Summary: Mrs X complained about the standard of care the Council commissioned care home provided to her late mother. We found fault as the care home did not properly consider her mother’s nutritional and fluid intakes after recurrent infections. We also found fault with the care home’s records and inconsistent accounts about the day Mrs X’s mother passed away. This caused significant frustration, uncertainty and distress for Mrs X. The Council agreed to apologise to Mrs X, pay a symbolic payment to recognise the injustice and take action to ensure the care home reviews its practices with care records.

The complaint

1. Mrs X complains about the care provided to her late mother at her Council arranged residential placement at Ashgrove House (the Home). She raised several concerns around inadequate standards, including her mother’s frequent Urinary Tract Infections (UTIs), hydration issues, and she said care staff did not act appropriately on the day of her mother’s death. She says this has caused her significant distress and frustration.

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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. 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 someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
4. 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 council or care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
5. We investigate complaints about councils and certain other bodies. Where an organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), 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).

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What I have and have not investigated

8. Mrs X came to us in April 2025. I have investigated events from April 2024 to April 2025 (when the Council and Home sent their final response to her formal complaint).
9. I considered Mrs X’s complaints about the actions of the Home and the Council. I did not investigate her concerns about the delay of healthcare organisations, decisions made by medical professionals, or actions by CQC. The Parliamentary and Health Service Ombudsman (PHSO) can consider these. Healthcare services are not in our remit to investigate. I included some information from healthcare organisations involved to provide relevant background to Mrs X’s complaints.
10. Mrs X raised many care concerns. Our role is to consider administrative fault. Some issues I would not be able to make evidence based or meaningful findings on without further supporting evidence from the time of events. I explain examples of concerns I did not investigate below:
1. Mrs X said clocks in the home, including in Ms Y’s room, were often wrong, which confused Ms Y. She said staff would not replace the batteries despite raising it several times. I recognise Mrs X’s frustration, but I cannot practically investigate this.
2. In March 2024, the Council reviewed Ms Y’s care plan at the Home. As part of the process, Mrs X raised concerns around staff breaks, laundry issues and Ms Y’s hair styling. Again, the above applies. These appear to be historical (see Paragraph 4) which she could have complained to us about sooner. The Home also recorded actions it would take with these at the time.
3. I also did not investigate Mrs X’s difficulties with the Council’s invoicing system when paying the outstanding balance for Ms Y’s care. She pointed out historical issues. The Council apologised for the avoidable frustration to Mrs X. It was aware of the issues, and it was undergoing the lengthy process of transferring to a new system which took time. The Council’s apology and replacement system are appropriate actions here. Further investigation would not achieve more on this.

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How I considered this complaint

11. I discussed the complaint with Mrs X and considered her views and information she provided.
12. I made enquiries of the Council and Home. I considered the written responses and information provided, including daily care records and care plans.
13. Mrs X, the Council, and the Home had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Relevant administrative background

Care services regulation and guidance

14. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards of care. The standards include Regulation 17: Providers must “securely maintain accurate, complete and contemporaneous records in respect of each service user, including a record of the care and treatment provided and of decisions taken”.

Diagnosis of Urinary Tract Infections (UTI) – dipstick and Midstream Urine (MSU) tests

15. Best practice in care homes state a dipstick test alone should not be relied on to diagnose a UTI in people over 65. As the presence of specific bacteria is common in older people, a dipstick test could likely indicate a positive result, whether the bacteria was causing an infection or not. A false positive result could lead to unnecessary antibiotics being given.
16. Clinical guidance recommends diagnosis for a UTI should be based on signs and symptoms, not just through a dipstick result. Care staff are expected to contact relevant medical professionals for their clinical judgement on diagnosis or appropriate treatment. If decided as necessary, Midstream Urine (MSU) tests can confirm UTIs and guide antibiotic choices. They are requested by medical professionals and sent to labs.

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What I found

Background

17. Mrs X’s elderly mother (Ms Y) resided at Ashgrove House Care Home (the Home), run by Warmest Welcome for a few years. The Council arranged and funded this placement. Mrs X paid assessed contributions on Ms Y’s behalf. The Home does not provide nursing care. It would contact external medical professionals when needed, who would attend as necessary.

What happened – summary of key relevant events in the period considered

18. In January 2025, Ms Y passed away at the Home in the afternoon.
19. Three days later, the Home sent Mrs X an email in response to a request she made. It outlined the history of GP visits and anti-biotics prescribed to Ms Y since 2024 for UTIs. It gave an account of the day of Ms Y’s passing:
• Ms Y was out of bed in the early hours of the morning. She buzzed for staff as she had discomfort and burning sensations. Staff took Ms Y to the lounge and had breakfast, she appeared chatty and alert. She said she was in pain; she went to the toilet a few times, checked and assisted by staff. A dipstick test later showed indications of a UTI. Around midday, the senior carer rang the out-of-hours GP requesting a visit. The GP rang back within two hours, declined a visit and prescribed antibiotics. Ms Y appeared her normal self but later collapsed in the afternoon and shortly passed away.
20. In late January 2025, Mrs X emailed the Home. She questioned the delay in calling the GP until midday, given Ms Y’s complaint about pain when she got up. The Home responded:
• They gave a similar general account of events as above.
• In the care notes, in the early evening the senior carer on the day shift described the night staff handover that morning. They noted the night staff said “[Ms Y] had been up since 4am as she was complaining of pain and burning down below”. The Home said night staff confirmed she did not complain of pain in the morning.
• The Home said while Ms Y felt unwell, there were no immediate serious concerns about her until later with the dipstick result around the afternoon. Before and after that, she was alert, chatty, ate food and staff carried out general checks on her.
• Mrs X said Ms Y had been off her food and tired lately. The Home noted Ms Y’s weight fluctuated from the end of 2024 but did not note a significant decline.
21. In early February 2025, Mrs X made a formal complaint to the Council. She included buzzers being out of reach of residents, and Ms Y, to call for help. She said Ms Y was often dehydrated as staff would not make tea the way she liked it. She said the Home did not do the correct MSU tests for UTIs which were more accurate than dipstick tests.
22. Mrs X also raised a complaint with CQC. In late February 2025, CQC emailed the Home asking it to investigate Mrs X’s concerns. The Home reported back with actions it had taken, including issuing reminders to staff to consistently record all fluids administered to residents.
23. The Council responded at Stage 1:
• A senior Home staff member would investigate and review the Home’s response, and they would contact Mrs X directly. The Council noted Mrs X raised the buzzer issue in March 2024 which it addressed at the time.
• The Council had received no other concerns about the Home through its feedback mechanisms. It would ensure hers were recorded into the monitoring process so if others were raised, it would be aware.
24. Mrs X responded to the Council. She added she did not agree or sign off on a decision in July 2024 to change Ms Y’s fee from residential to the dementia rate. She was not told about a visit to Ms Y for this. The Council explained the Home asked the Council to consider an uplift to reflect Ms Y’s increased needs. A social worker visited Ms Y to review and update her care plan. It accepted they should have contacted Mrs X to invite her and explain the visit.
25. In April 2025, the Home sent its final complaint response to Mrs X. Relevant to the issues investigated here:
• It took the issues of buzzers not being within reach seriously. It conducted a comprehensive audit of their use by residents within the Home. It identified many areas for improvement and follow up actions. In Ms Y’s case, it was satisfied her buzzer was always in reach in her room and she also had a pressure mat to call for staff. It said Ms Y regularly sat in the lounge where she had easy access to staff if she needed assistance.
• Its staff were trained to recognise early symptoms of UTIs, and they would address it promptly to reduce escalation into more serious conditions. Staff would carry out a dipstick test, which was quicker than sending an MSU to a lab. They would contact the GP with the results. If the GP requested further confirmation with an MSU test, staff would do this and send the sample to the lab. In Ms Y’s case, it noted she had three UTIs since 2024. The GP did not request MSU tests and prescribed antibiotics each time.
• It was satisfied with staff actions on the day of Ms Y’s passing. They had assessed her symptoms but noted no signs that warranted urgent intervention or an ambulance. It understood Mrs X’s concerns about delay, but staff monitored Ms Y closely throughout the time.
• It saw evidence staff monitored Ms Y’s hydration levels and did not have concerns. They recorded Ms Y typically did not drink a full cup in one sitting.
26. Mrs X then complained to us.

Analysis

27. We cannot say the actions of the Home (providing services on behalf of the Council) contributed to Ms Y’s deterioration and death or make findings of negligence. That can only be determined by a court. I can look at evidence around general standards of social care and actions taken by the Home.
28. I appreciate there may not be records of concerns raised by Mrs X directly to the Home. Mrs X regularly visited Ms Y, and she may have informally discussed them with the Home. However, we make evidence-based decisions and documentary records help with deciding what may have happened, on balance of probabilities. There is difficulty in retrospectively investigating some issues given the passage of time. I recognise the prompt to make a formal complaint was Ms Y’s unfortunate passing.

Call buzzers

29. Mrs X disputes her complaint was about Ms Y’s buzzer in her room. She said it was not accessible in the lounge for Ms Y and residents, with no staff being around to assist if needed. The CQC mentioned buzzer concerns to the Home without specific details, and I can see the Home responded to this, so I do not criticise the Home here.
30. In any event, I would not be able to practically investigate the substance of this part of Mrs X’s complaint, or remedy any alleged injustice to Ms Y. But I note the Home took proactive action itself in undertaking its audit exercise to ensure oversight and improvements in its services for other residents going forward. This is positive, even if it was not part of Mrs X’s complaint.

Hydration

31. Mrs X said the Home did not serve drinks to Ms Y in line with her preferences, so she did not drink. I cannot verify this, but I have reviewed records about her fluid intake. I can see staff generally recorded some drinks given and amounts daily. But the Home said it would not record all she drank and it did not have fluid charts for Ms Y as it was not necessary. It said her weight remained stable and she did not show signs of dehydration.
32. However, I have concerns with the Home’s position on this and how it satisfied itself of its actions on this part:
• Ms Y had UTIs in July, November and December 2024. These are classed as recurrent (three in six months) and included two within two months at the end of 2024.
• In late November 2024, a case record noted the nurse saw Ms Y due to a decline in meals and increased lethargy. In early December 2024, Ms Y had lost 3kg in a month. I do not consider that a stable weight change.
• Ms Y’s care plan said she had a Malnutrition Universal Screening Tool (MUST) assessment and nutritional risk assessment. It said if any weight loss was noted, a senior manager should be informed. The Home did not provide copies of the assessments, and I cannot see if Ms Y’s weight loss was reported or assessed.
• Dehydration can be a cause of UTIs. Given there were concerns about Ms Y’s lack of appetite and tiredness, it followed that these could be factors increasing Ms Y’s risk to UTIs. There are no records to show if the Home recognised or explored these in relation to Ms Y’s care. I cannot see if it considered whether it should have closer scrutiny on Ms Y’s intake or put steps in to monitor this further, such as fluid charts.
33. On balance, given the above circumstances, in my view the Home missed opportunities to properly consider Ms Y’s fluid and intake needs in the last few months before her passing. This is fault. I cannot remedy this for Ms Y. But I also cannot say had it not been for the fault, whether this would have prevented Ms Y from another UTI in January 2025. However, this creates injustice for Mrs X with a significant level of uncertainty and whether missed action could have made a difference to Ms Y’s situation.

UTIs - dipstick tests and MSU tests

34. The Home carried out dipstick tests when it suspected Ms Y had a UTI. It used these as a rapid initial assessment and staff would communicate the results to the GP. I recognise the clinical guidance in Paragraphs 15 and 16 recommends dipstick tests should not be used on residents. It says diagnosis should be based on the presence of symptoms. I note in the care notes, staff recorded and observed specific symptoms by Ms Y each time, before it carried out a dipstick test.
35. I appreciate Mrs X thinks the Home should have done an MSU test each time as they are considered more accurate. However, it is up to the GP to decide if this was needed before prescribing antibiotics. As per Paragraph 9, I cannot make a finding on this specifically. The Home had no records to confirm if the GP requested MSU tests. It said if these were outstanding, it did not receive any follow ups from the GP. The Home may not be using best practice as it has added an extra (potentially unnecessary) step with the dipstick test, but it relayed Ms Y’s symptoms and results each time to inform the GP. Regardless, it is ultimately a clinical decision by the GP who is responsible for medical judgements.
36. While I do not find the Home specifically at fault, I hope it would consider the use of an UTI assessment tool (as recommended by guidance) in future to strengthen its processes. It could also encourage care staff to prompt GPs about whether MSU tests are needed.

Care notes and the day of Ms Y’s passing

37. I have general concerns about Ms Y’s daily care notes as individual entries do not appear to be contemporaneous. It frequently recorded several tasks completed at one timestamp. This indicates care was not recorded in real time, which can lead to inaccuracies or missed entries of care details. Care should be recorded as it happens, not grouped together later. This is not good practice. This is fault with record keeping and falls below the standard we would expect in line with Regulation 17 (see Paragraph 14). I cannot say this caused an injustice to Ms Y, as care events were generally recorded. But this adds to Mrs X’s uncertainty around her care, which is injustice.
38. On a similar strand, there are contradictions in the two accounts given by the Home at different stages of Mrs X’s complaint about the day of Ms Y’s passing. The relevant care records are not as specific as they should be (see above). It appears some of the context was provided verbally by staff accounts at the time, but there are no recorded witness statements to further support this. There is inconsistency about whether Ms Y complained of burning pain when she woke up or not. I cannot make a safe finding on this, but this again adds uncertainty for Mrs X about the timeline of events and whether earlier action could have been taken or made a difference.

Uplift in fees for Ms Y’s care

39. I recognise Mrs X did not feel involved in the decision making or communication around the social worker’s visit in July 2024. She said it had no evidence of a change in need to justify moving Ms Y to the higher dementia rate. However, the Council funded Ms Y’s placement and the provider rate uplifts. It agreed to this increase. Mrs X, on behalf of Ms Y, continued paying the same assessed contribution to the Council. While I appreciate Mrs X’s frustration at the process, any increase did not result in significant financial injustice to Mrs X or Ms Y.

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Agreed Action

40. When someone has died, we will not normally seek a remedy for injustice caused to that person in the same way we might for someone who is still living, such as symbolic payments. This is because the person cannot benefit from such a remedy. However, if we consider the person who has complained to us has been adversely affected by the impact of any fault identified, we may make a recommendation to remedy their own distress.
41. 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 actions of the Home, I have made recommendations to the Council.
42. To remedy the injustice set out above, the Council has agreed to carry out the following actions within one month of the final decision:
• Apologise in writing to Mrs X for the injustice caused from the faults identified against the Home (in line with our guidance on making an effective apology) and pay Mrs X a symbolic payment of £300 to recognise this injustice.
43. Within two months of the final decision:
• The Council should ask the Home to review how staff are completing care records and make clear the requirement that daily care logs should be contemporaneously recorded. The Council should ask the Home to monitor this to ensure improvements in practice.
44. The Council should provide us with evidence it has complied with the above actions.

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Decision

45. I find fault causing injustice. The Council agreed to my recommendations to remedy the injustice. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman