Summary: Mrs B complained about the standard of care her mother, Mrs X, received when the Council organised a placement at Lakeside View Care Home. We uphold the complaint, having identified several areas of fault with the care provided to Mrs X, and inaccurate care records. There was also fault with the Council’s response to Mrs B’s complaint because it failed to acknowledge the distress caused by the Care Home’s actions. To remedy this injustice, the Council has agreed to apologise and make a symbolic payment.

The complaint

1. Mrs B complains about several areas of poor care provided to her late mother, Mrs X during the eight days prior to her death at Lakeside View Nursing Home (the Home). She says the Home was understaffed and not equipped to provide palliative care. Some staff falsified case records and provided inadequate care. This caused significant distress to Mrs X and her family.
2. She also complains about the Council’s response to her concerns.
3. Mrs B wants to be reassured ongoing monitoring is taking place and that other families do not suffer in the same way.

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The Ombudsman’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
5. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
6. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
7. 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.
8. Where an individual, organisation or private company is providing services for a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended).
9. 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. So, although we may find fault with the actions of the service provider, we will make recommendations to the council.
10. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.
11. 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

12. I considered evidence provided by Mrs B and the Council as well as relevant law, policy and guidance.
13. Mrs B 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

Relevant law and guidance

Safeguarding

14. A council must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

Fundamental standards of care

15. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The 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.
16. When investigating complaints about council-funded care placements, the Ombudsman considers the 2014 Regulations when determining complaints about poor standards of care.
17. Regulation 9 requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
18. Regulation 10 says that all service users should be treated with dignity and respect.
19. Regulation 12 sets out the requirement for care and treatment to be provided in a safe way for service users.
20. Regulation 17 requires care providers to keep accurate, complete and contemporaneous records of care and treatment.

What happened

21. In February 2024, Mrs X was discharged from hospital to the Care Home. She had recent surgery and several age-related medical conditions, including dementia. She sadly passed away after eight days.
22. Mrs B was concerned about several aspects of her mother’s care and raised a formal complaint to the Care Home shortly after her mother passed away. She said the Care Home:

• failed to administer palliative care medication early enough. It was only provided two days before Mrs X’s death. Mrs B says this was because staff were not suitably trained in this specific area of health need;
• did not provide sensitive and culturally appropriate care at the time of Mrs X’s passing;
• did not communicate effectively about end of life care, causing avoidable distress when palliative care was needed;
• falsified care records. Mrs B says the care records indicated care had been provided when she knows it could not have taken place because she was with her at the time;
• failed to position a fall sensor mat next to Mrs X’s chair. This meant staff were not alerted to Mrs X sliding out of her chair. When Mrs B went to visit, she found her mother lying on the floor; and
• left Mrs X alone for too long. This meant she was under-stimulated and had unmet care needs. Mrs B believed this was because the Care Home was understaffed, particularly at night.

23. The Care Home referred itself to the Council, under its usual safeguarding protocol. The funeral home also informed the Council that Mrs X’s body was heavily bruised and may warrant an autopsy, particularly as she had had recent surgery.
24. The Council carried out an enquiry under its safeguarding procedures. This involved a social worker speaking to both Mrs B and the Care Home Manager. The Council also notified the CQC and considered information provided by the Coroner.
25. The Care Home carried out its own investigation into Mrs B’s complaint. In response to Mrs B, the Care Home:

• accepted it did not position the sensor mat to be effective when Mrs X slid out of her chair;
• accepted it did not discuss end of life care with her on the day of admission. This was because many residents and their families preferred to have this conversation once they had settled in;
• accepted there were occasions when the care records were incorrect. This was because staff sometimes had to write case records at quieter times, and the incorrect icon had been selected on the computerized recording system;
• accepted a carer had inappropriately covered Mrs X’s face after she had passed, contrary to British culture; and
• accepted there was a large area of bruising, with no indication of cause that should have been investigated.

26. The Care Home apologised to Mrs B for these failings. Following discussions with the Council, it provided end of life trained to 50 members of staff and reminded staff of the importance of accurate and timely record keeping. Some staff also received training on “death and dying”. It also amended its admissions procedures, including photographing all bruises.
27. The CQC carried out an inspection and assessed the Care Home as being “Good”.
28. The Council completed its safeguarding enquiry in November 2024. It found the concerns raised were “substantiated”. The enquiry was closed because the Council was satisfied with the actions taken by the Care Home to address the issues raised in Mrs B’s complaint.
29. In a later reply to Mrs B, the Council said there was no evidence of neglect or that the actions of the Care Home led to harm to Mrs X. It confirmed the Council had recently visited the Care Home and found no significant areas of concern.
30. The Council said it would share the safeguarding enquiry documents with Mrs B.
31. Mrs B was disappointed with the Council’s response and felt her concerns had not been properly investigated and addressed. She says she remains traumatised by witnessing her mother’s undignified death, and has heard of others having had a similar experience. She believes the Care Home should be more carefully monitored and robust action taken to improve its standards.

Analysis

32. The Home has already accepted there were several occasions when Mrs X did not receive the care she was entitled to receive. This was endorsed by the Council when it recorded the outcome of its safeguarding enquiry as “substantiated”. My own analysis of the case records confirms there was fault with the actions of both the Care Home and the Council that require a remedy. The faults on the part of the Care Home were potential breaches of the regulations.
33. In respect of Mrs B’s separate areas of complaint, my findings are set out below.

Palliative care

34. Mrs B believes Mrs X should have been given palliative care medicine more responsively. I found no evidence that the Care Home delayed in administering such medication. The care records show the Care Home consulted with a doctor promptly when her condition deteriorated and received medication soon afterwards, and at regular intervals until her passing. I found no evidence of fault here.

End of life care

35. The Home has already accepted Mrs X’s face should not have been covered as it was. The staff member involved should have been trained to be able to deal with a resident’s passing in a compassionate and culturally appropriate way. His failure to do so caused understandable distress to Mrs B.

Inaccurate care records

36. In February 2023 we published a guide for care providers on good record keeping. This stresses the importance of care providers keeping comprehensive and accurate records. The Care Provider has accepted its care records were not always accurate.
37. My own analysis of the case records confirms there were at least four incorrect recordings of care having been provided when it was not. This included recording Mrs X having had her hair washed, a chiropody visit and having eaten. This was fault.
38. The inaccurate case records inevitably cast doubt on whether Mrs X’s care needs were properly met at all times during her short time at the Care Home.

Poor standards of care

39. The Care Home has already accepted it acted with fault when it failed to position the sensor mat correctly. Whilst there is no evidence that Mrs X suffered any physical harm as a result, this may only have been prevented by Mrs B’s timely arrival at the scene. But this incident could have potentially harmful consequences and should not have happened.
40. However, there is insufficient evidence, on balance of probabilities, that over the course of her short stay, Mrs X was neglected or suffered direct harm due to lack of care. Mrs B herself accepts that there many examples of excellent care, particularly during the day.
41. I accept that may have been some occasions where staff took longer to respond than should have been the case, particularly during busy periods or at night. I acknowledge any such delays would have been concerning for Mrs B’s family at what was already a very difficult time.
42. However, taken as a whole, the records show care staff generally responded in a timely manner to Mrs X’s care. In the absence of any further evidence, I found no further fault on this area of complaint.

Safeguarding

43. There was significant delay in completing the safeguarding enquiry. It took nine months for the Council to reach its conclusion and for Mrs X to be notified of the outcome. It took a further two months for Mrs B to be provided with a meaningful response. I understand this was due to pressure of work at the time.
44. I also found the Council’s response to Mrs B’s complaint slightly confusing. Its final letter to Mrs B said there was no indication Mrs X was neglected or had suffered because of lack of care. Whilst I do not criticise this conclusion, the Council’s response failed to properly acknowledge the several areas of poor care that had already been identified by the Care Home (set out in paragraph 23 above) that had led to the safeguarding enquiry being “substantiated”.
45. Nor have I seen evidence the Council’s safeguarding report was shared with Mrs B as promised in November 2024.
46. Although I am satisfied the investigation itself was carried out adequately because the appropriate enquires were made, the CQC was notified and action taken to address the concerns raised, the long delay and poor communication with Mrs B amount to fault.

Injustice and remedy

47. The concerns raised by Mrs B about Lakeside View Nursing Home have been investigated by the Home and the Council. This resulted in an action plan to improve the service delivered to other residents. From these investigations we know there were times when Mrs X did not receive the care she needed, for example when she was left on the floor because the sensor was not positioned correctly and at the end of her life
48. The care that Mrs X received fell below that which she was entitled to expect. This was fault which caused her an injustice. She was put at an increased risk of harm. However, I cannot say the sudden deterioration in Mrs X’s health was a result of poor care, but it would have caused avoidable distress to Mrs B.
49. 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. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. Mrs X has now sadly passed away and therefore it is not possible for the Ombudsman to remedy any injustice caused to her.
50. However, if we consider the person who has complained to us has been adversely affected by the impact of that poor care on their relative, we may make a recommendation to remedy their own distress.
51. In my view, the faults identified in this statement caused Mrs B significant distress and uncertainty. She had to liaise with the Care Home and the Council about her concerns. This created avoidable time and trouble.

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Agreed action

52. 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. So, although I found fault with the service of the Care Home, the following actions are against the Council.
53. Within one month of my final decision the Council should apologise to Mrs B and make a symbolic payment of £300 for the injustice caused to her.
54. I acknowledge the Council and the Care Home have already identified and implemented several service improvements. It is not necessary for me to make any further service improvements.
55. The Council should provide us with evidence it has complied with the above actions.

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Final decision

56. I find fault causing injustice. The Council has agreed to action my recommendations to remedy the injustice to Mrs B. On this basis, I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman