Summary: Mrs X complained about her late husband’s care and the way the staff at the Ashleigh Manor Residential Care Home treated her when she visited him. Mrs X complained the Care Home failed to recognise her status as Mr X’s wife. We found the Care Provider’s failure to keep detailed records regarding Mr X’s care and follow proper process regarding safeguarding concerns and decisions taken in Mr X’s best interest amount to fault. As do the Care Home’s failings in its communications with Mrs X. These faults have caused Mrs X significant distress and upset.

The complaint

1. The complainant, Mrs X complained about her late husband’s care and the way the staff at the Care Home treated her when she visited him.
2. Mrs X complained the Care Home failed to recognise her status as Mr X’s wife and next of kin and did not inform her about changes in Mr X’s condition, falls, admissions to hospital or death. She complains the Care Home falsely accused her of providing Mr X with unsuitable snacks and drinks, and wrongly restricted her contact with him.
3. Mrs Y is assisting Mrs X in raising this complaint.

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The Ombudsman’s role and powers

4. 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. If they have caused a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
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)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

7. As part of the investigation, I have:
• considered the complaint and the documents provided by Mrs Y;
• made enquiries of the Care Provider and considered the comments and documents the Care Provider provided;
• discussed the issues with Mrs Y; and
• Mrs X and Mrs Y and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

8. The Care Home says the management team in place at the time Mr X was a resident are no longer there. There is a new management team in place and they have been unable to provide most of the documentation requested for this investigation. The Care Home has provided copies of its multi -professional log from late October 2023 to January 2024.
9. Mr X became a resident at the Care Home in late July 2023. Prior to that he lived at home with Mrs X, who was his main carer. Mr X had a number of medical conditions, including vascular dementia and diabetes.
10. Mrs Y says Mrs X was concerned about the care that Mr X received at the Care Home. Mr X’s was always smart and clean and she was concerned to see him looking unkempt and in dirty clothes. Mrs X also expressed concerns Mr X was given a non-diabetic diet, including white toast with regular jam, sugar jelly, fruit cake and sausage rolls. She had also noticed chocolate biscuits in a draw in his room. Mrs X believes these were provided by Mr X’s daughter, Mrs Z.
11. Mrs Y says Mrs X careful with Mr X’s diet and has never provided him with anything he should not have.
12. Mrs X was also concerned the Care Home did not inform her when Mr X was unwell or had been seen by a doctor. The Care Home’s records show that following Mrs X expressing concern in early November 2023 a member of staff contacted Mrs Z to confirm who should be notified. Mrs Z asked that the Care Home contact her.
13. The Care Home records for late November and December 2023 show Mr X’s blood sugars levels were high. These records noted Mrs X felt this was the Care Home’s fault as she had repeatedly told them not to provide certain foods.
14. I have not received any evidence of concerns raised by the district nurses visiting Mr X, but the Care Home’s records state the district nurses were aware that most evenings when Mr X comes back from Mrs X’s visit his blood sugars are “through the roof”.
15. Mrs Y says that when Mrs X took Mr X out they only had a pot of tea, which would not have raised Mr X’s blood sugar levels. She maintains it was the Care Home that provided inappropriate foods.
16. The records say a district nurse asked the Care Home to monitor Mr X’s blood sugars regularly and keep a chart, especially when Mrs X had visited. The records for 1 December 2023 also note that an empty energy drink can and lots of biscuit wrappers were found in Mr X’s bin.
17. There is no record the Care Home spoke with Mrs X about Mr X’s blood sugar levels or any concerns about the food she provided at this stage. Nor did it discuss this with Mr X or ask whether he had drunk the energy drink or where it had come from. It did however contact Mrs Z to advise her of the concerns. It was agreed the Care Home would keep a snack box in the kitchen for Mr X and remove all snacks and food from his room.
18. According to the records Mrs Z advised the Care Home she intended to contact a social worker as she was concerned about Mrs X taking Mr X home over Christmas. The records say Mrs Z subsequently told the Care Home it would need to raise a safeguarding concern.
19. Mr X had several falls in early December 2023 and was admitted to hospital on 7 December 2023. The Care Home records show Mrs Z was informed, but Mrs X was not.
20. There is no record the Care Home made a safeguarding referral. However, the Care Homes records say someone from safeguarding called the home to discuss Mrs X in relation to Mr X’s blood sugars. A member of the Care Home staff told the safeguarding officer that a can of energy drink had been found in Mr X’s room and that Mr X’s blood sugars were up whenever Mrs X saw Mr X. The member of staff reported that the district nurses had also picked up on this. They also raised concerns about Mr X going home for Christmas.
21. According to the Care Home’s records the safeguarding officer said they would arrange a mental capacity assessment (MCA) for Mr X and get the legal framework in place as they felt it was not in Mr X’s best interests to go home with Mrs X.
22. A further entry in the Care Home’s records show a member of staff contacted safeguarding for an update on 20 December 2023. The notes say the safeguarding was still open, awaiting paperwork and an urgent MCA had been requested. The records state:

“We cannot physically stop [Mrs X] from taking [Mr X] out but [Mrs Z] can due to PoA [Power of Attorney]”

23. The notes then go to state:

“We been advised to make sure if [Mrs X] visits its to be in communal areas where she can be seen at all times as need to monitor foods.”…”a DoLs [Deprivation of Liberty Safeguards] has been applied for and its all for [Mr X] best interest.”

24. It is unclear who advised that Mrs X’s visits should be supervised, or how this decision was made. There is no record a mental capacity assessment was carried out or that a DoLS application was made. Nor are there any records of any Best Interest decisions.
25. Mr X was discharged from hospital on 19 December 2023 but was then readmitted on 22 December 2023. He returned to the Care Home again on 9 January 2024. The records note a member of staff from the Care Home contacted the hospital to clarify Mr X’s medication. During this conversation the hospital confirmed Mr X’s blood sugars had remained unstable while he was in hospital.
26. In late January 2024 Mrs Z wrote to the Care Home in her capacity as Mr X’s Power of Attorney and advised she did not give permission for Mrs X to visit Mr X in his room. If Mr X felt well enough to sit in the lounge where Mrs X could be supervised Mrs Z would agree to this. Mrs Z felt this was in Mr X’s best interest to keep him safe.
27. Following Mr X’s death in February 2024, Mrs Y made a formal complaint to the Care Home about Mr X’s care and its staff’s treatment of Mrs X. Mrs Y noted that when Mrs X had raised concerns about Mr X’s care in late October / early November 2023 a member of staff responded by accusing Mrs X of bringing in biscuits and energy drinks.
28. Mrs Y said that throughout Mr X’s time at that Care Home its communication with Mrs X was poor. The Care Home did not discuss Mr X’s care with her or inform her of any changes in his condition. Mrs Y was unhappy that when Mr X returned to the Care Home on 9 January 2023 Mrs X had to visit him in the lounge. She also complained that during a visit on 30 January 2024, a member of staff brusquely told Mrs X that changes had been made to Mr X’s care because he had been ill over the weekend. Mrs Z then told her a decision had been made that Mr X would receive palliative care. Mrs X had been unaware of the changes in Mr X’s condition or care.
29. In addition Mrs Y said Mrs X was unaware until the Care Home manager told them on 9 February 2024 that the home had put safeguarding measures in place against Mrs X. She questioned why the Care Home considered it appropriate for a patient to receive palliative care in the lounge with no privacy. She also questioned why Mrs X was not informed of the safeguarding concerns and was concerned Mrs X had been accused and found guilty without the opportunity to respond
30. Mrs X had been unaware her visits were being supervised and had no privacy with Mr X during his final days. This had caused Mrs X significant distress.
31. Mrs Y posed a number of questions, asking the Care Home for explanations for its treatment of Mrs X and the decisions it had made about Mr X’s care and contact with Mrs X.
32. The Care Home manager responded in March 2023 and sought to assure Mrs X that Mr X had received a quality standard of care at the home and appropriate referrals to healthcare professionals were made as needed.
33. It said the decision that Mrs X should visit Mr X in a communal area was not only taken by Mrs Z, but it was made in conjunction with the local safeguarding team due to Mr X’s unstable diabetes and the food/ drink given to him. The Care Home said Mrs Z’s instructions were based on concerns raised by the Care Home and the District Nursing team. And Mrs Z said she had made this decision in Mr X’s best interest.
34. The Care Home noted it had not prevented Mr and Mrs X from seeing each other, but it requested this take place in communal areas. It said its visiting policy is that visits can take place at any time, including overnight, so that relatives can be with their loved one at the end of life. The Care Home noted Mrs Z was visiting daily and communicating with other family members.
35. Mrs Z was listed as Mr X’s next of kin and first contact, and following his death was asked to inform the rest of the family.
36. The Care Home said staff had spoken with Mrs X regarding concerns about Mr X’s diet because of his unstable blood sugars and the impact on his health. It said that despite these conversations it found energy and other fizzy drinks and juice in Mr X’s room following Mrs X’s visits. The Care Home said it raised a safeguarding concern as it had a duty of care to Mr X, and that Mrs Z was aware of this.
37. It said that once a safeguarding referral has been made the safeguarding team would decide whether to investigate.
38. In relation to Mr X’s hospital admission and the decision he would receive palliative care the Care Home said it notified Mrs Z as next of kin and first contact. In doing so, it said it was carrying out the instructions it was given.
39. Mrs Y was not satisfied with the Care Home’s response. She asserted the decision to control and monitor Mrs X’s visits was based on false accusations. And that rather than allow her to spend time with Mr X at the end of his life the Care Home stopped Mrs X from seeing him at certain times. Mrs Y noted that Mrs Z had told Mrs X she would stop her seeing Mr X altogether unless Mrs Y withdrew her complaint about the Care Home. Mrs X was unable to see Mr X the week before he died.
40. Mrs Y also maintained that Mrs X was Mr X’s next of kin, not Mrs Z. And that the Care Home’s communication with Mrs X was poor, her position as next of kin was not respected and she was largely ignored. Mrs Y also said it was evident Mrs Z was not communicating any updates on Mr X’s condition to Mrs X. She would have expected the Care Home, as a minimum, to keep Mrs X informed of discussions about Mr X’s care plan.
41. She suggested the Care Home should have been familiar with the procedures for identifying and communicating with next of kins and also understand the limitations of the extent of powers of a Lasting Power of Attorney. Mrs Y said the Care Home failed to recognise Mrs Z was abusing her position as Power of Attorney and supported this abuse.
42. In response to my enquiries the Care Home says the manager is no longer at the home and it has not been able to find any documentation that the manager completed, leading it to believe nothing was investigated.
43. As far as it is aware no safeguarding was put in place relating to Mr or Mrs X by the Care Home as it can find no evidence of any safeguarding. Nor has it been able to find any best interest decisions or mental capacity assessments.
44. The Care Home believes the manager at the time did not carry out the correct procedure around Mr X and Mrs X and was not acting in the best interests of the home or Mr X.
45. It says Mrs Z was listed in its records as first point of contact with Mrs X listed as a second contact. Mrs Z was Mr X’s Lasting Power of Attorney for his finances and later in respect of his health and welfare. As Mrs Z had Power of Attorney the Care Home believes the manager was carrying out Mrs Z wishes and was led to believe Mrs Z was contacting Mrs X to relay information.
46. The Care Home says it has not found any records that Mrs X was unable to visit Mr X, only a letter from Mrs Z to state visits must be in the communal area.
47. In response to the draft decision the Care Home says it has completed a full audit of its systems, processes and actions and is in the process of moving to digital records.
48. It says its staffing teams complete safeguarding and MCA training and senior members of staff have also completed DoLS and best interest training with the local council. The Care Home says it has also implemented staff awareness boards to assist staff with improving their knowledge, and it has created handouts on a different area each month.
49. In addition the Care Home says it has reimplemented a monthly family coffee morning and catch up meeting which is advertised for all visitors to see and attend. And has introduced notice boards with photographs of the management team to show family members who they can talk to. It also has a resident and family information board detailing how to make a complaint and who to talk to.
50. Taking account of the actions the Care Home has taken, I do not consider it necessary to make recommendations for further service improvement.

