Summary: A care home, acting on behalf of the Council, acknowledged an initial oversight in having a bathing/showering plan in place for Mrs Y before the complaint came to this office. It verbally apologised to her daughter and took action to remedy the situation. There is no further remedy required from this office. There is no evidence to show the care home delayed seeking medical assistance for Mrs Y.

The complaint

1. Mrs X complains about the quality of care provided to her late mother, Mrs Y, in a residential care home. The placement was arranged and funded by the Council.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. 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

4. I have:

• considered the complaint and discussed it with Mrs X;
• considered information the Council and the care home provided to this office;
• taken account of relevant legislation;
• offered Mrs X, the Council, and the care home an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

5. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.

Background

6. Mrs Y was in her nineties. She went into the care home on 13 January 2025 and was resident there for approximately six weeks. The placement was arranged and funded by the Council.
7. I have had sight of the needs assessment and care plan completed by the Council prior to Mrs Y’s admission to the care home, both documents are completed appropriately and without fault. A mental capacity assessment was also completed, this concluded Mrs Y to have fluctuating capacity, confusion, and reduced cognition. Again, these documents are completed without fault.
8. Mrs X says for the first two weeks after Mrs Y’s admission all seemed well. Mrs X then went on holiday and was away for two weeks; it was on her return concern began. She says Mrs Y appeared low in mood, had food on her clothing and appeared generally unkempt. Mrs X spoke to care staff, and it became apparent Mrs Y had not had a bath or shower since entering the care home. Mrs X says the manager said she would investigate and remedy the situation immediately. Mrs X was particularly concerned about a lack of hygiene as Mrs Y had a suprapubic catheter and was prone to urine infections.
9. Later that evening, Mrs X received a call from Mrs Y, she was in much better spirits and confirmed care staff had supported her to shower.
10. Mrs X says the manager of the care home contacted her two days later to confirm there had been no bathing/showering plan in place for Mrs Y and offered a verbal apology.
11. As time progressed Mrs Y complained of feeling tired, appeared sleepy and seemed ‘out of sorts’. She wanted to remain in bed and was not eating and drinking as she had previously. She also appeared to be struggling to ‘catch her breath’. Mrs X says she alerted care staff on numerous occasions. She says she was present when a carer ‘forced’ her mother to drink some tea.
12. Mrs X also says there were issues with Mrs Y not having the correct medication. She believes there was a delay in the care home obtaining prescription medication for Mrs Y.
13. Mrs Y was admitted to hospital on 2 March 2025. A chest infection was diagnosed and antibiotics commenced. On 4 March 2025, Mrs X informed the care home that Mrs Y had sepsis and was receiving end-of-life care.
14. Mrs X believes the care home delayed seeking medical attention for Mrs Y. She believes this and a subsequent delay in Mrs Y’s admission to hospital contributed to her death.

Information from the Council / care home

15. The Council provided all the care records completed by the care home for the duration of Mrs Y’s stay. This includes notes of all medical advice and intervention the care home sought for Mrs Y.
16. The records confirm Mrs Y was seen by a GP and/or a district nurse on ten occasions between 27 January 2025 & 2 March 2025, when Mrs Y was admitted to hospital. Mrs Y did experience a blocked catheter and was re-catheterised by the district nurse, who also took a blood sample for testing. Mrs Y’s temperature and blood pressure were checked, along with ‘listening to her chest, all of which were within normal parameters. A sample of urine was taken for analysis and antibiotics prescribed for suspected infection. Three days after commencing antibiotics, Mrs Y saw the GP again and further treatment was prescribed. Two days later Mrs Y had not improved and appeared more unwell, so the care home called an ambulance. The attending paramedics could find no obvious cause for Mrs Y’s presentation but understood the concerns and transferred her to hospital, where she was prescribed further antibiotics.
17. In respect of personal care, the care home’s records confirm no bath/shower was offered to Mrs Y between 13 January & 18 February 2025. However, she was supported to wash and assisted with nail and mouth care. Mrs Y did on occasions refuse support. On 18 February 2025, there is entry in the records which says, “spoken to [Mrs X] reassured her things in place to ensure [Mrs Y] does not get left to do personal care”. From 18 February 2025 onwards, the records show occasions Mrs Y was offered a shower, and whether she refused or accepted.

Complaint to the Council

Mrs X submitted a formal complaint to the Council. The Council responded on 16 December 2024. Its response included some issues not dealt with in this complaint. In respect of issues relating to the care provided to Mrs Y, the Council said it had addressed this directly with the care home and the care home would respond to Mrs X directly.

18. The care home company wrote to Mrs X setting out its findings. The author of the letter said, “apart from two days when there was no log and two days in which she refused, mum was supported with washing and dressing, on reading her care plan, it does recognise some anxiety around using the shower”.
19. The author then set out the lessons learnt, and the subsequent action/improvements it intended to implement:

• Bath /Shower for new residents to be added to planned care on admission to the home.
• When taking residents observations to ensure all details are recorded in care notes.
• Remind staff to ensure detailed entries into care notes are recorded of conversations with family member.

20. Mrs X was dissatisfied with the care home’s response believing it did not address all her concerns.
21. The care home provided Mrs X with a final response on 8 April 2025 reiterating its position of its initial response. The author of the letter noted Mrs X had submitted a subject access request to Mrs Y’s GP which would provide information relating to medical intervention the care home sought for Mrs Y.

Analysis

22. There is no evidence of any delay by the care home in seeking medical assistance for Mrs Y. It is unfortunate that neither the care home nor the Council provided Mrs X with information which details the medical assistance sought, and which she received. Had the care home provided such information to Mrs X, it may have allayed her fears and avoided any uncertainty. After receiving information about this from this office Mrs X was satisfied with the care home’s actions.
23. The records do show some delay with prescription medication being available for Mrs Y, but this was not through any fault of the care home. The delay related to issues with Mrs Y’s registration at a local GP surgery, which a GP contacted the care home about on two occasions after which a prescription was obtained.
24. In respect of personal care provided to Mrs Y, there is no evidence that bathing/showering was offered to Mrs X between 13 January & 18 February 2025.This supports Mrs X claim that the care home initially failed to implement a bathing/showering plan for Mrs Y, as does the recommendations implemented by the care home; a matter the care home’s complaint response failed to address. Had it done so, Mrs X may have been more reassured her complaint had been properly considered. However, the author of the complaint response letter was correct in saying there was evidence to show Mrs Y was offered and/or supported with washing, and that on occasions she refused.
25. The care home manager verbally apologised to Mrs X for the failure to have a bathing/showering plan in place for Mrs Y. Overall, given Mrs Y was offered support to wash, I consider the verbal apology and actions taken by the care home adequate. There is no need for further recommendations from this office.

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Final Decision

26. The care home acknowledged an initial oversight in having a bathing/showering plan in place for Mrs Y before the complaint came to this office. The care home manager verbally apologised to Mrs X at the time the issue was raised and took action to remedy the situation. There is no further remedy required from this office.
27. There is no evidence to show the care home delayed seeking medical assistance from Mrs Y.
28. It is on this basis; the complaint will be closed.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman