Summary: We upheld a complaint about end-of-life care. The Care Provider will apologise and review its procedures for record-keeping.

The complaint

1. Mr X complained about the care of his late grandmother Mrs Y by the North Northumberland Hospice (the Care Provider). He complained about a care worker making unprofessional comments to family members, being rude and defensive. He also complained about the care worker spraying disinfectant in Mrs Y’s room potentially affecting her breathing and moving Mrs Y without ensuring she had pain relief first. Finally, Mr X complained the care worker removed Mrs Y’s care records when she left before the end of her shift.
2. Mr X said this caused the family avoidable distress.

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The Ombudsman’s role and powers

3. 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. (Local Government Act 1974, sections 34B and 34C)
4. 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)

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How I considered this complaint

5. I have taken the key information from the Care Provider’s internal investigation report. I spoke to Mr X about the complaint.
6. Mr X and the Care Provider 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

Relevant law and guidance

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
8. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
9. Regulation 10 of the 2014 Regulations says people using care services should be treated with dignity and respect.
10. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of clients.
11. Regulation 18 of the 2014 Regulations requires a care provider to have qualified, competent, skilled and experienced staff who have received appropriate support and training to enable them to carry out their duties.

What happened

12. Mrs Y was receiving end-of-life care in her own home following her discharge from hospital in the middle of November 2020. The complaint is about a care worker who was providing Mrs Y’s care on the night she died. Mrs Y’s family asked the care worker to leave before the end of her shift.
13. The Care Provider completed an internal investigation into Mr X’s complaint. This involved considering Mrs Y’s care records and interviewing the care worker, the district nurse and other staff working for the Care Provider and speaking to Mrs Y’s family.
14. Mrs Y’s care plans noted her pain was not well controlled. The district nurse and palliative care specialists from the NHS were involved regarding pain relief. The care plan said care workers needed to call the district nurse for an urgent review if Mrs Y had uncontrolled pain and she should only be moved if she could tolerate it. It also said Mrs Y should have pain relief before moving/repositioning by two people. When interviewed, the care worker acknowledged she should have followed the instructions on Mrs Y’s care plan, but she did not.
15. The records noted Mrs Y was showing signs of being in the last hours of her life.
16. When interviewed, the care worker said Mrs Y’s pad was wet and she needed to be changed to prevent skin breakdown and for dignity. She went on to say Mrs Y was settled and she felt a careful tilt of the bed would allow changing the pad without waking Mrs Y. The care worker said with hindsight, she should have arranged for pain relief before moving Mrs Y. She also acknowledged her comment about Mrs Y ‘soldiering on’ was inappropriate and she should not have asked another family member to help her with moving Mrs Y. The care worker said she felt intimidated by Mr X.
17. There were inconsistencies between Mrs Y’s family’s version of events and with the care worker’s records. Specifically:
• Mrs Y shouting. This was not within the notes, Mrs Y was recorded as having called out, but settling quickly.
• The care worker shouting at another relative and sharing her professional background.
18. The Care Provider’s investigation report recommended:
• The care worker was not to work alone until further notice
• She should have further moving and handling and duty of candour training and training in communication skills
• She was to undergo reflective sessions to understand:
1. Why she did not call for assistance to provide pain relief
2. Why she did not call for assistance if the environment was not conducive to providing effective care.
19. The care worker was disciplined according to the Care Provider’s policy.
20. The Care Provider reviewed its moving and handling and family support policies at the end of life. The outcome of the review said reasons for moving and handling should be to promote dignity. And judgement was to be used at the very end of life when moving a person for pressure relief was not the priority.
21. The Care Provider also arranged communication skills training for all staff and instructed staff to call for out of hours support with the district nurses no matter the time of day.
22. The Care Provider also reviewed its policies for using antibacterial spray.
23. Mr X received a copy of the report in April 2021. Unhappy with it, he complained to us.

Findings

24. The care to Mrs Y in the last hours of her life was not in line with the 2014 Regulations.
25. Mrs Y did not receive care as in her care plan and this was not in line with Regulation 9. The care plan said she should have received pain relief before repositioning and this did not happen. The district nurses should also have been involved for advice in line with Regulation 12(i) and this did not happen. The Care Provider’s report indicates Mrs Y’s care was also not in line with Regulation 10. Moving Mrs Y at this stage was not a priority as she was in her last hours of life. The priority should have been to avoid discomfort.
26. The care worker’s comments indicate she failed to seek support and guidance from her employer when she recognised a conflict between her and members of the family. This suggests a failure by the Care Provider to ensure staff were sufficiently skilled and experienced and potentially the service to Mrs Y was not in line with Regulation 18.
27. The Care Provider’s internal investigation report identified failings in its service and the care worker was subject to disciplinary action, restricted duties and retraining in the areas identified. The Care Provider also reviewed and amended relevant policies. This is a partial remedy for the injustice.
28. The fault I have identified caused avoidable distress. Within one month of this statement, the Care Provider will apologise to Mr X and the family. Within two months of this statement, it will review its procedures for record-keeping to ensure staff are clear about when to remove records from a patient’s home. I made this recommendation because the Care Provider’s report did not deal with the issue of the care worker removing Mrs Y’s care records before the end of her shift.

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Final decision

29. I uphold a complaint about end-of-life care. The Care Provider will apologise and review its procedures for record-keeping.
30. I have completed the investigation. I have shared a copy of my final decision with the CQC in line with our information sharing agreement.

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Investigator's decision on behalf of the Ombudsman