Summary: Mrs X complained about the care provided by the care home her father resided in before he passed away. We did not find fault with some aspects of how it handled her father’s deterioration. We found fault with the care home’s quality of daily case records and not appropriately recording reasons and evidence for specific decisions made when her father declined. This caused significant distress, frustration and uncertainty to Mrs X. The care home has agreed to apologise, make a symbolic payment to recognise the injustice, and improve its record keeping.

The complaint

1. Mrs X complains about the care provided to her late father (Mr Y) by the Care Home he resided in. She says it was inadequate, with concerns its actions contributed to her father’s rapid deterioration up until he passed away in summer 2023. She says her father’s health and wellbeing declined due to its care and has caused she and her family significant frustration and distress.

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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. (Local Government Act 1974, sections 34B and 34C) If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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 someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
4. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
5. 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(1), as amended)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

7. Mrs X complains of events from summer 2023. As per Paragraph 4, this is a late complaint. However, Mrs X initially complained to the Integrated Care Board (ICB). After an investigation eight months later, it signposted her to the Parliamentary and Health Service Ombudsman (PHSO). After a further seven months, the PHSO advised her to approach us for the Care Home element of the complaint. She promptly did in January 2025. I have therefore exercised discretion to consider Mrs X’s complaint to us as there are good reasons why she did not make the complaint to us sooner.
8. I considered Mrs X’s complaints about the Care Home’s actions. I have not investigated her concerns about delays of healthcare organisations or decisions made by medical professionals (e.g. the Advanced Nurse Practitioner). The PHSO can consider this part of the complaint as healthcare services are not in our remit. I have included some information from healthcare organisations involved for background to Mrs X’s complaints.
9. In Mrs X’s complaint, she raised some care concerns which I will not consider further. I explain why below:
1. She said the Care Home gave Mr Y a wheelchair without footrests to support his legs. She had photos from two occasions. The Care Home said all its wheelchairs had footrests. While there is evidence, it would be difficult to fairly establish how often this may have happened (whether it was reported each time) or if there was significant individual impact on Mr Y at the time. Additionally, given the passage of time, there have likely been changes in staffing and procedures in the Care Home since the time of events. It is unlikely we could achieve a meaningful outcome and so I consider it would not be proportionate to investigate this point. Even if we did, we could not remedy any alleged direct injustice to Mr Y as he has passed away.
2. Mrs X said the Care Home served Mr Y very hot drinks or food he did not like. Without further supporting evidence, I cannot make an evidence-based or meaningful finding on this.

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How I considered this complaint

10. I discussed the complaint with Mrs X and considered her views.
11. I made enquiries of the Care Provider and considered its written responses and information it provided, including daily care records and its internal policies.
12. Mrs X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Law and administrative background

Care services regulation and guidance

13. 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. The standards include Regulation 17: Providers must “securely maintain accurate, complete and contemporaneous records in respect of each service user, including a record of the care and treatment provided and of decisions taken in relation to the care and treatment provided”.
14. In February 2023, we published guidance for care providers on good record keeping.

The Care Home’s Challenging Behaviour Policy

15. The policy says: “the care service will discuss with the person and their representative any concerns about their behaviour, which could cause harm to the person or to others. We will record all concerns and the decisions reached with the person and their representatives about how to manage the identified concerns. We will carry out and fully record a risk assessment to assess the possible danger which is faced and the balance of benefits and disadvantages of the proposed course of action”.

Background

16. Mr Y moved into Lostock Grove Rest Home (the Care Home), run by Axelbond Limited (the Care Provider), in May 2023. He had a diagnosis of Alzheimer’s. The Care Home does not provide nursing care and external medical professionals would attend when needed.
17. After moving in, the Care Home informed Mr Y’s GP of his new address and completed a care plan for him. This said he mobilised with a walking frame with the support of a carer and at times with a wheelchair. It said Mr Y was occasionally incontinent and used continence pads to promote his dignity.

What happened – summary of key relevant events

18. In mid-July 2023, the Care Home notes recorded Mr Y’s recent unsettled behaviours during the nights with shouting out. The Advanced Nurse Practitioner (ANP) visited but Mr Y was at an appointment. The ANP prescribed him sleeping pills. Mrs X said they were not informed.
19. Later that week, the Care Home sent a referral as it noted Mr Y was sleepy, confused, with poor mobility. Two days later, the ANP visited. The ANP notes said they were unsure if it was due to the medication prescribed. They requested blood tests for Mr Y.
20. At the start of August 2023, a daily care record noted Mr Y had slid out of his chair and several carers took him to bed, where he did not physically co-operate with staff. The same day, the Care Home notes recorded it contacted the GP with concerns of Mr Y’s deterioration. The GP advised they would visit. The next day, the Care Home chased the GP. The GP said they would not visit as Mr Y did not have anything medically wrong with him, and it could be behavioural. The GP noted the blood test request but there was a backlog.
21. The next day, the Care Home made some amendments to Mr Y’s care plan, including Mr Y was not mobilising (bedbound), required two carers for transfers, and he was doubly incontinent. It also noted his continuous shouting behaviours during the night.
22. Two days later, the Care Home notes recorded the ANP visited Mr Y to review his unsettled behaviours and poor mobility with his chair. The ANP made a referral to Occupational Therapy (OT) to request assessment and prescribed sleeping pills, informing Mr Y’s wife.
23. The next day, a daily care record said staff moved Mr Y’s room to the ground floor.
24. Three days later, the Care Home manager called Mr Y’s family in to say the placement was not working out and it could no longer meet Mr Y’s increasing needs.
25. In mid-August 2023, the Care Home notes recorded concerns with Mr Y’s decline and weariness. It called the GP who advised to call 999 due to Mr Y’s sudden change. The Care Home did this. The paramedics checked him over. After discussion with the GP, they told the Care Home to stop the sleeping pills. It told the Care Home to monitor and call back if he became worse.
26. The next day, the Care Home sent a referral to the Speech and Language Therapy team (SALT), and later called the service, as Mr Y had difficulties with swallowing. The SALT team said it could not come for several days. It advised to also contact the GP. Later that day, the ANP visited and prescribed scoops of thickener for Mr Y.
27. The next day, the Care Home notes recorded the nurse came to take Mr Y’s bloods. Later he rapidly declined, and the Care Home called 999. Paramedics discussed with the family and agreed for him to stay at the Care Home. The ANP checked Mr Y and a GP video consultation held. The district nurses became involved in his care with medications prescribed. The blood results came back that day but were sent to Mr Y’s previous GP.
28. Three days later, Mr Y passed away. The day after, the current GP received Mr Y’s blood results. Mrs X said they showed he was dehydrated.

Mrs X’s complaint

29. In November 2023, Mrs X sent a complaint to the ICB, raising concerns about the medical care Mr Y received and the Care Home. This included (relevant to what I am considering):
1. the Care Home did not inform the family about the sleeping pills prescribed to Mr Y;
2. concerns about Mr Y’s declining mobility. She had concerns why they kept him confined to his bed and it should have explored options to improve his mobility;
3. how it responded to Mr Y’s shouting behaviours;
4. Mr Y having to use incontinence pads as he felt a loss of dignity; and
5. the decision to prescribe sleeping pills, delays with the blood test and the results, and referrals made by the ANP.
30. The ICB conducted a multi-agency investigation. As part of this, it asked the Care Home to investigate. In December 2023, the Care Home responded to Mrs X with its findings. It did not signpost her to us. It said:
1. it apologised for not informing the family of the medication and put procedures in place to prevent it happening again.
2. it noted Mr Y was at very high risk of falls and would attempt to launch himself from his chair when seated. It said the ANP acted on Mr Y’s mobility concerns through an OT referral.
3. due to complaints from other residents, it decided to transfer Mr Y to a ground floor room opposite the Manager’s office, but his shouting behaviour continued. It later spoke to Mrs X to advise Mr Y should move to a more suitable home.
4. Mr Y was not always aware of his needs to go to the toilet so he used continence aids to help with this.
5. it said these decisions were made by appropriate medical professionals as it was not a nursing home.

Analysis

31. We cannot say the actions of the Care Home contributed to Mr Y’s deterioration and death or make findings of negligence. That can only be determined by a court. I can look at evidence around general standards of social care and actions taken by the Care Home.

Blood tests, delays and referrals made by the ANP

32. The ANP and other healthcare services were responsible for the medical decisions, blood tests, results, and the OT referral. As per Paragraph 8, I cannot make findings on these.

Incorrect GP details

33. Mr Y’s blood test results were sent to Mr Y’s previous GP in error. This is not from fault by the Care Home. The Care Home evidenced sending Mr Y’s new address to his current GP shortly after he moved in. After this, any inaction with Mr Y’s records was the responsibility of healthcare systems and professionals, not the Care Home.

General standards of daily care notes

34. I am concerned about the general quality of Mr Y’s daily care notes, with examples and reasons below:
• They are handwritten where some entries are illegible or difficult to read.
• They are not contemporaneous. Entries appear to be general summaries written after or at the end of shifts, mostly without specific timings, and lack details of specific care given.
• Some entries noted specific observations about Mr Y’s presentation, but it is not clear whether these were followed up.
• There are some missing dates with no daily notes recorded. This includes two days in Mr Y’s final week, which is understandably a period which Mrs X is particularly concerned with.
• I note the Care Home regularly recorded Mr Y as generally having “good fluid and diet intake” each day. This changed in the last two weeks prior to Mr Y’s passing where it recorded more occasions of “poor fluid intake and diet”. This aligned with the increased concerns about Mr Y’s condition in those weeks to which the Care Home made requests to the ANP and GP to review him. However, “good” and “poor” are vague and not specific enough. They should have noted the frequency, timings, and amounts consumed by Mr Y, to enable comparisons when his condition declined and the notes do not show if this was specifically monitored.
• This also applies to entries regularly stating “all personal care needs met”. This is too general. It is not clear what specific tasks this referred to and timings. For example, I note the daily records did not generally refer to Mr Y’s pads being checked or changed, or whether it classed this under “personal care needs” so again, the evidence is unclear on whether this had been done or not.
• Mrs X pointed out inconsistencies with activities the Care Home said Mr Y participated in (which generally were not included in the relevant daily care note) and sometimes conflicted with diary entries where the family visited.
35. Overall, I consider the daily care records show poor record keeping. This is fault. This falls below the standard we would expect with respect to Regulation 17 (see Paragraph 13). This casts some doubt on the accuracy of these. This has caused significant uncertainty about the level of care Mr Y may have received. This is injustice to Mrs X and her family.

Mr Y’s deterioration

36. While not always reflected in the daily care notes, the records of professional visits show the Care Home generally made timely referrals or calls to appropriate medical professionals in response to concerns with Mr Y’s deterioration and behavioural changes. These are appropriate actions for it to seek their healthcare advice and decisions. This is not fault by the Care Home.
37. The Care Home accepted it failed to inform Mr Y’s family of the sleeping pills prescribed by the ANP. It apologised and dealt with it internally to prevent it happening again. I am satisfied this was a proportionate response to this part.

Mr Y’s incontinence

38. Mr Y’s initial care plan described some incontinence with aids to promote his dignity. The Care Home said it acted accordingly and regularly checked Mr Y’s pads, but I have already noted above that this was not clearly evidenced in the daily care notes. Further to this, the Care Home made a referral to the continence service for an assessment after he moved in, but I cannot see an outcome or if it chased it up, even after Mr Y’s continence issues worsened in August. This is fault. The assessment would have reviewed Mr Y and could have identified appropriate strategies or management plans according to his toileting needs. I cannot say if the assessment had been done what the outcome may have been. But there is some uncertainty for Mrs X and the family that it may have made a difference to Mr Y.

Mr Y’s behaviours

39. The care records indicate from the start of August, Mr Y spent the rest of his days in bed. The Care Home said this was for his safety because of his high risk of falls. But I have only seen one care log where it recorded Mr Y sliding out of his chair. I cannot see any other recorded instances where this happened or the results, which would support the Care Home’s decision making. This is fault and leads to uncertainty for Mrs X and the family.
40. I note the Care Home added some notes to Mr Y’s care plan around this time about changes in his condition. However, I cannot see anything to say he was now a high falls risk. I cannot see it carried out a risk assessment on how it would manage or respond to these concerns, which led to the Care Home’s decision to keep Mr Y’s care to his bed from this point. There are also no records to show when or how the Care Home informed Mr Y’s family of these decisions and if or how it considered their views about this response. There is a lack of transparency and proper recording of significant decisions at the time. This also includes the decision to move Mr Y’s room to the ground floor. This is fault and does not align with Regulation 17 or its own behaviour policy at Paragraph 15. This caused distress and uncertainty to Mrs X and her family, given their concerns about wanting him to mobilise and there are no records about whether this was considered.
41. The Care Home said it later spoke to Mrs X to say it could not meet Mr Y’s needs, and he needed a new placement. While it was appropriate to have a discussion first, if this was its position, then it should have formally given her a clear written decision and notice period. I cannot see it followed the process we would expect. This is fault, causing frustration to Mrs X and her family.

Complaint escalation

42. The Care Provider’s complaints policy refers to complainants being able to escalate complaints to us if they are dissatisfied with its initial response. Normally, we would expect the Care Home to signpost to us at the end of a complaint response. But in this specific case, I can understand why the Care Home may not have done so, as the ICB led the investigation into Mrs X’s overall complaint and it was part of a wider response from many agencies. Although, if the Care Home had done this, it may have reduced some time and trouble for Mrs X with where to pursue her complaint. But given the above, I do not consider it warrants a formal finding of fault.

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Action

43. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living, such as symbolic payments. This is because the person cannot benefit from such a remedy. However, if we consider the person who has complained to us has been adversely affected by the impact of any fault identified, we may make a recommendation to remedy their own distress.
44. To remedy the injustice set out above to Mrs X, the Care Provider has agreed to carry out the following actions within one month of the final decision:
• Apologise to Mrs X for the frustration and uncertainty caused by the faults identified (in line with our guidance on making an effective apology) and pay her a symbolic payment of £300 to recognise the injustice.
45. Within two months of the final decision:
• the Care Provider should consider and review our guidance “Good Practice Guide - Good Record Keeping” and share this with all relevant staff to highlight the standards expected for record keeping. This should include the requirement to keep accurate, legible and contemporaneous daily care logs providing sufficient details, timings, and decisions of the care provided to its residents. It should also inform us how it intends to monitor to ensure improvements in practice.
46. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

47. I find fault causing injustice to Mrs X. The Care Provider has agreed to actions to remedy the injustice. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman