Summary: Mrs C complained about the care her father, Mr D received at the end of his life in a Council-funded care home. We have found fault with the Care Provider. In addition to the action already taken to improve the Care Provider’s procedures, the Council has agreed to apologise to Mrs C, make a symbolic payment and ensure the Care Provider notifies the Council in future of complaints made about the care provided to Council-funded residents.

The complaint

1. Mrs C complained that Chippendayle Lodge (the Care Provider), funded by Kent County Council (the Council) to care for Mrs C’s late father, Mr D, failed to provide adequate care for him in the final two weeks of his life. This caused Mrs C and the rest of the family significant and lasting distress.

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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. 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

4. I considered evidence provided by the Council, the NHS Trust and Mrs C as well as relevant law, policy and guidance.
5. Mrs C and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC). 

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What I found

Fundamental Standards of Care

7. 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. They include:

Person-centred care

8. A person must have care or treatment that is tailored to them and meets your needs and preferences.

Food and drink

9. A person must have enough to eat and drink to keep them in good health while they receive care and treatment.

Good governance

10. The provider of a person’s care must have plans that ensure they can meet these standards.
11. They must have effective governance and systems to check on the quality and safety of care. These must help the service improve and reduce any risks to a person’s health, safety and welfare.

Staffing

12. The provider of the care must have enough suitably qualified, competent and experienced staff to make sure they can meet these standards.
13. Their staff must be given the support, training and supervision they need to help them do their job.

What happened

14. Mr D had dementia and was living in a care home, Chippendayle Lodge, run by the Care Provider. Towards the end of June 2025 Mr D’s health started to deteriorate. He experienced nausea and complained of feeling unwell. He started to refuse to eat or drink on some occasions.
15. On 22 June the doctor visited. They noted Mr D’s mouth was very dry, he had stomach pain, but other observations were normal. They referred Mr D to the home treatment team (HTT) and they came to take some blood to see if Mr D had any infections. The nurse who visited was unable to take blood due to Mr D’s distress. Later that evening the Care Provider telephoned the 111 service for advice as the nurse had not returned to try again.
16. A family member (Ms E) spoke to HTT who could not visit that evening. HTT reassured her that hospital was probably not the best place for him and intravenous fluids would be difficult due to his likely distress. Although he was dehydrated it did not appear severe and care staff should continue to encourage fluid intake. Later that evening the 111 service called back and said they would be asking the doctor to visit again.
17. On 23 June HTT visited Mr D. They witnessed he was refusing to take food or fluids. With the help of Ms E they managed to take some blood, but Mr D was very distressed. He complained of a painful mouth but there was no obvious cause. HTT prescribed anti-nausea medication to assist with food and fluid intake. HTT discussed the situation with Ms E and said it could be a progression of his dementia. If his eating and drinking did not increase it may be develop into an end-of-life situation. They agreed to complete a ‘do not resuscitate’ form. They also discussed a mouth spray but said this may be difficult if Mr D was non-compliant. They agreed to try the anti-nausea medication first.
18. On 24 June the doctor visited again but Mr D did not want to see him. He said he felt unwell and had sore gums. He was not eating or drinking at all. The doctor prescribed a mouth spray and toothpaste and said to keep monitoring him.
19. On 25 June the Care Provider suggested making a dentist appointment. The family felt this was an inappropriate suggestion. Mr D continued to refuse food and fluids, complained of feeling unwell and was refusing to take his medication. HTT saw him in the evening. They noted he was very dehydrated and provided constipation treatment and a saliva gel. The doctor emailed the treatment team asking for an update as the care staff had told him that the team had not taken bloods, there was no treatment plan in place, and care staff were not clear what the plan was.
20. HTT contacted the doctor to correct the information provided, as they had taken bloods and formulated a treatment plan. They said a face-to-face visit was needed to ensure staff were fully aware of the situation and the treatment plan. They carried out a visit on 26 June and updated care staff on the medications they had ordered to the pharmacy to help with constipation and dry mouth.
21. Also, on 26 June the doctor called for an update and the Care Provider confirmed Mr D was still not eating or drinking but was spitting out food and fluids. The doctor said they would refer him to the dementia team for an assessment. In the evening the care staff called an ambulance as they were concerned Mr D was drowsy and refusing all his medication. An ambulance did not arrive, but staff spoke to the 111 service the following day.
22. HTT visited again on 28 June. They noted Mr D had not eaten or drunk anything for the past five days and comfort care was a priority. They advised giving him oral care every 30 minutes and arranged for some more saliva replacement gel from the pharmacy. They also agreed to do a hospice referral and ask if social services could provide some 1:1 care as Mr D was at high risk of falling due to his dehydration. Throughout that evening the records show care staff attempted to give mouth care with a sponge stick, but Mr D repeatedly declined.
23. HTT spoke to Ms E on 29 June. She said the care staff had given her conflicting information about whether an ambulance had been called or just the 111 service. Neither had the home collected the saliva gel. HTT visited Mr D later that day. Care staff said the pharmacy had been out of stock of the saliva gel. Mr D’s wife had bought in her own swabs and was dipping these in juice for mouth relief. HTT said Mr D appeared instantly relieved by this and HTT again said staff should give oral care every 30 minutes. HTT felt there was conflicting evidence over Mr D’s fluid intake and suggested staff tried to keep a fluid chart. HTT made a referral to the hospice for further support.
24. On 30 June the dementia team said there was little they could do at this stage and discharged him.
25. On 1 July the community nursing team (CNT) spoke to the care home following a referral from HTT. The senior carer denied Mr D had any symptoms of pain or distress so initially the nursing service agreed to do an end-of-life assessment later that week. On 2 July HTT discharged Mr D from their care to CNT, the doctor and care home staff.
26. On 3 July CNT received a referral from Ms E who said Mr D was agitated and in pain. She said she had asked the care staff to contact CNT, but they had not done so. CNT telephoned the care home who said they were unaware of any difficulties.
27. CNT visited to review Mr D. They noted he looked uncomfortable and was displaying signs of pain and agitation. He had not eaten or drunk anything for two weeks and was unable to swallow. CNT noted he had not passed urine for some time and this may be the problem, so gave him some medication to help with the pain and agitation which would hopefully relax him. CNT said staff would need to assess his pad in a couple of hours and if it was dry contact the team again so a catheter could be fitted. CNT noted he did not have a suitable bed but one was due to be delivered the next day.
28. CNT tried to call the home several times that evening to get an update, but no-one answered. CNT planned to return the next day, but Mr D died that evening.

