Summary: Mrs X complained that the care provided by the Care Home was poor and did not meet her father’s needs as an elderly person with dementia. We found fault with the Home in that Mr Y’s care plan was not reviewed and updated when incidents occurred or his needs changed. This caused injustice to Mrs X and Mr Y in terms of uncertainty, distress, and unmet needs. The Care Provider has agreed to our recommendations to remedy this injustice.

The complaint

1. Mrs X’s complaint relates to the care provided by Wyndham Manor Care Home (the Home) to her late father, Mr Y, who was resident at the Home for the final month of his life in Summer 2024. She complained that the care provided by the Home (which is run by the Care Provider) was poor in many respects and did not meet her father’s needs as an elderly person with dementia.

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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 an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
3. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:
• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

4. If we are satisfied with an organisation’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)
5. 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

6. I discussed the complaint with Mrs X. I considered the information that she and the Care Provider have sent and the relevant law, guidance and policies.
7. Mrs X and the Care Provider had an opportunity to comment on a draft version of my decision and I considered their comments before making a final decision.

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What I found

Law, guidance and policies

Care Quality Commission and fundamental standards

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards which says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9)
• Service users must be treated with dignity and respect (regulation 10)
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12)
• The nutritional and hydration needs of service users must be met (regulation 14)
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service (regulation 17)

What happened

10. For the purposes of clarity and consistency, I have summarised and grouped Mrs X’s complaints, the Care Provider’s responses, my findings from the records, and my analysis of these matters, under separate headings for each area of care.

Care assessment and planning

What happened

11. Mrs X complained that the Home didn’t share care plans with the family or involve the family in the creation of them, and didn’t amend them when Mr Y’s condition deteriorated rapidly.
12. The Care Provider said that Mr Y’s care and support plan was fully completed and person centred. It said there was a clear audit trail of professional visits, and his care and support plans were updated when his needs had clearly changed.
13. I have reviewed the full care plan that was created by a nurse practitioner with Mr Y on 22 July, 11 days after he was admitted to the home. It includes consideration of his care needs in the areas of:
• Washing and dressing
• Continence
• Skin care
• Oral hygiene
• Sleep and night needs
• Eating and drinking
• Mobility and falls
• Psychological needs
• Capacity and cognition
• Medication
• Social activities
14. The Care Provider’s response to Mrs X’s complaint included recognition that: “based on his presenting needs on admission, a Deprivation of Liberty Safeguard Urgent and Standard authorisation should have been applied for, and further exploration should have been documented around Mr Y’s ability to consent, with completion of Mental Capacity Assessment”.

Analysis

15. The CQC’s guidance on how to meet the fundamental standards of care includes:

“Each person using a service, and/or the person who is lawfully acting on their behalf, must be involved in an assessment of their needs and preferences as much or as little as they wish to be. Providers should give them relevant information and support when they need it to make sure they understand the choices available to them.”

16. It was good practice that a full needs assessment was carried out shortly after Mr Y was admitted to the Home, covering all dimensions of care, and a care plan was created for him. However, Mrs X (who held Power of Attorney for her father) complained she was not involved in the assessment, and there is no evidence in the Home’s records that she (or any other family member) was asked to participate. Mr Y had a diagnosis of vascular dementia, from which he died just a month after admission to the Home from hospital. The care plan notes that Mr Y’s “son and daughter would make more important decisions on behalf of [Mr Y]”. The Care Provider admitted that Mr Y’s ability to consent should have been explored further. Given these factors, on the balance of probabilities, I find that Mr Y would likely not have been able to participate fully in the assessment and care planning process, and Mrs X, as the person lawfully acting on his behalf, should have been invited to contribute to the assessment. This Home’s failure to involve Mrs X (or another suitable family member) was fault.
17. The Care Provider said that Mr Y’s care and support plans were updated when his needs had clearly changed. I have seen that Mr Y’s care plan was updated in the area of eating and drinking on 8 August following assessment by the Speech and Language Therapy (SALT) team. However, the daily sheets completed by staff in the Home also documented significant deterioration in Mr Y’s continence, mood, behaviour, and mobility/falls, none of which were reflected in his care plan. The failure to note changes in Mr Y’s care plan was fault.
18. These faults caused Mr Y the injustice of uncertainty: as his needs may not have been fully captured by the initial assessment or reflected in his care plan, and that plan was not amended as his needs changed, his needs were less likely to have been met. I shall consider this issue in more detail below, and will make a recommendation to remedy this injustice.

Mobility/Falls

What happened

19. Mrs X complained that Mr Y had several falls whilst in the Home, each of which was unwitnessed.
20. The Care Provider said that Mr Y was at high risk of falls, having had several in the months prior to hospitalisation (that preceded his stay at the Home). The Care Provider said that Mr Y had sustained falls on 15, 19 and 21 July, and that “due to the level of Mr Y’s cognitive impairment, and his inability to recognise risks along with increased behaviours that challenge, without constant 1:1 input, there would always be an element of risk of further falls”.
21. Mr Y’s care plan included that he required the assistance of one member of staff when mobilising, to guide him and to prompt him to use his Zimmer frame. For transfers from bed to chair he required the assistance of one or two people. The Care Provider said that staff would assess his ability during each transfer: if his mobility had been poor or he was fatigued, then a stand aid or hoist would be used.

Analysis

22. I have reviewed the Care Provider’s Falls Prevention Policy and its policy on the Care of Someone Who Has Fallen. Both are appropriately detailed and up to date. The latter includes that “staff must complete the service’s accident/post falls report form and record the incident in the care plan.”
23. I was unable to reconcile the Care Provider’s account of Mr Y’s falls with the Home’s records. The daily sheets include mention of falls having occurred on 15, 19 and 26 July. The falls log refers to falls on 18, 20, and 21 July. This inconsistency in record keeping is fault.
24. Although the falls were noted in the daily sheets and falls log, I did not see evidence that accident reports had been completed, nor that Mr Y’s risk assessment and care plan had been updated following his falls, as the Care Provider’s policy sets out should happen. The Care Provider told me that Mr Y’s care plan “was updated following assessment for stand-aid/hoist”, but I did not see evidence of this.
25. These failings are fault, which caused Mr Y the injustice of being exposed to an unnecessary risk of further falls.
26. The Care Provider told me that it is “introducing a more thorough accident reporting system with monthly analysis. Falls sensor mats were purchased for all residents who were high risk of falls and more detailed information [will be obtained] regarding what was required to try and mitigate the risk of further falls/injuries.” I welcome these findings, which I consider should prevent further fault. I will also make further recommendations.

Privacy and dignity/continence

What happened

27. Mrs X complained that staff at the Home did not ensure that Mr Y was appropriately dressed, and his privacy and dignity maintained. She said the Home did not properly manage his continence needs or help him in the way required with toileting (he was left to use a nappy which he did not understand and it caused him distress). She complained further that carers dressed Mr Y in, and offered to buy for him, inappropriate clothing (specifically a one-piece garment to manage his continence issues).
28. The Care Provider’s response to Mrs X’s complaint said that staff may have been constrained in their ability to dress Mr Y appropriately because the frequency of his episodes of incontinence required numerous clothing changes, and he did not have unlimited clothing. It was also documented that he often removed his underwear and incontinence pads, urinated in inappropriate places, was resistant to personal care, and his feet were too swollen for his socks to be worn.

Analysis

29. I do not find fault with the Care Provider’s explanation set out in paragraph 28.
30. Both Mrs X’s complaints and the Care Provider’s response suggest that Mr Y’s incontinence worsened during the time he was resident in the home. The combination of this issue with deteriorating mobility and diminishing cognitive capacity meant that it was increasingly difficult for staff to maintain Mr Y’s privacy and dignity. However, whilst numerous incidents of “inappropriate wetting” were recorded in the daily log and the communication log, I did not see evidence that Mr Y’s care plan was updated, and action taken, to respond to his changing needs. This failing is fault, which caused Mr Y and Mrs X the injustice of distress that his needs were not met.
31. The Care Provider said that the one-piece garment had been recommended for other residents by the Community Psychiatric Nurse in order to help maintain residents’ dignity. If the one-piece garment mentioned to Mrs X was thought to be helpful in the maintenance of Mr Y’s privacy and dignity, then it should have been documented in the records rather than simply discussed informally with family. It was not. This failing is also fault.

Safety/night needs

What happened

32. The Care Provider provided me with copies of Mr Y’s sleep assessment sheets, which were signed hourly from when they were initiated on 30 July until his death of 14 August.

Analysis

33. Mr Y’s care plan, written on 22 July, included that he should be checked hourly overnight, to ensure that he was dry, and should be helped back to bed/sleep if he was unsettled (as he often could be).
34. I have not seen evidence that Mr Y was checked throughout the night during the week 23-29 July, after the care plan was created. This absence of documentation is fault. This fault caused Mrs X the injustice of uncertainty as to whether Mr Y’s needs were met, or whether he was exposed to additional risk of falls.

Personal care

What happened

35. Mrs X complained that Mr Y was left unshaven and his eyes were not bathed as required.
36. Mr Y’s care plan includes that he would require the assistance of one carer with washing, bathing/showering, shaving, oral hygiene and dressing/undressing. The Care Provider’s response to Mrs X’s complaint included that Mr Y was frequently resistant to being assisted with his personal care.

Analysis

37. My Y was resident in the Home for 34 days. The daily records do not mention personal care (as distinct from changes of incontinence products) on at least a dozen of these days. It was not possible for me to establish whether Mr Y’s personal care needs were not attended to on these days, or whether they were, but this was not documented.
38. The Care Provider said that Mr Y was “frequently resistant to being assisted with his personal care”, but there was only one mention of this in the daily sheets, which said that Mr Y was “refusing to stand for p/c [personal care]”. Had Mr Y refused care more frequently, I would expect this to have been clearly documented.
39. These gaps in the Home’s records are fault, which caused Mrs X the uncertainty of not knowing whether her father’s personal care needs were met.

Pressure care

What happened

40. Mrs X complained that My Y suffered from a lack of regular pressure care in the final days of his life.
41. The Care Provider’s response to Mrs X’s complaint said that Mr Y was at very high risk of pressure damage. It explained that his position was changed regularly but staff stated that he could still move around. When placed on his side, a support cushion was placed behind him, but he would manage to move the cushion.
42. The Care Provider also told us that “For pressure care he required the use of a slide sheet and the assistance of two members of staff.” Mr Y’s Care Plan included that he should be given reminders to change position when he was in bed for long periods.

Analysis

43. The daily sheets show that Mr Y received pressure care from 8 August until his death. However, as there was only a single mention on each day, it was not possible to assess how frequently this was carried out.
44. I find this lack of documentation was fault, but there is no evidence that Mr Y suffered any injustice (in the form of pressure damage) because of this fault.

Nutrition

What happened

45. Mrs X complained that Mr Y was given inappropriate food, causing an incident of choking followed by vomiting, in the last days of his life.
46. The Care Provider said that Mr Y’s care plan was updated on 8 August following assessment by the SALT team. They recommended that Mr Y have a Level 7 regular diet (which required staff to cut food into small pieces) and Level 1 fluid (thickened fluid in a small holed spouted beaker ensuring that he was fully alert and upright) and that full assistance was required.
47. The Care Provider interviewed the member of staff who had attended Mr Y on 12 August, during what Mrs X described as an incident of choking followed by vomiting, and included their account in its response to Mrs X’s complaint. It is a plausible account, but it says that Mr Y did not vomit, and it doesn’t mention choking. It is therefore at odds with the daily log for that day, 12 August, which states “he is choking on his food, referred [again] to SALT”.

Analysis

48. The lack of consistency between the staff member’s account and the record in the daily log is fault, which caused Mrs X the injustice of uncertainty as to whether Mr Y’s nutritional needs were met.

Medication

What happened

49. Mrs X complained that a staff member who administered medication was not aware of what the medication was for.
50. The Care Provider, in its response to Mrs X’s complaint, said that staff who administer medication must hold a relevant NVQ, and they receive training on safe handling of medications and further e-learning. They are then observed completing six competencies which they need to pass before they are able to administer medication.

Analysis

51. I find no evidence of fault in relation to this aspect of Mrs X’s complaint. While it may be part of a Healthcare Assistant’s role to administer medication, they are not necessarily expected to know the indications for the medications which they administer. Further, there is no suggestion that Mr Y suffered any injustice in this regard. That is, Mrs X did not complain that Mr Y was given the wrong medication or the wrong dose of medication.

Behaviour

What happened

52. Mrs X complained that the Home failed to recognise Mr Y’s advanced dementia and to manage his symptoms, instead insisting that Mr Y’s behaviour was “behavioural”.
53. The Home’s daily logs include entries on most days that Mr Y had been “very, very vocal”, “shouting all day”, “shouting at staff”, and on several occasions “urinating in different rooms”.
54. The Care Provider also provided copies of six behaviour charts, which related to incidents of Mr Y shouting, exposing himself, and urinating in inappropriate places.

Analysis

55. The behaviour charts provided in evidence by the Care Provider include the ways in which staff sought to manage Mr Y’s behaviour in the moment, usually by asking him what was wrong, spending time with him, or attempting to take him to the toilet. This was evidence of good practice.
56. However, I saw no evidence in the daily log, the behaviour charts, or the care plan, that staff made attempts to understand and address the underlying causes of Mr Y’s uncharacteristic behaviours, in order to determine how such incidents of challenging behaviour could be prevented, or managed better, in the future. The proforma behaviour charts do not include a section prompting staff to take such action, which may be a helpful addition.
57. After several such incidents, I would have expected Mr Y’s care plan to have been reviewed, as his needs had clearly increased since admission, and he was clearly distressed. It may, for example, have been appropriate to seek external clinical support. This did not occur.
58. These failings are fault, that caused Mr Y injustice in that his needs remained unmet in the medium term after each incident had been resolved in the short term, and caused Mrs X distress. I shall recommend accordingly.

Conclusion

59. Many of the instances of fault I have found above could have been avoided if the Home had updated Mr Y’s care plan each time an incident occurred, or his needs changed, as opposed to simply recording the fact of each occurrence in the daily logs or elsewhere. In the event, there was seemingly little attempt to draw a connection between Mr Y’s rapidly evolving needs and the care plan that had been created shortly after his arrival at the Home. My recommendations below reflect this.
60. My recommendations also reflect that the Care Provider referred itself to the CQC, which carried out an unannounced inspection in May 2025. This inspection found:
• a breach of the legal regulation in relation to good governance, including shortfalls in relation to record keeping and the management of medicines, nutrition and continence care.
• an effective system was not fully in place to ensure staff were trained and supported.
• there were gaps and shortfalls in staff knowledge and skills in relation to areas such as catheter care, the Mental Capacity Act (2005) and nutrition.
• the Care Provider had already identified many of the issues found by the CQC. They had introduced new recording and monitoring systems as well as a new electronic care management system. It was not possible for the CQC to check how effective these new systems were, since they had just been introduced and were not yet embedded into practice.
61. I have made my own decision on this complaint after an independent consideration of the facts. However, the CQC’s findings are helpful for guiding our service improvement recommendations. We aim to complement and build upon the insights of the CQC rather than conflict with or duplicate what they have already suggested. For example, had the CQC not found that the Care Provider had already introduced an electronic care management system, I would have recommended this, as it was difficult (for me and, I suspect, for staff working in the Home) to track incidents and areas of care across numerous different hard-copy documents.

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Action

62. Within one month of my decision, the Care Provider should agree to make Mrs X a payment of £500 in recognition of the injustice she experienced in terms of the stress, distress and frustration caused by failings in her father’s care. This is a symbolic payment recommended in line with our Guidance on Remedies.
63. Within two months of my decision, the Care Provider should also agree to the following recommendations:
• remind relevant staff of:
1. their duty to involve family members in the care assessment and planning process, when appropriate
2. their duty to amend care plans when incidents occur and/or needs change; and
3. the Care Provider’s internal policies (particularly the falls policies), and provide any training required
• consider reviewing the behaviour chart template to include triggers for a review or re-assessment of a resident
• further discuss, preferably with the Community Continence Service, the suitability of the one-piece garment for the management of incontinence.
64. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

65. I find fault causing injustice. The Care Provider has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman