Summary: The Council’s commissioned care provider failed to provide a good standard of care for the late Mrs X, failed to keep proper records in accordance with the regulations and did not provide her nutrition in accordance with the hospital discharge instructions. The Council agrees to recognise the considerable distress caused to Ms B and her family by the care provider’s failings.

The complaint

1. Ms B (the complainant) says the care provider failed to feed her late mother properly in accordance with the Speech and Language Team (SALT) guidance, filled out records in advance, and showed an uncaring attitude. She says her mother was often not propped up properly to be fed, and staff talked about her end-of-life care in her hearing. Some jewellery has never been recovered. She says the care in Aria Court has caused particular distress to her father who regrets placing Mrs X there.

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The Ombudsman’s role and powers

2. 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)
3. 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)
4. 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.
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I considered evidence provided by Ms B and the Council as well as relevant law, policy and guidance.
7. Ms B and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

8. 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.
9. Regulation 9 says “The care and treatment of service users must - (a) be appropriate, (b) meet their needs and (c) reflect their preferences”.
10. Regulation 10 says service users must be treated with dignity and respect.
11. Regulation 14 says service users’ nutritional needs must be must. “All communication with service users must be respectful”.
12. Regulation 17 says that care providers’ records must be “complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information”.
13. In 2023 we issued guidance to care providers on record keeping. We said, “We are likely to find a care provider at fault where records are illegible or have clearly been changed after the event.”
14. NHS-Funded Nursing Care (FNC) is the funding provided by the NHS to care homes providing nursing, to support the cost of nursing care delivered by registered nurses. If a person does not qualify for NHS Continuing Healthcare, the need for care from a registered nurse must be determined. If the person has such a need and it is determined their overall needs would be most appropriately met in a care home providing nursing care, then this would lead to eligibility for NHS-Funded Nursing Care

What happened

15. Mrs X, who had dementia, moved into the care home on 16 October 2024. She had previously been cared for at home by Mr X. Mrs X was no longer able to speak or feed herself.
16. Mrs X’s care plan said that she needed 1-1 assistance to feed and hydrate. It goes on “During each hourly sighting (Mrs X) should be encouraged to take a drink aiming for a target of 1200ml of fluid per day. When feeding (Mrs X) needs to be carefully positioned sitting up in her bed with pillows positioned at her sides to support her posture. The head and neck need to be positioned to enable the most comfortable eating position.”
17. Ms B says when she visited her mother on 19 October the care worker told her they had tried to give hourly fluids but Mrs X refused. Ms B says she was with her mother for at least two hours and no care workers checked Mrs X or offered her fluids during that time. The following day Mrs X was admitted to hospital with dehydration and suspected sepsis.
18. The Council’s case recording shows that Ms B spoke to the social worker with her concerns about the care provided in the few days before hospital admission. The social worker asked Ms B if she was happy to talk directly to the home manager about her concerns so the home had a chance to correct matters. She said if further concerns arose she could contact Mrs X’s allocated social worker.
19. The social worker also spoke to the team leader at the care home explaining that Mrs X was medically fit for discharge. She also gave her the SALT guidance for Mrs X’s return: in particular “Level 2 mildly thick drinks, level 4 puree food. Ensure that (Mrs X) is sat upright and alert and given full assistance for feeding. Ensure all drinks, soups and sauces are thickened to level 2 and monitor for signs of aspiration and chest deterioration”.
20. Mrs X was discharged back to the care home on 29 October. She was readmitted to hospital the next day.
21. Ms B says following her mother’s return to the care home on 14 November there were ongoing problems regarding her positioning while feeding. Ms B has photographic evidence of care workers trying to feed Mrs X with her head down. She says her mother had great difficulty swallowing by this stage too. She says at times care workers were also trying to feed Mrs X while she was lying on her side. She says she emailed the care provider twice in the next few days about the positioning of Mrs X at all times and especially during feeding, but did not receive a reply. She says the care manager told her she never received the email.
22. In December there was a meeting at the care home to compile a Decision Support Toolkit (DST) checklist to gauge Mrs X’s eligibility for NHS CHC funding. It became clear Mrs X had not been weighed for over a month. Ms B says after the meeting she went into her mothers’ room with the social worker. She says there was dried liquid food-supplement on her mother’s face and her positioning was ‘appalling’.
23. Mrs X’s social worker emailed the care provider after the DST meeting. He said “I noted today that care workers had attempted to feed (Mrs X) whilst she was in a reclined side laying position this as you know this position can be unsafe for feeding and will not encourage her to take on sufficient nutrition and hydration. The CHC nurse and I have suggested that 2 care workers visit (Mrs X) before each mealtime to support her into a more optimal feeding position of sitting up in the bed with a correctly positioned neck and head….Please document the support and position (Mrs X) has been supported into so I can use this as part of my review in a couple of weeks.” He also said that while Mrs X was supposed to have 1200mls of fluid a day, she was often only getting 800mls. He reminded the care provider to offer fluids at each hourly sighting and spoon feed if necessary.
24. As the social worker did not received a reply he followed up his email a fortnight later. The care provider replied that staff were now making sure of Mrs X’s positioning before feeding, and offering regular drinks. Ms B says that on 12 December (two days after the social worker’s email) she and her father visited. They found “mum was being fed on her side head down, no offer of a drink during this time. Carer left after feeding main course then another one came into feed pudding, not repositioned. Still no offer of fluids during this time”.
25. Ms X says staff openly talked, in front of Mrs X, about the end of life medication they were giving Mrs X. She says she observed care workers giving Mrs X large spoonfuls of the medication and not waiting for her to swallow before pushing another.
26. Ms X says on 10 January she saw a member of the nursing staff completing a 30 minutes observation sheet prospectively that Mrs X was asleep. She says she returned that evening at 7pm. A care worker entered the room at 8pm, filled out the sheet for that time and also for 7.30 pm. Ms B says she knew he had not been in at 7.30 pm as she was in the room herself.
27. Mrs X died on 11 January 2025. Ms B says the rings Mrs X wore on her left hand were missing and the care manager was unable to find them subsequently.

