Summary: Mrs C complained about the care her (late) father received at the care home commissioned by the Council, and the information she received from the Council before he went there. We found fault with regards to the information provided by the Council, and the way the family was kept informed about her father while in the home. As a remedy, the Council had already provided an apology for some faults and had already agreed to wave a sufficient part of her father’s care homes. The Council has agreed to provide an apology for any faults not apologised for so far.

The complaint

1. The complainant, whom I shall call Mrs C, complained to us on behalf of her (late) father, whom I shall call Mr F. Mrs C complained about the process through which the Council arranged her father’s move into a care home, and about the care he received at the home. Mrs C complains that:
• The Council lied to her about the reason her father was going into a care home.
• The Council should not have (initially) charged her father for his residential respite care, because it told her this would be free.
• The care home failed to keep her updated.
• Her father’s health deteriorated at the care home after around June / July 2019.
• Her father lost a lot of weight, because the care home failed to give him the food he liked.
• Even though she asked the home to call the GP to assess him, the care home failed to arrange this until late December 2019.
• The care home failed to look after her father’s personal care and dignity.
• The home failed to keep her father’s room clean and it had mice.
• There was broken furniture in her father’s room that staff only sometimes ended up replacing.
• She has been lied to about the circumstances in which her father died.
• Even though she regularly complained about the above, the care home and the Council failed to ensure the above was addressed and that his care improved.

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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 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

4. I considered the information Mrs C and the Council provided to me. I shared a copy of my draft decision statement with Mrs C and the Council and considered any comments I received, before I made my final decision.

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What I found

Relevant legislation and guidance

5. 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) issued guidance in March 2015 on meeting the 2014 Regulations (the Fundamental Standards). We consider the 2014 Regulations and the Fundamental Standards, as well as a provider’s policies and procedures, when determining complaints about poor standards of care. The following regulations are relevant to this complaint.

• Regulation 9. This requires a care provider to make sure that residents have care that is personalised specifically for them and reflect their preferences. For instance, residents must have a choice for food and drinks that meets their needs and preferences as far as is reasonably practical.
• Regulation 10. This requires a care provider to treat people with dignity and respect. Guidance explains people must be treated in a caring and compassionate way.
• Regulation 12. This requires care providers to provide care and treatment in a safe way, including that: assessments, planning and delivery of care and treatment should be based on risk assessments that balance the needs and safety of a resident with their rights and preferences, and include arrangements to respond appropriately and in good time to people's changing needs.
• Regulation 15: This requires care providers to ensure that a care home is clean and properly maintained. Providers should operate an appropriate cleaning schedule and monitor the level of cleanliness.
• Regulation 17. This requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

What happened

6. Mr F was 90 years old and lived with Mr and Mrs C. He was diagnosed with dementia in 2018 and received a care assessment from the Council in February 2019. At the time Mr C was living in the same house as his daughter. The assessment form said that:
• Mrs C said her father had lost interest in his personal hygiene and was self-neglecting this and his personal care needs. As such, he would go for days without having a shower or wash. This situation had caused the family stress.
• This could also result in self neglect and risks related to skin integrity.
• Mr F said he was happy to be supported with a shower twice a week. He had capacity to make a decision about this. It was agreed that care workers would encourage him to do his personal care and wash his back.
• If left on his own, he would not change his clothes. Mrs C therefore had to lay out clean clothes every day and encourage him to put them on.
• Mr F could mobilise independently.
• He did not need residential care.

The reason Mr F went into the care home

7. Mrs C says the Council lied to her about the reason her father was going into a care home. She says she told the Council she needed a break from supporting her father and the Council told her she would be entitled to a minimum of six weeks free residential respite care a year. The Council subsequently said it had found a home and Mr F would go there for a two-weeks respite break. He went into the home in April 2019, where he subsequently remained. It took until mid-August 2019 before she found out the Council had actually put him into the home because a safeguarding concern had been raised against her. This had not been mentioned at the time he went into the home.
8. A record states that a social worker told Mrs C on 22 April 2019, before he went into the home, that her father had said she had assaulted him. The social worker also explained the safeguarding process to her.
9. The Council has since told Mrs C that it should have told her, when her father went into the home, that the decision to move him into a care home was to provide some carer’s relief for Mrs C and address any potential risk to Mr F. Mr F did not have capacity to decide where he should live, so the social workers made a best interest decision that he should temporarily go into a care home. The social workers may not have mentioned that there would be a charge, because they did not want to escalate an already potential volatile situation.
10. Mrs C said she had to put in a lot of effort to convince her father to go into the care home. Mrs C told me that, if the Council had told her about the safeguarding investigation that day, she would not have encouraged her father to go into the home, as a result of which he would have stayed at home. In response, the Council said it would have applied to the Court of Protection for an emergency decision to place Mr F in a care home.
11. The Council subsequently involved an independent advocate (IMCA) to advocate on Mr F’s behalf. It extended the temporary placement on several occasions, until the Council finally decided it would be in Mr F’s best interests to remain at the home. This had also been Mr F’s expressed wish at that time.

Analysis:

12. The reason for the placement was to provide respite to Mr and Mrs C and to safeguard Mr F by moving him to a safe place. The Council has already acknowledged and apologised that it did not make this clear enough, which is an appropriate remedy for this aspect of the complaint.

The charge for residential respite care

13. Mrs C said:
• The social worker repeatedly told her that she and her father were entitled to six weeks a year of free residential respite care, which could be extended to eleven weeks if needed in an emergency. However, she soon found out, after her father had gone into the home, that the Council was trying to charge him for his temporary stay.
• It took her a lot of time and trouble to make the Council realise that she was right, which caused her distress.
14. The Council told me that:
• The social worker did not discuss charging, or the financial assessment process, with Mrs C on the day her father went into the care home. This was due to the volatility of the situation and the desire not to antagonise the situation any more than it already was.
• There is no record that says the social workers told Mrs C that she could have six weeks of free residential respite care a year, or that her father’s stay in April 2019 would be free.
15. It appears from the records that the Council decided to wave Mr F’s outstanding contribution in June 2020, because the Council agreed he had received a poor service while at the home. It waved an amount of £6,336, which was half of the total assessed contributions Mr F had to pay for the care he received between April 2019 and March 2020.

Analysis

16. There is insufficient evidence to conclude the Council provided incorrect information to Mrs C by telling her that her father’s respite care would be free. However, it is clear from the records that, based on the information Mrs C had received, she believed her father’s temporary stay would be free of charge. This is fault as the Council needs to ensure that clients have accurate and timely information about charging. While I can understand the Council felt it would be best, under the circumstances, not to explain this on the day Mr F went into the home, it should have provided this information at the next earliest opportunity. The Council should apologise for the delay in explaining to Mrs C that the respite care would not be free of charge.

The way the care home communicated with the family

17. Mrs C says the care home failed to keep her updated about any changes in her father’s health, visits by health professionals etc, even though she was the next of kin and the home had been told to do this.
18. At a best interest meeting at the end of May 2019, Mr C asked why the home had not told the family of a GP visit that took place about a suspected chest infection. The home said that it did not know it had to inform the family. The home was asked at the meeting to ensure it would keep the family updated.
19. However, I have hardly seen any records in the care home’s “Professionals visits and communications book” that show staff subsequently informed the family about visits or any relevant developments.
20. The care home told me that Mrs C visited her father once a week at which time senior staff members would update her. It said Mrs C would tell staff any concerns she had, which would be passed onto management for action. As such, changes in his health and care needs were discussed during her visits.
21. The care home sent a letter to Mrs C in March 2020, in response to her complaint. It said it would ensure the home would update her about all future professional visits. Mr F passed away three weeks later.

Analysis

22. The care home should establish with the resident and their family, at the start of a stay, how they would like the home to communicate and update the family about certain events / developments. The home failed to establish this at the start, which is fault.
23. The home was told in May 2019 to keep the family updated about relevant events, such as health visits or changes. The home said it did this during visits but did not record this. Although the home said it did this during visits, Mrs C said the home failed to properly update her about key developments. I have not seen evidence in the records to support the home’s view that it regularly updated Mrs C. As such, the home failed to establish a system through which it: could ensure it would always update the family when necessary, record any discussions or concerns the family would raise and what actions the home would take. This is fault.

Mr F’s deteriorating health: weight loss; staying in bed and GP involvement

24. Mrs C said her father’s health deteriorated while at the care home from around June / July 2019. She said:
• He became very withdrawn from June / July 2019 onwards, and refused to leave his bed from August onwards.
• He also stopped eating in September 2019 and lost weight. She complained to the home that it was failing to give him the food he liked from the list she had prepared.
25. When Mr F went into the home, he was 57 kilograms. This was a healthy weight but close to being classed as ‘underweight’ (according to the Body Mass Index). Mrs C told the home her father was a fuzzy eater and she had prepared a list of foods she said he liked and did not like.
26. At Mr F’s care review in May 2019, it was recorded that Mr F looked a lot thinner and the home had put a weight and a food input chart in place. Mr F’s GP was aware and scheduled to visit him. Mr F said he liked the home and the food and he would go to the lounge to watch tv and mix with other residents. He said several times he did not want to return to the home he shared with Mrs C.
27. The Council organised a best interest meeting at the end of May 2019. At the meeting:
• Mrs C was unhappy her father was still staying at the home. She was concerned this would result in him becoming more dependent on others to do things for him. Mrs C said that, when her father was at home, she was only concerned about his hygiene needs.
• The care home said it records showed that staff ask Mr F every day if he wants to walk to the shops. However, he did not want to do this. Mrs C said that staff would have to be stern with him to make him do things.
28. The care home records show the home was constantly updating the GP and Mr F’s social worker about the difficulties it had with regards to Mr F eating enough. The home made several requests for reviews, to which the GP responded. The GP made the first referral for a dietician at the end of May 2019 and Mr F received food supplements from June 2019 onwards. The dietician carried out several reviews throughout.
29. The Council carried out a mental capacity assessment with Mr F in June 2019. It concluded that Mr F did not have capacity to make decisions about his care:
• Mr F said he did not need support and would not ask staff for help. He was clear that he wanted to stay in the home and said “Everyone is nice”. He did not report anything negative.
• Mrs C said she was unsure if staying was in her father’s best interests, as it could reduce his independence. She said she would not allow a care agency to come to her house, if her father was to return home. Mrs C said her father had never been a social person.
30. A best interest assessment, as part of a DOLS application, concluded in June 2019 that it would be best for Mr F to remain in the home.
31. Neither the GP, dietician or IMCA reported any concerns with the way the home was managing Mr F’s nutritional needs, or his refusals to engage with staff. The dietician’s review report from 19 June 2019 says that staff was doing everything possible to get him the best nutritional intake possible.
32. Mr F’s Activity Log only has one record per day to state if he declined to go to the shops or go out of his room. However, the records do not evidence that staff would try to encourage him throughout the day. Nevertheless, it was clear that Mr F was increasingly not interested anymore in coming out of his room, or even his bed. A record dated 25 August 2019 says: “Mr F has asked we stop asking him to join in. He just wants to be left quiet”.
33. There were further reviews from the dietician in October and December 2019.
34. At Mr F’s care review in December 2019:
• A senior carer from the home said that Mr F had been declining care for about 3 months. Despite frequent encouragements, he would refuse to get out of bed or eat his meals. It was Mr F’s choice whether to engage and accept support, and staff could not force him to eat or wash.
• The social worker explained to Mrs C the care home was doing everything possible and were following advice from GP.
35. Mr F’s “Eating and Drinking” care plan:
• States the dietician discharged Mr F in December 2019 because she felt that, despite having done everything possible, he kept declining to eat.
• Said Mr F liked to choose his meals from the daily choice menu. Staff would record any foods he did not like and inform the cook and staff accordingly.
• Listed what Mr F liked and did not like to eat.
• Said staff should remind him of the importance of eating and risk of not eating.
• It included very detailed guideline about how staff could try to maximise his intake, including offering him something different and/or at a different time if he refuses a meal.
• His care plan was reviewed every month.
36. At a risk meeting in January 2020, multiple concerns were discussed about Mr F not engaging in his care at the care home. It said:
• The home advised the Council for five months that Mr F has not been engaging with his Care and Support Needs. He lacks mental capacity about the risks of his self-neglect when he declines care.
• Mrs C said she found it difficult to understand her father’s challenging behaviour associated with dementia.
• All present during the meeting agreed the strategies put forward around Nutritional Hydrating Needs etc.
37. The care provider said it gave two names to Mrs C after this meeting that she should contact directly if she has any concerns in the future, or put things in writing.
38. As of February 2019, Mr F’s weight had gone from 57 kilograms (when he arrived) to 46. However, he subsequently gained two kilograms. His BMI said he was underweight, from November 2019 onwards.
39. Mr C received visits from the mental health team, the last of which was in March 2020. The team discharged him because they were very happy with Mr F’s recent weight gain and the home’s ongoing plan in place about personal care.
40. In response to Mrs C’s complaint, the care home explained on 2 March 2020 that:
• The home was using the food likes and dislikes list she provided. The home offers him food from its daily choice menu and, if he does not like that, offers meals from an additional list made up from your preference list.
• However, there are times Mr F choose meals that he never used to eat when he was at home.
• The staff is encouraging Mr F as best they can and adding supplement powder to all foods and drinks. Staff is also offering food in smaller portions and at various times of the day, but this does not seem to work.
41. The care home says:
• It only ever received one official complaint from Mrs C, namely in February 2020 about his risk of malnutrition.
• The home offered various foods and he ate foods that were not on her list. The home gave him a choice every day and his tastes changed during his stay.
• Mrs C wanted staff to be more forceful with him and found it difficult to accept he had dementia. Through her own admission she did not understand and could not accept her father had dementia. His later behaviour were classic traits of someone with dementia. Even Mrs C was unable to make him eat or drink.
42. The Council has told Mrs C in 2020 that:
• The records showed the home had worked with the GP and other professionals throughout this period. The dietician was involved, undertook assessments, and provided advice and support to the home.
• There was evidence to support that when professional advice was required, it was called for and followed up promptly. The evidence suggests that Mr F was prompted and encouraged to meet all elements of his dietary and personal care needs.
• A review by the Memory Service in February 2020 reported that Mr F wanted to remain in his room more often and declined personal care and food more often.
• However, he declined personal care and he had been referred to the community dietician as he would sometimes refuse to eat.
43. Mrs C told me the home did not offer her father the amount of choice it has referred to.
44. On 30 March 2020, Mr F’s social worker, who had been closely involved in the case throughout, thanked the home for the excellent care they gave Mr F.

Analysis

45. Mrs C said her father was a fuzzy eater. The home immediately put a ‘food input chart’ in place and involved his GP and a nutritionist in a timely manner and throughout, asking for regular reviews. Detailed care plans and strategies were in place, developed with the GP and dietician, which were regularly reviewed. Mr F was regularly seen and reviewed by a range of professionals, none of whom raised any concerns, and all of which were very complimentary of the support the home provided.
46. The Council also organised regular risk management meetings with the care home and the family, to discuss risks involved with regards to Mr F’s decisions and to agree strategies to manage any risks from them.
47. While I understand Mrs C’s distress of seeing her father not receiving the amount of care and support he needed, the records show this was due to Mr C refusing support and the home not being able or allowed to force this on him.

Mrs C’s complaint about her father’s personal care

48. Mrs C says the care home failed to look after her father’s personal care, even though this was the main reason he was at the home. She said:
• The home failed to ensure he had a regular wash, so he smelled:
• He always walked around in the same clothes when she visited him once a week at the weekend. Staff told her they were his favourite clothes, and they would wash them overnight. Mrs C says there is no way to know if this version was correct, but his clothes did have stains on them.
• Staff did not comb his hair.
49. Mr F’s Personal Care Plan said that Mr F had a history of self-neglect with regards to his hygiene.
50. The home’s daily care records have a detailed section where staff can tick what personal care they have provided. It includes amongst others: full body wash, ‘top and tail’ wash, hair brushed, declined and self-cared. Mr F’s records show that he would have a regular ‘full body wash’ when he first arrived. Staff would also brush his hair every second day. However, by July 2019, this had already changed to mostly ‘self-care’. It is not possible to determine how much, if any, washing this involved.
51. After July 2019 there is very little evidence his hair was brushed. The records mainly showed ‘declined’ with regards to washing and brushing his hair. A record that was especially kept with regards to showers, showed that Mr F had three showers in total. However, staff regularly offered him showers, which he declined.
52. Mrs C raised concerns about her father not having a wash / shower since May 2019. The home has explained to Mrs C that said her father would decline personal care and the home could not force him. Mrs C has told the home it should be more forceful with him and just tell him he was going to have personal care. Not really give him the choice.
53. At the Risk Management Meeting in August 2019, Mr F’s IMCA said she had always seen Mr F well dressed, beard trimmed, and he never smelt. He had food choices, and a dietician was involved as well.
54. At a meeting in November 2019, Mrs C acknowledged that while her father had an en-suite, he would not get out of bed to have a shower.
55. At a risk meeting in January 2020, Mr F’s key worker said staff would ask Mr F to have a shower/strip wash on a daily basis. If he declined, the care worker would continue to encourage him throughout the day/evening. All present during the meeting agreed the strategies put forward about Personal Care.
56. In response to Mrs C’s complaint, the care home confirmed again in March 2020 that staff would regularly ask Mr F if he wanted a shower or wash, which he would refuse most of the time. All staff could do was to encourage and explain the consequences if he kept refusing. They could not force him to have a wash. The home had been transparent with all agencies involved in his care and had been following their advice.
57. The care home told me that:
• Mr F declined personal care support, so all the home could do was to encourage, advice, explain risks and agree strategies and seek advice. All of which it has done.
• The home regularly monitors the personal care charts of all service users, especially of those who may decline care.
• Mr F liked to wear the same clothes daily, as do most elderly people, and refused anything else. It was his choice. We explained this to Mrs C who refused to accept this. Staff would take his clothes for washing during the night and returned them during the morning.

Analysis

58. It is clear that Mr F did not receive the personal care support he needed from July 2019 onwards. However, the records show the care home was offering this to him, but he refused. The care home was open about this and it was regularly discussed during reviews and risk management meetings.
59. While I understand Mrs C’s distress of seeing her father not receiving the amount of personal care support he needed, the records show this was due to Mr C refusing support and the home not being able and allowed to force this on him.
60. Mr F was regularly seen and reviewed by a range of professionals, including his advocate, none of whom raised any concerns with regards to his appearance.

The cleanliness of Mr F’s room

61. Mrs C says she visited once a week, at the weekend, and felt the home failed to keep her father’s room clean. There were always crumbs etc on the floor, dust everywhere and stains were clearly visible. Furthermore, there was evidence of a mice infestation from mice droppings in her father’s room and a mousetrap. Her father had told her several times he had seen a mouse near the bathroom.
62. The records shows that Mr F reported seeing a mouse, after which staff immediately put a mousetrap in place and called the Council’s Environmental Health Department for further advice. The department said the home had taken the right action.
63. The care home’s daily care records had a separate section for “Room checked”. It had several items that need to be ticked (including changing bedding etc). The care home says its records show that his bedding was changed once a week.
64. In response to Mrs C’s complaint, the care home told the Council in March 2020 that:
• It has a very conscientious cleaner who works Monday to Friday. She completes her daily cleaning schedule and will report any concerns she may have. In addition to checking the cleaning schedule chart, the manager also carries out weekly and monthly audits around hygiene, infection control and the environment. Any concerns found are dealt with there and then, where possible.
• Mrs C only visited at the weekend. Over the weekend, the responsibility for monitoring the cleaning was with staff. Staff. When there was a shortfall, she would remind staff verbally and put reminders in the staff communication book.
• During the last environmental health inspection for food hygiene, the home gained a 5 star rating. The inspector was aware the home was using mouse bait boxes and she was fine with this. She did not demonstrate any concern.
65. The Council concluded in its complaint response in May 2020 that it was evident from its investigation that the described cleaning regime is not sufficient or acceptable for this home. It strongly recommended that immediate improvements would be made to hygiene, including a robust 7-day cleaning regime that is regularly checked, including regular checks of all rooms.

Analysis

66. There was a schedule of cleaning and monitoring in place Monday to Friday. However, at the weekend there was no cleaner, and the home manager was not around to monitor the rooms. This would have enabled the situation to arise as described by Mrs C, of her father’s room not being sufficiently clean.
67. The Council has already recommended the cleaning regime should be extended from 5 to 7 days, and rooms should be checked regularly throughout the week.

The complaint about broken furniture

68. Mrs C says the first time she went to her father’s room, at the end of June 2019, she noticed the base of his bed was broken. She made a complaint in July 2019 that:
• Her father’s bed was broken and then replaced by another very unstable wooden bed that was unsafe.
• The light bulb in her father’s side table lamp never worked.
• The window could not open properly.
69. The home told Mr F’s social worker on 24 June 2019 that it was told about the broken bed last night and had already sorted it this morning.
70. Mrs C says the broken bed (a divan) was replaced within a week by a second bed (pine-slated) that was screwed together too loosely and one of the slates at the pillow end had been repaired by screwing another 'slate' of thin wood on top.
71. At the risk management meeting in August 2019, Mrs C said:
• Her father’s bed was falling apart. The home said it had fixed the bed.
• His bedside lamp was still not working.
72. The care home has said that:
• When it was told that Mr F’s bed was broken, it immediately sent the handyman to fix this. On closer inspection it was found that 8 bolts were loose, which the home tightened. It also added additional screws.
• With regards to the replacement of the bulb. Staff inform the handyman of any issues with bulbs, who will replace them. Staff also have access to light bulbs, so they can replace them immediately if needed. The home now has a more robust weekly room check audit form in place which will prevent this from happening again.
• Mr F always had his main light on during the day and his bathroom light at night. There was therefore no need to keep another light on at night.
73. The care home’s maintenance file does not show if or when the bulb was changed. However, the care home confirmed to the family in writing in March 2020 that it had been replaced.
74. Mrs C says the bulb had only ever been removed and there was no bulb in place during her last visit on 14 March 2020.

Analysis

75. Mr C’s initial bed was not in an appropriate condition. This is fault, but the care home took steps to address this when this was raised by Mrs C. However, there is no evidence it replaced the light bulb in Mr F’s lamp within a timely manner. This is fault as well. The care home says this did not result in an injustice to Mr F because staff would leave a light on for him in the bathroom.

The alleged failure to improve her father’s care in response to her complaints

76. Mrs C said that, even though she regularly complained about the above to the care home staff and the Council, all concerned failed to ensure the above was addressed and that his care improved. She made most of her complaints about the Council and the care home verbally. She regularly spoke with senior staff at the home but was not able to speak to the manager, who was not at the home during visits.
77. The home said that:
• Whenever Mrs C had concerns, she would tell senior staff who would tell management. The senior would also implement any actions to rectify the concerns if needed. The home displays its complaints policy in the hallway and by the visitor’s book. There is also a copy in the service user handbook, which is in every room.
• Mrs C did not put in a formal complaint throughout 2019.
78. Mrs C says she never saw the service user handbook in her father’s room, as otherwise she would have used that.

Analysis

79. The records show that care reviews, best interest and risk meetings were held regularly, at which Mrs C had the opportunity to express any concerns. These were subsequently discussed and plans were agreed to address them. It is explained above why some of Mrs C’s concerns could not be addressed, which was due to Mr F’s refusal to accept some care support.

The circumstances of Mr F’s death

80. Mrs C said she has been lied to about the circumstances in which her father died on 25 March 2020. She said:
• A staff member told her that her father did not look well on the morning of his death. The staff member said she had asked if they should contact a GP. However, the home decided not to. As such, Mrs C says the care home should have called a GP in the morning to assess her father.
• She called the home around lunch time to ask why she had a call from the GP about not resuscitating. However, she was assured that her father was OK and there was nothing to be worried about. However, only 30 minutes later she received a call (at 2pm) to say that paramedics were trying to resuscitate her father.
• She arrived at 2.20pm but was refused to see her father and be with him. She screamed and cried but staff would not let her into the room. There was no sound coming from her father’s room to suggest that paramedics were trying to resuscitate him.
• When she saw her father after he passed away, her father felt very cold, stiff and he looked starved. She therefore believes that he died much earlier than 2.20pm, and that he died because of starvation.

81. According to the care home’s records, there were no concerns about Mr F’s presentation on 24 March 2020. The records state:
• AM: Refuses breakfast. Regular checks made. No concern.
• PM: poor intake all afternoon. Regular checks made. No concerns.
• Night: Refused his medication. In bed. Red out daughter’s letter. He enjoyed it. Settled night and slept well. No concern
82. I am unable, based on the available records, to determine exactly what happened on 25 March 2020, and when this happened, in the run up to the home calling for an ambulance.
83. The care provider has said that:
• It contacted Mr F’s G.P at 9am, because Mr F was no longer eating, drinking or taking his medication. The GP said he would not visit (due to Covid) and would talk to his colleagues about putting Mr F on the palliative pathway. This would have involved a discussion between the GP and Mrs C, part of which would have been about resuscitation.
• Mr F made a turn for the worse but, despite Covid restrictions, staff decided that Mrs C should come in and be with her father if possible. It called Mrs C at around 12.30 to say her father had taken a turn for the worse, experienced shallow breathing and was non-responsive, so she needed to come in.
84. The ambulance reports said that:
• It attended after Mr F became unresponsive. A care worker saw Mr F become unresponsive in bed at 1.40pm. Cardiac arrest time was 1.40pm.
• Advanced Life Support provided for 30 minutes. Resuscitation attempts stopped at 2.30pm. Spoke to GP. Cause: end of life frailty
85. The care provider said that, when Mrs C arrived at the care home, the paramedics were working on Mr F. The paramedics had placed him on the floor so they could better access him and treat him. It was the paramedics who said they did not want Mrs C to go into the room as he was on the floor and he was not in a very pleasant way (tubed etc). They allowed her in once they had settled him on the bed. He had died by then.
86. The Council told me that a detailed investigation found there was no evidence that Mr F fell before his death. The Police also made initial enquiries but found no evidence to support a fall had occurred.

Analysis

87. Based on the information available, I did not find evidence to support Mrs C’s view the care home had been at fault or provided incorrect information. The care home informed Mrs C had made a turn for the worse and she was therefore advised to come to the care home. Her father was found to be unresponsive at 1.40pm and staff called the ambulance service. Due to paramedics providing Advance Life Support to Mr F it was decided against allowing Mrs C into the room.
88. However, the care home failed to keep sufficient records that day to describe Mr F’s presentation, how it changed and what was discussed during various telephone calls. This is fault.

Overall analysis

89. I found there was some fault with regards to the care the Council arranged for Mr F and the actions of the Council itself. To remedy this, the Council has already previously waved an amount of £6,336.
90. As Mr F has passed away, we are unable to recommend a remedy to him for any injustice he has experienced. However, we can recommend a remedy for any distress Mrs C has experienced as a result of the faults we have identified. I have considered the financial remedy the Council has already provided and concluded it is sufficient in this case.

Agreed action

91. 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, although I found fault with some of the actions of the care provider, I have made recommendations to the Council.
92. I recommended that, within four weeks of my decision, the Council should provide an apology to Mrs C for any distress she has experienced as a result of the faults identified above.
93. The Council has told me it has accepted my recommendation.

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Final decision

94. For reasons explained above, I found there was fault, which caused an injustice. I am satisfied with the actions the Council will carry out to remedy this and have therefore decided to complete my investigation and close the case.

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Investigator's decision on behalf of the Ombudsman