Summary: Ms B complained on behalf of Mr & Mrs C about the care they received from Four Seasons (No 9) Ltd when it operated a care home they were both resident at; in Mrs C’s case with that care provided on behalf of the Council. We uphold the complaints, finding no evidence the Care Provider considered Mr or Mrs C’s need for contact with each other (or between Mr C and his wider family), after they moved to rooms on different floors of the care home. The Care Provider also failed to sufficiently communicate a decline in Mr C’s health before he died. There were also some failings in its management of Mrs C’s diet and nutrition. These failings have caused distress. The Council and Care Provider accept these findings. At the end of this statement, we set out the action they have agreed to take to remedy that injustice.

The complaint

1. I have called the complainant ‘Ms B’. She is the grandchild of Mrs C and her late husband, Mr C, who both received care at Cypress Court (‘the care home’) formerly operated by Four Seasons (No 9) Ltd (‘the Care Provider’). Ms B’s complaint is the Care Provider:

• did not do enough to communicate with Mr C’s family about his health and wellbeing while he was resident at the care home, especially in the final days of his life in January 2021. We have registered this as a complaint against the Care Provider as Mr C was funding his own care at that time;
• did not do enough to facilitate contact between Mr & Mrs C after they moved to rooms on different floors of the care home. Nor did it do enough to facilitate contact between Mr C and his wider family. We have registered this as a complaint against both the Care Provider and the Council as Mr C funded his own care at the time, while the Care Provider gave care to Mrs C on behalf of the Council, which funded her placement;
• did not have adequate infection control which may otherwise have prevented Mr C contracting COVID-19, from which he subsequently died. We have registered this as a complaint against the Care Provider;
• did not properly manage Mrs C's nutrition needs leading to a loss of weight. We have registered this as a complaint against the Council as the Care Provider was giving care on behalf of the Council which funded Mrs C’s placement.
• responded poorly to her complaints. We have registered this as a complaint against both the Care Provider and the Council.

2. Ms B says as a result of the above Mr C’s family believes he may not have contracted COVID-19 and that both he and they suffered unnecessary distress because of the circumstances surrounding his death. Mrs C has also suffered unnecessary distress through the Care Provider providing a poor quality of food and not meeting her dietary needs or preferences.

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The Ombudsman’s role and powers

3. We investigate complaints about Council ‘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)
4. We also 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)
5. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
6. This complaint involves events during the Covid-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether councils and care providers followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to Covid-19.” While we anticipate a temporary impact on the capacity for councils to deal with complaints, we still expect them to deal effectively with the most serious issues.
7. If we are satisfied with a 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

8. Before issuing this decision statement I considered:

• Ms B’s written complaint to the Ombudsman and any additional information she provided;
• correspondence Ms B had with the Care Provider before making her complaint to the Ombudsman where she raised her concerns;
• information provided by the Council and Care Provider in reply to our enquiries;
• relevant law and guidance where referred to in the text below.

9. I also gave Ms B, the Council and Care Provider a draft decision statement setting out my proposed thinking about the complaint. I took account of any comments made in response before finalising this statement and completing my investigation.
10. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share our final decision with the CQC.

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What I found

Relevant Law and Guidance

The fundamental standards

11. 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) issues guidance on meeting the regulations (the Fundamental Standards.) The Ombudsman considers the Regulations and the Fundamental Standards when determining complaints about poor standards of care.
12. I consider the following Regulations relevant to this complaint.

• Regulation 9 – this says the care and treatment given by care providers must reflect a resident’s needs and preferences.
• Regulation 14 – covers nutritional and hydration needs. This says providers must ensure people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. This is to reduce risks of malnutrition and dehydration.
• Regulation 16 – covers complaint handling. Care providers must have accessible complaint procedures.
• Regulation 17 - covers good governance which includes record keeping. Providers should maintain accurate, complete and contemporaneous records for all users of services, including a record of the care and treatment they receive.

The Human Rights Act 1998

13. The Human Rights Act 1998 brought the rights in the European Convention on Human Rights into UK law. Public bodies, including councils, must act in a way to respect and protect human rights. It is unlawful for a public body to act in a way which is incompatible with a human right. (Human Rights Act 1998, section 6)
14. Care Providers act as public bodies for the purposes of the Human Rights Act when they provide care or support if:

• the care or support is arranged or paid for (in part or full) by a council; and
• the care is arranged or provided under sections 2,18,19,20,38 or 48 of the Care Act 2014 (Section 73 Care Act 2014)

15. It is not our role to decide whether a person’s human rights have been breached.  This is for the courts. We decide whether there has been fault causing injustice.  Where relevant, we consider whether a council has acted in line with legal obligations in section 6 of the Human Rights Act. We may find fault where a council or care home acting on its behalf, cannot evidence it had regard to a person’s human rights or if it cannot justify an interference with a qualified right.
16. The Act sets out the fundamental rights and freedoms that everyone in the UK is entitled to. Article 8 protects your right to respect for your private life, family life, your home and your correspondence.
17. Article 8 is qualified which means it may need to be balanced against other people’s rights or those of the wider public. A qualified right can be interfered with only if the interference is designed to pursue a legitimate aim, is a proportionate interference and is necessary. Legitimate aims include:
• the protection of other people’s rights;
• national security;
• public safety;
• the prevention of crime; or

• the protection of health.

Background to events covered by this complaint

18. Before the events covered by this complaint Mr and Mrs C lived in their own home, having been married for around 50 years. For different reasons they were both admitted to hospital in September 2020. On discharge, they were both moved to the care home at the centre of this complaint. Both had physical disability but neither lacked mental capacity, meaning they took part in discussions around their care needs.
19. Initially Mr C’s placement at the care home was funded by the Council. That funding ended in October 2020. After that time Mr C began funding his own care.
20. Mrs C’s placement at the care home was initially funded by a local NHS Trust. But its funding came to an end in October 2020 and after that, the Council began funding her care.

Mr C’s care and contact with Mrs C and wider family

21. Both the Care Provider and the Council undertook care planning for both Mr and Mrs C. Mr C moved to the care home shortly before Mrs C and the Care Provider recorded he “could not wait” to see her. Later it recorded that he liked to spend time with his wife chatting and interacting socially with her.
22. When the Care Provider initially undertook care planning for Mrs C it said she expected to spend time with Mr C when possible. Her care plan also said she had expressed how important it was for her to move into the same care home as Mr C. Although a note was also added that Mrs C could become tired if spending too much time in Mr C’s company.
23. The Council’s assessment, carried out in October 2020, said Mrs C wanted Mr C to stay in the same care home as her and that Mr C was happy his wife was close to him and they saw each other daily.
24. When they initially moved into the care home, Mr and Mrs C were placed in rooms adjacent to each other on the first floor. However, Mr C would often disturb Mrs C – in particular, shouting out for her at night. Consequently, Mrs C asked for a room further away from Mr C. She therefore moved to a room on the ground floor of the care home around November 2020.
25. From the time Mr and Mrs C moved into the care home, and throughout the events covered by this complaint, the care home could not facilitate face-to-face visits to residents because of either local or national restrictions brought about by the COVID-19 pandemic. The Care Provider sent us copies of letters issued at a national level which updated relatives on visiting restrictions, and later policies, in force across its care homes. A letter sent in October 2020 said that local care home managers would keep families informed of how restrictions impacted on individual care homes.
26. In December 2020 the lift in the care home broke. An engineer inspected and identified the lift needed a new power unit which they advised would take four to seven weeks. A further lift inspection followed in February 2021 which identified further work needed to fix the lift. The lift did not come back into service until March 2021.
27. As an interim measure the Care Provider fitted a stair lift. However, due to their disabilities neither Mr C nor Mrs C could use that.
28. Mrs C reports that after Mr C moved rooms she only saw him once in the three months between the move and his death. Ms B reports Mr C’s wider family had no contact with him despite calling the Care Provider asking for updates on his wellbeing.
29. In its comments the Care Provider said Mrs C did not ask to see Mr C after they moved rooms. It also did not recall Mr C’s wider family showing an interest in his welfare. It says it would have facilitated contact between Mr C and his family, had the family asked it to. Commenting on the Care Provider’s statement Mrs B has said that Mrs C accepted that she could not visit Mr C while the lift was out of action but this did not mean she did not want to have contact with him if possible.
30. The Care Provider says it did have a policy of offering its residents video calls to family. It has a single record from early January 2021 which says Mr C “refused communication” when this was offered to him. Mrs B points out that Mr C was not familiar with much modern technology and this may have influenced his decision.
31. Care notes show Mr C was seen twice by his GP in December 2020 because of concerns about his breathing, as he had a chronic chest condition. He was referred to a specialist nurse and they said consideration should be given to end of life planning.
32. In mid-January 2021 care notes recorded a decline in Mr C’s health with him appearing "settled but lethargic". A GP was called and they discussed a change in medicine Mr C received for an ongoing chest condition. They also gave Mr C a COVID-19 test. Only brief notes of Mr C’s presentation were kept the following day. And the day after that he died. The care home notes show that at around 11:00am carers noted Mr C’s breathing had become more laboured. Staff from the care home contacted Mr C’s family and they came in to see him. But unfortunately, Mr C died within an hour of that call and they did not arrive in time.

The Care Home’s infection control

33. Mr C’s COVID-19 test was recorded as positive the day after he died.
34. Around one week after Mr C’s death a local NHS organisation undertook an infection control inspection as the care home had several cases of COVID-19. The inspection recorded the home was cleaned to a high standard; had appropriate supplies and use of personal protective equipment (PPE) and had confined the outbreak to one floor of the building.
35. During this investigation the Care Provider has further commented that:

• it always had staff to ensure a thorough cleaning regime at the care home;
• that all its staff used and regularly changed PPE;
• that staff would regularly wash and leave their uniform behind daily for laundry;
• that staff had to undertake regular testing and follow isolation guidance if they tested positive for COVID-19;
• that all visits to the home were limited; including from professionals such as GPs where possible;
• that it tested residents monthly for COVID-19.

Mrs C’s care

36. The Care Provider recorded Mrs C’s weight and body mass index (BMI) when she moved into the care home in September 2020. They were both healthy. By November 2020 Mrs C’s weight had dropped and subsequently fluctuated, although at no point did it fall to the point she was underweight using the BMI scale.
37. The Council’s assessment of Mrs C’s needs in October 2020, said her weight needed monitoring and she needed a high protein diet because of a health need.
38. When Mrs C’s weight dropped in November 2020 the Care Provider consulted her GP. While it has a record of the GP agreeing to assess Mrs C’s weight I was provided with no record from the Care Provider of what the GP recommended.
39. Mrs C says the care home often gave her food she did not like to eat or else was of poor quality. In January 2021 the care home recorded Mrs C talking to the chef and they agreed a list of dietary preferences. Mrs C repeated her preferences in a separate note in February 2021.
40. In March 2021 there is a note in the Care Provider’s records to Mrs C being under the care of a dietician. They said Mrs C required a high protein diet.
41. In March 2021, when reviewing her care plan, the Care Provider recorded that Mrs C did not always like the food it provided. While in April 2021, in response to a questionnaire, Ms C again expressed dissatisfaction with the quality of the food.
42. However, subsequent surveys from May 2021 recorded her being satisfied with the food. Ms B says these cannot be relied on as the forms were completed by care home staff and did not necessarily reflect Mrs C’s views on the matter. She says the family would often take food into Mrs C as she did not like the food served by the care home.
43. I noted from care records that in May 2021 it was reported Ms C had been discharged from the care of a dietician.
44. The Care Provider gave us copies of daily food logs for Mrs C and I consider these in my findings below.

Complaints made on behalf of Mr & Mrs C

45. In mid-January 2021 a complaint was first made on behalf of Mr and Mrs C (by a different family member to Ms B). This said:

• Mrs C could not visit Mr C because a lift serving the first floor of the care home was out of action; and
• that Mrs C had lost weight due to the poor quality of food.

46. Before the family had a response to this complaint, a second complaint was made following Mr C’s death. This said:

• the family had received no updates on Mr C’s health after he moved into the care home; they had received no notice that his medication had changed and had less than one hour’s notice he had been taken ill before he died; and
• they had also been denied any opportunity to visit Mr C before he died; including the possibility of a window visit.

47. The Care Provider replied to the complaint in mid-February 2021. I summarise its response as follows:

• that it had recorded Mrs C’s weight loss in November 2020 and thereafter had consulted her GP and begun recording her food and fluid intake. It said Mrs C rejected smoothies offered to her as a supplement but since February 2021 she had been drinking full fat milk as a supplement as well as being provided with other snacks. The reply also noted Mrs C’s conversations with the chef about food preferences. It said Mrs C’s weight had subsequently stabilized;
• it said the lift broke in January 2021 and could not be repaired due to its age, with replacement expected shortly. The Care Provider said it had installed a stair lift as an interim measure but noted Mr C could not use this because of his needs. It accepted this meant the family could not have window visits and that it was “sincerely sorry” it did not do more to facilitate video calls, which it was now providing for Mrs C;
• it provided details of its discussions with Mr C’s GP before Mr C died. It noted that a registered nurse had recommended a change in Mr C’s medication along with “advanced planning palliative care”. It said the staff had noted before Mr C died that he was “coughing a little more than usual”. But he had declined very quickly the following day.

48. Ms B responded on behalf of the family, escalating the complaint. She noted some grammatical mistakes in the reply which she said was unprofessional. She asked why the Care Provider had not begun giving Mrs C full fat milk and other snacks before February 2021. Ms B said the Care Provider was wrong to say the lift broke in January 2021, as it had been out of order since December 2020. She said the family knew nothing of the recommendation Mr C receive palliative care until the Care Provider’s reply to the complaint. Ms B also wanted to know more about the care home’s infection control policies given Mr C had died after contracting COVID-19.
49. In its final response sent in early March 2021, the Care Provider:

• apologised for the grammatical mistakes in its first response;
• said it had offered Mrs C full fat milk before February 2021 as a dietary supplement;
• clarified the lift had broken in December 2020 not January 2021 as first stated; it was still out of action and would be repaired later that month;
• accepted it should have done more to offer a video call with Mr C; but noted he had declined the offer of a video call in early January 2021;
• said Ms B should discuss with Mr C’s GP why the advice on palliative care was not passed on to the family;
• said the company had extensive infection control policies and had recently received an inspection which confirmed this.

50. In escalating the complaint to this office Ms B has asked us to consider:

• the family never knew the location of Mr C’s room on the first floor. After he died, they discovered it was located near the car park to the building. By standing on a grassed area adjacent to the car park, the family would have been able to see Mr C at the window of his room. Ms B sent me a film recording showing the location of Mr C’s room, so I could see how far it was from the car park and the grassed area;
• that family members had frequently rung the care home to obtain an update on Mr C’s wellbeing but were given limited information being told that he was often sleeping. Ms B sent me itemised telephone bills for part of December 2020 and January 2021. These showed her mother had called the care home twice in late December 2020 and had one conversation of around five minutes, the details of which were not recorded in the care home notes;
• that in its complaint responses the Care Provider had provided incorrect information on how the family could arrange visits with Mrs C while visiting restrictions remained in place. It took around three weeks for them to be provided with the correct information to enable visits to be booked online. So this delayed how long it took for them to resume face-to-face visits with Mrs C.

51. During this investigation the Care Provider has:

• disputed if Mr C could have received window visits because of the distance between his room and the car park;
• acknowledged sending Ms B wrong information on how the family could book visits online to see Mrs C in March 2021. However, it said the family could still have booked visits to see Mrs C by telephoning the care home.

52. In November 2021, the Care Provider sold the care home which is now operated by another company. Around the same time the Council also assessed that Mrs C had sufficient capital that she should be funding her own care and as a result, ended its contract with the Care Provider to provide Mrs C’s care.
53. Given that Mrs C’s care was funded by the Council during the events covered by this complaint I asked it about its complaint procedure and any interaction between that and the complaint procedure used by the Care Provider. The Council told me that:

• it expects care providers to adhere to the CQC fundamental standards including that which covers complaint handling; that in addition this is a contractual requirement it imposes on care providers when it places a user of services in their care;
• care home residents whose care the Council funds, can choose to make a complaint via the Council’s complaint procedure if they wish and this should be explained to such residents at the outset;
• it asked care providers to share data about complaints received on request;
• it also expected care providers to invite feedback from care home residents whose care it funds; in the form of a ‘feedback survey’ completed at least annually.

Findings

Complaint about communications and visiting between family and Mr C

54. I note that when Mr C moved into the care home, the Care Provider completed various care planning documents. These included documents which asked Mr C about his life story, family and social interactions. I note the information the Care Provider recorded about Mr C’s life history was brief. It recorded he had children but made no comment on how often he saw them or what contact he wanted with them. But the Care Provider did record that Mr C wanted contact with Mrs C. This is also confirmed by the Council’s records.
55. Further, all the records from when Mrs C moved into the care home to join her husband say the same thing – that she wanted to spend time with Mr C. It was noted that Mrs C could get tired sometimes in Mr C’s company, but not that she did not want any contact with him as a result. I also note that once Mr and Mrs C were together again in the care home, Mrs C asked for a room further away from him, because his shouting would disturb her at night. However, there is nothing to say she did not want to spend any time with Mr C as the Care Provider has implied. And there is nothing that says Mr C’s wish to spend time with his wife changed at any point.
56. Yet the facts in this case suggest that from the point Mr and Mrs C entered separate rooms, on separate floors, Mr C effectively became cut off from both his wife and his wider family.
57. For the three months where Mr C was separated from Mrs C, there is just one record of him being offered a video call to his family. There is no record of video calls being discussed with the family. There is no record of any consideration being given to a window visit – something I consider was possible and feasible given the location of Mr C’s room next to a grassed area adjacent to the car park.
58. There is nothing in fact which shows the Care Provider had regard for the needs or feelings of Mr C after this time. It is fault the Care Provider can provide no records that show:

• how it considered it could maintain Mr C’s need to see Mrs C after she moved to the ground floor both before and after the lift breakdown;
• it ever considered if Mr C had a need to maintain contact with his wider family;
• how it considered Mrs C and the wider family should be kept in touch regarding Mr C’s welfare given at that time it could not facilitate face-to-face visits.

59. There is also no record the Care Provider assessed if Mrs C needed to continue to see Mr C once they moved to separate rooms. I consider her need to see Mr C could potentially engage article 8 of the Human Rights Act. Again, we have seen no evidence that the Care Provider when acting on behalf of the Council gave any consideration to this matter. So that too is a fault.
60. These findings call into question the Care Provider’s commitment to person-centred care and its record keeping.
61. I accept any communications between Mr C and either Mrs C or his wider family would have been complicated by the COVID-19 restrictions on visiting and the broken lift. But I do not find these were decisive in preventing such communications. Because it simply does not appear the Care Provider gave any importance to considering such matters.
62. I also find fault that in the days before he died the Care Provider did not do anything to prepare Mr C’s family that his health had worsened. His health had clearly declined to the point where the care home had contacted the GP and there was discussion around him receiving palliative care. Yet there is nothing to show the family knew about this.
63. I accept that in the immediate days before he died Mr C remained stable and then suffered a rapid decline in his presentation in the final hour or so before he died. The Care Provider did contact Mr C’s family to alert them at that point and I do not think it could have done more on the day.
64. But had the Care Provider given due regard to the need to communicate with Mr C’s family it could have tried to facilitate a final visit for the family in the days before he died, knowing he was nearing end of life. Something Government guidance allowed for throughout the pandemic.
65. The injustice caused by these failings is that of distress. We do not know the extent to which Mr C suffered distress from being so cut off. I accept his care notes refer to him being largely settled in the Care Provider’s care. But this is not a record of what Mr C might have felt at his separation from his wife and family.
66. I am satisfied from my contact with Ms B that she, Mrs C and the wider family have also suffered distress that goes beyond that which might be expected when a relative dies. I also consider they will have some justifiable outrage at the Care Provider’s lack of consideration. This lack of regard to Mr C’s wife and family was also exacerbated when Mr C entered the final stages of his life. As no record exists of anything being done in the days before to prepare them for the worst despite this being discussed between the care home and GP, even if the timing of Mr C’s death could not be accurately predicted.

The complaint about infection control

67. I consider there is insufficient evidence to show there was any fault in the infection control measures used by the care home, which may have led to Mr C contracting COVID-19.
68. Aside from its own statements on this matter, the Care Provider has also provided the NHS review of its infection control measures which was completed only shortly after Mr C died. There is nothing in that which suggests fault by the Care Provider.

Mrs C’s complaint

69. Mrs C’s complaint about the food provided to her has two considerations. The first is one about the food Mrs C needs. It is recorded in her care notes and following advice from a dietician that Mrs C needs a high protein diet. I am satisfied this should have been known to the Care Provider from around the time Mrs C entered its care, given the Council recorded this in its needs assessment.
70. With regard to whether the Care Provider met Mrs C’s dietary needs, I found little evidence to show the Care Provider began offering Mrs C full fat milk and snacks before February 2021. Given it should have known of her need for a high protein diet I consider it at fault for this.
71. The second consideration is that of dietary preferences or likes. The records show food served to Mrs C has not always been in accord with her preferences and on occasion may have been of poor quality. I found for example that food items Mrs C said clearly she did not like in January 2021 were served to her over a dozen times in the weeks that followed. So, this was a fault.
72. I was not able to establish this remained a problem into the spring and I also noted that Mrs C appeared to have given more positive feedback on the food when asked about this after April 2021. And in considering the consequences of these faults I note that at all times Mrs C has maintained a healthy BMI and she was discharged from dietician support while in the Care Provider’s care. However, while giving some weight to these factors, I consider she will nonetheless have suffered some injustice from the lack of adequate service given by the Care Provider on behalf of the Council.

Complaint handling

73. I consider the Council could do more to monitor that care providers respond properly to complaints made by users of care homes whose places it funds. I do not consider it sufficient for the Council to only ask about such complaints on request. It should know when one of its users of services is dissatisfied. It should have been aware in this case, before we received contact, of Mrs C’s complaint. It is fault it does not ask care providers to routinely provide this information.
74. But that said, I have no reason to think in this case the Council would have intervened in the complaint procedure followed by the Care Provider. I make no specific finding of fault about that. I note there were some deficiencies in the first response provided. In particular, it contained some poor grammar which may have given an unprofessional appearance and it contained factual errors. It is also clear I have taken a different approach to some of the issues at the crux of the complaint. There are learning points for the Care Provider therefore. But they are not matters which would suggest it does not have an accessible complaint procedure in place.
75. I also note the unfortunate mix-up over how the family could arrange a face-to-face visit to Mrs C after being given details of the wrong website in March 2021. This resulted from an error by the Care Provider. However, I do not consider it proportionate to investigate this matter further. I accept that any delay in resuming face-to-face visits to Mrs C would have been distressing to Mrs C’s family given the length of restrictions on visiting caused by the pandemic. But even so I must note the mix-up was resolved within four weeks. I also consider the Care Provider makes a fair point that the family might have contacted the care home direct to arrange a visit or obtain the correct website details in the meantime. Although I also note this has not stopped the Care Provider apologising for its mistake. I do not consider we could expect it to do more for the reasons set out above.

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Agreed action

76. The Council and Care Provider accept the findings set out above. To remedy the injustice identified at paragraph 65 and 66 it is agreed that within 20 working days:

• both the Care Provider and the Council will provide a written apology to Ms B and Mrs C accepting the findings of this investigation;
• both the Care Provider and the Council will pay Mr C’s family of £500 in recognition of their distress; I suggest each contribute £250 to this; the Council and Care Provider can check with Ms B to whom this payment should be made.

77. To remedy the injustice identified at paragraph 72 the Council has agreed that within 20 working days:

• it will ensure Mrs C receives a payment of £250 in recognition of the failure of the Care Provider to always ensure her dietary needs and preferences were met. This payment may be made direct by the Council or from the Care Provider subject to discussion between both. Should the Council make the payment it will not be prevented from seeking recovery of the amount from the Care Provider if it believes it was contractually at fault for not meeting Mrs C’s dietary needs and preferences.

78. In addition, the Council has said it will learn wider lessons from this complaint. Within 20 working days of a decision on this complaint it will:

• brief the current operators of the care home to advise of our findings; it will encourage the new owners ensure they are keeping adequate records around residents wishes for social interactions with family and nutrition/dietary needs; the new provider will also be encouraged to offer a meeting with Ms C, with a member of her family present if she wishes this, to discuss any ongoing concerns about her diet and nutrition;

79. The Council has also said that three months of a decision on this complaint it will amend its contract with care providers to request providers’ routine complaints monitoring reports on a quarterly basis as part of the Council’s provider monitoring process. It will also ask providers to provide this information quarterly, albeit on a non-contractual basis with effect from Quarter 1 (April to June 2022). This is so the Council has more awareness of complaints being made by users of services and that it can better monitor complaint outcomes.

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Final decision

80. For reasons set out above I uphold this complaint finding fault by the Council causing injustice to Mr C, Mrs C and Ms B on behalf of their family. The Council and Care Provider accept these findings. They have agreed action that I consider will remedy that injustice. Consequently, I can now complete my investigation satisfied with their response.

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Investigator's decision on behalf of the Ombudsman