Summary: We uphold Mrs Y’s complaint about her grandmother’s care. We found fault with Mrs X’s continence care and some aspects of her end of life care. We also found fault with the Care Home’s record keeping and the Council’s communication. As a result, Mrs X did not always receive the care she needed. Mrs Y and her mother were also caused frustration and uncertainty. We recommend the Council and the Care Home apologise to Mrs Y and her mother and make improvements to processes.

The complaint

1. Mrs Y complains on behalf of her late grandmother, Mrs X, about the care provided to her by High Peak Lodge (the Care Home) between April 2023 and January 2024. Mrs X’s placement was arranged and partially funded by Wigan Metropolitan Borough Council (the Council) and later by Continuing Healthcare funding.
2. Specifically, Mrs Y complains about:
• Mrs X’s catheter care management which caused leaks and recurrent Urinary Tract Infections (UTIs);
• Mrs X’s end of life care including weight loss, poor hydration and nutrition and access to appropriate pain management;
• failure to properly complete risk assessments for Mrs X’s trips out with a relative; and
• poor record keeping by the Care Home, particularly in relation to completing body maps of injuries and bruising.
3. Mrs Y also complains about the way the Care Home and the Council jointly managed family visits to Mrs X, including:
• failure to act in line with the directions from the Court of Protection around managing visits;
• failure to enforce the visiting schedule;
• changing the visiting schedule without properly consulting all family members; and
• failure to ensure visiting schedules ensured Mrs X had sufficient time between visits to eat properly and rest.
4. Mrs Y complains about the way the Care Home and the Council communicated with her and her mother. She says she did not receive adequate responses to her concerns about Mrs X’s care. She complains that she was passed back and forth between the Care Home and the Council, and that her repeated requests for a joint meeting were ignored.
5. Mrs Y is also unhappy with the way the Council handled her safeguarding concerns about alleged abuse by a family member. She says it took the Council 18 months to conclude the safeguarding investigation, leaving Mrs X exposed to the alleged abuser throughout this period which put her at risk. She disagrees with the Council’s position that visits to Mrs X were adequately supervised to mitigate the risks. She also says the findings about financial abuse are unsound.
6. As a result, Mrs Y says Mrs X did not receive the care she was entitled to and was caused unnecessary harm and distress in her last years of life. She further says the actions of the Council and the Care Home caused further breakdown of fragile family relationships and caused her and her mother significant distress.
7. Mrs Y is seeking an independent review of events and answers to her questions. She would also like an acknowledgement of fault and the impact on her and her family and service improvements.

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The Ombudsmen’s role and powers

8. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
9. 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).
10. 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.
11. 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)

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How I considered this complaint

12. I have considered the information Mrs Y provided in support of her complaint. I have also received information from the Council and the Care Home, including the Care Home’s daily records and the social worker’s case notes. I have carefully considered all the written and oral evidence submitted, even if it is not all mentioned within this decision statement.
13. I shared this draft decision with Mrs Y, the Council and the Care Home and they had an opportunity to comment. I have considered the comments I received.

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What I found

Key legislation and guidance

National Institute for Health Care and Excellence (NICE)

14. ‘Care of dying adults in the last days of life – NICE guideline [NG31] December 2015: Support the dying person to drink if they wish to and are able to…Discuss the risks and benefits of continuing to drink, with the dying person, and those involved in the dying person’s care… Offer frequent care of the mouth and lips to the dying person….Assess, preferably daily, the dying person’s hydration status, and review the need for starting clinically assisted hydration, respecting the person’s wishes and preferences.

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations)

15. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance (the Guidance) on how to meet the fundamental standards.
16. I will refer to several specific parts of the Regulations later in this decision statement.

Funded Nursing Care and Continuing Healthcare

17. The NHS is responsible for meeting the cost of care provided by registered nurses to residents in all types of care homes. This can be through NHS-funded nursing care (FNC) or NHS-funded continuing healthcare (CHC).
18. FNC is the funding provided by the NHS to residential nursing homes that also provide care by registered nurses.
19. CHC is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. CHC funding can be provided in any setting.

What happened

20. Mrs X was an elderly lady in her late 90s with a diagnosis of dementia. Mrs X had a large family, including living six children and several grandchildren.
21. At one point, Mrs X moved in with her daughter, Ms A. Family members raised concerns about potential financial and emotional abuse by Ms A.
22. Mrs X later moved into High Peak Lodge (the Care Home). The placement was initially part funded by the Council and FNC.
23. Mrs Z (one of Mrs X’s daughters) and Mrs Y (Mrs Z’s daughter) had ongoing concerns about Ms A and also the suitability of the Care Home. Mrs X did not have capacity to decide about her residency and care. There were significant disagreements within the family about Mrs X’s care and who should be able to visit her.
24. The matter went to the Court of Protection (the Court). A Deputy was appointed to manage Mrs X’s finances. In March 2023, the Court ordered that Mrs X should remain at the Care Home permanently and should be able to receive visits from all her family. The Court ordered that a visiting schedule should be put in place.
25. Over the next few months, the Care Home produced a draft visiting schedule and shared it with the family for feedback. Some family members raised concerns about it, often with conflicting views.
26. A number of safeguarding concerns and complaints were raised by the family, including Mrs Y and Mrs Z.
27. In late 2023, Mrs X’s health deteriorated and a Statement of Intent outlining end of life care plans was put in place. Mrs X had a Fast Track assessment for CHC funding, which was backdated to late November 2023. From this point, her care was the responsibility of the local Integrated Care Board (ICB) who provided the CHC funding.
28. In late January 2024, Mrs X died.

Analysis

29. We conduct proportionate investigations; completing them when we consider we have enough evidence to make a sound decision. We have limited resources and investigate by focusing on general themes and issues rather than providing a response to every individual issue raised in a complaint. This means we do not try to answer every single question a complainant may have about what an organisation did or respond to complaints in the level of detail people might want.

Catheter care management

30. Mrs Y complains about Mrs X’s catheter management. She says Mrs X’s catheter regularly leaked and need replacing. Mrs X also had recurrent Urinary Tract Infections (UTIs).
31. I have reviewed Mrs X’s catheter care records and it is clear there were some difficulties managing this. Mrs X pulled out her catheter several times and found being recatheterised distressing. The catheter became blocked on multiple occasions. She had several incidents of blood in her urine and several courses of antibiotics to treat UTIs.
32. The care staff took prompt action when they identified concerns, regularly involving both Mrs X’s GP and the nurses. The nurses acted promptly when contacted. The GP referred Mrs X to a urology specialist to discuss a different type of catheter, as she kept pulling hers out. The Care Home acted in line with section 13.2 of the Nursing and Midwifery Council’s (NMC) Code to ‘make a timely referral to another practitioner when any action, care or treatment is required’. The urology team did not consider a different style of catheter would be appropriate but recommended the addition of a leg strap to reduce the risk of the catheter being pulled out.
33. However, there were regular gaps in Mrs X’s continence care. Mrs X catheter and continence pads should have been checked every 4 hours. The majority of Mrs X’s continence checks were not completed within the 4 hour timeframe. Some checks were 1-2 hours late. At other times the gap between checks were several hours, without explanation for the delay.
34. I am unable to say whether Mrs X received care during these longer gaps, or whether it simply was not recorded. There is one day with a lengthy gap between checks, where Mrs X was later found with faeces dried on her skin. This indicates that there had been an inappropriately long time between continence checks on this occasion. This is not in line with Regulation 10 of the Regulations, the Guidance for which states ‘people using the service must not be neglected or left in undignified situations.’
35. In July 2023, the Care Home acknowledged Mrs Y’s concerns around catheter care records and said it would take steps to improve this. I reviewed records until January 2024 and there were still ongoing issues with record keeping.
36. When investigating complaints, if there is a conflict of evidence, we may make findings based on the balance of probabilities. This means that during an investigation, we will weight up the available evidence and base out findings on what we think was more likely to have happened.
37. I have not seen clear records to confirm Mrs X received regular four-hourly continence checks. I have found, on the balance of probabilities, Mrs X did not receive the continence care as set out in her care plan. This is fault. As a result, Mrs X did not receive consistent continence care. This would have contributed to increased risk of UTIs. Mrs Y and Mrs Z were also caused frustration and distress.

End of Life Care

38. Mrs Y complains about Mrs X’s care, particularly over her final few months of life. Mrs Y says Mrs X was unhappy and complained to her and Mrs Z about this.
39. While I have no reason to doubt Mrs Y’s account, there is no record of Mrs X complaining about her care to anyone else. The Care Home records do not contain any complaints from Mrs X. The rest of Mrs X’s family were happy with her care and felt she was settled in the Care Home. Mrs X was visited by social workers, the safeguarding team and her Relevant Person’s Representative (RPR) who all found Mrs X was settled and receiving adequate care. Mrs X may have been saying different things to different people.
40. Having reviewed Mrs X’s daily care records between April 2023 and January 2024, I found Mrs X received adequate care for the majority of this time. However, I have found failings in care in relation to parts of her end of life care. I will address these individually now.
41. Mrs Y complains about Mrs X’s nutrition and weight management. The records show Mrs X generally ate well. The care records show she was mostly eating three meals a day plus snacks.
42. The Malnutrition Universal Screening Tool (MUST) is a flow chart consisting of five steps, which are used to identify adults who are malnourished, at risk of malnutrition or obese. MUST also contains management guidelines for use in developing care plans to ensure nutritional needs are met. A person’s MUST score indicates risk of malnutrition, with 2 or higher being high risk, 1 is medium risk and 0 is low risk.
43. Mrs X arrived at the Care Home with a MUST high risk score of 2. However, she gained weight well and within a few months, her score had dropped to 0. In September 2023, the Care Home said Mrs X had gone up three dress sizes since she moved in. In October 2023, it was confirmed Mrs X no longer needed dietetic input. However, in November and December 2023, Mrs X’s food intake slowly reduced. Care staff weighed Mrs X at regular intervals and noted her weight loss. They referred Mrs X to a dietician in a timely manner. Unfortunately, Mrs X died before she could be seen. The records show care staff were encouraging Mrs X to eat, offering her preferred foods and left snacks out. I have not found fault with Mrs X’s nutritional care and weight management.
44. However, there are gaps in the nutritional records, particularly between November 2023 and January 2024. While it is recorded what food was offered to Mrs X, her intake is not always recorded. This would have been important information, particularly when she was known to be actively losing weight. This is fault.
45. Similarly, Mrs X’s fluid intake and hydration was generally good and meeting her target levels. Again, in November and December 2023, this gradually started to reduce. Mrs X’s fluid intake would fluctuate each day. It wasn’t until Mrs X’s last week of life that her fluid intake became significantly reduced.
46. The records show care staff regularly offered Mrs X drinks and encouraged her to drink more. This encouragement continued consistently through her last week, however Mrs X was declining almost all drinks by this point and only receiving mouth care to help keep her mouth moist and comfortable. As explained above, the NICE guidance for ‘Care of dying adults in the last days of life’ says dying people should be support to drink if they are able and offered frequent mouth care.
47. It also says the person’s hydration status should be assessed regularly, ideally daily, including reviewing the need for starting clinically assisted hydration (such as a drip or tube). The benefits and risks should be discussed with the dying person and those involved with their care.
48. While Mrs X may not have had capacity to make such a decision, I have not seen any evidence of discussions with Mrs Z or Ms A about Mrs X’s hydration status and whether any hydration alternatives may be appropriate.
49. The Guidance for Regulation 9 of the Regulations says ‘providers must make sure they assess each person’s nutritional and hydration needs to support their wellbeing and quality of life. This includes when there is no expected cure for an illness.’ Further, the Guidance for Regulation 14 of the Regulations says ‘nutrition and hydration needs should be regularly reviewed during the course of care and treatment and any changes in people’s needs should be responded to in good time’. I have not seen any evidence that the Care Home took any specific action to consider Mrs X’s reduced fluid intake or considered whether anything more could be done to make her comfortable. The Care Home has not acted in line with the NICE guidance or the relevant Regulations. This is fault.
50. Mrs Y complains about Mrs X’s pressure care. In particular, she says care workers did not encourage Mrs X to take regular bed rest breaks to relieve pressure on her lower back.
51. The Care Home says care workers encouraged Mrs X to take bed rest but that she usually declined, as she preferred to be in the living area and did not enjoy being alone. I cannot say from the records whether Mrs X was encouraged as this is not specifically recorded. I have no reason to doubt the Care Home’s account and it is clearly documented the Mrs X was highly sociable and did have a clear preference for being in the living area with people to talk to.
52. Mrs Y raises concerns about Mrs X’s capacity to make such decisions. While Mrs X had been assessed to not have capacity to make big decisions about where she should live etc, she was found to be able to make smaller decisions about her day-to-day care. The Mental Capacity Act Code of Practice says ‘people may lack capacity to make some decisions for themselves but will have capacity to make other decisions. For example, they may have capacity to make small decisions about everyday issues...but lack capacity to make more complex decisions...’
53. The Care Home needed to strike a balance between protecting Mrs X’s pressure areas and allowing her the autonomy to make some decisions about her daily care. This included deciding where she wanted to spend her time. When commenting on the draft decision, the Council’s social worker noted Mrs X’s was highly social and preferred to sit in the lounge. The social worker said Mrs X’s happiness was balanced with safeguarding.
54. Care staff regularly repositioned Mrs X while in the lounge and, for the most part, she had good skin integrity and no sign of pressure damage. Therefore, it was reasonable to allow her to decide where she wanted to be and there is nothing to suggest this had an adverse effect on her.
55. I acknowledge Mrs Y says Mrs X would complain to her that her lower back was sore, but there is nothing in the records to suggest Mrs X raised this with staff and generally no sign of pressure damage.
56. In December 2023, Mrs X’s lower back did become red and the Care Home took appropriate steps, including implementing periods of bed rest, and this quickly resolved. Mrs X was also moved onto an airflow mattress. Prior to January 2024, I found no fault with Mrs X’s pressure care.
57. On 15 January 2024, Mrs X developed a Grade 2 pressure ulcer on her lower back. The nurse was informed, Mrs X was moved to bed rest and the area later dressed. However, over the following week, there are significant gaps in the Mrs X’s repositioning records. While Mrs X could previously reposition herself in bed, she was significantly weakened at this point, with known pressure damage. It would have been important to ensure that Mrs X was consistently repositioned in line with her needs. Mrs X’s daily care records stated she needed repositioning every two to three hours. There are some six to seven hour gaps in the repositioning records on some days. On the balance of probabilities, I have found Mrs X did not receive consistent pressure care in her last week of life. This is fault. As a result, Mrs X did not receive the standard of care she was entitled to and this likely impacted on her comfort.
58. Mrs Y complains about failure to manage Mrs X’s pain, both generally and in her final few days.
59. Mrs Y says Mrs X complained about pain to herself and Mrs Z, but this was not properly managed. Again, while I have no reason to doubt Mrs Y’s recollection, there is nothing in the records to suggest Mrs X complained of pain to anyone else. The Care Home used the Abbey Pain Assessment Scale to monitor Mrs X’s pain. I have seen her records for November 2023 to January 2024, where her score is mostly 0 for no indication of pain. It was recognised that, due to Mrs X’s health conditions, she would likely be experiencing some pain at times and that she had started regularly declining to take her oral pain relief medication. At this point, the Care Home appropriately involved Mrs X’s GP and the local hospice and a pain medication patch was introduced. I have not found fault with Mrs X’s general pain management.
60. Mrs Y raises a specific complaint that no syringe drivers were available for Mrs X during her final few days. In response to my enquiries, the Care Home explained to me it only has two syringe drivers, which is usually sufficient. It was unusual for both to be in use at the point Mrs X required one. The Care Home then tried to obtain a syringe driver for Mrs X from local hospices, district nurses and its sister homes but none were available. Mrs Y was then able to borrow one from her place of work.
61. It is unfortunate that no syringe driver was available for Mrs X when she needed one. This was service failure to Mrs X. Service failure can happen when an organisation fails to provide a service as it should have done because of circumstances outside its control. I recognise this was an unusual occurrence for the Care Home and it took reasonable steps to try and get a syringe driver from other sources. While the lack of a syringe driver was fault, Mrs Y provided one for Mrs X. As Mrs X had access to a syringe driver, there was no significant injustice to her.

Risk assessment

62. Mrs Y complains about failure to assess the risk of Mrs X’s trips out of the Care Home with relatives. Mrs Y raised concerns about fatigue, access to continence care and the safety transferring to a car with a single relative for support.
63. I have reviewed the Council’s risk assessment. It notes Mrs Y’s concern about fatigue, continence care and transfers. The plan mitigates the risk of fatigue by recommending any trips out are within 30 minutes of the Care Home. The plan also recorded that staff could recommend Mrs X did not go out on a particular day if she was feeling unwell or tired. The plan notes Mrs X’s continence needs could be met through incontinence pads and her catheter, and the 30 minute distance meant she could access continence care quickly if required. Body maps were also to be completed on return, following safeguarding concerns of unexplained bruising.
64. The risk assessment does not explicitly refer to the safety of transfers. This was a concern raised by Mrs Y and should have been addressed. This is fault. However, I have seen evidence that the Care Home checked this with the Council. The Council confirmed that an Occupational Therapist (OT) considered Mrs X safe to transfer. Therefore, I have not found any injustice to Mrs X.

Record keeping

65. Mrs Y complains about poor record keeping, particularly around body maps of injuries and bruising.
66. The care records show Mrs X had several bruises and small cuts during the period I investigated. Mrs Y raised this as a safeguarding concern. In May 2023, the safeguarding enquiry concluded that Mrs X was not at significant risk of harm. It noted Mrs X’s blood thinning medication made it easy for her to bruise and that her account of how she became bruised may be unreliable due to her cognitive impairment. However, the enquiry found the Care Home had not been consistent with completing body maps.
67. In August 2023, Mrs X’s RPR visited the Care Home and again noted that bruising had not been consistently recorded on body maps. The Care Home issues a reminder to staff to complete documents appropriately.
68. When reviewing Mrs X’s daily care records, I found the body maps continued to be inconsistent. For example, a bruise may be recorded one day, not noted for the next couple of days, and then recorded again as still being present. This happened on more than one occasion. It is concerning this continued to be an issue despite safeguarding concerns and inconsistent paperwork being raised previously.
69. I also found the continence records were not always completed consistently. As explained above, there was some significant gaps in Mrs X’s continence output records. The information recorded daily care tick chart, handwritten daily notes and continence output charts did not always match, which made it more difficult for me to review Mrs X’s care.
70. As mentioned above, the nutritional records did not always record the quantities eaten by Mrs X.
71. When I asked the Council, it had no concerns with the Care Home’s record keeping. It explained there had been regular quality assurance visits, monthly reviews of paperwork and random ‘dip samples’, none of which had raised concerns.
72. However, as explained above, I have found multiple instances of inconsistent record keeping within Mrs X’s care records. Regulation 17 of the Regulations refers to good governance. The Guidance says ‘17(2)(c) Records relating to the care and treatment of each person using the service must be kept and fit for purpose. Fit for purpose means they must be complete, legible, indelible, accurate and up to date…’ The Care Home’s record keeping was not line with the Regulations and the Council’s quality assurance checks did not identify this. This is fault.

Management of family visits

73. Mrs Y complains the Council and the Care Home failed to act in line with the Court’s directions around managing family visits.
74. In March 2023, the Court ordered ‘The local authority will seek the views of [the Care Home], family and RPR to put a formal framework in place to manage contact and communication with the care home.’
75. Mrs X’s family members had significantly different views, which made creating the visiting schedule challenging. There were various versions of the visiting plans. The schedules were shared with the family and comments invited. Then the schedule was sometimes amended to take these comments into account before the final version was shared.
76. Mrs Y complains that the schedule was changed to suit Ms A’s views only and without any further consultation. Having reviewed the records, I can see that both sides of the family were dissatisfied with the visiting plan. Mrs Y and Mrs Z raised concerns it was a ‘free for all’ which did not allow Mrs X time to rest. Other family members felt the visiting schedule was too restrictive and not in the best interests of Mrs X, who greatly enjoyed visits from all her family members.
77. The Council and Care Home had to try and propose a practical schedule which balanced Mrs X’s care needs and wishes, Mrs Y and Mrs Z’s views and the opposing views of other family members. While the family complained the visiting schedule was not reshared after changes were made, I do not think it would have been proportionate to do so. There was no requirement to have agreement from all parties before implementing the schedule. Given the significant difference of opinion, it was unlikely that any one solution would be agreed by everyone involved, no matter how many times the schedule was reshared. Mrs Y complains the changes to the schedule were biased, however I have seen evidence that various changes were made in response to comments from all parties.
78. The schedule was not always followed by all family members and this created difficulties. Mrs Y complains that the Care Home did not enforce the visiting schedule. Staff asked visiting family members to leave, if their slot was finished and other visitors had arrived. However, should that person refuse to leave, the staff could not be expected to escort people from the building.
79. I am satisfied the Council and Care Home sought the views of all parties as directed by the Court. This was evidently a difficult situation, and the records show the Council and Care Home struggled to balance the wishes of all parties. Nevertheless, I consider the Council and Care Home acted appropriately to manage Mrs X’s visits and I find no fault in this regard.
80. Mrs Y also complains about changes to the visiting schedule when Mrs X moved to end of life care. This allowed family to visit later and reduced the time between visiting slots. Mrs Y said the time was not enough to ensure Mrs X was receiving adequate care or rest.
81. The Council’s letter of 4 December 2023 explains the Care Home deemed a 15 minute rest period to be adequate, based on Mrs X’s needs and enjoyment of family visits. It explained Mrs X wouldn’t go to bed until around 9pm and it was considered in her best interests to offer family visiting up to this time. It was considered this was in line with Mrs X’s wishes to have her family with her as much as possible. Due to Mrs X approaching the end of her life, visiting times were flexible to allow Mrs X opportunities for quality time with her loved ones.
82. The daily care records confirm Mrs X usually went to bed around 9-10pm, not at 7pm as Mrs Y believed. Mrs X occasionally asked to go to bed earlier, which became more frequent in her final weeks. Mrs X’s requests were respected, and she was assisted to bed. I have seen nothing in the records to suggest that Mrs X was unhappy with the visits or prevented from resting when required. I have not found fault on this point.
83. Mrs Y complained that regular bed rest was not implemented as part of Mrs X’s pressure care. I have already addressed Mrs X’s pressure care above. I note other family members raised concerns about Mrs X being alone in bed, becoming distressed and feeling isolated. There was a need to balance the risk of pressure damage with Mrs X’s mental wellbeing and clear preference for being in the lounge area and, again, family members had conflicting views.
84. Once a Statement of Intent is in the place, the Care Home says it does not usually restrict visiting for residents. In late January 2024, the Council carried out a mental capacity assessment and made a Best Interests decision around visiting. Mrs X’s health had significantly declined and she was considered to be in her last days of life. Both the social worker and the RPR agreed that, in the circumstances, the visiting restrictions would be lifted and ‘family members expected to behave amicably for Mrs X’. I acknowledge Mrs Z was unhappy with this decision as she did not feel comfortable visiting with Ms A present. However, I consider the Council and Care Home’s management of Mrs X’s end of life visiting to have been appropriate.
85. It is not for us to take a view on whether a legal court order has been complied with. If Mrs Y had concerns about failure to comply with the Court order, it was open to her to return the matter to Court. Overall, this was a challenging and complex situation to manage. The records show the Council and the Care Home tried to take everyone’s views into account, as well as Mrs X’s best interests and preferences. I have not found fault on this point.

Communication

86. Mrs Y complains about poor engagement and communication with herself and her mother, Mrs Z. She is unhappy with the complaint handling and said it did not address all of her concerns.
87. From the records, I can see that for the most part, the Care Home updated both Mrs Z and Mrs A. However, it was not always consistent in doing so. For example, the Care Home did not notify Mrs Z that a hospice was coming to assess Mrs Z.
88. During its complaint handling, the Care Home accepted that communication was not always effective and sometimes conflicting information had been given. This would have been frustrating for Mrs Z and Mrs Y. The Care Home apologised and put a plan in place to improve communication and help ensure Mrs Z received relevant information.
89. Mrs Y complains that the Council has not answered all of her questions about Mrs X’s care and considers the Council ‘passed the buck’ to the local ICB once Mrs X became CHC funded. It is correct that, once a person becomes fully CHC funded, the Council is no longer responsible for that person’s care. The Council remained involved exceptionally to support with the visiting arrangements, due to its familiarity with the complex situation. The Council and Care Home received a substantial number of complaints from Mrs Y. It is not always possible or practical to respond to every aspect of someone’s concerns. Overall, I consider the Council’s complaint handling was proportionate. I have not found fault on this point.
90. Mrs Y complains that she was passed back and forth between the Council and the Care Home, but her repeated requests for a joint meeting was ignored.
91. I asked both the Council and the Care Home about this and receiving conflicting information. The Council said the Care Home manager did not feel able to facilitate a joint meeting.
92. The Care Home said it was actively engaging with the Council to try and arrange this however the Council would not accommodate it. Therefore, the Care Home went ahead and met with Mrs Y and Mrs X in July 2023.
93. Both the Council and the Care Home said another factor was that the Council was only responding to Mrs X’s children, and not her grandchildren. This was due to the number of children and grandchildren involved. This decision was explained to Mrs Y in the Council’s letter of 16 September 2022.
94. Having reviewed the records, I can see that, in June 2023, the social worker noted the request for a joint meeting but felt it was ‘not necessary’ as Mrs X’s care had been reviewed and the Council had no concerns.
95. The records show, in November 2023, the Care Home asked the Council about a meeting again in November 2023. The Council replied that a meeting with all siblings was ‘unlikely to be effective or productive’. The Care Home replied asking if the Council could arrange a meeting with family members separately, and if not, if it would arrange an independent meeting with family. I have not seen any reply from the Council.
96. It appears the Care Home was happy to participate in a joint meeting with the Council and Mrs Y, Mrs Z and other family members if deemed appropriate. It appears the Council did not wish to meet with any family members. The Council’s communication with the Care Home could have been better. I also have not seen anything to suggest the Council directly responded to Mrs Y’s multiple requests for a joint meeting, even if it was simply to decline. This is fault. Mrs Y has been caused frustration by the Council’s communication on this point.
97. Lastly, Mrs Y complains the Council failed to advise the CHC team that the Court proceedings had concluded until November 2023. She says this caused a significant delay to Mrs X’s CHC assessment.
98. The Council records show it contacted the ICB in April 2023 to advise Mrs X was now a permanent resident at the Care Home. While this did not explicitly state that the Court of Protection proceedings had concluded, the ICB could have asked further information if it was unsure. In July and August 2023, there were further discussions between the Council, the Deputy and the ICB about reviewing Mrs X’s FNC funding and whether Mrs X required a CHC assessment. I have not seen any evidence the Council failed to provide information to the ICB until November 2023. I have found no fault on this point.

Safeguarding

99. Mrs Y is unhappy with the way the Council handled her safeguarding concerns about alleged abuse by a family member. She says it took the Council 18 months to conclude the safeguarding investigation, leaving Mrs X exposed to the alleged abuser throughout this period which put her at risk. She disagrees with the Council’s position that visits to Mrs X were adequately supervised within the Care Home to mitigate the risks. She also says the findings about financial abuse are unsound.
100. The emotional abuse allegation was concluded prior to April 2023 and could have been considered as part of the Court of Protection proceedings. I have therefore not considered this as part of this investigation, which only considers events after the final court order. The Court would have been aware of the historic allegations when ordering that Mrs X should have contact with all family members. I note the Court order does not prevent any person visiting Mrs X or place restrictions on any family member.
101. The financial abuse allegation was ongoing during the period I investigated. Mrs X’s finances were being managed by a professional Deputy by this point. Neither Mrs X nor Ms A had access to Mrs X’s finances so there was no risk of financial abuse. The Deputy reviewed several years of Mrs X’s bank statements, both prior to her moving in with Ms A and afterwards. There were no concerns found. I have not found fault on this point.

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Agreed actions

Council and Care Home

102. Within one month of my final decision statement, the Council and the Care Home will write to Mrs Y and Mrs Z apologising for distress and uncertainty caused to them by the Care Home’s failure to support Mrs X’s continence needs in line with her care plan.
103. Within three months of my final decision statement, the Council and the Care Home will explain what action they will take to ensure the Care Home has appropriate guidance in place for care staff to provide continence care in line with a person’s care plan.
104. The Council and the Care Home will provide us with evidence they have complied with the above actions.

Council

105. Within one month of my final decision, the Council will apologise to Mrs Y for communication failings around her request for a joint meeting.
106. The Council will provide us with evidence it has complied with the above action.

Care Home

107. Within one month of my final decision statement the Care Home will write to Mrs Y and Mrs Z apologising for distress and uncertainty caused to them by the Care Home’s failings in Mrs X’s end of life care, specifically in relation to hydration management and pressure care management.
108. Within one month of my final decision statement, the Care Home will explain what action it has taken to date, or will take, to ensure it has appropriate guidance in place for care staff on maintaining “complete, legible, indelible, accurate and up to date” records in keeping with the Regulations.
109. Within three months of my final decision statement, the Care Home will:

• explain what action it will take to ensure it has appropriate guidance in place for care staff to regularly review and update a person’s care plan to ensure end of life care planning meets any rapidly changing needs; and
• explain what action it will take to ensure it provides appropriate end of life care in line with a person’s care plan and the NICE Guidance [NG31] ‘Caring for dying adults in the last days of life’.

110. The Care Home will provide us with evidence it has complied with the above actions.

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Final decision

111. I have found that fault with Mrs X’s continence care and aspects of her end of life care. I have also found fault with the Care Home’s record keeping and part of the Council’s communication with Mrs Y. As a result, Mrs X did not always receive the care she was entitled to. Mrs Y and Mrs Z have also been caused distress and uncertainty.
112. I have now completed my investigation.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman