Summary: There was fault by the Care Home in the quality of care it provided to Ms X’s late mother, Mrs Y and in the Care Provider’s complaint response. The Care Provider has apologised to Ms X, waived the care fees and made service improvements, which is an appropriate remedy for the distress caused.

The complaint

1. Ms X complained Brookwater House Care Home (‘the Care Home’) failed to provide adequate care for her late mother, Mrs Y, when she moved there, causing distress to Mrs Y and her family. Hamberley Care Homes (‘the Care Provider’) operate Brookwater House. Ms X complained about the handling of her complaint by Hamberley Care Homes, adding to her distress.

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The Ombudsman’s role and powers

2. 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. (Local Government Act 1974, sections 34B and 34C)
3. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
4. 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)
5. 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)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

7. I considered evidence provided by Ms X and Hamberley Care Homes as well as relevant law, policy and guidance.
8. Ms X and the organisation had the opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

9. 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 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);
• providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints (regulation 16).
• providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).

What happened

10. The following is a summary of the main events relevant to this complaint.
11. Mrs Y had dementia. She had been supported at home by her family until she moved to the Care Home in June 2025.
12. The Care Home completed a pre-admission assessment at the end of May 2025. The assessment included information about Mrs Y’s nutritional requirements and support, continence and personal care needs.
13. On the day Mrs Y moved to the care home her family completed a detailed ‘Who Am I’ questionnaire. This included a social and personal history as well as information about Mrs Y’s needs including:
• Mrs Y wears hearing aids.
• Mrs Y can be resistant to personal care support and would like to be supported by a female carer.
• Mrs Y needs assistance with eating and drinking.
14. During Mrs Y’s first days at the Care Home her family visited each day. Staff told her family Mrs Y did not sleep well, often refused support with her personal care and continence care and refused some of her meals.
15. Ms X said family members observed poor practice during their visits including:
• Giving Mrs Y her medication without explaining what they were doing.
• Care staff referring to Mrs Y as ‘difficult’ and demonstrating a lack of skill supporting someone with dementia.
16. Ms X said after around three days Care Home staff told her Care Plans had not yet been prepared for Mrs Y and staff were not aware of the information she had provided in the ‘Who Am I’ document.
17. Ms X said the same day she reported Mrs Y’s feet appeared swollen and asked staff to review them. Care Home staff advised her the GP would be visiting the home the following day.
18. The following day Mrs Y did not see the GP as she had not yet been registered with the new practice.
19. Ms X arranged a meeting with the Care Home Manager to discuss her concerns. Before this meeting took place Ms X was invited to an unplanned meeting with another member of staff. Ms X said at this meeting they were told the number of family visits was hindering Mrs Y’s transition into the care home. The family arranged to reduce their visits to one per day.
20. When Mrs Y’s family visited the following day Mrs Y had not been assisted with personal care or continence care and had continued to refuse her meals. Ms X said care staff could not provide them with any information about how they had tried to care for Mrs Y that day.
21. The following day Ms X took Mrs Y out of the care home.
22. A safeguarding concern was raised and considered by the Council. The Care Provider told the Council it would be making improvements to its service following Mrs Y’s experience. The Council decided no further action was required.
23. Ms X contacted CQC to advise them of her concerns about the Care Home.

Complaint Handling

24. Ms X made a complaint to the Care Provider at the end of June. She provided a detailed chronology of Mrs Y’s time at the Care Home and said she disputed the invoice she had received.
25. The Care Provider provided a complaint response from a senior manager in July 2025, this included an apology and acknowledgment that Mrs Y’s experience fell short of the expected standards. The response also said the Care Provider had completed a review of Mrs Y’s transition to the care home and her time there. The response said:
• The transition process lacked co-ordination and Mrs Y’s care plan did not reflect her personal history, preferences or behaviours. This resulted in staff being unable to provide person-centred care.
• Information about Mrs Y’s needs was not recorded or communicated between shift changes.
• Communication with Mrs Y’s family was not timely or transparent.
• It had completed a review of admission protocols.
• It would be making improvements including staff training, a clearer allocation of responsibilities and improved handover processes.
• It would not be seeking payment for Mrs Y’s time at the Care Home.
26. Later in July Ms X made a further complaint to the Care Provider. She said when she went to collect Mrs Y’s belongings and a copy of her care records from the Care Home she was advised nobody from the Care Provider had spoken with staff at the Care Home about the complaint.
27. The Care Provider responded in in July 2025. It said:
• Some of the comments in the complaint investigation were derived from investigations into wider operational practices at the Care Home as well as Mrs Y’s individual circumstances.
• Care Home staff had been spoken to as part of the complaint investigation.
• The Care Provider apologised for the distress caused both during Mrs Y’s stay at the Care Home and as a result of the subsequent communication.

Response to my enquiries

28. In response to my enquiries, the Care Provider acknowledged:
• Mrs Y’s care notes were not detailed or reflective of the care given.
• There was limited evidence of monitoring or escalation of concerns.
• Care Plans were not fully aligned with pre-admission information and their use was inconsistent.
• Concerns raised were not logged and there was a limited audit trail of actions.
29. The Care Provider also provided Mrs Y’s daily care records. These showed that at times Mrs Y was supported with personal and continence care by male as well as female care staff.
30. The Care Provider said it had made service improvements in line with those in the complaint response. It had:
• Completed staff training on care planning and documentation.
• An improved daily huddle handover process and a focus on care plans.
• A ‘Who Am I’ document shared with the team for each resident.
• An improved procedure for GP registration.
• Strengthened procedures for logging any concerns.

Findings

31. The pre-admission assessment and admission information provided by Mrs Y’s family was not read or used by staff supporting Mrs Y. This is fault and meant Mrs Y was not provided with her hearing aids and not supported with meals in a way that would optimise her food intake.
32. Mrs Y’s daily care notes record her as ‘content’ at a time when she was refusing assistance with care and meals. This is fault and caused distress to Ms X as she was not able to receive accurate information about Mrs Y’s care.
33. There was poor communication between Care Home staff and Mrs Y’s family. This is fault and caused distress and frustration to Ms X.
34. These faults were not in line with the CQC fundamental standards.
35. Ms X had asked for Mrs Y to be assisted by female carers. Mrs Y’s care notes show she was assisted at times by male care staff. It could be that only male care staff were available to support Mrs Y at certain times, in which case the Care Provider should have discussed this with Ms X and made her aware this may happen. Ms X said no such discussion took place. I have not investigated this further because it is not now possible to determine the injustice to Mrs Y or whether she consented to support from a male carer at the time.
36. There was further fault by the Care Provider in its complaint response to Ms X as it failed to make it clear that some of its recommendations arose from a review of wider operational practices rather than through the investigation of Ms X’s complaint. This caused Ms X distress and led to further mistrust of the Care Home.
37. In its complaint response the Care Provider has acknowledged its failings and apologised to Ms X. It said it would make service improvements and, in response to my enquiries, has confirmed it has completed these including:
• Improvements to the way concerns are logged and governance processes.
• Completion of training for all staff. The Care Provider provided a copy of its staff training records.
• An improved daily handover process and focus on care plans. The Care Provider provided an example of the daily meeting record.
• A ‘Who Am I’ document shared with the team for each resident.
• An improved procedure for GP registration.
• The ongoing implementation of the Care Provider’s Dementia Strategy and it has provided us with a copy of this strategy.
38. The Care Provider has acknowledged its faults. Mrs Y has since died so any injustice caused to her by the Care Provider’s faults cannot now be remedied.
39. In its complaint response the Provider apologised to Ms X and waived the fees associated with Mrs Y’s stay at the Care Home. This action, combined with the service improvements it has made, is an appropriate remedy for the distress caused to Ms X.

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Decision

40. I find fault causing injustice for which the Care Provider has already taken appropriate action.

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Investigator's decision on behalf of the Ombudsman