Summary: There is evidence the care provider failed to ensure that the late Mrs X always had a varied and nutritious diet which met her needs. The care provider did not complete its response to Mrs A’s complaint. The care provider says it has improved the catering standards since this complaint. The care provider now agrees to apologise to Mrs A, provide evidence of the improved standards, and offer a sum in recognition of the anxiety caused to Mrs A.

The complaint

1. Mrs A (the complainant) says the care provider’s staff regularly failed to provide her late mother with the “balanced, nutritious diet” stipulated in her care plan or respond to her individual needs, and suggested Mrs A was trying to control her mother’s eating. As a result, she says her mother became overweight while in the home. She says when Mrs X had to move onto a soft then pureed diet, she was frequently offered the same food for consecutive meals. She also complains the care provider failed to respond to her complaints after her mother’s death.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

5. I considered the information provided by the care provider and by Mrs A. I spoke to Mrs A. Both parties had an opportunity to comment on this draft statement and I considered their comments before I reached a final decision.

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What I found

Relevant law and guidance

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
7. Regulation 14 says the nutrition and hydration needs of service users must be met. It says, “A variety of nutritious, appetising food should be available to meet people's needs and be served at an appropriate temperature. When the person lacks capacity, they must have prompts, encouragement and help to eat as appropriate.

Where a person is assessed as needing a specific diet, this must be provided in line with that assessment. Nutritional and hydration intake should be monitored and recorded to prevent unnecessary dehydration, weight loss or weight gain. Action must be taken without delay to address any concerns.”

8. Regulation 17 says care providers must investigate and respond to complaints.

What happened

9. Mrs X, who had dementia, went to live in the care home in 2018. Her weight was within the normal range. Her care plan said, “(Mrs X) will be supported to have a balanced, nutritious diet and maintain a healthy weight”.
10. Mrs A says (and has provided documentary evidence of her emails) that over the years she reminded staff on many occasions of food that her mother either did not like or could not tolerate, such as caffeinated or sugary drinks, peppers, processed meat products. She says she only really became aware that Mrs X was still frequently served these items after Mrs X started to need help with eating, in mid-2022, when she started visiting nearly every day. She has provided photographic evidence of the food served.
11. Mrs A prepared a notice to be put up in Mrs X’s room to remind staff of the items Mrs X could not or would prefer not to eat, but she says it was never put up.
12. By the end of 2022 Mrs X had gained 11 kgs to the point where her BMI was now regarded as unhealthy (she was overweight). Mrs A says when she raised the matter with the home manager, the manager referred to her as “controlling” her mother’s food choices. The manager told her that Mrs X had developed a sweet tooth, but Mrs A says her mother was now being offered cakes and biscuits as often as five times a day. Mrs A says, “In June, it was agreed that Mum be given just one sweet treat a day but leaving this to “free choice” of when to have that treat was also too difficult for staff, so by August, it was agreed Mum would have cake at 3pm to simplify things for staff”.
13. Mrs A also says that even when her mother was supposed to be given a healthy diet (a separate stipulation which had to be chosen) there were times when for example she was given pie when fish had been ordered.
14. By September 2023 Mrs X was struggling to swallow and was coughing when she ate, which prompted a decision to change to a soft food diet. An assessment by the Speech and Language Therapist confirmed the need for a level 5/6 diet – ie. ‘minced and moist’ foods. Mrs A says “Her meals consisted almost daily of some form of mince and mash, sometimes with vegetables, often without. I won't of course know whether her meals were actually mince twice daily which is a very disturbing thought. Sometimes the meals were served with veg that couldn’t be mashed with a fork.” She says sometimes no special food was supplied by the kitchen, so staff just offered what they thought was appropriate – for example, beans and mashed potato.
15. In December 2023 Mrs X moved onto a pureed diet. Mrs A says these were bought in from a catering company which provides a large variety of choices, but the number of choices purchased by the care provider was very limited. She says her mother was often being given the same food (a pureed beef bolognaise pasta) several meals in a row. As a result, she says she personally began to buy pureed foods and keep them in the fridge at the care home for the staff to serve her mother.
16. Mrs A says when she asked for a meeting to discuss her concerns her mother was moved onto the nursing unit at the home without, she says, any change in her condition.
17. A new matron started work at the home in January 2024. Mrs A raised her concerns about the catering with him, and pointed out that it was not simply the lack of variety but also the apparent lack of understanding of how to deal with residents with dysphagia which was concerning to her. He acknowledged there were problems with the catering. She said she understood he intended to tackle the issue and asked if in the interim she should continue to purchase the additional foods. She never received a reply to the question.
18. Mrs X’s health deteriorated, and she died in February 2024.
19. Mrs A complained to the Ombudsman in May 2024. She said the home had given inappropriate food and drink over a long period of time which had resulted in her mother gaining a lot of weight. She said the limited choice when her mother had moved onto a soft, then pureed diet was in itself a problem as apart from the lack of variety, there were some choices her mother simply did not like. She says on occasion they were overcooked and dried up at the edges which defeated the purpose of having pureed foods.
20. The care provider says “In the period over December 2023 and January 2024 we did have supply issues with some pureed meals which limited choice for a period. This was due to a manufacturing issue for the producer of the pureed meals. We prepare all minced options in house but purchased the pureed savoury meals as they have better texture and look, like the normal version of the meal, better than we can create.

There was a short time when some meals were overcooked, but the catering team found a solution and rectified this problem”. The care provider denies however that there was a limited number of pureed options available and says Mrs X enjoyed the meals.

Statements from staff suggest the limited options were the minced and soft foods and say that the pureed options were more varied (it is unclear whether that was because those were the options purchased by Mrs A).

21. The care provider also says Mrs X was moved to the nursing unit in consultation with the GP as her condition deteriorated. Mrs A says however there were previosu attempted to move Mrs X without evidence of clinical need.
22. The care provider acknowledges that it did not write to Mrs A again about the complaint after Mrs X died. The matron says he assumed that receiving that correspondence would add to the distress Mrs A was feeling already.
23. Finally the care provider says “We have looked at the systems that were in place and made improvements to how care teams access information on dietary requirements at the point of service, to ensure food and drink is served which always matches their care planned nutritional needs. This has improved since January 2024.” But it says it does not accept the “magnitude” of the complaints. It says Mrs A requested salad options for Mrs X which staff felt Mrs X did not enjoy, and they found it challenging to try and meet Mrs A’s expectations. One member of staff comments that Mrs X was gaining weight on a monthly basis and so Mrs A wanted her to have a healthy eating plan.

Analysis

24. The documentary evidence (the documented weight gain, for example) as well as the anecdotal evidence suggests that the care provider failed to meet Mrs X’s nutrition needs. Mrs X gained weight as a result of the diet provided at the care home, to the point that she became unhealthily overweight. That was not only fault in itself and a failure to adhere to her care plan, but also a potential breach of the regulations.
25. It was unfortunate that Mrs A’s many attempts to improve the diet her mother was offered were very clearly seen by staff as challenging and an attempt to control what Mrs X was eating, rather than a desire to ensure Mrs X was being provided with a nutritious diet. That attitude also pervades the care provider’s response to me about Mrs A’s approaches to staff.
26. The care provider denies there was a lack of variety in the pureed food options offered but it is difficult to see why Mrs A would purchase those additionally if there was sufficient variety offered. Residents should not be faced with the same pureed option at consecutive meals.
27. The care provider should have completed its response to Mrs A. That was an error which caused Mrs A additional distress.

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Agreed action

28. The care provider says it has improved the way in which care teams respond to individual care plans in terms of the required diet. Within one month of my final decision the care provider will provide me with one week’s food diary from three different (anonymous) residents from September this year and a copy of their care plan to evidence that improvement.
29. Within one month of my final decision the care provider will apologise to Mrs A for its failure to complete the complaints process. It will also apologise for the distress caused to her by the way in which staff failed over a long period of time to adhere to Mrs X’s care plan.
30. Within one month of my final decision the care provider will offer Mrs A the sum of £500: £250 in recognition of the time and trouble she was put to in bringing this complaint when it could have resolved the issue sooner by a proper company response, and £250 to acknowledge the distress caused to her personally by witnessing the care provider’s failure to adhere to Mrs X’s care plan properly.
31. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

32. I have completed this investigation. I find the actions of the care provider caused injustice to Mrs A which completion of the recommendations at paragraphs 28 to 30 will remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman