Summary: Mrs X complained about the care given to her late mother by the Care Provider and that she did not have a face-to-face visit with her before she passed away. We find the Care Provider’s management of her mother’s weight loss, how it told Mrs X of her death and its complaint handling all caused injustice to Mrs X. The Care Provider accepts these findings and has agreed to take actions set out at the end of this statement to provide a remedy for that injustice.

The complaint

1. I have called the complainant Mrs X. Her complaint concerns the care provided to her mother, Mrs Y, by Saveo Care Ltd (‘the Care Provider’) at Kingfishers Nursing Home (‘the care home’). Mrs X complains the Care Provider:

• failed to recognise that Mrs Y was nearing the end of her life during her final weeks at the care home in July 2020; she says it failed in particular to adequately monitor or address significant weight loss Mrs Y experienced during that time which Mrs X considers was an indicator her mother was nearing her end of life;
• did not allow Mrs Y’s family the opportunity of visiting her in person during the final weeks or days of her life, or of being with her when she passed away;
• failed to observe Mrs Y’s religious wishes at the end of her life and told Mrs X that Mrs Y had passed away in an insensitive manner;
• handled poorly her complaints about the above.

2. Mrs X says because of the above she and other members of Mrs Y’s family have suffered significant unnecessary distress.

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The Ombudsman’s role and powers

3. We 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)
4. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (Local Government Act 1974, section 26A or 34C)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. This complaint involves events that occurred 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 the care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19

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How I considered this complaint

7. Before issuing this decision statement I considered:

• Mrs X’s written complaint to the Ombudsman and any supporting information she provided;
• communications Mrs X had with the Care Provider about the matters covered by this complaint which pre-dated our investigation;
• information provided by the Care Provider in reply to my enquiries;
• any relevant law or guidance as referred to in the text below;
• comments made by Mrs X and the Care Provider on a draft of this decision statement.

8. The Care Quality Commission (CQC) is an independent regulator of all health and care services in England. Under an information sharing agreement between the Local Government and Social Care Ombudsman and CQC, we will share this decision with CQC.

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What I found

Relevant CQC guidance

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the ‘fundamental standards’ which all care providers should meet in delivering care. We consider the 2014 Regulations and accompanying CQC guidance when determining complaints alleging poor standards of care.
10. Of relevance to this complaint are the following:

• Regulation 14 – “Meeting 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 - “Receiving and acting on complaints”. This says providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints. Guidance from the CQC says this includes making sure those who complain are provided with information on how they can escalate their complaint if dissatisfied with the reply.

Relevant national guidance on visiting arrangements in care homes during the COVID-19 pandemic

11. On 2 April 2020 the Government issued guidance for care homes. This said family and friends should be advised not to visit care homes, except next of kin in exceptional situations such as end of life, in which case visitors should be limited to one at a time.
12. The Government issued new guidance to care homes on 22 July 2020. Care providers were advised to develop a policy for limited visits where community transmission rates were low.

Chronology of Key Facts

13. Mrs Y entered the care home in February 2020. The Care Provider drew up a care plan with Mrs Y on admission, which said she had full capacity to take part in discussions about her care. Mrs Y signed to say she agreed the contents. The Care Provider reviewed the care plan monthly.
14. Part of the initial care planning included a section on end of life planning. The Care Provider recorded that Mrs Y was Catholic and that she would like her family to be told if she was approaching end of life. It said there would be further discussion with Mrs Y about her end of life wishes. The Care Provider recorded reviewing that document five times subsequently. On two occasions the notes of those reviews indicate it spoke to Mrs Y again about her end of life wishes but that she had not decided anything further. In other cases it is not recorded what the review consisted of.
15. Also, as part of initial care planning, the Care Provider undertook a nutritional assessment. It found Mrs Y was of healthy weight; had a good appetite and no difficulties eating. Her assessment score was zero, meaning she was at no risk of malnutrition. The Care Provider reviewed that assessment monthly. The score it awarded did not change; i.e. it continued to record that Mrs Y remained of healthy weight, had a good appetite and no difficulties eating.
16. Attached to the nutritional assessment were notes for staff on what action the Care Provider should take if the assessment score rose to ‘4-5’ indicating a medium risk of malnutrition. These say staff should add snacks to the resident’s diet; record food and fluid intake; take weekly weight recordings and to refer to GP or other health service if the score did not improve after a month.
17. Where the assessment score rose to 6 or above the resident would be considered at ‘high risk’. In these circumstances staff were advised to take the same actions as in medium risk cases except that any referral to a health service professional would be immediate and they should offer assistance to the resident with eating.
18. The Care Provider also completed a second malnutrition screening tool on Mrs Y’s admission, although this was not reviewed monthly. This took account of Mrs Y’s body mass index (BMI); the rate of any weight loss and the impact of any acute disease. The Care Provider did not find Mrs Y at any risk of malnutrition until the final occasion it updated this record, in mid-July 2020.
19. The Care Provider kept a separate record of Mrs Y’s weight, which it recorded monthly. These records show she lost around 2kg in her first two months in care. Then she lost another 3kg by the start of May 2020, a further 2kg in June and another 4kg by early July. There are no weekly weight records for Mrs Y.
20. Care records show that from March 2020, when the Care Provider first recorded Mrs Y losing weight, it said it would observe her eating and offer her milkshakes. In April the case notes said Mrs Y still had needs in this area and in May they recorded Mrs Y “still” taking fortified milkshakes. In June the notes recorded Mrs Y received help with eating. I noted the Care Provider kept a separate record from late May onwards of making milkshakes for Mrs Y. These were separate to daily food logs and fluid intake charts which it also kept.
21. I noted from the daily food logs that from around June 2020 onward Mrs Y was regularly declining at least one meal a day. In late June 2020, Mrs X says at her suggestion, the Care Provider referred to a dietician for advice. The dietician was not given a food diary showing what Mrs Y was eating. But they noted the Care Provider said they gave Mrs Y fortifying meals and milky drinks. The dietician recommended the Care Provider continue keeping records of Mrs Y’s food and fluid intake and supplement her diet with snacks and milkshakes, “between meals”.
22. Mrs Y had various physical health needs including epilepsy, which she only began experiencing after she moved into the care home. She experienced seizures as a result. The Care Provider kept a record of these. It noted a significant increase in the number of seizures Mrs Y experienced from May onwards and they became more frequent again in June 2020. The Care Provider believed this contributed to her weight loss as these episodes caused tiredness. I noted case records said Mrs Y sometimes stopped breathing after her seizures for up to 20 seconds.
23. The Care Provider kept notes of regular conversations with Mrs Y’s GP and a specialist nurse about her seizures. In mid-July 2020 a senior member of staff spoke to Mrs X about this issue. The member of staff said the care home was also concerned that Mrs Y was losing weight. It was around this time Mrs X first learnt staff were helping Mrs Y with eating and she learnt of the advice that Mrs Y should be provided with high calorie snacks. Mrs X arranged to provide some of those to supplement Mrs Y’s diet. I found some reference to Mrs Y being given snacks on daily food records but only after mid-July 2020.
24. Around this time there was also discussion around visits to Mrs Y. The Care Provider was facilitating window visits but Mrs Y struggled with these as she could not always hear Mrs X through the window. Mrs X proposed a visit where Mrs Y could sit in the doorway to the care home garden. Mrs X said she would wear full personal protective equipment. The Care Provider initially rejected this suggestion. But a few days later Mrs X met with the care home manager and they agreed to the suggestion.
25. The care home arranged Mrs X would come for a visit the following week, a few days later than Mrs X suggested. Mrs X asked the Care Provider to bring the visit forward and repeatedly expressed fears her mother may die before she had chance to see her. Care home managers sought to reassure Mrs X that her mother was not in the final stages of life. But Mrs Y passed away two days before the scheduled visit. This was in late July, shortly after the Government had updated its advice to care homes on visiting. At the time the care home also said in a newsletter: “please be assured if a relative is at end of life we will do everything we can to accommodate the family with regard to seeing a loved one.”
26. Around the time Mrs X was negotiating to visit Mrs Y, a family member who lives abroad, was also arranging to visit. She needed a visa to return to her home country. The family asked the Care Provider to sign a letter in support of the visa application in which it described Mrs Y as being at ‘the end of life’. The Care Provider agreed, and a manager signed the letter.
27. Mrs X also describes speaking to Mrs Y’s GP around the same time. Mrs X said the GP recognised the decline in Mrs Y’s health and this could mean she was nearing the end of life. The GP contacted the care home asking it to facilitate a visit from Mrs X. The Care Provider has provided notes of various contacts with health professionals during Mrs Y’s stay, but I could not identify any contact with the GP where it recorded any discussion around visiting and whether Mrs Y may be at end of life.
28. In the last two days of her life Mrs X had video calls with Mrs Y. However, both had to be cut short. Mrs Y was experiencing seizures and was very tired.
29. On the day Mrs Y died, the daily care log recorded staff helping her to eat her breakfast and lunch and said she had eaten around half. In the afternoon Mrs Y had a seizure and was given personal care. The Care Provider recorded in case notes that staff found Mrs Y on a crash mat next to her bed at 7:45pm (care notes record that Mrs Y sometimes slept on the crash mat rather than in bed and they sometimes record her expressing this as a choice and that she declined being helped into bed). The note described Mrs Y as “comfortable”. But at 8:15pm the notes recorded Mrs Y had stopped breathing.
30. The Care Provider went on to telephone Mrs X to tell her of Mrs Y’s death. I have listened to a recording of that call. As Mrs X was told that Mrs Y had passed away there can be heard various alarms in the background. Mrs X was distressed during the call and asked for details of how Mrs Y had been found and asked questions about what had happened. She also repeatedly said how much she had wanted to visit Mrs Y and was afraid she would die without seeing her in person. The member of staff did not respond to all these questions and comments. They told Mrs X the Care Provider needed to know details of an undertaker and pressed for information on this when Mrs X said she needed to think about that. They also told Mrs X that if they wanted to see Mrs Y they had to come in to the care home that evening.
31. I read Mrs Y’s care records for the month before she passed away. I noted no changes in her pattern of food or fluid intake. In particular, I noted her fluid intake was generally higher than recommended in the days immediately before she died. However, as noted above, it is recorded her weight continued to fall despite interventions and that she continued to experience regular seizures.
32. I also noted in May 2021 the CQC carried out an unannounced inspection of the care home and this focused on concerns around risk management. The inspection found the Care Provider was supporting those with risks associated with their weight to maintain healthy nutritional and hydration levels. It said the Provider had appropriate systems in place to manage this.

Mrs X’s complaint

33. Mrs X first made a complaint in July 2020, before Mrs Y passed away. She raised concerns about the care home’s communications and Mrs Y’s weight loss. The care home manager replied. Their reply:

• said the care home had communicated regularly with Mrs X but recognised staff could have explained Mrs Y’s weight loss sooner;
• summarised its actions in response to the weight loss and increased seizures Mrs Y experienced;
• said it remained very concerned about Mrs Y’s health; had spoken further with Mrs Y’s GP about this and would be having further discussion with them.

34. The care home manager’s letter did not explain how Mrs X could escalate her complaint.
35. After Mrs Y passed away Mrs X complained further. Her letter said:

• the Care Provider had overlooked evidence Mrs Y was at the end of life; as shown by her weight loss; increased sleeping; general lessening of engagement and growing weakness;
• had failed to facilitate reasonable requests for a visit; Mrs X noted that within days of Mrs Y passing away photos posted on social media showed another resident having a birthday celebration with a relative in the care home garden;
• had communicated the death in an insensitive way;
• the care home had not escalated her earlier complaint to the company head office.

36. A senior manager for the Care Provider replied to Mrs X in August 2020. Their response said:

• the care home staff did not think Mrs Y was ‘actively dying’. Her GP had not said she was at end of life. On the day of her death, Mrs Y had been alert and eating and drinking. The Care Provider understood Mrs Y’s weight loss arose from her frequent seizures and resultant exhaustion, for which it had sought help and advice. It had written to the family member saying Mrs Y was at the end of her life to help facilitate a successful visa application;
• arranging visits during the COVID-19 pandemic involved balancing the needs of residents, their families and staffing resources. It had been facilitating two window visits a day at the care home but would allow urgent visits if a resident became unwell or was “expected to pass away”. It said with hindsight it would have brought Mrs X’s scheduled visit forward and was sorry this did not happen. It said the social media post of a garden visit did not reflect policy and explained why it had allowed this as a one-off. It apologised for the distress caused to Mrs X by seeing this image;
• it agreed it had communicated news of Mrs Y’s death poorly, in a way that was “not in line with company policy” and “not to the standard” expected. It recognised this caused Mrs X distress and said it was “truly sorry for the way this news was delivered and for the pain this must have caused”. It said it had shared concerns with the member of staff and implemented company-wide training on this issue;
• it had dealt with Mrs X’s earlier complaint in line with its complaint policy and it had been appropriate for the care home manager to reply.

37. I note the letter did not offer Mrs X any signposting on escalating her complaint.
38. Next Mrs X requested copies of Mrs Y’s care records. After she received these, in March 2021, Mrs X wrote again to the Care Provider, reiterating many of her earlier concerns. Mrs X said the care notes did not support the statement that Mrs Y had been alert, eating and drinking on the day she died. Mrs X also provided an analysis of the Care Provider’s nutritional risk assessments and completion of the malnutrition screening tool. She queried how the assessment could have found a ‘zero score’ from May 2020 onward and not identified Mrs X at risk of malnutrition from that time. This was after taking account of Mrs Y’s weight loss, her loss of appetite, her need for help with eating and other risk factors.
39. Mrs X also pointed out other discrepancies in the Care Provider’s records; for example that Mrs Y’s weight was recorded differently on two records dated mid-July. She also said the dietician’s advice to give Mrs X three milkshakes a day was wrongly recorded as two milkshakes in the care plan.
40. The Care Provider replied in April 2021. It said its position on the care it gave to Mrs Y had not changed and that it would not review every detail of its care plans. It did not think it could add to its earlier reply. It did not offer Mrs X any signposting on how to escalate her complaint.
41. During our investigation the Care Provider has made further comments. It says:

• there are different definitions of when someone is at end of life; it uses the phrase ‘actively dying’ to distinguish cases where the resident is “expected to die in the coming months, weeks or days”. The Care Provider does not have a screening tool to identify such cases but says staff look for different signs which can include matters such as changes in breathing, fatigue, change in skin colour, loss of appetite and so on. It says in such cases staff will ask a GP to review needs and give an opinion on whether a resident is at the end of life. The Provider reiterated its earlier explanation for why in this instance staff had not thought Mrs Y was at the end of life;
• says it does not have a full record of all discussions it had with Mrs Y’s GP about her case;
• believes it could have done more to establish clarity about Mrs Y’s wishes when she reached the end of life and that it could have spoken to her family about that. It said it has now given its staff more training in this area;
• that it accepts Mrs X’s analysis of its nutritional assessments. It says it has now made its “nutritional screening tools more user friendly making it easier to identify weight loss or where a MUST score has changed”;
• it says the pandemic put its staff under exceptional pressure but that it could not use that as an excuse and that in its management and recording of Mrs Y’s nutrition it had fallen short of its own standards;
• it reiterated its apology for the call made to Mrs X when Mrs Y passed away recognising it was not sensitive or empathetic in tone; was not made from a quiet place; that its staff member had not answered Mrs X’s questions and had asked insensitive questions of their own;
• explained more about its visiting policy in force in July 2020 and again apologised Mrs X did not have a face-to-face visit with Mrs Y before she died.

42. The Care Provider also provided a copy of its complaint procedure that it gives to residents and relatives. This has two stages. The first stage says the care home manager will reply unless the complaint is about their personal conduct. If they do not resolve the complaint then the second stage is for a senior manager from the company’s head office to respond. There is no advice on escalating complaints beyond these two stages. The Care Provider says it also has a more detailed version of the policy for staff which refers to the role of this office.

My findings

43. I find there was no fault in the Care Provider’s initial care planning for Mrs Y which included a nutritional assessment and end of life care planning. The Care Provider also reviewed Mrs Y’s care plan monthly which was good practice. There is also evidence the Care Provider noted Mrs Y’s loss of weight and took measures to address this, adding milkshakes to her diet, possibly as early as March 2020. Further, there is evidence the Care Provider sought advice from professionals around the increased seizures Mrs Y experienced, which it understandably believed caused a consequent weight loss.
44. However, there was also some poor practice here. As Mrs X pointed out, and the Care Provider now accepts, there were flaws in the review of Mrs Y’s nutritional assessment and the associated malnutrition screening tool. Some of the record keeping around Mrs Y’s food intake was also hard to follow at times. A record was made of milkshakes being made for Mrs Y but a record was not always kept of whether she drank them. I also found many of the daily food logs were not detailed, generally referring only to meals as ‘breakfast’, ‘lunch’ etc and not giving a clear picture of what food stuffs Mrs Y ate. It also appears snacks were only added to Mrs Y’s diet in mid-July 2020 despite the Care Provider receiving advice from a dietician to do so around three weeks previously. Had the nutritional assessments been reviewed properly then this is also something the Care Provider should have considered adding to her diet sooner. It should also have been taking weekly weight measurements from around May 2020 onward if following its own policy. This combination of poor practice was fault.
45. I consider uncertainty results from this fault about how these failings impacted on Mrs Y. Had the Care Provider kept better records of Mrs Y’s case I consider it would have attempted more intervention, or at an earlier time, to try and increase her nutrition. However, the Care Provider did nonetheless follow some of the procedures expected of it where a resident is at high risk of malnutrition. It consulted with a dietician and there was an effort made to supplement Mrs Y’s diet with milkshakes and appropriate support was offered with feeding. These interventions did not stop Mrs Y’s weight loss. So, on balance, I cannot say the Care Provider could have prevented this. But the trajectory of Mrs Y’s deterioration in health may still have been different. The Care Provider accepts this finding of uncertainty and I set out below the actions it has agreed to remedy this injustice.
46. I also note the CQC inspection which took place some months after Mrs Y’s death did not find any failure of the Care Provider to meet the relevant fundamental standard. While I accept practice may have improved in the months after Mrs Y’s death, this suggests the Care Provider does have any systemic failings in this area.
47. Turning to whether the Care Provider knew Mrs Y was at the end of life, there was some poor record keeping around the conversations the Care Provider had with Mrs Y’s GP. While in general the Provider kept good records of its communications with professionals and with Mrs X, there is no record of any conversation in the final days of Mrs Y’s life, after Mrs X had raised the issue of whether Mrs Y was at end of life. It is known the GP spoke to the Care Provider and it is likely the subject of Mrs Y being at end of life was discussed. But that conversation, or part of the conversation, was not recorded in the notes. Given the importance of such a conversation I consider that a fault.
48. I note that clearly Mrs Y’s health had been declining since she moved to the care home. In particular she had suffered significant weight loss and increased seizures. The care notes also indicate Mrs Y becoming more withdrawn with fewer references to conversations and more references to her sleeping. She had also begun needing help with eating. I find it understandable that Mrs X wanted to see Mrs Y in person as a matter of urgency given that decline and given that neither window visits nor video calls had succeeded in achieving meaningful contact in the weeks before Mrs Y passed away.
49. I also noted the content of the letter signed by the Care Provider for Mrs X’s relative, which referred to Mrs Y as at the end of life. However, as the Care Provider says there are differing interpretations of what the term ‘end of life’ means. In this context I consider the Care Provider was referring to the wider expectation that Mrs Y may not have been expected to live for many months. I also consider it was behaving compassionately, wanting to provide the relative with an opportunity to see Mrs Y for which they needed a visa. I therefore find the letter does not show the Care Provider believed Mrs Y was entering the final days of her life when it was written.
50. I also have no reason to doubt the sincerity of the Care Provider that had it known Mrs Y was entering her final days it would have brought forward Mrs X’s planned visit. I can also see why, from the care records, the Care Provider did not think in the immediate days or hours before she died that Mrs Y was in the final stages of life. I recognise that some of the indicators of end of life which the Care Provider has said it looks out for, were present in Mrs Y’s case. But I also noted no difference in the pattern of Mrs Y’s eating and hydration, with the latter giving no cause for alarm. While Mrs Y still experienced regular seizures there is also no indication these had increased and may in fact have decreased with the highest number being recorded around mid-June, with Mrs Y having begun medication. Further, there is nothing in the daily log which suggests Mrs Y’s passing was anything but unexpected at the time it occurred. I note in particular the reference that Mrs Y was recorded as being ‘comfortable’ just 30 minutes before she was found unresponsive.
51. I also note that most of the events covered by this complaint took place before the Government gave advice to care homes on how or when they should facilitate face-to-face visits for relatives, with the exception of those known to be at the end of life – a term the Government did not define. I consider the Care Provider had a reasonable policy in place for visiting in July 2020 in this context. I also note that it went to efforts to support window visits and video calls.
52. On balance therefore I cannot find the Care Provider at fault for not facilitating a visit by Mrs X to Mrs Y before she passed away.
53. Leading on from the above, it also follows that I could not find the Care Provider at fault for not ensuring that Mrs Y received the last rites before she passed away. I note here the Care Provider, while knowing Mrs Y was a Catholic, did not know of any specific wishes she may have had relevant to end of life planning. I find the Care Provider did have an appropriate conversation with Mrs Y about her wishes for her end of life. It gathered certain important information about this and it tried to ascertain if she had more specific wishes. As part of those discussions, I consider the Care Provider could have offered a prompt to Mrs Y about whether or when she may have wanted it to call a Priest if she was nearing end of life. But I consider that a matter of best practice and I do not fault the Care Provider for not doing so. However, I welcome its commitment to learn lessons on how it can improve its end of life planning. In particular it recognises that with Mrs Y’s consent it could have sought to involve Mrs X in end of life planning decisions. I also consider its notes could have said more at times about how it reviewed this matter with Mrs Y.
54. I have considered next what happened after Mrs Y passed away. As the Care Provider acknowledges, and for the reasons it gives, the manner in which it told Mrs X of Mrs Y’s death was unacceptable. This was a fault and caused unnecessary distress. However, it is to the Care Provider’s credit that it recognised this. I find it has taken the appropriate action in offering a comprehensive apology to Mrs X for her distress and for taking steps to try to ensure there is no repeat. I consider there is nothing further I could recommend here.
55. Finally, I considered the Care Provider’s complaint handling. I make no criticism of the substance of the response provided by the care home in July 2020 to Mrs X’s complaint, nor that of the subsequent letter she received from the company manager in August 2020. The latter in particular was comprehensive, empathetic in tone and offered suitable apologies for areas where the Care Provider recognised it had got things wrong.
56. However, both letters were let down by the failure of the Care Provider to either signpost to the next stage of its procedure or to this office. I find that fault also extends to the written complaint procedure given to residents and relatives, which also contains no mention of the Ombudsman. As I explained above the CQC Fundamental Standards place an expectation on care providers to signpost complainants on how they can escalate their complaints. So, the evidence suggests the Care Provider may not be meeting this standard. This fault caused injustice to Mrs Y as she was put to unnecessary time and trouble in escalating her complaint.
57. I also consider the Care Provider could have done more in April 2021 when asked to reconsider its complaint response by Mrs X. While I recognise the Care Provider would not want to go over all its previous response, Mrs X did raise significant new information in her analysis of the Provider’s nutritional assessments. As the Provider now recognises this demonstrated it had fallen short in its recording and actions. That acknowledgment should have been provided at the time. And that letter too also failed to offer Mrs X appropriate signposting. These faults will also have added something to Mrs X’s time and trouble.

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Agreed action

58. The Care Provider says that it accepts these findings. To remedy Mrs X’s injustice it has agreed that within 20 working days of this decision, it will:
1. write to Mrs X providing a further apology which accepts the findings of this investigation; and
2. pay Mrs X £400 in recognition of her injustice; £250 is to recognise her distress as uncertainty and £150 to recognise her time and trouble.
59. The Care Provider has also agreed to learn further lessons from this complaint to improve its procedures, Within two months of this decision it will:
1. revise and reissue the complaint procedure it gives to residents, which will now include reference to this office once its complaint procedures have completed; and
2. ensure its home managers are briefed on the change and advised on the importance of signposting in any complaint responses they provide.

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Final decision

60. For reasons set out above I uphold this complaint finding the Care Provider’s actions have caused injustice to Mrs X. The Care Provider accepts my findings and has agreed action that I consider will remedy that injustice. Consequently, I have completed my investigation satisfied with its response.

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Investigator's decision on behalf of the Ombudsman