Summary: There was no fault in the way the Council commissioned care home supported the late Mrs Y.

The complaint

1. Mrs X complained on behalf of her grandfather about the quality of care the Council commissioned care home provided to her grandmother Mrs Y. Mrs X considers this impacted Mrs Y’s health and led to a deterioration in her condition.

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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 investigate complaints about councils and certain other bodies. Where an individual, 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) In this case the Council commissioned the care home so we consider the Council is responsible for its actions.
4. 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

5. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
6. I gave Mrs X and the Council 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

7. 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. This includes:
• Regulation 9 requires care and treatment to be appropriate and person-centred based on an assessment of their needs and preferences.
• 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
• Providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).

What happened

8. In late November 2024 Mrs Y moved into the care home on a temporary basis for a recovery period, following a fall and hospital stay. The Council’s assessment noted Mrs Y spent long periods of time sleeping and being nursed in bed. She required regular positional changes and the support of two people because of her care needs. It noted Mrs Y’s swallow had deteriorated. She was assessed as needing a pureed diet and normal fluids. She was at high risk of aspiration (accidentally inhaling food) and needed to eat at a slow pace and encouraged to swallow between mouthfuls.
9. The care home assessed Mrs Y when she moved in. It noted Mrs Y had very high needs, dementia and was unable to make complex informed decisions. She was unable to weight bear and was to be nursed in bed for safety. She was at risk of pressure injuries and had a catheter.
10. Mr Y regularly visited and spent long periods of time with Mrs Y and assisted her with meals. In January 2025 the care home informed Mr Y that only trained staff would support Mrs Y with meals due to concerns about her swallow function and following a speech and language therapy (SALT) assessment. This recommended Mrs Y be fully assisted with feeding, fed on a teaspoon only with one sip of drink at a time, be encouraged to swallow per sip of drink and then to swallow a second time and be sat upright for at least 30 minutes after feeding.
11. In late January 2025 the care home and Council met with the family and agreed Mrs Y needed funded nursing care (care in a care home with nursing care funded by the NHS, delivered by registered nurses) and it was in Mrs Y’s best interests to stay in the care home. The Council assessment noted Mrs Y was unable to weight bear and that feeding should be carried out by trained staff in line with the SALT guidelines. The social worker made a referral to the therapies team regarding Mrs Y’s sitting balance and potential for a prescribed chair to enable her to sit out of bed.
12. The care home’s records show care staff assisted Mrs Y with meals and her personal care, regularly weighed Mrs Y and her weight remained relatively stable. Care staff regularly checked Mrs Y’s catheter. The records show she was re-catheterised in mid December 2024 and mid February 2025 due to concerns her catheter was bypassing.
13. In mid-February 2025 the notes record the care home discussed Mrs Y’s medication with the GP as she was struggling to swallow tablets. The GP advised the medication could not be crushed and so should be stopped due to the swallow risks. The GP prescribed a spray if required for chest pain.
14. Mrs X visited Mrs Y regularly. When she visited in early March 2025, she said she spoke to care workers as she had concerns Mrs Y was not herself. On the same day the care home’s records show it took Mrs Y’s observations which were normal and it checked her catheter which was functioning normally.
15. The following day the notes record Mrs Y’s care and dietary needs were met by staff.
16. A day later the notes record Mrs Y appeared sleepy and had reduced dietary intake as a result. Staff assisted with a body wash and nightwear change. The notes record staff attempted to wake her at lunch but she was asleep. Staff notes record Mr Y was concerned she was so sleepy and staff advised Mr Y that if Mrs Y appeared no better, they would have her checked by the GP surgery the following day. At teatime a care worker attempted to feed Mrs Y a fortified drink but she refused this, and they noted she had a handful of sips but was struggling to swallow. The care home gave Mr Y a meal.
17. In the early evening care staff noticed Mrs Y was having problems breathing. They noted she had food debris in her mouth which a staff member removed. This did not resemble the food staff had attempted to give her at teatime. Mrs Y accepted sips of water. The care home’s nurse was concerned Mrs Y may have aspirated on food and following advice called for an ambulance. Mrs Y had an increased temperature and reduced oxygen levels.
18. Mrs Y died in hospital a few days later. The coroner decided not to hold an inquest.
19. Mrs X complained to the care provider in April 2025. Her complaints included:
1. Mrs Y’s urine was dark in hospital which indicated a urine infection and that Mrs Y had choked.
2. She had raised concerns Mrs Y was unwell, two days prior to Mrs Y being admitted to hospital which were not taken seriously.
3. A care worker had asked her if she wanted to support Mrs Y with feeding on the day before Mrs Y’s hospital admission when only trained staff were meant to support Mrs Y and on that day she noticed Mrs Y was making gurgling sounds.
4. Mrs Y’s toenails had not been cut despite Mr Y paying for this to happen the previous week to her hospital admission.
5. Hospital appointments were missed and she was given tablets which she could not swallow.
6. No attempts were made for Mrs Y to sit out of bed despite an Occupational Therapy referral in January 2025.
20. The care provider responded the following month. In summary, it set out:
1. It checked Mrs Y’s catheter regularly. Mrs Y only accepted small amounts of food and fluid which would impact her urine output and no signs of infection were documented by staff. It gave its explanation of what happened on the night Mrs Y aspirated on food. It said Mrs Y appeared to have mashed up food in her mouth which a nurse removed. The food did not correlate with what it had given Mrs Y.
2. It said it took Mrs Y’s observations on the day Mrs X visited, which were normal.
3. It could not find evidence to support Mrs X’s assertion she was asked to assist with a meal. However, it said this should not have taken place and it had addressed this with staff as only care staff were responsible for feeding Mrs Y. It said staff had supported Mrs Y with eating and drinking which was reflected in her weight remaining stable.
4. An outside chiropodist attended the care home on an eight week basis. Their last visit to Mrs Y was early January 2025. It was not aware if Mr Y had booked and paid for another visit and any complaint about this would need directing to the chiropodist.
5. Mrs Y missed a hospital appointment as Mr Y asked it to cancel the appointment as it was not four weeks since she had injured her arm. The care home said it had contacted the hospital who confirmed this was a routine appointment where treatment would not be given and if Mrs Y was not up to it, it could be re-arranged. It had consulted the GP about medications which could not be crushed and followed their advice.
6. An occupational therapist referral was sent. It was unfortunate they did not attend in the time Mrs Y was at the care home but it was out of their control. It was safer for Mrs Y to be cared for in bed until this assessment was completed.
21. It said at the review meeting in late January 2025 the family had been happy for Mrs Y to remain at the care home.
22. Mrs X remained unhappy and complained to us.

Findings

23. The records show the care home assessed Mrs Y’s needs and provided support in line with those needs. When it had concerns about her swallow function it sought additional support from the SALT team and followed their recommendations. The care records show staff supported Mrs Y with personal care and eating and drinking and that her weight remained relatively stable. It regularly checked Mrs Y’s urinary output and catheter and recorded this. There is no evidence from the records of fault in the way the care home supported Mrs Y.
24. Mrs X had concerns about Mrs Y’s presentation two days before she was admitted to hospital. However, the records show Mrs Y’s observations were normal and there is no other evidence to suggest the care home should have sought additional support at that time.
25. On the day of her hospital admission the notes record Mrs Y was sleepy and that she did not want to eat or drink. Mr Y raised his concerns, and the care home said it would ask the GP surgery to visit if she remained unwell the following day. Later that day, Mrs Y appeared to have food in her mouth which was not the food recently given to her by the care home staff. The records show the care home acted appropriately when Mrs Y showed signs of aspirating and called an ambulance when Mrs Y’s condition deteriorated. There is no evidence of fault in its actions.
26. From the records I have seen, the care provider properly investigated Mrs X’s complaint and responded to the points she raised. The records show the care provider sought GP advice regarding Mrs Y’s medications and any issues with the chiropodist were outside the care home’s control. It acknowledged that Mrs X should not have been asked to support Mrs Y with eating and addressed this with staff. That was appropriate and there is nothing else I could achieve by investigating that issue further.
27. The records show Mrs Y was referred to the OT when her stay became permanent in late January 2025. Mrs Y was not seen by the OT before she died. It may have been good practice for the care home to have followed this up and I have seen no evidence it did this. Even if I were to say this delay was fault, any injustice caused by this delay was to Mrs Y and Mrs Y has died so any injustice to her cannot be remedied. I cannot now know what that assessment may have concluded and the extent to which Mrs Y may have been able to sit out of bed, or for how long. So I do not intend to investigate this issue further.

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Decision

28. The Council was not at fault.

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Investigator's decision on behalf of the Ombudsman