Analysis

51. The lack of records regarding Mr X’s care and decisions apparently taken in his best interest is a concern and amounts to fault. Decisions regarding the Care Home’s communication with Mrs X and how and when Mrs X could visit Mr X appear to have been taken by Mrs Z and supported by the Care Home.
52. There is no evidence that Mr X was unable to make these decisions for himself, or that he was even consulted about his views and wishes. There is no evidence any mental capacity assessments were completed or that a proper process was followed in order to make best interest decisions if/ when Mr X lacked capacity.
53. Nor is there any record the Care Home made a safeguarding referral or carried out any investigation regarding concerns about Mr X being given unsuitable foods and drink. There was however a clear assumption Mrs X routinely gave Mr X drinks and snack which raised his blood sugars, but there is no record of where or with whom this assumption began. This was not discussed with Mrs X or Mr X. There is no record of the foods provided by the Care Home, even though Mrs X complained he was given a non-diabetic diet.
54. The Care Home’s failure to follow proper process and to instead accede to Mrs Z’s requests and instructions without due consideration of Mr X’s wishes and best interests is fault. The Care Home’s actions have caused Mrs X significant distress and upset and have impacted on her ability to spend quality time with Mr X at the end of his life.
55. The Care Home would have been aware of the strained nature of Mrs X’s relationship with Mrs Z. Its records show that at one stage it advised Mrs Z that the Care Home did not get involved in family disputes. I would therefore have expected the Care Home to clearly document Mrs Z’s request to be first contact and for this to be explained to Mrs X. Mrs X would then have had the opportunity to challenge this or at least request that she was also contacted. As Mr X’s wife, Mrs X had a clear expectation that she would be informed of any changes in Mr X’s care or condition, and certainly that she would be informed of his death.
56. In the circumstances, I consider the Care Home’s failings in its communications with Mrs X were fault and again caused Mrs X significant distress.

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Agreed action

57. The Care Provider has agreed to:
• apologise to Mrs X for the distress and upset caused by fault identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• pay Mrs X £1000 in recognition of the significant distress and upset she experienced as a result of the Care Home’s actions and decisions, and poor communication;
58. The Care Provider should take this action within one month of the final decision on this complaint and provide us with evidence it has complied with the above actions.

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Final decision

59. The Care Provider’s failure to keep detailed records regarding Mr X’s care and follow proper process regarding safeguarding concerns and decisions taken in his best interest amount to fault. As do the Care Home’s failings in its communications with Mrs X. These faults have caused Mrs X significant distress and upset.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman