Summary: We found fault with the end of life care provided to Mrs Y by the Nursing Home. The Nursing Home pay Mrs Y’s daughter, Ms X, a symbolic financial remedy in recognition of the distress this caused.

The complaint

1. Ms X is complaining about the care provided to her mother, Mrs Y, by Oak Lodge Nursing Home (the Nursing Home). The initial period of Mrs Y’s placement was funded under the Discharge To Assess (D2A) process. Hampshire County Council (the Council) was responsible for social care services provided by the Nursing Home during that period.
2. Ms X complains the Nursing Home failed to provide her mother with appropriate end of life care. She says the Nursing Home:

• failed to plan Mrs Y’s care appropriately;
• did not make Mrs Y comfortable;
• did not treat Mrs Y with compassion and consideration;
• failed to provide appropriate nutritional care
• failed to manage Mrs Y’s medication appropriately;
• did not set up a syringe driver for Mrs Y;
• failed to contact her when Mrs Y was in distress; and
• did not allow her time to arrange for a minister to attend when Mrs Y died.

3. Ms X says her mother was left to suffer at the end of her life and this caused her great distress. Ms X says the way the Nursing Home behaved following Mrs Y’s death made the situation much worse and caused her further trauma.

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The Ombudsmen’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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).
5. 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.
6. If we are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, we can complete our 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)
7. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 

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How I considered this complaint

8. In making my final decision, I considered information provided by Ms X and discussed the complaint with her. I also considered relevant information from the Council and Nursing Home, including copies of the care records. In addition, I took account of relevant guidance and legislation. I invited comments on my draft decision statement from all parties and considered the responses I received.

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What I found

Relevant guidance and legislation

End of life care

9. In 2019, the National Institute for Health and Care Excellence (NICE) issued the clinical guideline ‘End of life care for adults: service delivery [NG142]’. This provides guidance health and social care professionals on organising and delivering end of life care services. The guideline deals with providing care and support in the final weeks and months of life and the planning for this. It aims to ensure people have access to the care they want and need in all care settings. It also includes advice on services for carers.
10. The guideline recommends the importance of coordinating care services to meet a person’s needs and ensuring care staff have the skills to provide effective care.

Care Act - Safeguarding

11. Section 42 of the Care Act 2014 says that a council must make necessary enquiries, or cause others to do so if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. The council must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.

Background

12. Mrs Y had several long term health conditions, including heart failure and poor kidney function.
13. In October 2021, Mrs Y was discharged to a care home under the D2A process. following a period of treatment in hospital. A palliative care doctor reviewed her on 6 October. The doctor completed a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) for Mrs Y. This is a plan intended to create a summary of recommendations for a person’s clinical care in a future emergency.
14. Mrs Y was discharged to a residential care home under the D2A process. However, the care home was unable to meet Mrs Y’s care needs. In December, Ms X arranged for Mrs Y to be transferred to the Nursing Home.
15. Mrs Y was transferred to the Nursing Home later that month.
16. The care records show Mrs Y was generally settled and eating relatively well. However, remained frail due to her long-term health conditions.
17. In early February, Mrs Y asked to see a GP as her ankles and legs were swollen.
18. A GP visited Mrs Y the following day. The GP prescribed an antibiotic. GP advised Nursing Home staff to contact emergency services if Mrs Y experienced shortness of breath, due to her complex heart failure.
19. On the same day, a member of Nursing Home staff explained to Ms X that Mrs Y’s heart failure was progressing and that her kidney function had deteriorated.
20. By early March, the care notes show Mrs Y remained very frail. However, she was still able to eat and drink with assistance and was able to make her wishes known to staff. However, Mrs Y’s appetite deteriorated over the following days, and she was considered to be at the end of her life.
21. A GP visited Mrs Y on 13 March and arranged for a catheter and syringe driver.
22. Mrs Y died on 14 March 2022.
23. Later that month, Ms X provided the Council’s safeguarding team with a written summary of her concerns. Section 42 of the Care Act 2014 did not apply as Mrs Y had died. However, the Council decided to undertake discretionary enquiries.
24. The Council made enquiries with the Nursing Home and took clinical advice from the local Integrated Care Board (ICB).
25. In June 2023, Ms X met with the Council and Nursing Home to discuss her concerns. The meeting agreed the Nursing Home would produce an action plan to address some of these concerns.
26. In July, the Nursing Home produced its first action plan. The Council visited the Nursing Home later that month. This led the Council to ask the Nursing Home to produce a revised plan.
27. In September, the Nursing Home produced the revised plan.
28. In October, the Council found the Nursing Home’s action plan successfully addressed concerns about the care provided to Mrs Y. The Council then closed the case to safeguarding.

My analysis and findings

Care planning

29. Ms X says the Nursing Home delayed in completing an appropriate care plan for Mrs Y. Ms X said she did not have an opportunity to go through Mrs Y’s care plan, even though she held Lasting Power of Attorney (LPA). Ms X said this meant important instructions from the palliative care doctor were not reflected in the care plan. This included instructions around anticipatory medications (sometimes also known as ‘just in case’ medications) and the fact that Mrs Y was not to be readmitted to hospital.
30. Mrs Y was admitted to the Nursing Home on 14 December 2021. I understand the Nursing Home completed an assessment of her needs on 6 January 2022. Ms X said she repeatedly asked for the care plan to be discussed with her but was ignored or given excuses. The subsequent care plan provided to me by the Nursing Home was dated 18 February 2022. This was over two months after Mrs Y’s admission. I accept part of this delay was attributable to the need to quarantine new residents during the pandemic. Nevertheless, this does not fully explain the delay. This was fault on the part of the Nursing Home.
31. The decision not to include Ms X in the care planning process meant important information was omitted from the care plan. For example, the care plan did not reflect Ms X’s conversation with the palliative care doctor in October 2021 or the resulting ReSPECT form. This contained relevant information for the management of Mrs Y’s medications and whether she should be readmitted to hospital as her condition deteriorated. These were potentially important omissions and represent further fault by the Nursing Home.
32. I accept Mrs Y was not considered to be at imminent risk of death when she entered the Nursing Home. I also acknowledge that Mrs Y was reviewed by a GP regularly during the early part of her time there and that her condition remained relatively stable initially. Further, there is evidence to show Mrs Y’s daughters remained in contact with the Nursing Home during this period.
33. Nevertheless, the NICE guidelines emphasise the importance of effective care planning in the final weeks and months of a person’s life. The evidence I have seen suggests there was some confusion regarding Mrs Y’s care in the final week of her life. This might have been avoided with more comprehensive care planning.
34. This matter was also considered as part of the Council’s safeguarding enquiries and addressed in the Nursing Home’s action plan of September 2023. This set out that care planning would begin as soon as possible following the four-week quarantine period. This planning process would involve the resident’s relatives where appropriate. The action plan also set out that each resident would be allocated a nurse to complete regular care plan reviews.
35. This represents appropriate action by the Nursing Home to reduce the risk of similar problems occurring in future.

Leaving Mrs Y in her chair

36. Ms X said Nursing Home staff failed to make Mrs Y comfortable in bed and, instead, left her to sit in a chair where she was uncomfortable. Ms X said she was eventually able to assist Mrs Y into bed and she was subsequently much more comfortable.
37. The care records show Mrs Y was experiencing significant fluid retention around her torso. This was a result of her advanced heart failure. Mrs Y spent much of her time in her chair. The Nursing Home said this was because there was a risk of her slipping down in bed when she needed to remain upright. However, Ms X spent time with Mrs Y in her room and said she often complained of being uncomfortable in her chair.
38. Ms X said she eventually managed to persuade staff to assist Mrs Y to bed on 3 March. Ms X said she remained comfortable until her death on 14 March.
39. There were risks associated with caring for Mrs Y in bed. Sleeping in an incorrect position (such as on her side or flat on her back) would have increased the risk of further fluid build-up. It may also have increased Mrs Y’s breathlessness. These factors needed to be balanced against Mrs Y’s preference to be cared for in bed.
40. I found no evidence to suggest the Nursing Home properly assessed this aspect of Mrs Y’s care needs. Further, there is no record of any earlier discussion with Mrs Y or Ms X about how to manage this aspect of Mrs Y’s care. This would have allowed for a proper exploration of Mrs Y’s needs and wishes. It would also have presented an opportunity to consider whether other measures were available to make Mrs Y comfortable in bed. These omissions represent fault by the Nursing Home.
41. This caused Mrs Y and Ms X distress.
42. As above, I am satisfied the improvements made by the Nursing Home to its care planning are appropriate. This includes the allocation of a nurse to each resident to review care plans.

Catheter care

43. Ms X also complained that Nursing Home staff delayed in fitting a catheter for Mrs Y, leaving her in unnecessary pain and discomfort. Ms X says that, when a catheter was eventually fitted, it drained two litres of urine.
44. The Nursing Home told me that it tries to avoid using a catheter until necessary. This is because catheterisation carries an increased risk of infection. The Nursing Home said Mrs Y continued to pass urine up to 12 March. It said a catheter was fitted the following day as prescribed by a GP.
45. The care records show care workers were assisting Mrs Y to use the toilet during the early part of her admission. Care staff noted that Mrs Y continued to eat and drink reasonably well.
46. Mrs Y became frailer in early March. However, care staff continued to change her incontinence pads regularly. Mrs Y continued to drink regular fluids. A GP reviewed Mrs Y on 7 March and did not identify the need for a catheter.
47. Mrs Y’s condition began to deteriorate over the following days. On 12 March, Ms X was staying with Mrs Y in her room. That day, Mrs Y was noted to be in significant pain. Ms X asked the care staff to call a doctor using the NHS 111 service. The doctor recommended further medication.
48. Throughout the night, Ms X said Mrs Y continued to complain of pain in her abdomen and said she needed to urinate. Ms X said Mrs Y could only pass a small amount of urine when using a bedpan.
49. At 9.14am on the morning of 13 March, Mrs Y was noted to have passed around 500ml of urine. However, she was unable to pass urine again. An out of hours doctor visited Mrs Y that afternoon and prescribed a catheter. This drained around two litres of urine.
50. The Nursing Home is correct to say there are risks associated with insertion of a catheter. This includes the increased risk of infection. This would have been a serious consideration for Mrs Y as she was so frail.
51. There were other factors to consider, though. Mrs Y was taking diuretic medication (sometimes known as water pills). These can be used to treat heart failure and fluid build-up. They are intended to help a person pass water through their urine. This means a person is more likely to need to pass urine frequently. In turn, this makes urinary retention a greater risk. This was not recorded as a risk factor in Mrs Y’s care plan. This was an important omission and represents fault.
52. The care records show that, for much of her admission, Mrs Y was passing urine frequently and maintained good fluid intake. However, by the afternoon of 12 March, Mrs Y was noted to be in abdominal pain and discomfort. Ms X said this continued throughout the night.
53. I cannot say whether Mrs Y’s pain on 12 March was due to urine retention. This is because her care needs were complex by this point, and she was very unwell.
54. Nevertheless, a more comprehensive care plan would have enabled care staff to explore whether a catheter was indicated sooner than they did. The lack of an effective care plan is further evidence of fault. As above, the improvements subsequently made by the Nursing Home to its care planning should address this.
55. However, I recognise this caused Ms X unnecessary distress and uncertainty.

Compassion and consideration

56. Ms X said staff acted without care and compassion. She described an occasion when two members of staff assisted Mrs Y to use her commode and left her in her room in a state of breathlessness and great distress. Ms X also said staff made her feel unwelcome when staying with Mrs Y.
57. The first incident Ms X refers to took place on 6 March. The complaints correspondence shows there was some dispute as to what had occurred. Ms X said Mrs Y was in great distress and queried why the care workers had left her in that state. The care workers involved did not feel Mrs Y was distressed when they left her.
58. I cannot say, even on balance of probabilities, what happened. This is because there is no further independent evidence to assist me. Nevertheless, this was evidently a distressing moment for Ms X at what was already a very difficult time.
59. I note this was addressed through the Council’s safeguarding enquiries. As a result, the Nursing Home discussed Ms X’s concerns with all care staff through supervision. In addition, the Nursing Home completed a wider review its end of life care procedures. This, along with the improvements to care planning I have highlighted above, should reduce the risk of further incidents occurring in future.
60. I now turn to the other incident. Ms X said the Nursing Home manager informed her that she could visit Mrs Y in her room for as long as she wanted.
61. However, on 9 March, Ms X said staff told her Mrs Y was not in the last 24-hours of her life. They said would not expect family to stay until that point. I found no record of this conversation in the care notes. This contradicted what she had been told by the manager. Again, there is no record of this conversation.
62. I am satisfied, on balance of probabilities, that this incident happened as described by Ms X. This is because Ms X emailed the Nursing Home manager the same day with a detailed account. This demonstrated a lack of compassion for Ms X. This was fault.
63. This caused Ms X and Mrs Y further unnecessary distress.
64. In its complaint response, the Nursing Home apologised that Ms X and Mrs Y did not experience the level of service they were entitled to expect. The Nursing Home also apologised that Ms X was made to feel unwelcome. In my view, these apologies represent a proportionate remedy for the distress caused to Ms X by this incident.

Nutritional care

65. Ms X said the Nursing Home continued to pressure Mrs Y to eat, even when she made it clear she did not want to. She queried whether this was done to control Mrs Y’s blood sugar levels.
66. The care records show Mrs Y’s appetite and nutritional intake remained relatively good for the early part of her admission. As her condition deteriorated, her appetite reduced. This is normal for a person who is approaching the end of their life.
67. Ms X was concerned that staff were offering Mrs Y bananas and biscuits at bedtimes. She said Mrs Y found having a full stomach painful because of fluid retention around her torso caused by her heart failure. Ms X said she spoke to the Nursing Home manager about this several times but that nothing changed.
68. Ms X said it was only when she emailed the Nursing Home manager that the situation changed.
69. The Nursing Home addressed this in its response to the safeguarding enquiries. It said a person’s condition can fluctuate and that they may feel more like eating on some occasions than others. As a result, the Nursing Home said it always offers residents food to encourage them to eat. However, the Nursing Home acknowledged that it is important to recognise when to stop offering food, such as when a person is very near the end of their life. The Nursing Home said it had addressed this with care staff through training and supervision.
70. The Council’s safeguarding enquiries identified the importance of ensuring that a person’s preferences for food and drink are properly recorded. This is important to person-centred care.
71. I accept this was a frustrating situation for Ms X and Mrs Y. However, I do not consider it so significant an issue as to warrant a finding of fault. In my view, the improvements the Nursing Home has made to its care planning should reduce the risk of problems like this occurring in future.

Medication – failure to administer

72. Ms X said the Nursing Home failed to administer Mrs Y’s prescribed medication. This included medication to treat Mrs Y’s constipation and her anticipatory (sometimes also known as ‘just in case’) medication. This would usually include medications such as pain relief or anti-sickness drugs.
73. The care records suggest that Mrs Y was not taking medication to treat constipation for the early part of her admission. However, Mrs Y seems to have been passing regular bowel movements and maintained a good appetite. During this period, Mrs Y was reviewed three times by GPs. These consultations did not identify any problems with constipation.
74. On 28 February, Mrs Y was seen again by a GP. On this occasion, the GP prescribed a medication to treat constipation. The care records show Mrs Y sometimes refused this medication. However, staff continued to administer the medication until 13 March, by which point Mrs Y was very unwell.
75. I found no fault with regards to the care provided by the Nursing Home in this area.
76. As explained above, a palliative care doctor first reviewed Mrs Y in October 2021. At that stage, the doctor said he would contact Mrs Y’s GP to arrange anticipatory medication. It is not clear from the evidence available to me whether the doctor did so.
77. However, in February 2022, shortly after Mrs Y’s admission, Ms X wrote to the Nursing Home manager to make her aware of the consultation. There is no evidence to suggest the Nursing Home followed up the anticipatory medication with a GP at that stage.
78. Mrs Y was seen by a GP on 7 March. This consultation found Mrs Y was now at the end of her life. Again, there is no evidence that any anticipatory medications were arranged. Indeed, it was not until Ms X spoke to a GP on 12 March that this was done.
79. This delay meant the medications were not available for Mrs Y when her condition began to deteriorate around 10 March. This delay might have been avoided if arrangements for Mrs Y’s end of life care had been more clearly reflected in her care plan. As above, this reflects a failure in care planning by the Nursing Home.
80. This caused Ms X additional distress as she was concerned Mrs Y was in pain and discomfort unnecessarily.
81. This situation was exacerbated by subsequent confusion between the pharmacy and the Nursing Home. This is because the anticipatory medications were labelled incorrectly as for administration by syringe driver. As a result, the duty nurse said she could not administer them. The situation was not resolved until the following morning when the shift changed.
82. The Nursing Home acknowledged this should not have happened and that there was no reason to delay administering the medication. The Nursing Home said the nurse in question could have called the out of hours GP to clarify this.
83. I am satisfied the Nursing Home has addressed this matter appropriately. Mrs Y’s care has been subject to scrutiny by the Council’s safeguarding investigation and the ensuing Nursing Home action plan. This sets out significant improvements to the Nursing Home’s end of life care that should benefit future residents.

Medication – stopping unnecessary medications

84. Ms X said the Nursing Home failed to stop other medications even when there was no longer any benefit to her taking them.
85. The Nursing Home explained that the decision on when to stop medication can be a complex one. Nevertheless, it recognised the importance of stopping medication when it was no longer beneficial.
86. Mrs Y multiple health condition meant she was taking several medications regularly. The notes show that, by 10 March, Mrs Y’s nutritional intake had started to reduce. Staff continued to administer Mrs Y’s oral medications during this period. On 12 March, staff noted that Mrs Y had twice vomited large quantities of brown fluid. This is known as ‘coffee ground vomit’ and indicates internal bleeding. Staff noted Mrs Y was “very ill”. Despite this, staff continued to administer the oral medication. Ms X said she witnessed Mrs Y vomit more than the two times recorded by staff.
87. The Nursing Home manager spoke to an out of office doctor regarding Mrs Y’s insulin medication that day. However, the manager did not seek any advice about her other medications and whether to stop them. Nor did the Nursing Home consult with the local palliative care service.
88. It is correct for the Nursing Home to say that it is not always possible to be precise about when a person is nearing the end of their life. Nevertheless, the palliative care team or GP would have been able to offer specialist advice and support. The Nursing Home’s failure to seek this specialist input was fault.
89. I am unable to say whether Mrs Y’s medication would have been stopped even if the Nursing Home had sought specialist advice. However, this situation was clearly very distressing for Ms X.
90. I am satisfied the Nursing Home’s action plan makes provision for more consultation with specialist end of life care. This includes a weekly review with the palliative care team and the hospice community team. I am satisfied this should help improve end of life care at the Nursing Home.

Medication - Syringe driver/morphine

91. Ms X said the Nursing Home failed to arrange a syringe driver, as prescribed by a GP.
92. In its response to the Council’s safeguarding enquiries, the Nursing Home said it did not consider the syringe driver to be an appropriate option for Mrs Y. This was due to problems she was experiencing with fluid retention.
93. An out of hours doctor saw Mrs Y late in the morning of 13 March, noting that she “[n]eeds urgent syringe driver” to administer additional pain relief.
94. The records suggest that there was then some confusion and delay. Ms X spoke to a nurse that afternoon who told her Nursing Home would be unable to call the district nursing service for assistance until the medication was on the premises.
95. When Ms X’s sister arrived with the medication at around 4.30pm, the nurse said she felt the syringe driver would no longer necessary. She said Mrs Y was now settled and would find a syringe driver uncomfortable. Ms X said the nurse in question administered the medication subcutaneously (under the skin) at around 6.30pm. This was recorded as 7.20pm in the records.
96. Ms X said Mrs Y slept comfortably until around 1.30am, when she began to show signs of distress. However, the nurse on duty refused to administer further medications. Ms X said she was eventually able to persuade a different nurse to administer the medication. This was recorded at 5.40pm. Mrs Y died shortly after 7.00am.
97. As above, there appears to have been considerable confusion surrounding the administration of Mrs Y’s medication and the use of the syringe driver. This meant Mrs Y did not receive her anticipatory medications when she should have. This is fault by the Nursing Home.
98. This caused Ms X further distress as she was present when many of these events were taking place.
99. The Council’s safeguarding enquiries also identified these problems. The Council found Nursing Home staff required additional training in the use of the syringe driver. This was subsequently provided by the local ICB.
100. In addition, as I have already explained, the Nursing Home’s action plan outlined further improvements. These included improved consultation around end of life medication. These are appropriate measures given the failings in the care provided to Mrs Y.

Communication with the family

101. Ms X said a nurse told her Mrs Y had been sick and in distress on 10 and 11 March. The nurse said she had asked the Nursing Home manager to call Ms X so she could visit to support Mrs Y. Despite this, Ms X said nobody called her. She said Mrs Y was left alone and in distress unnecessarily.
102. Mrs Y’s care plan clearly records that Ms X was happy to be contacted at any time if Mrs Y’s condition deteriorated. The evidence shows staff were aware of the family’s wishes. A nurse to spoke to one of Mrs Y’s daughters on 9 March to reassure her that they would call if Mrs Y’s condition changed.
103. The care records suggest Mrs Y’s condition was relatively stable during 10 and 11 March. On the afternoon of 11 March, the Nursing Home manager spoke to Ms X to reassure her that she could visit Mrs Y at any time and with no time limit.
104. Mrs Y was becoming frailer by this point. However, I found no evidence to suggest she was vomiting or in distress until 12 March.
105. It is important to note that Mrs Y was resident in the Nursing Home during the COVID-19 pandemic. This placed great pressures on staff time and their ability to communicate with families. Nevertheless, the evidence I have seen shows staff made efforts to keep the family informed. Once Mrs Y’s condition deteriorated significantly, the manager informed Ms X so she could stay with her.
106. I found no fault by the Nursing Home on this point.

Arrangements following Mrs Y’s death

107. Ms X said Nursing Home staff acted in an inconsiderate manner when Mrs Y died. She said care workers did not allow her any time to sit with Mrs Y and instead immediately began to make arrangements. Ms X said a member of staff told her Mrs Y’s body had to be moved within three hours and there was not enough time for her to arrange for a minister to attend.
108. In its response to Ms X’s complaint, the Nursing Home said it did not have a policy in place stating that a body should be removed within three hours. The Nursing Home apologised for the impersonal way in which staff had communicated this to Ms X. The Nursing Home also said it would address these comments directly with the staff member concerned. This was clear evidence of insensitive communication and represents fault by the Nursing Home.
109. This caused Ms X further distress at a very difficult time.
110. In my view, the Nursing Home’s apology was an appropriate response. This matter was further addressed in the nursing Home’s action plan. This set out that end of life residents would receive visits from hospice support staff. In addition, a minister attends regularly to and can visit residents as required. These measures should improve the support offered to residents and families.

Summary

111. My investigation identified fault with several aspects of the care provided to Mrs Y. These events caused Ms X significant and unnecessary distress. I have made a recommendation below to reflect this.
112. However, it is important to note that Mrs Y’s care has already been subject to scrutiny by the Council and ICB as part of the safeguarding enquiries. These enquiries identified many of the same concerns.
113. This led to the Nursing Home producing an action plan to address concerns about the quality of end of life care at the placement. For the reasons I have explained above, I am satisfied this action plan was robust and appropriately addressed these concerns. For this reason, and given that over two years have now passed since these events occurred, I have not made any further recommendations for systemic remedies to the Nursing Home.

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Agreed actions

114. In response to my enquiries, the Nursing Home offered to reimburse the family £1,525.00. This is intended to be a symbolic recognition of the distress caused to Ms X by these events.
115. In my view, this represents an appropriate financial remedy for the distress caused to Ms X by the fault I identified. The Nursing Home should pay this remedy within one month of my final decision.
116. The Nursing Home should provide us with evidence it has complied with the above action.

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Final decision

117. I found fault by the Nursing Home in terms of the care provided to Mrs Y, particularly in the final part of her time in the placement. I am satisfied the recommendation above represents a proportionate remedy.
118. I found no fault by the Council for the social care services provided to Mrs Y during the first three weeks of her placement under the D2A process.
119. I have now completed my investigation on this basis. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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Investigator's decision on behalf of the Ombudsman