Summary: Based on the evidence seen so far, we propose to end our investigation into Mrs X's complaint about the care her mother received. While there is evidence of fault in the care provider's assessment, care planning and monitoring, the provider has already offered a remedy which appropriately addresses the injustice caused. Further investigation is unlikely to achieve a more meaningful outcome.

The complaint

1. Mrs X complained a care home could not provide the standard of care her mother, Mrs Y, needed. She said she had to remove Mrs Y after three weeks due to a significant decline in her health.
2. She wants Mrs Y to receive the money she paid to the care home and further financial remedy for the care her husband had to provide at home.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe it is unlikely we could add to any previous investigation by the care provider, it is unlikely further investigation will lead to a different outcome, or we cannot achieve the outcome someone wants. (Local Government Act 1974, sections 34B(8) and (9))
4. 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

How I considered this complaint

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

Back to top

What I found

What happened

8. Mrs Y went into Park View Care Home on 3 July 2025 for a planned five-week respite stay while her husband had surgery. On admission, records described Mrs Y as living with advanced dementia, non-verbal, doubly incontinent, unable to mobilise independently, and needing help from two staff with all areas of personal care, nutrition and hydration. Her husband told the home she normally ate a minced and moist diet and preferred to drink from a normal cup rather than a beaker with a spout.
9. For the first ten days, care records recorded Mrs Y eating most of her meals as well as additional food and drinks, including milkshakes, juices, mousse, yoghurt and snacks. Daily notes described Mrs Y as settled and taking part in activities. However, records also show Mrs Y needed extra help with eating and drinking, and there were times when she pushed food or drinks away or bit the lid of a beaker rather than drinking from it.
10. From mid-July records show a decline in Mrs Y’s nutritional intake. Records show she ate only small amounts at breakfast and around 40% of her lunch and evening meal. Staff continued to offer drinks and alternatives such as juices and jelly.
11. Staff recorded on 15 July 2025 that Mrs Y repeatedly pushed food away and declined attempts made by staff to help her with meals. Although Mrs Y’s observations were normal, staff noted she was eating and drinking little.
12. The following day, staff recorded that Mrs Y refused all food and fluids and became agitated when these were offered.
13. On 17 July 2025 a discussion took place between family members and staff. Mrs Y continued to have a poor intake. The weight chart records Mrs Y to be 70.2kg. Mrs X says this represented a 10kg loss since admission.
14. Staff contacted Mrs Y's GP on 18 July because of concerns about constipation, a reduced appetite, reduced fluid intake and gagging during meals. The GP prescribed medication for constipation and advised the home to monitor her condition and seek a further review if there was no improvement. Records show bowel activity later that day, but food and fluid intake remained poor.
15. Between 19 and 25 July 2025, records continued to show that Mrs Y either refused food or ate small amounts. Mrs Y drank relatively little despite encouragement from staff. Notes record ongoing concerns about poor intake, dry mouth and constipation. Mrs X says staff did not inform her about these concerns.
16. Around this time, staff noted they would check Mrs Y’s urine and seek further medical review if necessary. There is no evidence that a urine sample was taken.
17. During a visit from Mrs X on 23 July, staff were able to encourage some additional food intake while Mrs Y was distracted by the visit.
18. Family members told the home they intended to end Mrs Y’s placement.
19. Mrs Y left Park View Care Home and returned home with her family on 26 July.
20. After leaving the care home, Mrs Y went to hospital. Hospital discharge notes show Mrs Y had experienced acute kidney injury, dehydration and a heart attack.
21. Mrs X sought information from the home about her mother’s food and fluid intake and later made a formal complaint about the care provided.

Complaint investigation

22. The care provider asked a senior manager to investigate Mrs X’s complaint and produce an investigation report.
23. The investigation did not conclude that poor care at Park View caused Mrs Y's decline. Instead, it found evidence Mrs Y already had significant care needs and had experienced a decline in her health before admission. The investigation found staff generally recognised Mrs Y’s needs, encouraged food and fluids, and correctly contacted the GP when medical concerns arose.
24. However, the investigation identified several flaws in assessment, care planning and monitoring, which I will summarise below.
• The pre-admission assessment was incomplete, lacked detail and relied heavily on information from Mrs Y’s husband without enough information about medical history.
• There was confusion within records about the correct food texture level Mrs Y needed and staff should have documented this more clearly.
• Nutritional assessments and MUST [Malnutrition Universal Screening Tool] scores did not consistently reflect the risks associated with Mrs Y's declining intake. One assessment incorrectly identified Mrs Y as low risk at a time when her nutritional risk was significant.
• There was no evidence Mrs Y was on a food and fluid monitoring regime despite concerns about her intake. The investigation also noted discrepancies between food records and fluid charts.
• While staff contacted the GP on 18 July because of concerns about constipation and poor intake, the investigator could not find evidence that staff administered prescribed constipation after this date or that the GP was contacted again when symptoms continued.
• Staff should have obtained a urine sample to rule out a urinary tract infection and should have paid greater attention to the possibility of constipation.
25. Regarding Mrs X’s specific concerns, the investigation concluded with the following findings.
• The home used funnel cups and other drinking vessels. The investigation concluded there was no evidence the cup materially affected Mrs Y's intake.
• The investigation said there was no evidence in the records to support the allegation that Mrs Y slid out of a chair while staff ignored this.
• There was no evidence to support the allegation the home incorrectly stated the use of laxatives had been successful.
• Any shortcomings in the care provided did not cause Mrs Y's decline, although it noted she experienced dehydration associated with poor fluid intake.
26. The investigation did not conclude the care provided caused Mrs Y's decline. However, as summarised above, it did find some failures in the way in which the home delivered and recorded care. As a result, the investigation concluded with recommendations to improve the assessment processes, nutritional care planning, food and fluid monitoring, management of constipation and infection risks, and the follow-up of GP advice and prescribed medication.
27. As a ‘gesture of goodwill’ the care provider also agreed to refund 50% of the fees paid by Mrs Y during her stay at the home.
28. Dissatisfied with this, Mrs X complained to the LGSCO. She sought further financial remedy in recognition of the significant decline in Mrs Y’s health and for the subsequent care which Mr Y provided to his wife.

Was there fault in the actions of the care provider causing injustice?

29. I have considered Mrs X’s complaint. In my view, the outcomes she seeks are not consistent with the Ombudsman's approach to remedies. The role of the Ombudsman is to remedy injustice caused by fault; we do not award compensation or apply punitive damages. Any financial remedy must be proportionate to the injustice found and supported by evidence that the fault caused the claimed injustice.
30. The Ombudsman's guidance recognises that where complainants make a link between serious health consequences and poor care, it is often not possible to establish a direct causal link through an Ombudsman investigation. In this case, the evidence I have seen does not show the faults identified directly and solely caused Mrs Y's decline, later hospital admission or wider health concerns.
31. Instead, it is my view the injustice caused by the fault is distress and uncertainty about whether better assessment, monitoring and follow-up would have made a difference. This was especially important in the context of Mrs Y’s declining intake and the impact on her weight and overall wellbeing. The Ombudsman's guidance suggests that remedies for uncertainty are normally reflected through a symbolic payment for distress, rather than refund of fees or large financial remedies.
32. The Ombudsman would only normally recommend repayment of care fees where there is clear evidence that services were not provided or the quality of care fell to an unacceptable standard. In cases where the person received some care, any refund would reflect the difference between the service paid for and the service received, rather than the full cost of the placement.
33. In this case, the care provider has already offered to refund 50% of the fees paid by Mrs Y. Given the nature of the faults identified and the absence of evidence establishing a direct link between those faults and the medical outcomes complained of, that offer is more generous than the symbolic remedy the Ombudsman would usually recommend for distress and uncertainty, which is normally up to £500.
34. It would therefore not be a proportionate use of public resources to investigate the remaining disputed elements of the complaint solely to seek a larger financial remedy. Even if we found further fault, it is unlikely the Ombudsman could achieve a more favourable outcome than the remedy already offered.
35. Finally, the Ombudsman's role is not only to remedy personal injustice but also to recommend improvements to benefit other service users, where appropriate. In this case, the provider has already identified and acted on the areas needing improvement as summarised in paragraph 26 of this statement. The key service improvements that would ordinarily be sought through an Ombudsman investigation have therefore already been identified.
36. For these reasons, we have ended our investigation. There is no worthwhile outcome that further investigation could achieve. The provider has already offered a remedy that exceeds what we would be likely to recommend for the injustice identified and has taken appropriate action to address the service improvements highlighted by the investigation.

Back to top

Decision

37. I find fault causing injustice. The Care Provider has already provided an appropriate remedy, and we do not recommend anything further.

Back to top

Investigator's decision on behalf of the Ombudsman