Summary: Mrs X complained about the care provider’s handling of Mr Y’s care. She said this caused her family avoidable distress. She would like the care provider to make service improvements. We have ended our investigation because there is no worthwhile outcome achievable by our investigation.

The complaint

1. Mrs X complains about the care provider’s handling of Mr Y’s care. Specifically, she complains the care provider:

1. administered medication incorrectly;
2. did not suitably manage Mr Y’s behaviour;
3. did not keep proper records; and
4. communicated poorly.

2. Mrs X says this caused her family avoidable and unnecessary distress and uncertainty.
3. Mrs X would like the care provider to make changes and improve its service.

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The Ombudsman’s role and powers

4. We provide a free service but must use public money carefully. We do not start or continue an investigation if we decide there is no worthwhile outcome achievable by our investigation. (Local Government Act 1974, section 24A(6), as amended, section 34(B))
5. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended) 

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How I considered this complaint

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

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What I found

9. 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. 
10. In November 2025, the CQC inspected the care provider. It found breaches in regulations relating to person-centred care, safe care and treatment, its premises, recruitment and good governance.
11. The CQC found the care provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. It found gaps in residents’ medical records, which did not show whether doses were given and the reason doses were not given. The record keeping was inconsistent and did not always show the chosen dose where variable doses were prescribed.
12. The CQC identified the care provider did not always provide care to meet people’s needs that was safe and supportive. It identified risk assessments had not been updated and so did not provide staff with the guidance needed to support people safely. It found some identified risks had not been assessed and there was no risk assessment or guidance for staff on how to support a resident when they became distressed and presented challenging behaviours.
13. The CQC found the care provider did not keep proper records. It found the care provider did not update residents’ records properly which meant their health and wellbeing could not be properly monitored. It found daily records lacked detail and the care provider did not always record incidents and safeguarding issues.
14. The CQC asked the care provider to complete an action plan to address the concerns identified in its inspections. I am satisfied the substantive matters in Mrs X’s complaint are addressed in the CQC’s inspection findings and are also addressed in the action plan. The CQC is the regulatory body of care services and there is nothing further we could add with our more limited powers.
15. It is not a proportionate use of public resources to investigate complaints about poor communication if we are not investigating the substantive matters.

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Decision

16. I have ended my investigation because further investigation cannot achieve a worthwhile outcome for Mrs X.

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Investigator's decision on behalf of the Ombudsman