Summary: Mrs B complained about aspects of care received by her mother in the final months of her life when she lived in one of the Care Provider’s care homes. We found some evidence the Care Provider was at fault, in particular around meals served to the complainant’s mother. But we also found the Care Provider had offered suitable apologies and taken measures to avoid a repeat. We completed our investigation therefore, finding there was no unremedied injustice caused to Mrs B.

The complaint

1. Mrs B complained about aspects of the care her late mother, Mrs C, received while resident at the St Mark’s Care Home (the Care Home), operated by Akari Care Limited (the Care Provider).
2. Specifically, in February 2025 Mrs B complained:

• about staffing levels in the Care Home;
• that staff left Mrs C alone in her bed and did not regularly check on her;
• about the standard of food in the Care Home.

3. Later, in February 2025 when Mrs B escalated her complaint, she also complained about:

• staff at the Care Home not doing enough to encourage Mrs C to eat and drink;
• that a member of staff had wrongly recorded giving medication to Mrs C one day while Mrs B visited her;
• that staff had insensitively asked her about settlement of the Care Home bill when Mrs C was close to the end of life.

4. Mrs B made her complaint to the Ombudsman in July 2025, unhappy with the Care Provider’s replies to her complaints. In particular, she found the Care Provider did not believe her account of some events and this has caused her distress.

Back to top

The Ombudsman’s role and powers

5. 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 the future, we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
6. 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:

• their personal representative (if they have one), or
• someone we consider to be suitable. (Local Government Act 1974, section 26A(2) and 34C(2), as amended)

7. If we are satisfied with a care provider’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)
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

9. I considered evidence provided by Mrs B and the Care Provider as well as relevant law, policy and guidance.
10. I gave Mrs B and the Care Provider a chance to comment on my draft decision. I took account of any comments they made before finalising the content of the decision statement.

Back to top

What I found

Relevant legal and administrative considerations

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. Only the CQC, as the care regulator, can decide if a care provider meets the standards or is in breach of them. However, we consider the standards relevant to our investigations when deciding if a care provider was at fault. So, we take them into account and any accompanying guidance published by the CQC.
12. I consider the following fundamental standards relevant to this complaint:

• Regulation 12, which covers ‘safe care and treatment’. Providers must be able to show they have taken all reasonable steps to ensure the health and safety of those in their care and can manage risks arising while providing care.
• Regulation 14, covering the meeting of nutrition and hydration needs. Providers must try to ensure people using their service do not become malnourished or dehydrated. They must take account of their preferences, religious and cultural background when preparing food. They must assess people’s need for support with nutrition and hydration and keep those assessments under review. They must provide support if someone needs it to eat and prepare food in line with any dietary needs they have.
• Regulation 16, covering the ‘receiving of and acting on complaints’. Providers must have effective and accessible procedures for identifying and responding to complaints. They must tell people who complain what further action they can take if they are unhappy with the reply to their complaint.
• Regulation 17, which covers ‘good governance’. Providers must keep accurate, complete and detailed records about each person using their service.
• Regulation 18, which refers to ‘staffing’. Providers must have enough suitably qualified, competent and experienced staff to meet the needs of people using their service. Providers must adopt a systematic approach towards calculating their staffing needs.

My approach to investigation

13. Below, I set out how I considered each part of Mrs B’s complaint in turn, grouping parts of the complaint together where appropriate. In each section I provide a brief summary of Mrs B’s concerns, the Care Provider’s response and then my analysis of relevant records and my findings. I also set out my thinking about the Care Provider’s complaint handling.

The complaints about staffing levels and the Care Provider leaving Mrs C in her room without support

Summary of Mrs B’s complaint

14. In her complaints to the Care Provider, Mrs B expressed concern that staff appeared overworked on the floor of the Care Home where Mrs C lived. She said she often stayed with Mrs C in her room and helped with her personal care and tasks such as cleaning and changing the bed. Mrs B said she sometimes found no staff came to check on Mrs C’s health and wellbeing while she sat with her.
15. Mrs B highlighted one day in January 2025 when she found the Care Home particularly short-staffed. She told me that she understood this was because of sickness absences. Mrs B also told me the day had bad weather affecting roads in the area.

Summary of the Care Provider’s reply

16. In its first reply to Mrs B’s complaint, sent in February 2025, the Care Provider said that it had checked its staffing levels during December 2024. It said that it provided four Care Assistants and one nurse for the floor occupied by Mrs C. But in addition, staff working on other floors could also help at times. It considered this a safe staffing level.
17. In its second reply, sent in May 2025, the Care Provider explained more about how it calculated its staffing levels, saying it reviewed these monthly. It remained satisfied staffing levels in the Care Home had never fallen below a safe level. This included on the day in January 2025 referred to by Mrs B. It said that often relatives visiting residents in the Care Home would support with tasks such as helping them with meals. But that it expected staff should ensure they were happy to do so.

My investigation and findings

18. I checked first the most recent inspection of the Care Home undertaken by the CQC. I noted this dated from 2022. However, I noted the CQC expressed no concern with staffing levels then.
19. Next, I considered more recent information provided to us by the Care Provider. This included copies of staffing rotas at the Care Home for a six week period beginning late November 2024. The Care Provider also sent us details of how it calculated staffing levels, although those calculations did not cover the same time period as the staffing rotas.
20. I found the Care Provider had a systematic approach for calculating the staffing levels it needed. I could not say for sure how it had calculated its staffing for the period where it sent us rotas because of the mismatch in dates mentioned above. Nor did the staffing rotas explain which staff worked on which floor in the Care Home.
21. However, I had no reason to doubt the Care Provider would have used a different method of calculation for staffing for the period covered by the rotas. And the number of staff on duty appeared consistent with the calculations of staffing levels. The Care Home had 11 to 12 staff on duty most days, including at least two more qualified or senior Care Assistants and a nurse. Those numbers gave me no cause for concern.
22. I noted there were two days in the period covered by the rotas, when daytime staffing levels fell below this number. And one of those was on the day specified by Mrs B, when the Care Home recorded three members of staff absent. I accepted Mrs B’s account therefore that on that day, staff appeared more pressed than normal, in completing care tasks.
23. But I considered the evidence of that alone insufficient to find fault with the Care Provider’s approach towards staffing. And noted that on Mrs B’s own account the day was exceptional because of staff sickness and / or the adverse weather.
24. More generally I also considered a judgement about the safe levels of staffing in a care home, to be something more suited to the regulatory function of the CQC than this office. Although I found no reason to consider the Care Provider might be in breach of Regulation 18 of the fundamental standards.
25. I also noted that part of Mrs B’s reasoning for thinking staffing levels at the home might be inadequate was because of her experience when visiting Mrs C. In particular, I understood that in the latter weeks of her life Mrs C spent more time in her room. Mrs B spent much time with her and noted how rarely staff came to check on Mrs C while she sat with her.
26. I did not find this confirmed by detailed care records sent to us by the Care Provider, including daily logs of its checks on Mrs C. These showed care staff consistently checked on Mrs C’s wellbeing. But in its complaint response the Care Provider had accepted there were times when staff did not check on Mrs C, because Mrs B was with her. If the primary purpose of a check was to ensure Mrs C was safe and well, I thought that reasonable enough. It could assume Mrs B would raise the alarm if something was not right.
27. But even so the Care Provider committed to learn from the complaint. It sent us a copy of a Care Home staff meeting minute from February 2025, where it encouraged its care assistants to still check on residents if they had visitors.
28. I also found no evidence suggesting the Care Home failed to support Mrs C with tasks such as personal care or encouraging her to eat meals when Mrs B was not present. I had no evidence therefore that pointed towards any possible breach of Regulation 12 requiring the Care Provider to deliver safe and effective care to people using its service.
29. In summary therefore, I could not uphold this part of the complaint. There was not enough evidence to find fault with the Care Provider’s service. And it had, in any event, sought to improve its service following Mrs B’s complaint.

The complaints about the standard of food and management of Mrs C’s nutrition and hydration needs

Summary of Mrs B’s complaint

30. In her complaints Mrs B made a general observation that the quality of meals at the Care Home was poor. She also highlighted one specific occasion where a Care Assistant had served Mrs C with both a savoury and sweet dish on the same plate. Mrs B sent the Care Provider a photograph of that, along with other photographs of meals served to Mrs C.
31. Later, Mrs B added that she had concerns staff did not do enough to encourage Mrs C’s nutrition and hydration in the latter stages of her life. She said she gave Mrs C drinks, which it did not record.

Summary of the Care Provider’s response

32. In its first reply, the Care Provider recognised that Mrs C had received a plate with both a savoury and sweet item on it. The Care Provider said this was unacceptable and explained a Care Assistant mistook the sweet item for a savoury one, because of a ‘language barrier’. It said that it needed to improve communication between the kitchen of the Care Home and staff and that a kitchen assistant would serve meals moving forward. It also apologised if other meals were poor. It said it had recently recruited a new “catering lead” who had redesigned menus and would ensure better presentation.
33. In its second reply, the Care Provider said it had kept daily food and hydration records for Mrs C. It recognised in the latter stages of her life it had not always succeeded in providing Mrs C with the drinks recommended. However, she was frail then and often sleeping. It explained that up to December 2024 it had regularly checked Mrs C’s weight which remained consistent and fell within the ‘healthy’ BMI (body mass index) range.

My investigation and findings

34. The Care Provider sent us records of when it checked Mrs C’s weight. I found these broadly confirmed what it told Mrs B in its complaint reply (although I did not locate a measurement of Mrs C’s weight after November 2024). It also sent us detailed records of Mrs C’s nutrition and hydration intake from the beginning of December 2024 until her death in mid-January 2025.
35. Those records showed the Care Home offered Mrs C meals regularly that were consistent with what its care plan recorded of her dietary requirements. Its staff logged times when they found her asleep, or refusing food. The records showed a marked decline in Mrs C’s food intake over the time examined, which coincided with her decline in health. The records did not indicate the quality or presentation of food caused Mrs C to decline it. Although the Care Home recorded one expression of dissatisfaction from Mrs B and Mrs C about this in December 2024.
36. Similarly, I found over time a gradual fall in the hydration staff recorded Mrs C taking. But again, the records suggested this coincided with Mrs C’s decline in health and that she was increasingly frail and spending time sleeping.
37. On balance therefore I could not find the Care Provider at fault for how it sought to manage Mrs C’s nutrition and hydration in the final weeks of her life. The evidence did not point towards any failure by the Care Provider to meet Regulation 14 of the fundamental standards.
38. That said, I accepted Mrs B’s account that how the Care Home presented food at times was poor, something I found confirmed by her photographs. Also, clearly on one occasion, Mrs C received an unacceptable plate with both a savoury and sweet item on it. This was enough for me to say the Care Provider was at fault, even if it continued to meet Mrs C’s nutrition needs.
39. However, I found the Care Provider had recognised this. It gave a detailed and candid explanation to Mrs B for how that particular incident happened and apologised for it. I considered this remedied any injustice caused to Mrs B from this incident.
40. I also noted the Care Provider provided a clear commitment to improve how it presented food to residents of the Care Home. It said following Mrs B’s complaint, it had introduced a new procedure aiming to avoid any further misunderstandings where Care Assistants did not recognise the food on offer. I considered this a positive and proportionate response. I did not consider I had reason to recommend that it need do more.
41. In summary therefore, I upheld this part of the complaint, but found the Care Provider had provided a satisfactory remedy to it.

The complaint about the medication record

Summary of Mrs B’s complaint

42. Mrs B says that on one morning, while she sat with Mrs C in her room, a member of staff recorded giving Mrs C medication. Mrs B said that could not have happened as Mrs C received no medication while she sat with her.

Summary of the Care Provider’s response

43. The Care Provider put this suggestion to the Care Home which defended its record keeping. The member of staff said their record was correct. A member of the Care Home’s management team and a member of nursing staff also said they recalled Mrs B raising concern at the time. Neither considered the member of staff at fault and believed they had given medication to Mrs C as stated.

My investigation and findings

44. Unfortunately, I considered this was not a complaint I could resolve. There was no dispute about what the medication record said; the dispute centred on its accuracy. I found Mrs B had one account of what happened and the Care Home a different account. I had no reason to doubt the sincerity of either.
45. I faced a conflict of evidence, therefore. And without any other evidence which might lead me to find support for one account over the other, I could not resolve this conflict. I also saw no way to gather such evidence in this case, noting the Care Provider had given a thorough account of what the Care Home staff had recorded and recalled.
46. I did not consider I could add to the Care Provider’s investigation. In which case, I could not uphold this part of the complaint.

The complaint about a member of staff asking Mrs B to settle Mrs C’s bill

Summary of Mrs B’s complaint

47. Mrs B said that near the end of Mrs C’s life, a member of staff contacted her about an outstanding balance on Mrs C’s bill for care, asking for settlement. This upset Mrs B who felt the timing of the request very insensitive.

Summary of the Care Provider’s response

48. In its reply, the Care Provider apologised for the timing of its request. It said the member of staff had not realised how ill Mrs C was at the time they called Mrs B.

My investigation and findings

49. Mrs B told me the member of staff who made the request of her, worked close to the Care Home manager. She found it unlikely they did know how ill Mrs C was, when they called her.
50. While I could understand how Mrs B came to that view, I had no evidence to find this was so. I therefore could not find the Care Provider employee contacted her in the knowledge that Mrs C was near end of life.
51. However, I understood why the contact distressed Mrs B. So, if it had not already done so, I would have wanted the Care Provider to apologise for this. But with it having done so, I could not see there was scope for me to investigate this matter further nor recommend any action it should take. Because even if I said the Care Provider was at fault for the contact, I considered its apology would remedy any injustice caused to Mrs B as a result.

The Care Provider’s complaint handling

52. I considered the Care Provider’s replies to the complaint satisfactory in their content. It clearly made efforts to engage with the different headings of Mrs B’s complaint. I found it recognised where it had something wrong and apologised satisfactorily.
53. However, two aspects of its complaint handling gave me some concern. First, in its initial reply to Mrs B’s complaint, the Care Provider did not explain how she could escalate her complaint further. I considered that a matter of basic good administrative practice, noting it was also the CQC’s expectation as set out in the advice it publishes in support of Regulation 16. However, I found no injustice resulted to Mrs B from the omission as she went on to successfully escalate her complaint. I also noted that properly, as part of its final reply, the Care Provider directed her to this office.
54. Second, I noted there was delay in the Care Provider giving its final response to Mrs B’s complaint. She escalated her complaint at the end of February 2025. But did not receive a reply until late May 2025. I considered the Provider should aim to respond more quickly than that. While it did not publish its complaint procedure online, I anticipated this would usually place an expectation on it replying within a month.
55. However, I also noted the Provider had apologised to Mrs B for its delay. I also found Mrs B did not suffer an injustice because of the delay, although I am sure it caused her some understandable frustration.

Back to top

Decision

56. For reasons set above I completed my investigation finding there was no outstanding fault by the Care Provider which it had failed to remedy.

Back to top

Investigator's decision on behalf of the Ombudsman