Summary: We have ended this investigation about the care provided to Mr F at a Care Home. This is because further investigation would not lead to a different outcome and we could not add to any previous investigations carried out.

The complaint

1. Ms X complained about the respite care her father, Mr F, received from a care home. She said the failings included substandard care, medication breaches, inadequate staffing and poor communication. This led to her father’s health, safety and dignity being put at risk and severe distress to the whole family.

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The Ombudsman’s role and powers

2. 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)
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 future we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
4. It is our decision whether to start, and when to end an investigation into something the law allows us to investigate. (Local Government Act 1974, sections 24A(6) and 34B(8), as amended)
5. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we are satisfied with the actions an organisation has taken or proposes to take. (Local Government Act 1974, section 24A(7), as amended)
6. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide:

• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

7. 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

8. I considered evidence provided by Ms X and the Care Home as well as relevant law, policy and guidance.
9. 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 legislation

10. 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.
11. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

What happened

12. I have summarised below the key events; this is not intended to be a detailed account.
13. The Care Home provided short term respite care for Mr F in May 2025.

The complaint

14. Ms X complained to the Care Home in May 2025 about the care provided to her father, Mr F. There were several parts of her complaint, these included concerns about administration of medication, continence mismanagement, rapid health deterioration, medical neglect, inadequate staffing and loss of personal belongings.
15. The Care Home responded in June 2025. The letter explained the Care Home had conducted a thorough investigation. It responded in detail to each part of Ms X’s complaint and apologised for the distress caused. The Care Home said it would refund Mr F’s fees in full which it has done.
16. Ms X complained to the Ombudsman in July 2025. She said the Care Home provided substandard care for her father. She said this led to her father’s health, safety and dignity put at risk and severe distress to the whole family. Ms X said, ‘There is absolutely nothing they can do to put this right.’

Other investigations

17. The Care Quality Commission (CQC) investigated Ms X’s concerns in July 2025. The Care Home cooperated with the enquiry. The CQC did not identify any regulatory breaches and closed the enquiry with no further action.
18. The Council carried out a Safeguarding Enquiry in July 2025. It partially substantiated the concern and reflected:
• The Care Home was responsive to incidents and sought appropriate medical input.
• There was no substantiated evidence of intentional neglect or incorrect medication administration.
• That it was not possible to substantiate that Mr F’s health deterioration was caused by poor care, as opposed to progression of need.
• Learning was required in relation to escalation of complaints to safeguarding and management of personal belongings.
19. The Council closed the Safeguarding Enquiry with no further action required.

Analysis

20. In her complaint to us, Ms X said was not happy with the complaint response from the Care Home.
21. The Care Home provided a detailed response to Ms X’s complaint, apologised for the distress caused to the family and said it would refund Mr F’s fees in full. If the Ombudsman was to investigate and found the Care Home at fault, it is unlikely we would recommend the Care Home refund the whole amount of care fees. This is because we would consider some of the fees went towards care which the individual satisfactorily received, for example the “hotel” part of the care such as accommodation and food. The Care Home has already offered to refund all Mr F’s care fees; this is a satisfactory remedy. It is unlikely that further investigation by the Ombudsman would achieve a better remedy for Ms X.
22. The CQC and the Councils Safeguarding Team have both investigated this case. These organisations are well placed to investigate this matter and further investigation by the Ombudsman cannot add anything to this. If the Ombudsman was to investigate now, it is unlikely we would make any different findings to those already made.

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Decision

I have ended my investigation as further investigation would not lead to a different outcome and we could not add to any previous investigations.

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Investigator's decision on behalf of the Ombudsman