Summary: The Care Home met Ms X’s mother’s, Ms Y’s, care and support needs. The Care Home was at fault for poor communication with the family which it has already accepted in its complaint response and has apologised to the family.

The complaint

1. Ms X complained the Council failed to properly meet her mother’s, Ms Y’s, care and support needs. This caused Ms X and her family distress. She would like the Council to apologise.

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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)

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How I considered this complaint

4. I considered evidence provided by Ms X and the Care Home as well as relevant law, policy and guidance.
5. Ms X and the Care Home 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

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:
• providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences (regulation 9).
• providers must be responsible for the proper and safe management of medicines and equipment (regulation 12).
• providers must make sure that people who use their services have adequate nutrition and hydration to aid good health. People must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition (regulation 14); and

Complaints on behalf of someone else

7. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)

Care Plan

8. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan. The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.
9. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.

What happened

10. I have summarised below the key events; this is not intended to be a detailed account.
11. Ms Y moved into the Care Home in the middle of November 2024. Before this, Ms Y was in hospital after a fall in a different care home.
12. The support plan completed by the hospital lists behavioural and psychological symptoms of dementia on Ms Y’s medical history. It said she was confused on the ward and would call out for her mother. It said she was doubly incontinent. The plan said Ms Y could self-transfer with a frame and mobilise short distances with supervision, as she was at high-risk of falls. Ms Y had a normal diet and fluid intake.
13. The Care Home produced a care plan when Ms Y moved into the Care Home. It said she was at high-risk of falls. It said she had no issues with eating and drinking. The care plan said Ms Y was doubly incontinent but can ask to use the toilet. Ms Y was low risk of pressure sores. It noted Ms Y could weight bare and could walk with the help of a frame. The care plan said Ms Y had been diagnosed with behavioural and psychological symptoms of dementia and was at high risk of disorientation.
14. The notes from Ms Y’s first day and overnight show she was very unsettled and screamed a lot. The Care Home told the family about this.
15. The following day, the Care Home referred Ms Y to the local doctor (GP) and explained Ms Y was very unsettled, kept screaming and had not slept. The GP prescribed some medication to help settle Ms Y. The Care Home staff told Ms Y’s family and updated the care plan.
16. The notes from the Care Home show there were several instances of Ms Y being unsettled. For example she was sat in the lounge, calling out, and upsetting other residents. The notes also show she struggled to weight bare and moved in an unsafe and unpredictable manner which presented a high risk of falls. In late November, the notes show staff assisted Ms Y to her bedroom to keep her safe.
17. There are other occasions where the notes show Ms Y was settled, sat in the lounge, ate in the dining room and slept through the night.
18. Towards the end of November, the Care Home emailed the GP and asked for a telephone consultation. This was because Ms Y was still unsettled and the medication had not had any effect. The notes show she was agitated. The same day, the GP called the Care Home and advised to continue to give the medication for up to two weeks. The GP asked for urine sample to rule out infection.
19. The Care Home contacted the family to tell them about Ms Y’s behaviour and explained she was staying in her own room for her safety as other residents had become aggressive towards her. They also explained the medication prescribed by the GP.
20. The following day, the Care Home sent a urine sample sent to GP. The results showed Ms X had an infection. The GP prescribed medication. The Care Home staff told the family the same day
21. Within the first week of December, the notes show Ms Y had been in bed for few days. The staff planned to get her out of bed but struggled as she had no sitting balance. They left her in bed for her own safety. The Care Home staff referred Ms Y to the physiotherapist. The Care Home contacted the family and told them about the referral. They also explained the medication the GP recently prescribed had no impact on Ms Y’s behaviour.
22. The following day, the Care Home contacted the GP and explained the medication had no effect on Ms Y’s behaviour. They also explained Ms Y’s mobility and sitting balance had gone and she was bedbound for her own safety.
23. At the end of the first week in December, the notes show Ms Y was spitting her food out and coughing while trying to eat. The Care Home updated the care plan the following day and noted Ms Y’s poor appetite and fluid intake. It said this had caused Ms Y to lose weight and she was at risk of dehydration. The care plan said to increase Ms Y’s calories to prevent further weight loss, check for causes of lack of appetite, ensure staff presented Ms Y’s food nicely and offer snacks. Staff were to monitor her weight weekly. The Care Home referred Ms Y to the Speech and Language Team (SALT) which recommended the Care Home should thicken her drinks.
24. The physiotherapist visited Ms Y within a couple of days of the referral with the Occupational Therapist (OT). When they arrived, Ms Y was shouting and screaming. The physiotherapist and OT decided it was not a suitable time for therapy.
25. A couple of days later, Care Home staff noticed category two pressure damage to Ms Y’s sacrum. The district nurse visited Ms Y and dressed the pressure sores. The Care Home staff updated the care plan.
26. The morning of the following day, the Care Home emailed the GP and asked for an urgent phone consultation due to the change in Ms Y’s health. The Care Home asked the GP for a referral to palliative care. Ms Y’s appetite was poor, she had lost weight, had poor mobility and broken skin. The Care Home called Ms Y’s family to update them.
27. By lunch time the same day, Ms Y’s condition had become worse. The records show staff noted a change in Ms Y’s breathing, she had become pale and sweaty and was semi-conscious. The Care Home staff called 999 and the paramedics transported Ms Y to hospital. The Care Home staff called the family.
28. The paramedics noted Ms Y’s condition was severe and raised concerns she was not already on palliative care. They raised a safeguarding concern.
29. Ms Y died in hospital three days later.

The complaint

30. Ms X complained to the Care Home at the end of February 2025.
31. In its response, the Care Home accepted communication was not as effective as it should have been and apologised for the distress caused.
32. The complaint response explained Ms Y was medically fit for the hospital to discharge her but she was not clinically well. Ms Y needed nursing care. It also said Ms Y’s behaviours were documented in the hospital admission and pre-admission assessment. Such distress is not uncommon in advanced dementia.
33. The complaint letter said the Care Home was satisfied the increase in Ms Y’s medication was in line with safe and appropriate limits as prescribed by the GP.
34. The response also said Ms Y already struggled with her mobility while she was in hospital and this unfortunately decreased while she was in the Care Home.

Analysis

35. The Care Home drafted a care plan for Ms X when she moved into the Care Home. This covered every area of her care including personal hygiene, continence, eating and drinking, transfers and mobility and communication. The Care Home created a person-centred plan for Ms X and complied with regulation nine. The Care Home’s care plan recognised the same concerns as identified by the hospital in its support plan. This shows the risks and concerns in supporting Ms X were existing before she moved into the Care Home.
36. The Care Home kept the care plan under review and updated it when Ms Y’s condition changed. For example, it changed the plan to reflect Ms Y was unsettled when she first became a resident at the Care Home and when her appetite declined and advice was received from SALT. The Care Home responded to Ms Y’s needs and changed the plan as required. This is what I would expect the Care Home to do. It was not at fault.
37. The records show the Care Home referred to the GP when it was concerned with Ms Y’s health. It contacted the GP the day after Ms Y moved into the Care Home and raised concerns about her being distressed overnight. It administered the medication to Ms Y as directed by the GP and when this did not settle Ms Y, it referred to the GP again for further advice. It also referred to the GP when Ms Y could not mobilise and lost her balance and asked for an urgent consultation when Ms Y’s condition worsened. The Care Home staff referred to the GP when they were concerned about Ms Y and followed the advice provided and administered the medication as prescribed. The Care Home followed regulation nine and provided person centred care to Ms X when she needed medical support and regulation 12 as it administered the medication according to GP advice and guidance. It was not at fault.
38. The Care Home also referred Ms Y to the physiotherapist and OT when she was struggling with her balance and mobility. It referred Ms Y to SALT when she lost her appetite and was struggling to eat and drink and complied with regulation 14 to support Ms Y to receive adequate nutrition. When the staff noticed Ms Y had pressure sores, it referred to the district nurse who dressed these the same day. The Care Home acted appropriately as it made referrals to medical professionals when needed. It was not at fault.
39. From when Ms Y moved into the Care Home until around the end of November, the Care Home kept the family updated about how Ms Y was presenting and the care it provided. It told the family each time it called the GP or other medical professional. It also advised the family that Ms Y was staying in her bedroom for her own safety. During most of November, the Care Home provided updates to the family. It provided good communication and was not at fault.
40. From December onwards, the records show the Care Home did not provide the family with the same level of updates about Ms Y. In its complaint response, the Care Home accepted its communication with the family was poor and apologised for this. I do not need to investigate this further as the Care Home has already accepted it is as fault and has provided a satisfactory remedy by apologising in its complaint response.

Summary of fault causing injustice

41. The Care Home wrote and reviewed a care plan for Ms Y while she was in its care and referred to the GP and medical professionals when needed. It kept the family updated about Ms Y’s health and wellbeing during November. The Care Home acted appropriately. It was not at fault.
42. The Care Home was at fault for poor communication with the family from around the beginning of December onwards. It has already accepted this in its complaint response and apologised to the family.

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Decision

I find fault causing injustice which the Care Home has already remedied.

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Investigator's decision on behalf of the Ombudsman