Summary: The Care Home responded to Mrs Y’s reports of uncleanliness in her father, Mr X’s, room. The Care Home was at fault for not trying to engage Mr X in activities. On balance, I cannot say this contributed to Mr X’s death. The Care Home has agreed to apologise to Mrs Y.

The complaint

1. Mrs Y complained about her father, Mr X’s, care at Ingleby Care Home (the Home). She says Mr X’s room was unclean and the Care Home failed to engage Mr X in activities. Mrs Y says this led to a decline in Mr X’s health. She wants the Care Home to learn from its mistakes to ensure they don’t happen again.

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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 future we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
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)

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How I considered this complaint

5. I considered evidence provided by Mrs Y and the Council as well as relevant law, policy and guidance.
6. Mrs Y and the Council have had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Regulations and procedures

Fundamental Standards of Care

7. 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:
• providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences (regulation 9).
• providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints (regulation 16).
• providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).

The Care Home’s cleaning programme

8. The Home operates a cleaning programme for residents’ bedrooms and bathrooms to ensure a clean and hygienic environment for its residents. The frequency of cleaning tasks varies between daily and weekly depending on the task. The programme also allows for a deep clean of all areas and spot cleaning as required.
9. The cleaning programme sets out that daily tasks for bedrooms include clearing waste and cleaning touch points, care equipment, furnishings and personal items. Bedroom fixtures and fittings are to be cleaned weekly. All bathroom fixtures and surfaces are to be cleaned daily, with no weekly tasks.

What happened

10. Mr X was admitted to Ingleby Care Home (the Home) in June 2024 for a period of assessment following a stay in hospital. Mr X had dementia. The Care Home assessed Mr X as needing the following:
• Support with personal care and hygiene.
• Basic communication, with staff checking he understood instructions and requests.
• Support when moving around.
• Support using the toilet and pads for incontinence.
11. The Home’s care notes show it started to deliver Mr X’s care in line with his care plan. In September 2024 Mrs Y complained to the Home. She said Mr X’s room was often unclean, with an unmade bed, a bedside lamp that did not work and curtains hanging off the rail. She said Mr X’s wife, Mrs X, had found him not wearing his own clothes and had to remind staff to turn the TV on in his room and make sure it was working.
12. On 10 October the Home’s housekeeper noted a delay cleaning Mr X’s room due to an incident elsewhere in the Home. They said Mrs X had visited before they could clean the room and found faeces on the floor.
13. The Home responded to Mrs Y’s complaint on 14 October 2024. It said it had deep cleaned Mr X’s room, and this would be done monthly. It had cleaned Mr X’s carpet and re-attached the curtains. It said it would remind staff to make Mr X’s bed, but this was sometimes difficult as he spent a lot of time in bed. It said its maintenance team would ensure the TV was working. It apologised to Mrs Y.
14. Mr X was admitted to hospital in November 2024. While he was in hospital his family ordered a new mattress for his room at the Home. Mr X returned to the Care Home two weeks later. The Care Home noted Mr X’s condition had deteriorated and he had lost a significant amount of weight. Mr X now needed two staff to help him move and was noted as being quieter and unable to maintain a conversation. The Care Home updated its assessment of Mr X. It referred Mr X to an occupational therapist to assess its moving and handling of him out of bed, and a dietician to look at his weight loss.
15. Shortly after Mr X returned to the Care Home Mrs Y emailed the Care Home with concerns for his health and condition. She said she was increasingly concerned for Mr X’s care, and he required a full assessment. She said she was happy with the staff and care given previously but Mrs X had found Mr X looking uncomfortable in bed, with no bedding.
16. Mr X was then readmitted to hospital. The Care Home responded to Mrs Y’s concerns. It confirmed it had deep cleaned Mr X’s room and installed the new mattress. It said Mr X was quite rigid since his return from hospital and was at risk of slipping out of his chair. It said it was waiting on an occupational therapy referral to replace Mr X’s chair. It apologised for how Mrs X found Mr X and said it would relay Mrs Y’s concerns to its staff. Mrs Y thanked the Care Home for its reply and its care of Mr X. Mr X died a few days later.
17. Mrs Y complained again to the Home. She said it was not clean, and the Care Home had not addressed the issues raised in her first complaint. She said hospital staff had commented on Mr X not walking and moving enough. She said staff had shown little sympathy when she returned to the Care Home to collect Mr X’s belongings and she felt Mr X’s death was preventable.
18. The Home carried out an investigation of Mrs Y’s complaint and responded in January 2025. It said it had responded to most of her points of complaint in October 2024 and was satisfied it had met Mr X’s care needs. It said it would discuss its emotional support for family of residents with staff. Mrs Y complained to the Ombudsman.
19. In response to our enquiries the Care Home provided a statement from its activities coordinator. They said Mr X occasionally joined in with activities but preferred watching TV in his own room. They said they asked Mr X to join activities throughout his stay, but he refused.
20. It also provided a sample of Mr X’s daily records. They show staff regularly checked on Mr X, supported Mr X with his personal care and continence and with meals.

My findings

21. The records show the Care Home assessed Mr X when he was admitted and updated his care plan as his needs changed. It made appropriate referrals when Mr X’s condition changed. The records I have seen show it supported Mr X’s care needs throughout his stay and there is no evidence of fault in the way it did this.
22. Mrs Y complained Mr X’s room was often unclean. When Mrs Y first reported this to the Care Home it accepted the room had not yet been cleaned on that day and then carried out a deep clean of Mr X’s room. It did this again when Mr X was admitted to hospital. Without further evidence, I cannot say, even on balance, to what extent Mr X’s room was cleaned in line with the Home’s cleaning programme. However, the Care Home responded appropriately to Mrs Y’s concerns and deep cleaned Mr X’s room. There is nothing more I can achieve by investigating this further.
23. Mrs Y also complained the Care Home failed to engage Mr X in activities. The Care Home has provided a statement from its activities coordinator, with details of its efforts to engage Mr X in activities. However, Mr X’s care records make little reference to specific instances of when this occurred. Shortly after the events in this complaint, CQC issued an improvement notice against the Care Home. It said the Care Home lacked processes to encourage and support people to engage in social activities. On balance, I cannot say the Care Home made efforts to engage Mr X in activities. The Care Home was at fault. The CQC report says the Care Home’s plans to address this failing. CQC will now monitor the Care Home and take further action if appropriate. Because of this, I have not recommended any service improvements.
24. Mrs Y says the Care Home’s failure to engage Mr X in activities led to him moving less and contributed to his death. It is clear Mr X’s condition deteriorated toward the end of his stay at the Home. On balance, I cannot say this was due to the Home’s actions. Its care records show how Mr X struggled with his mobility following his stay in hospital. It noted the decline in Mr X’s condition and was in the process of seeking advice from an occupational therapist and dietician before Mr X died. The Care Home was not at fault.
25. Mr X has since died and we are unable to remedy any injustice caused to him by the care home's actions. However, the faults by the care home caused Mrs Y distress and uncertainty over whether there could have been a better outcome for Mr X.

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Action

26. Within one month of the final decision the Care Home has agreed to apologise to Mrs Y for the distress and uncertainty caused by the failings identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology.

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Decision

I find fault causing injustice, which the Care Home has agreed to remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman