Summary: Mrs X complained the Council delivered poor care to her late father, Mr Y. We found the Council was at fault in how it managed the provision of Mr Y’s mattress and his repositioning, and in its record keeping of medication administration. This caused Mrs X frustration and avoidable uncertainty. The Council will apologise to Mrs X and make a symbolic payment to recognise the distress caused.

The complaint

1. Mrs X complained the Council delivered poor care to her late father, Mr Y, whilst he was residing in a care home. Specifically, she says the care provider:

• was not a suitable placement for her father
• incorrectly administered medication to her father
• did not manage his nutrition well which caused him to lose weight and deteriorate
• delayed in supplying him with the correct mattress

2. Mrs X says this has had a significant emotional impact on her.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. 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) and 34C(2), 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)

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How I considered this complaint

6. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
7. Mrs X and the Council 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

Legislation and guidance

8. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions.

ASC provider (definition)

9. We can investigate complaints about actions by adult social care providers that can be regulated by the Care Quality Commission. Such activities include giving personal care or other practical support in the place where the person lives. This might include complaints about residential accommodation and personal care provided as a condition of treatment for substance misuse, but we cannot investigate complaints about the treatment or therapy itself. Non-regulated activities include day centre services. We cannot investigate complaints about those services if they have been privately arranged.
10. The law defines ‘personal care and other practical support’ as ‘physical assistance (or prompting and assistance) given to a person in connection with:

• eating or drinking (including giving nutrition other than by mouth or alimentary canal);
• toileting (including in relation to menstruation);
• washing or bathing;
• dressing;
• oral care; or
• the care of skin, hair and nails (except for nail care provided by a chiropodist or podiatrist)’.
  (Health and Social Care Act 2008 (Regulated Activities) Regulations 2010

Care Plan

11. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.
12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. Regulation 17 requires care providers to maintain an accurate, complete and contemporaneous record of the care provided for each service user. This includes retaining the records for a period after someone has left a care home.
13. Under the Mental Capacity Act 2005, if a person in a care home has been assessed as having the capacity to make a specific decision, the care home must listen to and abide by that decision, even if they believe the decision is unwise.

What happened

14. The Council completed a Care Act assessment for Mr Y in January 2024 and found he had capacity to make decisions about his care. At that time, he was living at home.
15. In February, Mr Y moved to emergency respite placement, while his wife, his main carer, was in hospital. The Council allocated a social care practitioner in March, who visited Mr Y at the care home.
16. Mr Y was at risk of pressure sores; his care plan recorded he required a profiling bed with an alternating mattress and repositioning every four hours. The correct bed was in place on admission, and this remained until June 2024.
17. In April, Mr Y raised with nurses that he found the mattress uncomfortable and requested a foam pressure-relieving mattress.
18. In late April, a district nurse visited Mr Y to discuss his request and advised him of the benefits of remaining with his current mattress as listed in his care plan.
19. The Council says Mr Y was also seen by a GP at this time. An assessment was completed using the Braden Scale. This is the tool used to assess a patient’s risk of developing pressure ulcers. This assessment concluded Mr Y scored as ‘high risk’.
20. Mr Y stated he still wanted to change bed and, as he had capacity, the nurse supported his decision.
21. In May, following the death of Mr Y’s wife, a review care assessment was completed as Mr Y was transitioning from respite care to permanent residency. This assessment found Mr Y’s needs had developed to requiring nursing care rather than residential.
22. A Speech and Language Therapy (SaLT) assessment completed in May stated Mr Y required a little and often approach when staff are supporting him with eating, and his preference of food was soups or meals of a level 4 puree consistency due to his struggles with swallowing.
23. In late May and June, Mrs X raised concerns about Mr Y’s care. She said he was not eating enough, questioned the quality of nutrition records, and was unhappy with the placement. She also raised concerns about medication management and the suitability of his mattress.
24. The care home responded that Mr Y was offered appropriate food in line with professional guidance and encouraged to eat but sometimes declined. As he had capacity, staff respected his choices. It also said the GP and SaLT team had advised that Mr Y’s weight loss was consistent with his underlying health conditions.
25. In June, a support meeting found Mr Y eligible for NHS funding and plans were made to move him to a nursing home. Shortly after, his prognosis deteriorated and it was agreed, in consultation with Mrs X, a fast-track assessment was completed. Mr Y moved to a nursing home later that month.
26. In August, Mr Y passed away. Following Mr Y’s death, Mrs X escalated her concerns about his care.

The complaint

27. Mrs X complained to CQC in September and then to us in January 2025. The Council at this stage had not had the opportunity to investigate as it was not aware of the complaint. We notified it of the complaint.
28. The Council contacted Mrs X regarding her complaint in February.
29. In its final response, the Council addressed each complaint point. The Council said:
• It had visited the care home and discussed the concerns with the registered manager, who confirmed the home could meet Mr Y’s needs.
• The care home said staff liaised with the SaLT to provide appropriate food and noted he had capacity and could not be forced to eat.
• In relation to medication, the care home said it was administered at the correct times in line with his prescription but apologised for any concerns about its management.
• Regarding the mattress, the care home said it discussed this with the nursing team and that both Mr Y and Mrs X were informed it would not be provided. It also said staff liaised with the GP and were aware about the need for two hourly turns in bed.
• It concluded by apologising for any distress caused to Mrs X and advised her of her right to approach the Ombudsman if she remained dissatisfied.

Council response to enquiries

Nutrition

30. The Council provided several documents relating to Mr Y’s nutrition, including his care plan, nutrition care notes, a SaLT assessment, and the outcome of the care provider’s investigation
31. Mr Y’s care plan state he was on a pureed diet with level-thickened fluids. It assessed him as being at very high nutritional risk and recommended daily monitoring of his dietary intake. This was consistent with the SaLT assessment, which indicated Mr Y may prefer level 4 pureed foods and soups.
32. A sample of the nutrition care notes shows Mr Y was offered a range of pureed foods, with daily records of his intake. This included occasions where he refused to eat.
33. As part of its investigation, the care home manager spoke with Mr Y, who said he did not often feel hungry and would prefer drinks over food. He reported telling staff this but felt they continued to encourage him to eat, which he found frustrating. The manager also spoke with care and kitchen staff, who demonstrated that appropriate pureed meals and thickened soups were being prepared and labelled for Mr Y, and showed an understanding of his dietary requirements.

Medication

34. Mr Y’s care plan recorded he required daily medication, with staff support for administration. The care home maintained a Medication Administration Record (MAR), which was shared with us.
35. The MAR lists Mr Y’s prescribed medication in line with prescription details. While the labels specify frequency, they do not record exact times. One medication was required to be taken 30 minutes before food.
36. Our sample of the MAR shows daily staff signatures, indicating medication was administered. However, timings are recorded only in general terms (e.g. “morning” or “lunch”), rather than specific times. This makes it unclear whether time-sensitive medication, particularly that required before food, was given properly.
37. In response to our enquiries, the Council acknowledged inconsistences in the MAR. There are gaps in recording and unclear stock balances.

Mattress and repositioning

38. Mr Y’s care plan recorded he required to be offered repositioning every four hours. The Council records show this was initially every two hours, but Mr Y found this to be too frequent and disturbed him during the night. The care plan was then adjusted to every four hours, to support Mr Y’s views.
39. However, in the Council’s complaint investigation, the care home said it was aware of the need to be repositioned every two hours, which was incorrect according to the care plan.
40. The Council acknowledged the charts contain inconsistences, including occasions where the position recorded is unclear, and instances where there is more than a four-hour gap without a record offer, refusal or completed reposition.
41. Our sample of the chart shows inconsistencies. Including:
• 25th June repositioned at 04:35am and next offer at 13:08pm
• 24th June repositioned at 06:46am and next offer at 12:46pm
• 22nd June repositioned at 03:35am and next offer at 09:46am
• 7th June repositioned at 10:17am and next offer at 15:29pm.
42. The Council stated it had been unable to establish why the mattress change that Mr Y requested had not been actioned. It told us the care home had been unable to retrieve documents from the nursing team nor the notes between the GP and the district nurse in relation to its mattress discussions due to the time passed.
43. The Council offered Mrs X a payment of £250 for the avoidable distress.

My findings

44. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them.

Nutrition

45. Mrs X says the care home recorded that Mr Y was eating when he was not. However, we can only base our findings on the evidence available. The nutrition records show staff recorded both Mr Y’s intake and occasions where he refused food. The records also align with his assessed needs, including a pureed diet and thickened fluids, and the investigation indicates staff understood and followed this guidance.
46. On balance, the records provide a reasonable and consistent account of the care delivered. I recognise this would have been distressing for Mrs X given her concerns about her father’s weight loss; however, I do not find fault in how the care home managed Mr Y’s nutrition.

Medication

47. When reviewing the MAR charts, I found some entries were not clearly legible. The charts used coded entries (for example, letters to indicate outcomes such as refusal), but it is not clear whether these were used consistently or what they refer to, as they cannot clearly be read. This means I cannot reliably determine whether medication was administered or refused.
48. Accurate and legible records are essential to demonstrate safe medication administration. As the records cannot be clearly understood, I cannot be satisfied Mr Y always received medication as prescribed. The lack of timings also mean it cannot be determined if the time specific medication was administered at the correct time. This is fault. This caused Mrs X avoidable uncertainty and worry about whether her father received appropriate medication.
49. During its complaint investigation, the Council discussed medication with the care home and accepted assurances it followed prescription label timings without further scrutiny. However, in response to our enquiries, the Council later accepted there were faults in medication management. This meant it failed to adequately scrutinise the provider’s records and missed an opportunity to identify these issues earlier.

Mattress and repositioning

50. The repositioning charts contain gaps and unclear entries, including periods exceeding the four-hour requirement with no record of whether repositioning was offered, refused or completed. I therefore cannot be satisfied Mr Y received appropriate pressure care in line with his care plan. This is fault.
51. It is unclear why Mr Y was not provided with the mattress he said he preferred. While clinical advice indicated the existing mattress was appropriate, the provider also acknowledged that, as Mr Y had capacity, his wishes should be respected
52. There is inconsistency in the records. The care home told the Council that Mr Y and Mrs X were informed the mattress would not be provided. However, the care notes suggest the request was still being progressed, and Mrs X’s continued complaints indicate she was not aware of any decision. In the absence of clear records, I cannot establish what was decided or how this was communicated.
53. I cannot be satisfied that a clear, properly recorded and communicated decision was made about Mr Y’s mattress, despite him having capacity to express a preference. This creates uncertainty about whether his wishes were appropriately considered and followed, as per paragraph 14. This lack of clear decision-making and recording is fault.
54. The provider was also unable to retrieve key records relating to clinical decision-making. Care providers are required, in line with statutory guidance, to retain accurate and complete records, generally for a minimum of eight years. As Mr Y left the care home less than two years ago, these records should have been available. This is fault and further limits our ability to determine what happened.
55. These faults caused Mrs X avoidable distress and uncertainty, as the lack of clear records means she cannot know whether Mr Y received appropriate pressure care or how decisions about his mattress were made.

Suitability of placement

56. The Council completed a Care Act assessment in January 2024 which identified Mr Y’s needs as stable and not requiring nursing care. This remained current at the time of the emergency placement in February and was shared with care homes. On this basis, the initial placement was suitable.
57. Following placement, the Council carried out reviews, including a visit in March where Mr Y raised concerns about night-time staffing, which were addressed. A further review was completed when the placement became permanent.
58. The evidence shows Mr Y’s needs increased from April 2024 onwards. The Council responded by reassessing his needs in May, involving health professionals, and progressing arrangements for a nursing placement. It then appropriately fast-tracked his assessment as soon as it became aware of his change in life expectancy.
59. On the evidence available, the placement became unsuitable due to a deterioration in Mr Y’s needs rather than being unsuitable from the outset. I am satisfied the Council acted appropriately once this change was identified. I therefore do not find fault in the suitability of the placement.
60. The Council has offered to pay Mrs X £250 in recognition of the distress and uncertainty caused by the faults identified, including poor record keeping around medication, repositioning, and the mattress decision. I consider this offer to be reasonable and proportionate to the injustice experienced, when offered alongside the service improvements as below. In line with our guidance, a payment in this range is appropriate where fault has led to avoidable uncertainty and distress.

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Action

61. To remedy the injustice caused by the above faults, within four weeks of the date of my final decision, the Council will:
• Apologise to Mrs X in line with our guidance on Making an effective apology.
• Pay Mrs X £250, as previously offered, to recognise the distress and avoidable uncertainty caused.
62. Within three months of my final decision the Council will:
• Remind the care home of its statutory obligation to retain care records of its residents.
• Work with the care home to ensure that all Medication Administration Record charts and repositioning records are accurately recorded and legible.
• Review complaint-handling procedures for commissioned care homes to ensure that responses are not based solely on information provided by care providers, and that any information gaps are promptly identified and addressed.
63. The Council should provide us with evidence it has complied with the above actions.

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Decision

64. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman