Summary: Ms X complained about the quality of care Mrs Y received while resident in a care home. We do not find the Council at fault.

The complaint

1. Ms X complains about the adequacy of care her late mother, Mrs Y received between October 2024 and December 2024. Ms X says neglect from the Care Home led to Mrs Y passing away from aspiration which could have been avoided and has caused considerable distress and upset for her and her family.

Back to top

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 cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
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. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. Sometimes it is not possible to make findings even on the balance of probabilities.
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)

Back to top

What I have and have not investigated

7. I have investigated Ms X’s complaint as set out above between October 2024 and December 2024.

Back to top

How I considered this complaint

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

Back to top

What I found

Relevant law and policy

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has issued guidance on how to meet the fundamental standards.
11. Regulation 9 says care and treatment must be appropriate and meet service users’ needs.
12. Regulation 10 says service users must be treated with dignity and respect.
13. Regulation 12 says care and treatment must be provided in a safe way for service users.
14. Regulation 17 says care providers should maintain accurate, complete, and contemporaneous records in respect of each service user.

What happened

15. I have summarised below some key events leading to Ms X’s complaint. While I have considered everything submitted, this is not intended to be a detailed account of what took place.
16. Mrs Y was admitted to the Care Home, which was outside of the Council’s area, in October 2024 as a temporary respite placement while an alternative permanent placement was sought. The Council commissioned Mrs Y’s placement and contributed financially towards her care.
17. The Council contacted the Care Home around a week after Mrs Y was admitted and was told she had settled well and there were no concerns.
18. The Council has provided notes from the time Mrs Y was admitted to the Care Home. These show Ms X raised concerns around the setting and Mrs Y’s medication. The Council raised these concerns with the nurse who had been caring for Mrs Y and was told her medication had recently been reviewed.
19. The Council contacted the Care Home again later in the month to check on Mrs Y’s welfare. It was informed she was doing well with taking her medication and making friends. However, the Care Home said Mrs Y needed a lot of encouragement and support at mealtimes.
20. In November 2024 Ms X contacted the Council to express concerns. She said she had visited Mrs Y and found her in pain with her head tilted downwards. Ms X said Mrs Y was dehydrated and had been suffering with ulcers on her feet. Ms X said she was not happy with the level of care Mrs Y had received from the Care Home.
21. The Council contacted the Care Home who advised they had arranged for a doctor to review Mrs Y and they had prescribed pain relief medication. The Care Home explained when Ms X saw her, Mrs Y had only been up for an hour so had not consumed much fluid, however there were no concerns around hydration based on her fluid charts. The Care Home confirmed ulcers had been identified when she arrived and a chiropodist had been consulted. They confirmed Mrs Y had been doing well at the Care Home.
22. The Council spoke to the Care Home again later that month. The Care Home confirmed they were waiting for an appointment for an x-ray on Mrs Y’s neck. However, Ms X took Mrs Y for an x-ray before this appointment was put in place. The Care Home also explained they had referred Mrs Y to a dietician as she was eating poorly, and they had been giving her milkshakes to supplement her meals. The Care Home confirmed food and fluid charts were in place to monitor Mrs Y’s intake. The Care Home also explained Mrs Y’s medication was now all in liquid form.
23. In December 2024 the Council spoke to the Care Home again. They explained they were aware Mrs Y has a moist lesion and were treating this with a barrier cream as well as monitoring skin integrity. The Care Home confirmed Mrs Y was having a diet that was recommended by a dietician but required a lot of reassurance and support to eat and drink.
24. Mrs Y moved out of the Care Home on 5 December. She was diagnosed with a chest infection shortly after this.

Analysis

25. When considering complaints, if there is a conflict of testimony or evidence, we make findings based on the balance of probabilities. This means weighing up the available relevant evidence and basing our findings on what we think was more likely to have happened. Often this means we have to give most weight to documentary evidence and notes that exist over verbal testimony and recollections. Sometimes it is not possible to come to a finding, even on the balance of probabilities, where there is no independent evidence and both sides have differing views on the same events.
26. Ms X has concerns around how Mrs Y’s nutrition was managed during her time at the Care Home and rapid weight loss while she was there. I have reviewed the meal records from the time and these appear to be fairly comprehensive in setting out what meals Mrs Y was given, and how much she ate. The records show Mrs Y regularly only consumed very little at mealtimes despite support and encouragement from care staff. Corresponding notes show that as a result of this, the Care Home referred Mrs Y to a dietitian who was happy with her meal plan and prescribed milkshakes to supplement this, which the care staff delivered. I can understand Ms X’s concerns here, particularly as Mrs Y lost a substantial amount of weight very quickly, but I do not have enough evidence to say even on the balance of probabilities that the Care Home was at fault in the way in managed Mrs Y’s nutritional intake.
27. Ms X also says she regularly found Mrs Y to be dehydrated. I have looked through a copy of the fluid charts from the time Mrs Y spent at the Care Home. These show the Care Home recorded how much fluid it was giving Mrs Y every day and exactly how much she actually consumed. The notes show the Care Home was monitoring Mrs Y’s fluid intake and had no concerns with the amount she was consuming. I understand Ms X disagrees with this, but I have seen no reason to question the notes I have been provided so I cannot find fault here.
28. The Care Home has agreed there was one occasion where Ms X picked Mrs Y up for an appointment where she would have seemed thirsty. However, it explained Mrs Y had only been up for an hour when Ms X picked her up so had not drunk much by that point. Again, I understand Ms X disagrees with the Care Home’s account, but there is not enough evidence for me to find it at fault.
29. Ms X has also raised concerns around how the Care Home managed Mrs Y’s general health needs. These include ulcers on her feet, a neck issue which meant she was unable to lift her head, wound care and a chest infection that was diagnosed once Mrs Y moved to a new care home. I understand this would have been a distressing time for Ms X, however the notes I have reviewed show the Care Home was in regular contact with doctors and health professionals about Mrs Y’s needs throughout the time she spent there. The Care Home appears to have made decisions about Mrs Y’s health needs based on information it received from the relevant medical professionals and I cannot find it at fault here. I understand Mrs Y was diagnosed with a chest infection very quickly after leaving the Care Home, but I have seen no evidence to suggest this ought to have been diagnosed sooner and that the Care Home was at fault here.

Back to top

Decision

30. I find fault no fault and I have completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman