development of a back ulcer, was deemed to be a fault. The investigation concluded that Mrs X did not receive the standard of care she was entitled to, which left her in discomfort in her final week of life.
Mrs Y’s specific complaint that no syringe drivers were available for Mrs X was labelled as a service failure of the Care Home. This was a failure outside of the Care Home’s control, despite being a fault. It was also determined that Mrs X faced no significant injustice due to the equipment shortage, as she did eventually gain access to a syringe driver.
In response to the complaint about risk assessments for Mrs X’s trips outside of the care home, the Ombudsman found no injustice was caused to Mrs X. Further, there was no fault found in the organisation of the family visiting schedule by the Care Home. The investigation concluded that both the Council and Care Home sought the views of all parties (both sides of the family) as directed by the Court of Protection in March 2023.
The Council’s communication with the Care Home relating to a joint meeting was also deemed a specific fault by the Ombudsman. The investigation determined that the Council inadequately responded to Mrs Y’s requests for a meeting, which left Mrs Y frustrated.
Mrs Y had complained against the Council regarding safeguarding concerns and familial abuse of Mrs X. Mrs Y stated it took 18 months for the Council to conclude the investigation, which put Mrs X at risk of further abuse. Mrs Y also felt Mrs X was not adequately supervised in visits to prevent the risk of abuse. The emotional abuse allegation concluded prior to April 2023 and hence was not considered by the Ombudsman. The allegation of financial abuse was investigated, and it was found that neither Mrs X nor Ms A had access to her finances at that point. Hence, no concerts or faults were found.
Generally, the inconsistent record keeping at the Care Home was determined to be at fault, but for which the Council had to bear the responsibility.
The agreed actions and remedies identified by the Ombudsman were as follows:
- A written apology from the Council and Care Home to Mrs Y and Mrs Z for the uncertainty and distress caused (specifically their failure to support Mrs X’s continence needs).
- Within 3 months of the report, an explanation from both the Council and Care Home of the action they will take to ensure the Care Home gives its staff sufficient guidance to follow a person’s care plan.
- An apology from the Council to Mrs Y for their communication failings.
- A written apology from the Care Home to Mrs Y and Mrs Z for distress caused through failings in Mrs X’s end-of-life care.
- Within 1 month of the report, an explanation from the Care Home of actions it will take to ensure appropriate guidance for staff in keeping records up to date.
- Within 3 months of the report, an explanation from the Care Home of actions it will take to ensure it provides appropriate end-of-life care.
- Also, publishing practice guidance for care staff to review and update a person’s care plan to meet changing needs.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
Although this appears to be a report about faults by a care home in terms of care and record keeping, this report also skates lightly over a family at war, for whom the Court of Protection’s involvement had not done much good, from what one can tell.
One of course notes the failings of the care home but it deserves some credit for the fact that it did not choose to ‘dump’ the client because of the extra responsibility of keeping a watchful eye over the family members over a lengthy period of end-of-life care.
Any Council that is aware of problems between family members regarding each other’s conduct cannot just shut its eyes to that conflict, because it is bound to have an impact on the person in the care home, and the care home’s management. Where the Court of Protection has made it a condition of someone’s deprivation of liberty authorisation in a care home that there be a visiting schedule and that everyone sticks to it, one can be assured that there has been conflict to a serious degree.
The Council IS the care planner and needs to take account of the surrounding circumstances of the person that are relevant to managing the package of care it is funding.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Wigan Metropolitan Borough Council (23 013 793) report.
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