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Stalybridge care home failed to tell family their mother was dying
Wednesday 1st August 2018 @ 16:06 by Tom Greggan
News Stalybridge Tameside

A Tameside family was not able to say goodbye to their dying mother because staff at a Stalybridge care home didn’t call them in time.

The Local Government and Social Care Ombudsman found out the family was informed of the death by police, instead of staff at Oakwood Care Centre, where their mother lived.

In 2016, the Ombudsman investigated a number of concerns the family raised about their mother’s care at the home in Millbrook. Tameside Council, which placed the mother in the home, has also been criticised for the way it initially dealt with the family’s safeguarding concerns when they were raised, and the first investigation they carried out following the family’s complaints.

The family told the Ombudsman the care home neither told them about their mother’s rapid deterioration when she became unwell, nor sought medical advice about her condition until a few hours before she died.

The Ombudsman’s report found faults with the way the woman was cared for at the time of her death, including vital records going missing and care staff moving her downstairs shortly before her death – meaning she died in a wheelchair rather than in her own bed.

The care home has since come under new management, although back in March, it was rated inadequate by the Care Quality Commission (CQC) after an inspection in December 2017.

Michael King, Local Government and Social Care Ombudsman, said: “This report highlights to care homes the importance of having well thought out procedures for communicating with families about very ill relatives, and the need to seek timely medical advice, regardless of whether instructions are in place not to resuscitate.

“I would also like to remind care providers of the crucial need to maintain proper, detailed and legible records of their care for residents throughout their stay.

“Despite the problems we found with both the council and care provider, I am pleased with the mature way they have responded to our investigation, and the recommendations we have made.”

The Local Government and Social Care Ombudsman’s role is to remedy injustice and share learning from investigations to help improve public, and adult social care, services.

In this case, Tameside Council has agreed to pay the daughter £1,000 to recognise the distress she and her family suffered because of the loss of opportunity to say goodbye to her mother. It will pay a further £300 for the additional distress caused by the poor response to the family’s initial complaint, and £200 for failing to maintain full records of these events, which has prevented the family from receiving a full response to their complaints.

The Ombudsman also has the power to make recommendations to improve a council’s processes for the wider public. Therefore, Tameside Council is introducing a revised Safeguarding Adults Policy, and will provide updated training to relevant staff. It will also refresh staff understanding of how to handle safeguarding concerns.

Additionally, the council will share with care staff the Care Quality Commission (CQC) guidance on seeking medical advice.

It has undertaken training for adult social care staff on handling complaints and will share this report with staff at Oakwood Care Centre.

A Tameside Council spokesperson said: “We have taken the Ombudsman’s investigation and report extremely seriously and have quickly implemented the recommendations made to ensure any complaints are dealt with appropriately and that the services we commission at care homes are of the quality our residents deserve.  These include introducing a revised Safeguarding Adults Policy, providing updated training to relevant staff and ensuring that they have a clear understanding of how to handle safeguarding concerns.

“We appreciate the Ombudsman’s approval of our response to the report and would like to reassure residents that what has been learnt from the recommendations will be widely shared.  We have been working closely with the care home’s new manager, providing significant support through our Quality Improvement Team and we are regularly monitoring their progress at our Strategic Commissioning Board.”

As part of future contracts for care it commissions, the council will require care homes to agree with residents’ families the level of notification they would like about changes in their condition, and record this in the resident’s care plan.

Oakwood Care Centre has also undertaken a number of service improvements. It has introduced a new ‘Unexpected Death Policy and Procedure’, and staff will be required to sign to confirm they have read it.

It has introduced new care plans, which clearly indicate whether resuscitation should be attempted. The manager and deputy manager are now ‘safeguarding adult’ managers and it will shortly review its process for notifying families of changes in the health of relatives.