Summary: St Marys Care Services Ltd was at fault for failing to provide Mrs X’s late mother with suitable care while she was resident in one of its care homes. The fault caused Mrs X distress and uncertainty for which the Care Provider will apologise and make a symbolic payment. To prevent similar fault in future, the Care Provider will issue staff reminders.

The complaint

1. Mrs X complained the Care Provider, St Mary’s Care Services Ltd, provided inadequate care for her late mother, Ms Y, when Ms Y was a resident in one of its care homes, Shipley Manor Care Home. Mrs X said this caused her significant concerns and stress.

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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 injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. 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.
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. Ms Y moved into Shipley Manor Care Home in mid-2023. Initially, Ms Y’s local council funded her care so it was responsible for any failings by the Care Provider. By mid-December 2023, Ms Y began paying for her care herself, so the Care Provider was responsible for any issues from then until the date Ms Y moved out of the care home in June 2024. Mrs X can complain to Ms Y’s council if she is unhappy about the care the Care Provider delivered between the date she moved into the care home and mid-December 2023. This investigation begins at the date Ms Y began paying for her care herself.
8. 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). Mrs X complained to the Ombudsman in February 2025. This means the period between December 2023 and February 2024 is late. I have chosen to include the late period in my investigation because it was a short period of time, which is linked to this complaint and it would be illogical to exclude it. Therefore, I am investigating the Care Provider’s actions between mid-December 2023 and June 2024.
9. The law says we cannot normally investigate a complaint unless we are satisfied the organisation knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the organisation of the complaint and give it an opportunity to investigate and reply. (Local Government Act 1974, section 26(5), section 34(B)6). Mrs X’s complaint to the Ombudsman included that the Care Provider did not keep fresh water in Ms Y’s room. Mrs X has not complained to the Care Provider about this issue but I have decided to include it in my investigation because it would be unnecessarily onerous for Mrs X to pursue a new complaint about that issue alone.
10. We investigate complaints about adult social care providers. We provide a free service but must use public money carefully. We do not start or continue an investigation if we decide there is not enough evidence of fault to justify investigating, or the injustice is not significant enough to justify our involvement (Local Government Act 1974, sections 34B(8) and (9)). I have not investigated the following concerns Mrs X raised in her complaint to the Ombudsman because either there is insufficient evidence of fault, or any fault did not cause a significant injustice.
• The Care Provider took too long to let Ms Y’s family into the care home when they came to visit her.
• The Care Provider failed to employ enough staff. Mrs X said she felt she should have been able to see staff about the care home. There is no evidence staffing levels led to issues with care workers supporting residents.
11. I also have not investigated Mrs X’s specific concern that care workers were not knowledgeable about Ms Y’s needs and were defensive. Any flaws in the care workers’ knowledge or their attitude to Ms Y would be evident from poor care. I have considered the quality-of-care Ms Y received as part of this investigation.

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How I considered this complaint

12. I considered evidence provided by Mrs X and the Care Provider as well as relevant law, policy and guidance.
13. Mrs X and the Care Provider 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

14. 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.
15. Regulation 9 of the Regulations says care and treatment of residents must be appropriate, meet their needs and reflects their preferences. Associated guidance says to do this, care providers should produce a clear care plan. The guidance also says the representative of a person receiving care must have all the necessary information about their care and treatment.
16. Regulation 14 states care providers must meet the food and drink needs of people they care for.
17. Regulation 17 states care providers must keep an accurate and complete record for each resident.

Background

18. Ms Y moved into the care home in mid-2023 and moved out in early June 2024.
19. Ms Y’s care plan noted she had several health conditions, one of which affected her decision-making. Despite this, she was able to make decisions about what care and support she wanted. The care plan said Ms Y:
• Needed help washing, grooming and dressing and should be offered a shower each day;
• Was fully continent, meaning she was able to control when she went to the toilet;
• Received foot care from a chiropodist when needed;
• Should be offered a hair appointment when she wanted one;
• Should be offered a drink every hour.
20. The fact that Ms Y needed help with grooming and dressing was repeated many times throughout the plan. However, the plan also occasionally said did not need support with that personal care.
21. The plan also said the Care Provider should consider weighing Ms Y monthly and noted Ms Y would sometimes refuse to accept support.
22. Ms Y’s relative, Ms W raised a complaint with the Care Provider in July 2024. I have set out each of Ms W’s concerns and my findings on them below.

Personal care

23. Ms W told the Care Provider she was concerned care workers:
• Left Ms Y’s hair dirty;
• Had failed to help Ms Y see the chiropodist for her feet, which meant she developed a fungal infection and her toenails became very long;
• Had not taken care of Ms Y’s nails on her hands and let them become overgrown;
• Had not supported Ms Y to get washed; and
• Failed to help Ms Y use her toiletries which led Ms Y to put denture paste or shower gel on her face.
24. In response to Ms Y’s complaint, the Care Provider said:
• Ms Y did not see a hairdresser consistently throughout her stay;
• It accepted that Ms Y’s care plan did not contain any information for staff on what to do if Ms Y did not want to see the hairdresser, or how to wash her hair themselves;
• There were no records staff had helped Ms Y wash her hair;
• Ms Y saw the chiropodist in May 2024;
• Care workers had offered to help Ms Y with her foot care but she would sometimes refuse support.
• Its care plan should have included information on Ms Y’s preferences for her hand nail care;
• Care workers offered to help Ms Y with a shower and her personal care but she would refuse sometimes. It accepted staff should have told Ms Y’s family when that happened;
• The care records showed that in May 2024, Ms Y washed her face with shower gel which irritated her skin. Following that incident, care workers had reviewed Ms Y’s care plan and alerted staff to what happened; and
• It could not see that it had apologised to Ms Y or Ms W or explained what it had done to prevent a similar incident in future.
25. Care records show that:
• Ms Y saw a hairdresser for a wash and set four times in April 2024 and five times in May. She also saw a hairdresser in January 2024, but it is not clear what that appointment was for. There is no record Ms Y saw a hairdresser in December 2023, February 2024 or and March 2024;
• Between December 2023 and June 2024, care workers helped Ms Y to wash her hair on 12 occasions. Ms Y refused support four times;
• Care workers checked Ms Y’s nails and toenails often;
• Ms Y had seen a chiropodist eight times between December 2023 and June 2024. However, records of Ms Y’s outgoings show she only paid to see the chiropodist once in that time period, in May 2024;
• Care workers offered Ms Y a shower occasionally and instead supported her to wash at the sink;
• Mrs X visited Ms Y and found her face was irritated after Ms Y had accidentally washed it using shower gel; and
• Ms Y was at least partially incontinent and relied on pads to manage her toileting needs alongside going to the toilet with support from a care worker.
26. After a member of Ms Y’s family asked the Care Provider to arrange for Ms Y to see the chiropodist in November 2023, it explained that Ms Y did not have enough spending money to pay for that appointment. It advised Ms Y’s family member to book and pay the chiropodist directly, which they did. The Care Provider also said Ms Y needed more spending money.
27. In late February 2024 Ms Y’s family told the Care Provider that Ms Y should be on the list to see the chiropodist regularly. The Care Provider explained it would not put Ms Y on the list as she had insufficient funds. A few weeks later, Ms Y had more spending money from her family, and the Care Provider added her to the list for chiropody. Ms Y then had the appointment in May.
28. The lack of spending money also meant Ms Y was unable to pay to see the hairdresser. Once the family provided more funds, Ms Y saw the hairdresser every week from April.

Findings

29. Ms Y’s care plan wrongly stated she was fully continent and in places, that she was independent with grooming and dressing. This was fault. There is no evidence the fault caused Ms Y a significant injustice because care workers nonetheless supported her with going to the toilet, getting dressed and grooming herself, which showed they understood Ms Y needed that support.
30. The Care Provider accepts it did not do enough to support Ms Y to take care of her hair. I agree with that conclusion. Ms Y’s care plan did not contain enough information about hair care and care workers did not offer to help Ms Y wash her hair enough and failed to tell Ms Y’s family when she refused support. This was fault.
31. Ms Y did not have regular hair or chiropody appointments between December 2023 and spring 2024, but this was not due to fault by the Care Provider. The lack of appointments occurred because Ms Y did not have sufficient funds.
32. However, the Care Provider’s records wrongly state Ms Y saw a chiropodist eight times between December 2023 and June 2024. Instead, records of Ms Y’s payments to the chiropodist show she had treatment on one occasion in that period, in May 2024. This poor recording keeping was fault.
33. The Care Provider acted appropriately when it became aware Ms Y had a fungal infection, by reminding staff to ensure they dried Ms Y’s feet fully after helping her wash and by contacting her doctor.
34. The Care Provider accepts its care plan should have included information on Ms Y’s preference for hand nail care. I agree the lack of information was fault and meant care workers did not know what support Ms Y needed with the nails on her hands.
35. The Care Provider did not offer Ms Y a shower every morning, in line with her care plan. This was fault.
36. After Ms Y accidentally used shower gel to wash her face care workers acted appropriately by applying a cold compress, reviewing Ms Y’s care plan and alerting staff of the incident. It was not at fault and there is no evidence similar incidents happened at other times during Ms Y’s stay. However, the Care Provider accepts it should have apologised to Ms Y and Ms W and told Ms W about the steps it had taken to stop a similar incident in future. I agree its failure to do so was fault.

Food

37. Ms W told the Care Provider she was concerned care workers failed to monitor or act on Ms Y’s weight loss.
38. In response, the Care Provider said Ms Y had lost 6kg between December 2023 and May 2024. It said this was because Ms Y was taking short-term medication for a health condition and that once she stopped taking that medication, her weight loss stopped. Records support the Care Provider’s view and show it weighed Ms Y once a month.
39. Records also show Ms Y normally ate the meals and snacks offered to her, but on one day there is no record care workers offered Ms Y breakfast.

Findings

40. There is no evidence Ms Y was refusing to eat food offered to her and records support the Care Provider’s statement that Ms Y’s weight loss stopped when she stopped taking the medication to reduce her fluid retention. The Care Provider monitored her weight loss appropriately by weighing Ms Y once a month. It was not at fault.
41. However, on one day, the care records do not show whether Ms Y had breakfast. It is not clear whether this was because Ms Y declined to eat breakfast or if care workers failed to offer her any. This poor record keeping was fault.

Water

42. Mrs X told us Ms Y did not have water in her room.
43. Ms Y’s care plan noted care workers should offer her a drink every hour. Records show care workers offered Ms Y a drink often, although on some days they did not offer Ms Y a drink between lunch and dinner.

Findings

44. The care records show the Care Provider failed to offer Ms Y a drink every hour, as set out in her care plan. This happened often enough to amount to fault.

Medical care

45. Ms Y told the Care Provider she was unhappy:
• About how care workers had reacted when Ms Y developed urinary tract infections (UTI’s);
• The Care Provider had not told Ms X’s family when she had fallen or developed infections; and
• Care workers had not monitored Ms X’s sodium levels when they were low.
46. In December 2023, blood tests showed Ms Y had low sodium levels. Another test the following week showed her sodium level was normal again.
47. Ms Y developed an ear infection in mid-January 2024 and her GP prescribed medication for it. There is no evidence care workers told Ms Y’s family.
48. In late January 2024, Ms Y fell in the evening. Care workers checked Ms Y over and sought medical advice. The doctor recommended staff keep Ms Y under observation. They recommended half hourly checks for two hours total, then hourly checks for four hours. Care workers did not do this. They checked on Ms Y after an hour and a half then again after a further one hour and 45 minutes. After another one hour and 45 minutes, Ms Y called for help as she had fallen and hit her head. The Care Provider alerted medical staff who said to treat Ms Y’s wound and keep her under observation. Several hours later, Ms Y fell again. A GP saw Ms Y who said they did not have any concerns and that Ms Y might need a walking frame.
49. The Care Provider told Ms W about Ms Y’s falls the following morning.
50. Ms Y was taken into hospital for matters unrelated to her falls. Blood tests showed Ms Y had low sodium levels again. Hospital staff monitored her sodium levels and noted they were improving.
51. In mid-March 2024, Mrs X asked the Care Provider if it had done a dip test of Ms Y’s urine to see if she had an infection. The Care Provider explained Ms Y’s GP had seen her the day before. It said it did not normally do dip tests because guidance for care homes said they were unreliable. It said it would monitor Ms Y and contact the GP if she presented symptoms of a UTI.
52. In late May, one of Ms Y’s relatives asked the Care Provider to do a dip test of Ms Y’s urine because she appeared confused. The Care Provider did a test the following day, which did not indicate Ms Y had a UTI.

Findings

53. The Care Provider was not at fault for declining to do a dip test of Ms Y’s urine in March 2024. This was in line with guidance for care homes.
54. Despite this, the Care Provider agreed to take a dip test when Ms Y’s family asked it to in late May 2024. This was a decision the Care Provider was entitled to make, and it carried out the test without delay. It was not at fault.
55. The Care Provider was not at fault for not monitoring Ms Y’s sodium levels itself. Medical staff were checking them and acting accordingly.
56. The Care Provider failed to promptly tell Ms Y’s family about her ear infection and the falls she had in late January 2024. This was fault. It acted appropriately to seek help for Ms Y by alerting medical staff after each incident but failed to keep Ms Y under observation as directed by the doctor. This was further fault.

Mobility and mood

57. Ms W complained the Care Provider failed to encourage Ms Y to move or exercise.
58. Two weeks after Ms Y fell in January 2024, the Care Provider asked Ms Y’s GP to refer her to physiotherapy for support with walking. A physiotherapist saw Ms Y three weeks later.
59. In mid-May 2024, the Care Provider spoke to Ms Y’s GP because it was concerned about her mood. The GP recommended care workers encourage Ms Y to get out into the garden. Care records show workers took Ms Y on a walk on one day but did not offer to help her walk outside on any other occasions in the remaining three weeks before she moved out. The Care Provider accepts staff did not encourage Ms Y to walk enough.

Finding

60. The Care Provider acted promptly to refer Ms Y for medical attention about her walking after her fall in January 2024. It was not at fault.
61. However, the Care Provider failed to carry out the GP’s later recommendation for care workers to encourage Ms Y to walk in the garden. The one walk staff supported her with was not in line with the GP’s advice and was fault.

Environment

62. Ms W complained Ms Y’s room was dirty and that during one visit, family had found Ms Y’s used continence pads in the toilet and wardrobe.
63. The Care Provider said it had cleaners who took care of resident’s rooms. It accepts care records do not show this happened daily, which it said was likely due to poor record keeping.
64. The Care Provider also said Ms Y liked to be independent with her personal care which meant she could sometimes refuse help to deal with her used continence pads. It said it was possible Ms Y had been the person who put the used pads in the toilet and wardrobe. The Care Provider said it had acted immediately when it heard there were used pads in Ms Y’s room but accepted it had not updated Ms Y’s care plan to remind staff to check her room for used pads.

Findings

65. The Care Provider accepts poor record keeping means it cannot evidence that it cleaned Ms Y’s room daily. This was fault.
66. I have seen no reason to question the Care Provider’s view that Ms Y might have been responsible for putting used pads in the toilet and wardrobe. However, the Care Provider accepts it should have amended Ms Y’s care plan to prompt care workers to check for used pads left in her room. I agree with this conclusion, the Care Provider’s failure to amend Ms Y’s plan was fault.

Injustice

67. Ms Y has died so it is not possible to remedy any injustice she experienced because of the faults set out above. However, the faults caused Mrs X avoidable distress about how Ms Y was cared for and leave her with uncertainty over what would have happened had the Care Provider acted as it should have.

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Action

68. Within one month of the date of my final decision, the Care Provider will take the following actions.
1. Apologise to Mrs X for the distress and uncertainty she experienced because of the faults set out in the decision. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Care Provider should consider this guidance in making the apology.
2. Pay Mrs X £300 in recognition of that injustice. Mrs X has not paid the outstanding fees Ms Y owed to the Care Provider. The sum I have recommended should be paid to Mrs X directly and not used to reduce the outstanding fees.
3. Remind care workers that they must ensure a person’s care plan is an accurate reflection of their needs and is sufficiently thorough to ensure care and support is suitable for that person. If a person’s needs change, care workers should amend their care plan without delay.
4. Remind care workers that when a medical professional recommends they monitor a person’s condition, they must do so at the frequency recommended.
69. The Care Provider will provide us with evidence it has complied with the above actions.

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Decision

70. I find fault causing injustice. The Care Provider will take actions to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman