Summary: Ms X complained on her own behalf and that of her mother, Mrs Y, that the Care Provider failed to properly care for their late father and husband and says its actions contributed to his death. There was fault by the Care Provider which caused Ms X and Mrs Y distress and uncertainty. The Care Provider has agreed to apologise and make a symbolic payment. The Care Provider has also agreed to make a service improvement and provide evidence of service improvements it has already carried out.

The complaint

1. Ms X complained about the quality of care provided to her late father, Mr Y, by the Care Provider during his respite placement. She says inadequate care and neglect by the Care Provider led to his death in December 2024. Ms X says the Care Provider’s actions caused her and her family significant distress and trauma.
2. Ms X wants the Care Provider to acknowledge what went wrong and apologise for its failings. She also wants it to learn from its mistakes, so the same thing does not happen again.

Back to top

The Ombudsman’s role and powers

3. 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 the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) 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 34C(2), as amended)

5. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)

6. 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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

8. I considered evidence provided by Ms X and the Care Provider, as well as relevant law, policy and guidance.
9. Ms X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

Back to top

What I found

Legislation and guidance

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; and
• oral care.

(Health and Social Care Act 2008 (Regulated Activities) Regulations 2010)

11. 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.
12. Regulation 12 says care providers must provide care and treatment in a safe way for service users. Care providers should:

• have arrangements in place to respond appropriately and in good time to people’s changing needs;
• review risk regularly and take reasonable steps to mitigate risks; and
• adjust care plans as needed and always follow care plans.

13. Regulation 14 says nutrition and hydration needs must be met, including providing support with eating and drinking if needed. Care providers should:

• regularly review nutrition and hydration needs and risks, and respond to changes in good time; and
• follow the latest care plan and take appropriate action if people are not eating and drinking in line with their assessed needs.

14. Regulation 17 says care providers should maintain accurate, complete, and contemporaneous records for each person.

Background

15. In November 2024, Mr Y moved into Lanercost Care Home (the care home), owned by Barchester Healthcare Homes Limited (the Care Provider), for a two-week respite placement. Mr Y had Parkinson’s disease. He had previously stayed at the care home for short term respite stays.

What happened

16. This section sets out the key events in this case and is not intended to be a detailed chronology.
17. When Mr Y went into the care home, it reviewed and reinstated the previous risk assessments and care plan it had carried out during his previous stay in January 2024.
18. The Care Provider’s case notes, referred to as ‘wellbeing observation records’ reflect that, the following day, it decided two staff needed to assist Mr Y’s movements as he had reduced mobility. It also decided he needed to use incontinence pads. It started a diet and fluid intake log. It noted on this date that Mr Y’s diet and fluids were ‘not very good’.
19. Over the next few days, the case notes show Mr Y became ‘a little muddled’, but his diet and fluid intake had improved, and the staff now considered them ‘good’.
20. On 20 November, the staff recorded that Mr Y now ‘appeared very muddled’ and noted he was hallucinating. They took a urine sample as they suspected he might have an infection. The test results showed he did not have an infection.
21. Over the following days, the case notes show the care home noted Mr Y was now unable to stand or walk with the support of two staff members. It observed he still ‘appeared confused’ and was struggling with his food and fluid intake.
22. A staff member noted that Mr Y had reduced food intake and had developed a cough. They completed his clinical observations which were all within the normal range.
23. Later that day, Ms X tried to contact Mr Y, but he did not answer his phone. Ms X then phoned the care home as she was worried about him and felt he had not been himself over the weekend. She said he was very unsteady and could no longer drink independently. A staff member told her they had repeated his clinical observations, and his oxygen saturations were low, but they believed this was due to his back pain. They said they would issue painkillers but were not concerned.
24. Later that evening, Ms X called the care home again and requested it seek medical advice. Ms X said that initially, the staff member she spoke to refused to contact the on-call health team for medical advice as they had to carry out other duties before completing his observations. Ms X called again shortly after and insisted the staff member seek immediate medical advice.
25. The staff member then repeated Mr Y’s observations and found he had reduced oxygen levels, and his blood pressure had dropped. They then consulted a clinician from the on-call health team, who advised care home staff to call an ambulance immediately. A staff member called 999 and Mr Y was admitted to hospital that evening.
26. When Mr Y went into hospital he was found to have an infection. Mr Y was also ‘severely dehydrated’ and was put on an intravenous (IV) drip. He was also given oxygen and antibiotics.
27. Mr Y sadly died a week later, at the beginning of December.
28. Ms X complained to the Care Provider, also acting on behalf of Mrs Y, in January 2025. She said the care home’s neglect of Mr Y had caused his death. She said that his infection had progressed to pneumonia and had the care home treated him sooner he would not have died. She said he had been severely dehydrated when admitted to hospital and felt this was due to neglect. She said she had noticed a decline in Mr Y’s mobility the week after his admission to the care home. Before his admission he had only needed support to move from one person.
29. Ms X also said the Care Provider had not made her aware Mr Y was using incontinence pads or that there had been a change to his care needs. She also said Mr Y had been hallucinating for days yet the Care Provider had not informed her or sought medical attention. She further complained about the staff member who refused to seek medical attention for Mr Y on the night he was admitted to hospital.
30. The Care Provider issued its complaint response in March. It did not accept responsibility for Mr Y’s death but accepted there was fault in its recording and management of Mr Y’s fluid intake. It also acknowledged there was fault in its recording of his wellbeing checks, including on the day he was admitted to hospital. It apologised for its lack of communication with both Ms X and Mrs Y regarding Mr Y’s use of incontinence pads, the change his health during his stay, and his hallucinations. It did, say, however, that it had put Mr Y’s health changes down to the progressive nature of his illness. It accepted it failed to carry out a full care plan review on Mr Y’s admission to the care home.
31. Ms X approached the Ombudsman in March. She also raised the issues with the CQC and another regulator.
32. Ms X remained unhappy with the Care Provider’s response so requested it consider her complaint further.
33. The Care Provider issued its stage two response in July. It explained it monitored Mr Y’s hydration for the first three days of his stay but did not consider he was at risk of hydration so stopped tracking his fluid intake after that. It added that the staff member who spoke to Ms X the night Mr Y was admitted to hospital had reflected on how they had communicated with her, though they maintained their clinical view that Mr Y did not require immediate medical attention. The Care Provider apologised for Ms X’s experience and said it had reminded staff of the importance of acting on families’ concerns about the health of their loved ones.
34. The Care Provider also said it had learned lessons about the importance of completing accurate and through records, including the use of fluid charts when a resident’s fluid intake fluctuates. It also said staff had received refresher training about completing care assessments and managing a resident’s deterioration in health.

Back to top

Analysis

Fluid monitoring

35. The Care Provider said it recorded Mr Y’s fluid intake for the first three days of his respite stay but then stopped because it considered he was not at risk of dehydration.
36. I have reviewed the Care Provider’s case notes and fluid monitoring records. Although it says it believed there was no risk, the notes show Mr Y’s fluid intake was poor the day after his arrival at the care home. His intake improved over the next couple of days but then declined again.
37. Despite Mr Y’s fluctuating fluid intake, the Care Provider did not restart monitoring his fluid intake. This calls into question whether the Care Provider took necessary steps to ensure he was receiving adequate hydration. Mr Y was admitted to hospital severely dehydrated and required IV fluids.
38. The Care Provider’s absence of evidence showing it monitored Mr Y’s fluid intake creates uncertainty about whether he received the care he needed. However, I cannot say, even on balance, whether his dehydration was caused by the Care Provider’s actions.
39. This is not in line with regulation 14 and is therefore fault. This resulted in Mr Y not receiving the level of care he needed and caused Ms X and Mrs Y the distress and frustration that the Care Provider did not sufficiently meet Mr Y’s care needs.

General record keeping

40. I have reviewed the Care Provider’s ‘Well Being Observation Records’ that shows a contemporaneous log of Mr Y’s day, including his sleep, fluid and food intake, and other general observations of his wellbeing.
41. I can see the Care Provider logged his observations hourly on the day he first arrived at the care home. The observations then became less regular over the next few days, though these increased again when the care home suspected Mr Y had an infection and had been hallucinating. However, towards the end of November, when Mr Y had become very unsteady, and was not drinking fluids, there was a significant gap in the recorded observations of nearly 14 hours. On the day of Mr Y’s admission to hospital, there was a gap in observations of eight hours.
42. The Care Provider has accepted that the wellbeing checks were not completed to an acceptable standard, and it cannot therefore establish that Mr Y was observed properly throughout the day, although it says care staff did report any concerns they had to the nurse on duty.
43. The lack of record of the wellbeing observations of Mr Y leads to uncertainty about what care he received and when, particularly around the time he became unwell and was admitted to hospital. This failure to keep a complete and accurate record of the Care Provider’s intervention and observation is not in line with Regulation 17. This is fault, which has caused Ms X and Mrs Y significant distress in the form of uncertainty about whether Mr Y received appropriate care during his stay at the care home.

Review of care assessment

44. The Care Provider failed to complete a new care assessment when Mr Y began his respite stay and instead reinstated his care plan from his previous stay in January 2024.
45. The Care Provider accepted it should have completed a new care assessment given the length of time between stays, and the fact that Mr Y had Parkinson’s disease, which is progressive in nature.
46. The Care Provider’s case records, referred to as ‘Progress and Evaluation Records’ reflect there had been ‘no changes to his care’ since January 2024 and it had reinstated the old care plan. The Care Provider has accepted it failed to reassess Mr Y’s care needs, despite evidence of deterioration of his health. The case records show that throughout Mr Y’s stay at the care home, he became increasingly unsteady and towards the end of his stay could no longer be supported by two staff members. The staff also noted episodes of hallucinations. This further highlights the importance of a timely reassessment, which the Care Provider did not carry out.
47. The Care Provider later explained its staff had noted these changes to Mr Y’s health and believed these were caused by the progression of his Parkinson’s disease. However, it is not sufficient to just notice the changes. This highlights even further that the Care Provider was aware his needs had changed yet still failed to complete a new care assessment.
48. The Care Provider’s failure to complete a new assessment creates uncertainty about whether Mr Y’s care plan accurately reflected his needs, and therefore whether his care needs were being met. This caused Ms X and Mrs Y distress and frustration.

Communication

49. Ms X said the Care Provider failed to inform her of changes in Mr Y’s care needs. She says it did not inform her that Mr Y was considered to have continence care needs. She also said it failed to tell her he had been hallucinating and had become distressed. Ms X was also concerned it had not told her that Mr Y needed support of two staff members to move and highlighted that he only needed assistance from one person, his wife, before his stay.
50. The Care Provider has accepted its communication with Ms X around the changes in Mr Y’s state of health was poor and says it should have informed her of these changes. It explained two staff members had also been required to support Mr Y’s movements during his previous stays, and this was for the safety of the staff. It accepted it had not communicated this to her.
51. The Care Provider’s failure to communicate changes to Mr Y’s care needs and deterioration in health caused Ms X and Mrs Y distress. This also caused them a lack of clarity and subsequent uncertainty about Mr Y’s welfare.

The Care Provider’s response to Mr Y’s decline in health

52. Ms X says the staff member on duty the night Mr Y was taken to hospital failed to seek immediate medical attention when his health deteriorated. She feels his death could have been prevented had the staff member acted on her wishes to call 999 and ask for an ambulance straight away.
53. The Care Provider says the staff member did not consider it clinically necessary to call an ambulance earlier in the evening when Ms X had asked them to. They took Mr Y’s observations and noted his oxygen was low but said his other observations at the time had been within the normal range. The staff member also said they were not initially concerned as they believed changes in Mr Y’s health were due to his Parkinson’s disease. This changed later in the evening, when the staff member repeated the observations and found them to be outside the normal range.
54. I understand Ms X strongly disagrees, but the staff member’s decision not to seek medical advice at the time was a matter of professional judgement. It is not the Ombudsman’s role to say whether a different decision made by the staff member, or earlier action would have prevented Mr Y’s death. The Care Provider says it has reminded staff to consider the wishes of relatives where they request advice of external medical professionals. This is suitable and so I have not recommended a service improvement in relation to this.

Injustice

55. I understand the circumstances of what happened are extremely distressing for Ms X and Mrs Y. However, we cannot say, even on the balance of probabilities, whether the Care Provider’s actions likely caused or contributed to Mr Y’s death. There are others better placed to make such a decision.
56. However, I have outlined the injustice caused to Ms X, Mrs Y, and Mr Y by the Care Provider’s actions above. Our guidance on remedies states that a symbolic payment can acknowledge the distress caused to Ms X and Mrs Y by uncertainty of not knowing if Mr Y’s death was preventable and whether he received a suitable level of care. Our guidance says I cannot remedy Mr Y’s injustice as he has sadly died.
57. When deciding a figure for symbolic remedy, I have considered that Ms X’s and Mrs Y’s uncertainty and distress is particularly severe because they relate to the care and death of a relative. The payment is symbolic only, and we recognise it cannot fully address Ms X’s or Mrs Y’s injustice.
58. The Care Provider said it has implemented changes and issued reminders following Ms X’s complaint. This includes implementation of digital care records which will provide clarity around a resident’s day and wellbeing observations. It has also said it has reminded staff of the importance of monitoring and recording fluid intake where a resident’s intake is fluctuating. The Care Provider also says it has reminded staff of the importance of updating a person’s care plan where changes have been identified, or when a significant amount of time has passed since a previous stay. These are suitable actions. I have recommended the Care Provider provides evidence of these actions below.

Back to top

Action

59. Within one month of the final decision the Care Provider has agreed to:
1. Apologise to Ms X and Mrs Y for the uncertainty and distress the fault identified above has caused them and for the uncertainty that deterioration in Mr Y’s health could have been avoided.
2. Pay Ms X £500 in recognition of the uncertainty and distress caused by the identified fault.
3. Remind staff to increase and record wellbeing observations when a person’s health or behaviour changes.
60. Within two months of the final decision the Care Provider has agreed to provide us with evidence to show that it has already taken the following actions:
1. Reminded staff of when and how to record fluid intake in cases where intake is fluctuating.
2. Reminded relevant staff they should complete a new care assessment when they identify changes or deterioration in a person’s health or circumstances, or when there has been a significant amount of time in between residential stays.
61. The Care Provider should provide us with evidence it has complied with actions above. It should also provide us with evidence it has already carried out the service improvements in the paragraph above.

Back to top

Final Decision

62. I have completed my investigation and uphold Ms X’s complaint. The Care Provider’s actions caused Ms X, Mrs Y, and Mr Y an injustice. I cannot remedy Mr Y’s injustice, but the Care Provider has agreed to make suitable remedies to address the injustice caused to Ms X and Mrs Y.

Back to top

Investigator's decision on behalf of the Ombudsman