Summary: The complaint is about the late Mr C’s care in a council-funded care home. We uphold the complaint. There were failings in Mr C’s care including poor record keeping, a failure to follow NHS advice and a failure to address poor food and fluid intake. The Council gave no written feedback on the safeguarding enquiry and there was also a failure to address all Miss A’s complaints. The Council will apologise and pay £1000 to reflect Miss A’s avoidable distress.

The complaint

1. Sunderland City Council (the Council) arranged and funded the late Mr C’s care at Victoria Lodge Care Home, Sunderland (the Care Home) which was owned by Four Seasons Healthcare Ltd (the Care Provider). His daughter Miss A, complains:
1. Staff did not support Mr C’s needs around his leg or hand or follow the directions of the physiotherapist about splints, exercises and equipment
2. There was a failure to address poor food and fluid intake and to keep adequate records of these
3. Communication by staff was poor (staff told another care home he had dementia, but this had not been diagnosed; a Do Not Resuscitate form was handled badly in March 2016)
4. She received no feedback about safeguarding concerns
5. There was a failure to address all her concerns and complaints
6. Mr C’s clothes went missing.
2. Miss A says her father’s mobility declined due to poor care and he was admitted to hospital with dehydration and malnutrition. She seeks an acknowledgement that Mr Y received inadequate care, an apology, payment and an improvement to services.

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What I have investigated

3. I have investigated complaints (a) to (e). My reasons for not investigating complaint (f) are at the end of this statement.

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The Ombudsman’s role and powers

4. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
5. Miss A’s complaints are about Mr C’s care in 2015 and 2016. They were over 12 months old when we received her complaint and so are late. I have exercised discretion to investigate complaints (a) to (e) because Miss A was signposted to a different ombudsman by a third party and there was delay before her case was correctly forwarded to us. That delay was not Miss A’s fault. And, Mr C’s care records are available from Four Seasons Healthcare (the care provider which managed the Care Home at the time).
6. 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’. 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 injustice is not significant enough to justify our involvement. (Local Government Act 1974, section 24A(6), as amended)
7. We investigate complaints about councils and certain other bodies. 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)
8. If we are satisfied with a council’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

9. I considered Miss A’s complaint, the Council’s response to her complaint and documents described later in this statement. The parties received a draft of this statement and I took comments into account.

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What I found

10. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)
11. Abuse includes neglect and acts of omission including ignoring medical, emotional or physical care needs and failure to provide access to appropriate health or care support. (Care and Support Statutory Guidance, paragraph 14.17)
12. 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. When investigating complaints about council-funded care placements, we consider the 2014 Regulations when determining complaints about poor standards of care.
13. 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.
14. 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 residents.
15. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.
16. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.

What happened

17. The Care Home was owned and managed by the Care Provider when Mr C lived there. It is now owned and managed by a different care provider.

The Care Home’s records

18. The Care Home assessed Mr C shortly before he moved there in May 2015. The assessment recorded his weight as 48.7 kg with a body mass index of 18. This meant Mr C was underweight. A nutrition assessment described Mr C as at high risk of malnutrition and said the Care Home should keep food and drink charts to record Mr C’s intake. The Care Home kept food charts for the first two weeks of Mr C’s stay and then from September 2015. Records of snacks and supplements were inconsistent.
19. The Care Home weighed Mr C every month. His weight was between 46 and 47 kg until October 2015 when it dropped to 42.9 kg. His weight remained between 42 and 43 kg in November and December. There are no further records of Mr C’s weight available.
20. The Care Home kept fluid charts for Mr C for two weeks in May 2015. Mr C’s target was 1000 ml of fluid a day. The charts had no totals, were not always dated and appear to be incomplete. On some days, Mr C’s recorded fluid intake was far lower than 1000 ml. Some of his fluids were recorded on the food chart making it hard for staff responsible for reviewing the charts to get an accurate picture of intake.
21. The Care Home drew up care plans. The care plans noted Mr C had splints to his left arm and leg. But he did not tolerate them and moved his arm and leg away when staff tried to apply them. The physiotherapy team were aware and said for Mr C just to wear them when he agreed.
22. Nurses at the Care Home completed monthly reviews of Mr C’s care plans. I have summarised relevant parts below:
• Mr C had a cognitive impairment due to a stroke. He did not know time or place and lacked mental capacity to make decisions about his care. He could be verbally aggressive and make inappropriate comments to carers and could grab female staff. He could not weight bear and needed assistance of two carers for all personal care and used a hoist and sliding sheet for transfers. He had bed rails. He sat in a modified chair for up to two hours a day. In November 2015, the review noted Mr C continued not to tolerate the splints and kicked at staff when they tried to put the leg splint on and removed the hand splint. The physiotherapist recommended exercises. In December 2015, the physiotherapist recommended arm exercises. Senior carers were shown these and staff attempted them when Mr C could tolerate them.
• Mr C had a soft mashable diet and normal fluids in a spouted beaker as recommended by a speech and language therapist (SALT.) The dietician prescribed supplements. Staff supported Mr C to eat and drink and watched him in case he coughed or choked. He was in an upright position for eating and drinking. His weight dropped and the plan was to continue with monthly weights and to document milk and snacks on a food chart. The dietician would write to the GP to prescribe additional supplements. Recommendations following a review in January 2016 by the SALT were thickened fluids in a spouted beaker and pureed food from a spoon. Staff were aware of these changes and monitored Mr C for swallowing difficulties. He was also to be offered snacks.
23. Staff kept daily records of Mr C, noting the care they gave, any activities, his mood, general health and demeanour as well as recommendations from any health professionals who had reviewed Mr C. There were frequent entries noting showering, washing and changing and general comments about Mr C eating well. There were also regular entries saying Mr C went to the lounge or was sitting in his chair/ wheelchair. There were entries indicating episodes where Mr C was aggressive to staff during care.
24. The SALT reviewed Mr C on 3 August because of weight loss. The SALT told staff to contact the GP about this and they did. The dietician also reviewed Mr C, noting his weight loss; he was 45.1 kg. The recommendation was full cream milk with each meal and to offer snacks and supplements.
25. The physiotherapist saw Mr Y on 23 September. She recommended Mr C wore the hand splint for two hours each morning and afternoon.
26. The dietician saw Mr C on 2 October noting his weight had fallen by 0.9 kg over the previous month. The dietician’s recommendations were to continue with monthly weights, to record Mr C’s intake of milk, supplements and snacks on a chart. The dietician changed the supplements.
27. The Care Home kept records of Mr C’s food for the second half of September and October. These listed the food he had eaten. The charts indicated Mr C only had supplements occasionally and that he ate a good diet.
28. The SALT reviewed Mr C on 6 October. He was to continue having fluid from a spouted beaker and a soft normal diet. The SALT agreed to update Miss A.
29. On 19 October, the physiotherapist saw Mr C and considered options for splints to improve Mr C’s hip, but none were suitable due to him having contractures (shortening and hardening of muscles, often leading to deformity and rigidity of joints). The physiotherapist referred Mr C to an NHS clinic for further treatment. (the treatment was injections, which Mr C received at the clinic.) The physiotherapist advised staff to continue to support Mr C with leg exercises and to enable him to sit for short periods with the aim being for Mr C to have a better sitting position.
30. The dietician, SALT and OT reviewed Mr C on 2 November. Miss A and a nurse from the Care Home were also present. Mr C had lost 3.4 kg. He generally ate quite well, but did not always finish portions and was not having snacks. He was not having his full supplement prescription every day or having milk twice daily. Miss A was concerned his dentures were not cleaned or used regularly and staff were not always giving him foods he liked. The agreed plan was:
• To keep a full record of Mr C’s food and fluid intake, including supplements
• Regular teeth brushing
• Use of splint
• Encourage a fortified diet and offer milk twice a day, milky puddings and snacks between meals
• Change and increase food supplements.
31. The physiotherapist visited Mr C on 12 November and spoke to Miss A after. The Care Home’s record of the visit noted the physiotherapist said some of Miss A’s ideas and views were not realistic. There was no further detail about what exactly Miss A was being unrealistic about.
32. The dietician saw Mr C on 16 November and recommended a soft mashable diet and fortified food and weekly weights, fortified food, milk. The dietician noted the Care Home’s record of Mr C’s snacks was unclear and staff should be completing full food and fluid charts, weighing Mr C weekly and continuing to offer him supplements and milk.
33. An occupational therapist assessed Mr C on 24 November for a tilted wheel chair. A pelvic positioner (‘t-roll’) was required to help with Mr C’s sitting position. The OT was going to look at costings for this.
34. On 1 December, the physiotherapist showed staff how to do daily exercises with Mr C. On 16 December, the physiotherapist saw Mr C. She noted a small skin tear where Mr C had removed the arm splint. Staff applied a dressing to the skin tear.
35. On 21 January, the physiotherapist measured Mr C for a t-roll.
36. On 23 January 2016, a manager from a different care home came to assess Mr C as Miss A was considering moving him elsewhere. The note of the visit said Mr C would not co-operate and the manager of the new home felt they could not meet his needs.
37. On 26 January, the dietician reviewed Mr C and recommended snacks and fortified milk. Mr C was referred to the GP to refer to the SALT as he was ‘chesty’ after eating and drinking.
38. On 29 January, the SALT carried out a further review of Mr C’s swallowing. She recommended thickened fluids from a beaker and a pureed diet from a teaspoon and for Mr C to sit upright when being fed.
39. On 31 January, the physiotherapist reviewed Mr C and advised staff to continue doing daily exercises with him. He was to wear a hand splint one to two hours daily morning and afternoon and staff were to document on the chart in his room. The Care Home was going to buy a t-roll to help Mr C position on the bed.
40. A carer rang Miss A on 4 March to say the t-roll had arrived and the physiotherapist would be coming to train staff in how to use it.
41. On 4 March, Mr C was not himself. A nurse checked him and took nursing observations (oxygen, pulse, breathing). He did not improve and was noted to be lethargic.
42. Mr C’s advance care plan noted:
• There was a ‘do not attempt resuscitation’ in place. (This was a decision by NHS professionals and Miss A that it was not appropriate to do CPR on Mr C should he stop breathing.)
• Mr C did not have mental capacity to decide on whether he should have CPR.
• Miss A had agreed with the GP’s decision that Mr C was not to have CPR.
43. On 6 March 2016, a nurse checked Mr C. She thought he may have had a stroke and rang an ambulance. The paramedics arrived and the nurse also rang Ms C who was present when the paramedics were there. The paramedics rang Mr C’s GP as Mr C had a ‘do not attempt resuscitation’ and an advanced care plan. Mr C was admitted to hospital. Miss A said she had not agreed to the advanced care plan.
44. From hospital, Mr C moved to a different care home. He died in January 2017.

The Council’s records

45. On 28 October 2015, Miss A contacted the Council to raise a safeguarding concern. She said:
• Mr C had various appointments made for him at the stroke clinic which he did not attend as the Care Home had not told her about the appointments.
• He was now being nursed in bed.
• He had lost weight since admission to the care home in April.
46. The Council allocated a social worker for a welfare check and to review Mr C’s care needs.
47. On 12 November, the stroke team raised a safeguarding concern about the Care Home not following healthcare professionals’ recommendations. The referrer said:
• Mr C had developed contractures since leaving hospital
• It was difficult to get information from the Care Home about how he was managing their recommendations and his position at meal times did not promote safe swallowing
• He was underweight with a current body mass index of 15.7 (a healthy body mass index is between 18.5 and 25). The referrer could not get information from staff and care documents were unclear about provision of snacks, milk and supplements as recommended by dietician. Dentures were not being used; preferred meals were not offered
• The Care Home was provided with advice on use of splints and stretches, but these were not carried out. The leg contracture was worse on review. Advice was not followed about sitting out.
48. The Council started a safeguarding enquiry in response to the concerns from Miss A and the stroke team. The record of actions taken said the stroke team had met with the manager of the Care Home and had done training with staff and Mr C was referred to the spasticity clinic. Officers offered to meet with Miss A to give her feedback on the actions taken but she declined.
49. The social worker completed an assessment of Mr C’s needs at the end of November 2015. This noted he’d had two strokes and did not have mental capacity to make decisions about his care. He could make simple choices and express his needs at the time. He was no longer weight-bearing and used a hoist, wheelchair and specialist chair. He slept in a hospital bed and had support from the occupational therapist and physiotherapist. He had injections to relax the contractures in his legs. He also needed support with exercises to stretch his legs and he wore a hand splint on his left hand for six hours a day with a rest of 30 minutes every two hours. The assessment noted the social worker could not find the exercise chart in his room. He was incontinent and needed help from two carers with personal care, and one person to feed him and help him drink. He lost weight in hospital and had food supplements and saw a dietician. The speech and language therapist recommended a soft normal diet. He was to be weighed weekly.
50. On 2 December, there was a meeting with Miss A, Mr C and the social worker. Miss A raised concerns about feeding, transfers into the chair and use of the splint. Miss A was looking at other care homes but she wanted matters resolved.
51. On 8 December 2015, the Council carried out a reassessment of Mr C’s care needs. This noted the Care Home’s care plans did not reflect the changes in support identified in the last month. It said the daily records were too general and so it was not possible to conclude changes in care were actually being delivered and the nurse was not aware of some of the changes because another nurse was responsible for updating care plans. There was no behaviour care plan yet a nurse said Mr C’s behaviour had deteriorated. The social worker asked if staff had been completing physiotherapy exercises or putting on Mr C’s splint. The nurse said he disliked both. The social worker found no pictorial charts with the exercises and so questioned how staff would know what to do.
52. Miss A contacted the Council again on 23 December and 11 January 2016 to report a concern about the Care Home not implementing changes to Mr C’s supplement prescription. She also said recommendations from the spasticity clinic were not being followed.
53. The Council asked the Care Provider’s Regional Manager to review Mr C’s care plan and this took place. She spoke to Miss A and offered her a meeting. The Regional Manager reported:
• She had visited the Care Home three times and reviewed Mr C’s records. Monthly reviews of the care plan were taking place but these needed to reflect recommendations from the NHS.
• His care plans would have been rewritten but he was moving. The care plans did not have enough detail.
• The GP referred Mr C to the mental health team at the end of January.
• All staff had received training in moving and handling.
• Staff should complete a behaviour care plan and continue to record Mr C’s behaviour.
• Staff needed to get a leaflet from the physiotherapist describing the exercises Mr C needed to do.
• Staff needed to put exercise and splint charts in Mr C’s room and record when they offered to help and when he declined. The charts needed to record the physiotherapist’s recommendations about time and how long Mr C had been wearing the splint for.
• Mr C should be referred to the mental health team.
54. On 13 January, the social worker spoke to Miss A who raised concerns about her father’s eating and drinking over Christmas. Miss A said on one visit, there was no fluid recorded for the day and so she gave him a drink. Miss A alleged when she came back the next day the record had been completed in retrospect. Miss A said the chart with exercises and the splint chart had not been put in the room.
55. The social worker visited the Care Home on 14 January to review Mr B’s care. She noted his needs around diet and mobility were being met but there was no mention in the Care Home’s records of the splint or physiotherapy. She noted the behaviour care plan was completed retrospectively and behaviour charts were partially completed with some in the daily notes. No referral had been made to the mental health team. There was a position chart in his room but each record said he was on his back and he had not been repositioned. Reviews of the care plan were not up to date.
56. On 4 February, Miss A spoke to the social worker and said the Care Home had wrongly told another care home that Mr C had dementia. She said when she visited he was not given thickened fluids which had been recommended and there was nothing in the care plans about exercises. There was no exercise or splint chart in his room
57. Miss A emailed the social worker on 8 February to express concerns about Mr C’s care. She said:
• The chart in his room for his exercises had not been completed to say if he had worn the hand splint since the physiotherapist’s visit the week before. She said the recommendation was for the splint to be worn every day.
• The charts showed he had been left in bed for 24 hours and not had a position change, this was against the occupational therapist’s recommendations.
• He was left too long in a chair (it should only be one to two hours at a time.)
• Staff gave him breakfast after 9.30 and when she asked for him to have breakfast earlier. Staff were not giving him the meals she had chosen for him. She was concerned he was not having enough to eat.
• She had complained to the Care Home’s head office.
58. The social worker spoke to a nurse at the Care Home on 12 February. The nurse explained a dietician had given Mr C a meal plan for staff to follow, however Miss A had also given staff a meal plan. The nurse said staff were following the dietician’s recommendations. Mr C was losing weight but it was unclear why as he was having three meals plus milk and supplements. The nurse said communication with Miss A had broken down.
59. On 6 March, the social worker visited the Care Home and spoke to a member of staff. The member of staff claimed Miss A was locking the door when she visited and feeding Mr C solid food when he was on a liquid (pureed) diet. She said Miss A had shouted at carers. Miss A told me that she only locked Mr C’s door on one occasion, when she and a Father were praying for Mr C. Miss A also denies giving staff her own meal plan. She told me she worked closely with the hospital and only gave her father soft diet options that had been recommended and that he could manage.
60. The social worker spoke to Miss A who said she had agreed Mr C should not be resuscitated but Miss A was not aware an end of life care plan was in place. Paramedics would not transfer him unless the GP overruled the end of life care plan which the GP had.

Complaint

61. Miss A complained about Mr C’s care in November 2015 and January 2016.
62. The Care Home’s response in March 2016 did not address the issues Miss A raised in January 2016, only those in her earlier November letter. The response said:
• Mr C’s trousers and one slipper were missing but had been found and returned. All clothing had labels. It was sorry for this;
• Visiting care managers had been given correct information about Mr C. Staff reported Mr C could be aggressive during personal care;
• A staff member had been feeding Mr C with a fork. This had been addressed with the person concerned;
• Food charts were available and Miss A could see them;
• The Speech and Language Therapist (SALT) visited at short notice, so there was not enough time to invite Miss A to the meeting. The SALT spoke to her after;
• The correct continence aids were used and there were always enough in stock. A nurse should not have told her to ask Mr C’s GP for a continence assessment as this was the care home’s responsibility;
• Staff waited for specific instructions from the physiotherapist about use of the new splint; this was the correct approach. Mr C was taking it off himself and he needed to build up tolerance to 1 to 2 hours twice a day;
63. In June 2016, Miss A instructed an advocate. The advocate complained to the Parliamentary and Health Service Ombudsman (PHSO) in September 2016. PHSO declined to investigate as the complaint had not been through all stages of the Care Home’s complaints procedure. In March 2017, Miss A met with a manager of Four Seasons Healthcare and its final brief complaint response suggested Miss A sought compensation, advised her to ‘make a claim’ and signposted her to us. The minutes of the meeting did not set out any detailed discussion of the complaints.
64. In May 2017, Miss A’s advocate complained again to PHSO. PHSO referred the complaint to us in August 2018 with her permission. PHSO decided not to investigate because Mr Y’s care was mainly funded by the Council and her complaints were not about health care. So the complaint fell within our remit.
65. The Council told me it accepted Miss A did not get written feedback on the outcome of the safeguarding enquiry. This, it said, was an oversight and its new computer system would not allow a worker to close a case without providing feedback to the referrer. The Council also told me it had received a letter of complaint from Miss A in April 2016, but the complaints manager did not see it and the letter was filed without a response.
66. Miss A told me the care records implied that her father was verbally aggressive, confused and grabbing staff all the time when this was not the case. She wanted to emphasise that her father had a cognitive impairment that contributed towards his behaviour changes. She also told me she felt the Care Home misled the paramedics about what she had agreed to as part of Mr C’s end of life care.

Was there fault?

67. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So any fault with the actions or service of the Care Home is fault by the Council.

Complaint a: Staff did not support Mr C’s needs around his leg or hand or follow the directions of the physiotherapist about splints, exercises and equipment

68. NHS professionals recommended staff completed exercises with Mr C and encouraged him to wear his splints for a specified period of time every day. The aim of this was to improved Mr C’s sitting position. There is no evidence staff followed the NHS recommendations and this was fault. Mr C’s care was not in line with Regulations 9, 12 or 17 of the 2014 Regulations.
69. The records that are available are poor quality. There are no visual charts of the exercises staff were supposed to do with Mr C and no records of when they done them, or offered to do them but Mr C had declined. I note Mr C did not like wearing the splints and was said to dislike the exercises as well. That should not have prevented staff from continuing to offer the splint and exercises and recording Mr C’s refusal. As there are no records of use of the splint or of the exercises, the Care Home cannot evidence it delivered personalised, tailored care for Mr C. This was fault.
70. There was a delay in providing a t-roll which would have supported Mr C’s hips and knees with the aim of achieving achieve a better position. The t-roll was identified by the OT in November 2015 but not obtained until March 2016. The physiotherapist measured Mr C for the t-roll which suggests the NHS funding it. But it did not arrive until March. There was a failure by Care Home staff to liaise with the NHS to chase up the t-roll and this was a failure in Mr C’s care which was not in line with Regulation 12. It seems likely Miss A would have bought the t-roll for her father sooner had she been aware of the relatively low cost (between £50 and £100, available on line.)

Complaint b: There was a failure to address poor food and fluid intake and to keep adequate records of these

71. Assessments on admission identified Mr C was at high risk of malnutrition and so according to the nutrition assessment, staff were required to document his food and fluid intake. They did not do so properly and this was fault as it was a failure to act in line with Regulation 14 of the 2014 Regulations. The fluid charts are available for the first two weeks of Mr C’s stay, they are incomplete and show a very poor intake on some days. I cannot say whether this was a failure to record true intake. If the records are accurate as opposed to incomplete, it raises concerns about adequate hydration. There was no reason given for stopping the fluid charts – given Mr C’s low recorded intake they should have continued.
72. The food charts in May 2015 show a good intake, yet Mr C did not gain weight and was still below the healthy weight range when the charts were stopped. Mr C’s weight dropped further in October. The Care Home did not act on the dietician’s recommendation to monitor all his food intake namely snacks, milk and supplements. It was unclear whether care staff were acting on the dietician’s recommendations as there are inadequate food charts. Care was again not in line with Regulations 9, 12 or 17 of the 2014 Regulations.

Complaint c: Communication by staff was poor (staff told another care home he had dementia, but this had not been diagnosed; a Do Not Resuscitate form was handled badly in March 2016)

73. Mr C’s care plan said he was not to be resuscitated. It did not say that he should not be taken to hospital. I do not uphold the complaint about the Care Home’s actions when Mr C was taken to hospital. Staff acted in line with Regulation 12 of the 2014 Regulations. It was for the paramedics and Mr C’s GP to decide on whether it was in his best interests to go to hospital for treatment. There was no fault by the Care Home.
74. There is no evidence to support Miss A’s claim that staff told another care home Mr C had dementia so I do not uphold this complaint.

Complaint d: Miss A received no feedback about safeguarding concerns

75. I note social workers met with Miss A on at least two occasions and offered to meet with her to provide feedback on the safeguarding enquiry but she declined. Miss A raised the same concerns again and some new ones.
76. Communication and feedback in writing are a standard expectation in a safeguarding enquiry and I would have expected the Council to provide some written feedback on the outcome. The failure to provide Miss A with written feedback was fault.

Complaint e: There was a failure to address all Miss A’s concerns and complaints

77. I uphold this complaint. The Care Provider’s complaint response did not address the concerns Miss A raised in January and its final brief response advised her to ‘make a claim’ (start court proceedings). This was poor complaint handling and was fault.
78. Miss A also complained to the Council. She did not receive a response to her letter. This was poor complaint handling and was fault.

Did the fault cause injustice?

79. Mr C has died and any injustice in receiving poor care was personal to him. We do not generally recommend payments to an estate for failings in the person’s care. However, Miss A suffered avoidable distress as she was heavily involved in her father’s care and visited him regularly.

Agreed action

80. The Council has accepted my recommendations to apologise to Miss A and pay her £1000 to reflect the avoidable distress identified. It will do so within one month of my final decision. I have taken into account Miss A was involved with her father’s care, saw him regularly and raised concerns on many occasions over a period of several months.
81. It is not appropriate to recommend changes to procedure because the Care Home has changed hands and is now run by a different care provider.

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Final decision

82. The complaint is about the late Mr C’s care in a council-commissioned care home. We uphold the complaint. There were failings in Mr C’s care including poor record keeping, a failure to follow NHS advice and a failure to address poor food and fluid intake. The Council gave no written feedback on the safeguarding enquiry and there was also a failure to address all her complaints. The Council will apologise and pay £1000 to reflect Miss A’s avoidable distress.
83. I have completed the investigation.

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Parts of the complaint that I did not investigate

84. I did not investigate complaint (f) because the injustice is not serious enough.

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Investigator's decision on behalf of the Ombudsman