Summary: We will not investigate Mrs X’s complaint about the Care Home providing poor care to her late father, Mr Y. This is because we could not add to the Care Provider’s investigation and a further investigation would not lead to a different outcome. It accepted fault and offered a remedy which was appropriate.

The complaint

1. Mrs X complained the Care Home provided poor care to her late father, Mr Y. She said the matter caused her distress. She wants the Care Home to acknowledge it acted with fault and ensure it makes service improvements, so it does not deliver poor care to other residents.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide:

• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

3. I considered information provided by Mrs X and the Care Provider.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. Mr Y was a resident at the Care Home between May and September 2025. Mrs X complained to the Care Provider and as part of her complaint she said:
• Mr Y had a fall and was acutely admitted into hospital. The Hospital found Mr Y was severely dehydrated which had led to his fall. Mrs X said she found Mr Y was in his bedroom without a drink;
• the SALT Speech and Language Therapy) Team carried out an assessment with Mr Y as he had difficulty swallowing. Following the assessment, SALT and Mrs X agreed Mr Y should consume pureed food, thickened drinks and soft bite-sized foods. However, the Care Home failed to meet Mr Y’s dietary needs. She also said the Care Home did not consider Mr Y’s food and drink preferences and it served him egg which he had an allergy to;
• the Care Home had administered Mr Y medicine in a capsule form. Mrs X said this should not have happened as Mr Y was at risk of choking;
• there was mould present on a drinking bottle in Mr Y’s bedroom and the bedroom was unclean which increased the risk of infection; and
• staff did not provide adequate personal care to Mr Y.
6. Mrs X also said the Care Provider told her it would report her concerns to the Council’s safeguarding team and CQC (Care Quality Commission) yet it had failed to do so.
7. In response to Mrs X’s concerns, the Care Provider carried out an investigation. It accepted faults in the care it provided to Mr Y such as:
• poorly recording Mr Y’s food and fluid intake;
• failing to identify Mr Y required thickened fluids;
• mistakenly serving Mr Y egg and failing to consider his food and drink preferences; and
• it accepted its level of cleanliness had been poor;
8. The Care Provider said it offered Mr Y baths, showers and oral care which he sometimes refused. However, it recognised its oral care records had been poor. It informed Mrs X it appropriately administered medication in a capsule form to Mr Y in line with guidance from Mr Y’s General Practitioner and a pharmacist however, it had failed to communicate this with Mrs X at the time of administering the medication. It had failed to notify the Council’s safeguarding team and CQC when it said it would do so however, since Mrs X’s complaint, it had actioned this.
9. The Care Provider apologised to Mrs X and explained what it would do to prevent a recurrence of faults. It also offered Mrs X a remedial payment of approximately £5,000.
10. We will not investigate Mrs X’s complaint. This is because we could not add to the Care Provider’s investigation and a further investigation would not lead to a different outcome. The Care Provider accepted fault and said it would make service improvements to prevent a recurrence of fault. This was appropriate and what we would expect it to do. It apologised to Mrs X which was also appropriate and offered her a financial remedy of £5000 which is more than what we would recommend. It is open to Mrs X to accept the offer.

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Final decision

11. We will not investigate Mrs X’s complaint because we could not add to the Care Provider’s investigation and a further investigation would not lead to a different outcome.

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Investigator's decision on behalf of the Ombudsman