Formal complaint

29. Mrs C complained to the Care Provider on 7 July about the end-of-life care Mr D received in the last two weeks of his life. She said:
• Internal communication was very poor and staff did not have consistent knowledge about Mr D’ condition or treatment.
• No-one took any action over the fact he had stopped eating and drinking or communicated with the family about this worrying development.
• It was Ms E who had contacted the health professionals regarding Mr D’s care and not the Care Provider.
• The Care Provider suggested Mr D’s discomfort was due to a dental issue even though it was clear his agitation was due to the final stages of dementia.
• The Care Provider did not inform the family that the saliva gel was not in stock at the pharmacy and failed to source any alternative. The family provided mouth sponges themselves, and it was only then that care staff carried out oral care.
• The Care Provider had called for an ambulance even though the family and HTT had agreed he should not be resuscitated or receive any hospital treatment.
• The Care Provider did not contact the hospice or social services for support despite HTT suggesting these as sources of possible help.
• The Care Provider did not put a fan in Mr D’s room even through the weather was extremely hot. The family bought one instead.
• The Care Provider had not sourced a hospital bed soon enough even though it was clear one would be needed.
• Food was still being brought to his room, even though he was on end-of life care.
• The Care Provider did not monitor Mr D’s urine output as instructed by CNT.
• The Care Provider did not act quickly to recall CNT, despite Mr D being in visible discomfort. Family members had to call CNT themselves.
• CNT expressed concern that Mr D ‘s discomfort could have been alleviated, and they had tried to call the home seven times on the night he died but no-one answered.
• The Care Provider did not explain what was happening, offer any condolence or express concern throughout the whole experience.
30. The Care Provider responded on 24 July. They said the manager had been away during this period and apologised for the lack of proper care given to Mr D. They said Mrs C had genuine reasons for raising concerns:
• the care staff had failed them;
• the communication had been poor;
• staff had not chased up the saliva spray or provided any oral care;
• the failure to find a fan was appalling;
• the provision of a specialist bed was the responsibility of CNT not the Care Provider;
• the dining room staff were not aware of Mr D’s condition and so were still sending him food. This should not have happened and they apologised;
• the relief management let the family and Mr D down with the lack of contact, concern or condolence.
31. The Care Provider said they would look further into why there was a delay in calling CNT to provide pain relief for Mr D and what happened with the hospice referral.
32. It said it would be taking the following action as a result of the complaint:
• Arranging meetings with staff about improving communication and record-keeping. These took place in August 2025.
• Employing a third management team member so there should always be two managers on shift. There was a delay to this due to the existing deputy manager being dismissed and the new deputy manager failing her probation.
• Group supervisions would take place concerning care and compassion including end-of-life care. These took place in August 2025.
• Oral hygiene packs were now available for staff to use.
• Liaison with the hospice service for more information on the support it could provide in end-of life situations. This took place in July 2025 and the hospice explained how to make a referral, how its staff would then come in and support the residents, staff and relatives. The hospice sent some information leaflets and free training in end-of-life mouth care.
• Appropriate personnel action will be taken with specific staff involved in these events.
33. Mrs C then complained to us.
34. In response to my enquiries the Council said that as a result of the investigation it had visited the Care Provider in April 2026 to discuss the learning from the complaint and formulate an action plan. This included:
• Management and leadership structure, supervision and training.
• Management cover and escalation for support during holidays or unexpected situations.
• End-of-life training for all.
• Training regarding communication with families and health professionals especially end-of-life.
• Ensuring information is available for families to read.
• Ensuring a manager is available for families.
35. The Council will monitor the implementation of the action plan and hold a follow-up meeting with the Care Provider at the end of the first quarter of the year. It will continue to monitor the situation until all the actions are completed.

