Summary: We have ended our investigation into Mr X’s complaint about the respite care provided to his father Mr Y. The care provider has investigated Mr X’s concerns, accepted gaps in its recording of the care Mr Y received, apologised to Mr X and taken appropriate action. It is unlikely further investigation of the same issues would lead to a different outcome for Mr X.

The complaint

1. Mr X complains Barchester Healthcare Homes Limited Care Home (care provider) provided poor respite care to his late father, Mr Y at a care home. Mr X says it caused him and family distress and uncertainty as shortly after Mr Y’s discharge from the care home, he died. Mr X wants the care provider to acknowledge it acted with fault, provide an apology and a financial remedy for the injustice caused. He also wants the care provider to make service improvements to prevent a recurrence of fault.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. We investigate complaints about adult social care providers. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• the action has not caused injustice to the person who complained, or
• the injustice is not significant enough to justify our involvement, or
• it is unlikely we could add to any previous investigation by the care provider, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants, or
• there is another body better placed to consider this complaint.

(Local Government Act 1974, sections 34B(8) and (9))

Injustice to a deceased person

4. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.
5. A decision about what a suitable remedy should be for a complaint is one for us to decide. Each case is considered on its own merits. Our Guidance on Remedies for staff sets out the general principles that investigators should apply when deciding what recommendations to make.

Back to top

How I considered this complaint

6. I considered evidence provided by Mr X and the care provider as well as relevant law, policy and guidance.
7. Mr X and the care provider had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

Back to top

What I found

CQC and Fundamental Standards of care

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
9. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

What happened in this case

10. The following is a summary of key events. It does not include all the information I considered as part of my investigation.
11. Mr Y had a diagnosis of Alzheimer’s disease. He stayed at the care home for a week’s respite care in May 2025 following a pre-admission assessment by the care home’s manager with Mr and Mrs Y at their home. After Mr Y returned home from the respite care he saw his GP who admitted Mr Y to hospital. Mr Y was reported to have a UTI which was not treatable and sadly he died a few days later.
12. Mr X complained to the care provider about the care Mr Y received while at the care home. In summary Mr X said Mr Y’s main cause of death was the UTI, but Mr Y’s GP raised concerns about dehydration and malnourishment. Mr X said the UTI may have been a pre-existing condition which worsened during Mr Y’s stay. Mr X said Mr Y could eat, drink and walk despite the Alzheimer’s diagnosis. But considered Mr Y had visibly deteriorated at the care home, lost weight, appeared frail and needed support with walking when leaving.
13. Mr X said family members had called the home during Mr Y’s stay. They had been told he had needed some help with food and fluid but was fine. Mr X questioned why the family were not told of Mr Y’s decline and if he was not eating and drinking enough.
14. The care provider responded to Mr X’s complaint. In summary the care provider confirmed:
• Staff had carried out a pre-admission assessment on Mr Y and considered the care home could meet his needs. Staff noted he had dementia, struggled to verbalise and so would be regularly checked by staff in case he needed support.
• Staff carried out a risk assessment on Mr Y about nutrition and hydration. He was assessed as of being a medium risk of dehydration, so staff were required to monitor his fluid intake.
• It was acknowledged during the pre-admission assessment with Mr and Mrs Y there were some concerns about Mr Y losing weight, but he had not seen his GP about it. The care provider said Mr Y had lost weight on discharge, but staff had no concerns about it. And although his food and fluid intake was poor from his first day at the care home staff regularly offered him food and drink which he declined. The staff thought Mr Y’s poor food and fluid intake was normal for him. The care provider apologised it did not share this information with the family.
• Staff were monitoring and recording Mr Y’s food and fluid intake as required for new residents to assess how they managed oral intake for three days. The staff continued to monitor Mr Y’s fluid intake as he was assessed at medium risk of dehydration. Although this was largely being recorded there were a few incidences where only the food and drink offered were recorded not what his intake was. So, there were gaps and the care provider acknowledged it could not reliably say what Mr Y’s full food and fluid intake was.
• Mr Y was able to mobilise independently when he arrived at the care home and throughout his stay although he was unsteady on his feet. The care provider had no concerns about Mr Y’s mobility and could not say why Mr Y needed Mrs Y’s help when leaving.
• It noted Mr Y cause of death and said the UTI may have been present before his stay at the care home. Staff had no concerns about his health. If Mr Y was to stay for longer the care provider would have put further measures in place including recording his weight. It would then if needed make any escalations to health care professionals. The care provider considered the care home should improve record keeping to ensure it could provide accurate and important information, and it would share this with the care home.
• It noted Mr Y declined personal care at times.
15. Mr X remained unhappy with the care provider’s response and responded in summary that;
• He had concerns about inaccuracies in the pre-admission assessment. And Mrs Y was not given an opportunity to read it through, correct or sign it before Mr Y was admitted.
• He was concerned the care home had failed to record all Mr Y’s food and fluid intake and considered it a serious care failing. Mr X said the care home should have assessed Mr Y as being of a high risk of dehydration. And that correct information should have been given to relatives when they directly asked about food and fluid intake especially as Mr Y’s food and fluid intake was recorded as poor.
• Mrs Y had told the care home Mr Y could manage at mealtimes with a fork, smaller portions and did not decline food. But did need help with feeding.
• Mr Y returned home with two unused packs of incontinence pads so Mr X questioned how frequently Mr Y had been changed and whether concerns should have been raised if he was dehydrated.
• Mr Y had been able to talk in a jumbled manner but was unable to speak when discharged from the care home.
• Mr Y had suffered visible weight loss on being discharged from the care home and his GP considered he should not have suffered such a severe decline in seven days even with his underlying health conditions. Mr X considered the care home staff should have been able to see the decline and taken action.
• The care home reported Mr Y declined personal care, so Mr X asked how often it had happened. Mr X said the family provided Mr Y with toiletries, and these appeared unused.
16. Mr X requested the care provider issue a formal apology to Mr Y’s family, admit it had been negligent and given a poor standard of care. Mr X asked the care provider for a commitment to review procedures and provide assurance these would be completed. And to provide him with confidence the failings were corrected so other families would not go through what Mr Y’s family had done.
17. The care provider responded to Mr X’s concerns. It said, in summary:
• Mrs Y had been present at the pre-admission assessment and it included her input. While there was no requirement for the pre-admission assessment to be signed the care provider recommended to the general manager of the care home, they read the pre-admission document back to residents and families to ensure accuracy as best practice going forward. The care provider noted Mrs Y’s disagreement over some comments attributed to her. But it could only respond based on the care records and staff recollections. The care provider apologised for any confusion caused over recollections. It confirmed the general manager had reminded staff of the importance of documenting all conversations held with residents and families on the care files for reference.
• The fluid charts in Mr Y’s case occasionally only recorded the fluid offered but not the intake which was unusual. The care provider reviewed Mr Y’s charts and could understand Mr X’s concerns about consistency. But assured Mr X the person in charge would be reviewing Mr Y’s daily care records to see whether he had received enough fluid that day. The care provider apologised the documents did not reach the high standards it expected. The care provider confirmed the general manager had spoken to staff to ensure they completed the fluid charts on the digital system to improve this area going forwards.
• It explained the pre-admission assessment considered information from Mr and Mrs Y about his risk of dehydration and staff carried out an assessment on admission. The previous complaint response acknowledged the care home would have carried out a further assessment had Mr Y been staying for longer and referrals made if required.
• The care home had used the pre-admission assessment document and staff observations to create a nutrition plan for Mr Y. It showed he was at low risk of malnutrition but would need help at mealtimes. The care home considered staff had followed the care plan which was supported by the care notes. It was noted Mr Y’s food and fluid intake was poor from admission. The care provider apologised again it was not fully communicated with Mr Y’s family. The care provider confirmed it had made the general manager of the care home aware of this.
• It confirmed Mr Y was doubly incontinent and needed staff support with continence care and monitoring of his skin. The care provider was satisfied from Mr Y’s continence care records he had received this support. Although it noted one day where there was no recording. This had been reported back to the care home to ensure its digital recording system was improved.
• There appeared to be differing recollections of Mr Y’s mobility on discharge. It was satisfied Mr Y had been mobilising independently during his stay as supported by the care home’s records.
• Mr Y was noted to have lost weight before being admitted to the care home and his weight on admission gave staff no cause for concern. It was unable to confirm his weight on discharge, but staff considered Mr Y was content during his stay. And Mr Y’s GP had not raised any concerns with the care home.
• The care provider considered the records showing personal care interactions and was satisfied Mr Y had received care apart from one missed recording. It confirmed the care home had implemented a new digital care recording system before Mr Y’s stay and it had revisited training with staff to ensure improved documentation going forward.
18. The care provider confirmed to Mr X it had shown a commitment to learn from areas where it had identified room for improvement. And it had taken action to ensure change at the care home.

My assessment

19. Mr X considers the care provider has been at fault and negligent in the care of Mr Y and is seeking a financial remedy for the distress caused. However, it not our role to determine whether a care provider has been negligent and its actions resulted in Mr Y’s death. This is because we cannot make a link between the care Mr Y received and his cause of death. If Mr X considers the care provider has been negligent then it is an issue for him to pursue through the courts. So, we cannot achieve the outcome Mr X is seeking on that point.
20. We can only consider if the actions of the care provider have caused an injustice to the person complaining. The documents provided by the care provider show it has acted on the concerns raised and investigated Mr X’s complaints. The conclusions reached by the care provider are supported by the care records and evidence it has provided about the care given to Mr Y. These show Mr Y was offered food and drink and encouraged to partake, given personal care and recorded as walking about most days including the day he was collected. Because of this I do not consider we can add to the investigation the care provider has already carried out.
21. The care provider has acknowledged it needed to make some areas of improvement including staff using its digital recording system to ensure more robust records. The evidence provided shows it has taken appropriate action in response to Mr X’s concerns. The care provider has accepted there will have been some uncertainty for Mr Y’s family about his food and fluid intake. However, any injustice caused by this will have been mainly to Mr Y which we can no longer remedy. The care provider has apologised to Mr X about the uncertainty which is suitable action for it to take. The apology and the action taken to improve its recording system is likely be the outcome we would recommend if we investigated the complaint further. So, I consider it unlikely that further investigation would lead to a different outcome for Mr X.

Back to top

Decision

22. I have ended my investigation into the complaint.

Back to top

Investigator's decision on behalf of the Ombudsman