The complaint

28. Ms B complained to the care provider. The care provider responded with an acknowledgement that it had not always responded to her contacts or used a proper tone in its communications. It apologised for that. It agreed that sight charts had been completed retrospectively and apologised: it said the staff member responsible was going through the company disciplinary process. It added, “Additionally, we are implementing training and coaching sessions to ensure all staff understand the correct procedures for completing chart documentation accurately. This training will also emphasize the importance of maintaining thorough records while residents receive visits from friends and loved ones”.
29. The care provider acknowledged that jewellery remained missing but said it had been unable to find it.
30. Ms B complained to us
31. The Council says it had not seen the complaint prior to our contact. It says although the care provider responded, it did not comply with the clause in its contract with the Council which requires it to notify its contacts manager about complaints.
32. The Council says, in respect of the retrospectively completed records, that the management at the care home has changed. It says along with the new manager it is seeking to improve staff knowledge of the need to maintain proper records.
33. The Council says the issues about positioning during feeding were first raised at the DST meeting and after that the social worker obtained assurances from the manager that Mrs X was being positioned properly.
34. In its response to my draft decision the Council has provided evidence that the care provider has already made improvements of adherence to SALT guidance and how this is reflected in its record-keeping.

Analysis

35. There were concerns voiced by Ms B about Mrs X’s positioning for feeding from her readmission to the home in November. Despite the care plan and the discharge note from the hospital, care workers continued to try and feed Mrs X when she was poorly positioned. That was a potential breach of the regulations: it was not treating Mrs X with dignity, it failed to meet her nutritional needs properly and it was not appropriate for her needs. It caused Ms B and Mr X significant distress to see it continuing.
36. The care provider acknowledges it failed to maintain records properly, or communicate properly with Mrs X’s family. That was also a potential breach of the regulations. Inaccurate records for one resident cast doubt on the entirety of the care provider’s recording system.
37. The missing jewellery is a further distressing event for Ms B and Mr X. While it may not be possible for the care provider to trace that now, there should have been an accurate record of where it was.

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Action

38. The Council should continue to review with the current management the concerns about adherence to SALT guidance for residents and how training can be improved in that respect. That should include knowledge about positioning. After a further three month’s review the Council should let me know the position then.
39. Mrs X has now died so any injustice she suffered as a result of the poor positioning cannot now be remedied. Within one month of my final decision however the Council will offer £500 each to Ms B and Mr X in recognition of the distress they suffered witnessing the care provider’s failures to treat Mrs X correctly in this way.
40. Within one month of my final decision the Council will also offer £250 to Ms B in recognition of the time and trouble she has been put to in making this complaint.
41. The Council is already addressing the record keeping in the home so I make no further recommendations there.
42. The Council should provide us with evidence it has complied with the above actions.

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Decision

43. I have completed this investigation on the basis that there was fault by the Council’s commissioned care provider causing injustice to Ms B and Mr X .

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Investigator's decision on behalf of the Ombudsman