Findings

36. Mr D had a progressive terminal condition which was likely to deteriorate at some point. The Care Provider said it provided dementia care and the family reasonably assumed that Mr D would be well-cared for at the end of his life.
37. However, from the records provided, it is clear the Care Provider had not put any plans in place for this scenario. I accept Mr D’s deterioration was fairly rapid, but this cannot have been a unique situation. There was no evidence of:
• a holistic prepared approach to his care or an end-of-life care plan, even when it was apparent Mr D was nearing the end of his life.
• adequate internal communication to ensure all care staff throughout the home were aware of Mr D’s condition, prognosis and care.
• any management intervention or oversight of the care or communication with the family throughout the two-week period.
• any concern about Mr D ceasing to eat or drink anything: no one considered completing a nutrition and fluid monitoring chart or seeking mor specialist advice.
• little evidence of meaningful liaison with other health professionals involved in Mr D’s care apart from the 111 service who had no knowledge of Mr D’s condition or care and could only give generic advice.
• a sense of urgency to find an alternative solution to problems such the lack of saliva gel/oral care or provision of a fan.
• a professional or caring approach to Mr D’s pain relief in his final hours with care staff misrepresenting Mr D’s condition to CNT, delaying in calling them back as his condition deteriorated and failing to answer the telephone on many occasions when CNT was trying to find out how Mr D was progressing.
38. This was fault which caused significant distress to family members including Mrs C and Ms E, at a very difficult time. They had to contact health professionals themselves and provide their own mouth sponges, due to the failings of the Care Provider. They were left uncertain as to what was happening, whether Mr D was in unnecessary pain or whether everything possible was being done for him to ease his suffering.
39. I also consider there were potential breaches of CQC’s fundamental standards of care:
• Person-centred care: Mr D received no individualised end-of-life care. There was no discussion the family or health professionals over his wishes, treatment or pain relief.
• Food and Drink: No action was taken or advice sought when Mr D stopped eating or drinking.
• Good governance: There was no evidence of any management oversight or any procedures in place for care at the end of someone’s life.
• Staffing: It was not clear that the care staff had sufficient knowledge of Mr D’s condition or treatment or the skills to undertake tasks such as oral/mouth care.
40. I welcome the Care Provider’s acknowledgement of the failings and the attempts to improve its procedures for the future. I also welcome the Council’s intervention and progress with an action plan, even though this happened belatedly and only after Mrs C had complained to our service.

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Action

41. In recognition of the injustice to Mrs C and Ms E, I recommended the Council within one month of the date of my final decision:
• apologises to Mrs C and makes a symbolic payment of £300.
• ensures that the Care Provider reviews its complaints policy to include a requirement to notify the Council about complaints it has received about the standard of care given to a council-funded resident and the complaint outcome including any recommendations for improvements.
42. The Council has agreed to the recommendations and should provide us with evidence it has complied with the above actions.

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Decision

43. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman