Summary: Mr X complained about the standard of the care the Council commissioned care home provided to his late wife. He also complained about the Council’s handling of the retrospective safeguarding enquiry. We find the Council was at fault for its delays in completing the retrospective safeguarding enquiry and review and for its failure to keep Mr X properly updated. The care home was at fault for failing to follow its falls policy, its record keeping and for how it handled Mr X’s wife’s food and fluid intake. These faults caused Mr X uncertainty, distress and upset. The Council has agreed to apologise to Mr X, make a payment to him and implement service improvements.

The complaint

1. Mr X complained about the standard of care the Council commissioned care home (The Dell Care Home) provided to his late wife (Mrs X). He adds the conduct of care home staff on the day of Mrs X’s death was poor.
2. Mr X also complained about the Council’s handling of the retrospective safeguarding enquiry. He says it was not comprehensive or detailed.
3. Mr X says the matter has caused distress and the family cannot gain closure.
4. Mr Z is representing Mr X in bring this complaint to the Ombudsman.

Back to top

The Ombudsman’s role and powers

5. 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)
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
7. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by their personal representative (if they have one), or someone we consider to be suitable.(Local Government Act 1974, section 26A(2), as amended)
8. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
10. 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(i), as amended)

Back to top

How I considered this complaint

11. I considered evidence provided by Mr X, Mr Z and the Council as well as relevant law, policy and guidance.
12. Mr X, Mr Z and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

Care services regulation and guidance

13. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which 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.
14. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards.
15. Regulation 14 says care providers must meet service user’s nutritional and hydration needs.
16. Regulation 17 says care providers should “maintain securely” records and should have “an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.

Safeguarding

17. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

The care home’s fall policy (applicable when Mrs X was a resident)

18. This policy says if a service user’s fall was unwitnessed, staff must complete a full assessment. If there is no apparent injury, staff should assist the service user to a comfortable place, alert the GP and observe the service user for 72 hours.
19. If the service user has sustained a minor injury (bruising, minor wounds to skin, slight discomfort) staff should administer first aid, observe the service user for 72 hours and inform the GP. If there is any change in condition causing a concern staff should call the GP or 999.

What happened

20. This chronology provides an overview of key events in this case and does not detail everything that happened.
21. Mrs X had a diagnosis of Alzheimer’s disease. She became unwell and went into hospital in October 2021. The Council completed an assessment of Mrs X’s needs while she was in hospital. It also spoke to Mr X. Mr X said he was worried about Mrs X’s behaviour and the deterioration in her health. He asked the Council to consider a respite placement for Mrs X.
22. The Council found a residential placement for Mrs X at The Dell Care Home (the care home). Mr X agreed with this placement.
23. Mr X emailed the Council and said he had serious concerns Mrs X was not eating and drinking. The Council passed the information onto the hospital. The hospital responded and said it had asked for palliative input to support Mrs X’s discharge to the care home.
24. The care home contacted the hospital on the same day. It said Mr X had been in touch and said Mrs X needed end of life care. It asked the hospital for Mrs X’s behavioural charts so it could review her needs further. It also said it was unsure whether it could meet Mrs X’s needs.
25. The care home spoke to the hospital the following day to get a further understanding of Mrs X’s needs. It decided it could meet her needs based on feedback it had received from hospital staff.
26. The hospital emailed the Council and said it had discharged Mrs X to the care home. It said a consultant had reviewed Mrs X’s condition and she did not need end of life care or nursing care. The consultant said carers would be able to manage Mrs X’s needs.
27. The care home told Mr X he could not visit Mrs X because of its COVID-19 policy. It said she would need to be in isolation for 10 days.
28. A few days after Mrs X became a resident, the care home made a safeguarding referral to the Council. It said Mrs X had been physically aggressive towards staff. The following day, a member of staff found Mrs X on the floor. She completed a head-to-toe assessment and noted Mrs X was not hurt. She let Mr X know.
29. The care home asked for the doctor to assess Mrs X as she was refusing medication, food and fluids. The doctor visited Mrs X the following day. He said the hospital notes referred to palliative care. The care home asked the doctor whether Mrs X needed palliative care. The doctor said no, but that he would review Mrs X in a couple of days. He told care home staff to keep trying to give Mrs X medication and fluids.
30. The doctor had a meeting with Mr X, Mr and Mrs X’s daughter (Ms Z) and a member of staff from the care home. He said the palliative staff care team at the hospital assessed Mrs X and asked her doctor’s surgery to refer her for end-of-life care. Mr X and the care home said they were unaware of this. The doctor said if Mrs X did not eat or drink, she would decline quickly. He said he would review her again in a few days.
31. Due to serious condition of Mrs X’s health, the care home told Mr X and Ms Z there would be no visiting restrictions.
32. A member of staff from the care home contacted the Council to ask who Mrs X’s social worker was. The records state the member of staff was waiting for a call back from the Council to discuss Mrs X’s needs and additional support. The Council called the care home two days later and left a message for the manager to call it back.
33. The care home contacted Mr X and said it had contacted the palliative care team and put in place anticipatory medication. Anticipatory medication is prescribed in anticipation of symptoms patients experience when they are ending the terminal phase of their life.
34. Mrs X sadly passed away at the end of October. Mr X said when he turned up to visit Mrs X the care home kept him waiting and would not tell him what was wrong. He said a member of staff took him to a side room and then explained they thought Mrs X had passed away. When he went to Mrs X’s room, she was cold, which suggested she had died a while ago. The care home has a different version of events to Mr X. It said Mr X came to visit Mrs X shortly after she had passed away. When he arrived, the team leader was on the phone to 111. Another member of staff asked Mr X to wait until the team leader had finished the phone call. When the call finished, the team leader explained to Mr X that Mrs X had just passed away.
35. Mr X complained to the care home at the end of December about the care it had provided to Mrs X. He also complained how it handled matters on the day of Mrs X’s death.
36. The care home responded to Mr X’s complaint in late January 2022. It said it followed a robust admissions process. It also made referrals to medical professionals to ensure Mrs X received appropriate medical care and it spoke to Mr X and Ms Z to update them on Mrs X’s health. Finally, it said staff were upset on the day of Mrs X’s death. No one took the lead to tell Mr X about Mrs X’s death because staff thought they needed to offer him a cup of tea before telling him. It apologised to Mr X if he thought this was inappropriate. It also said staff asked a question regarding undertakers as there was no information on file. It said it was sorry if Mr X thought this was inappropriate. It said it would ensure its staff completed training on how to address family members following a loss.
37. Mr X remained dissatisfied with the care home’s response to the complaint. He contacted the Council in late July about his concerns.
38. The Council responded to the complaint in late August. It said care home staff tried to encourage Mrs X to eat and drink but it was mostly unsuccessful. Care home staff responded to Mrs X’s falls by reducing the length of time between checks on her. Finally, it said the care home had acknowledged Mr X’s experience on the day Mrs X died was not good, and it had apologised for this. It said it would follow up with the care home to ensure it had put in place the training it mentioned in its complaint response.
39. Mr X contacted the Council in October and said he was still unhappy. The Council had a meeting with him and Ms Z at the end of November. It agreed to complete a retrospective safeguarding enquiry. It said it would not continue with the complaints process while it was completing the enquiry.
40. Mr X emailed the Council in early February 2023 and asked if there was any update on the safeguarding enquiry. The Council responded and said it was still investigating matters. The safeguarding officer had a conversation with Mr X the following week to discuss his concerns about the care Mrs X received.
41. Mr X contacted the Council in April and said he had not heard anything further. The Council responded and said the safeguarding enquiry was still progressing. It said it was hopeful the team would issue a report within three weeks.
42. Mr X emailed the Council in late May. He said no one had contacted him.
43. The Council sent its safeguarding enquiry report to Mr X in June. Its report said:

• The care home’s care notes were not person centred.
• Food and fluid information was limited despite Mrs X regularly refusing food and drink. There was no evidence care home staff referred this to the GP as urgent or offered food supplements.
• There was limited or no information about what happened on the day of Mrs X’s death as the care home had not provided the notes.
• The care home had limited information about Mrs X (her likes, dislikes, hobbies) on her file.
• There was no evidence of neglect or abuse at the care home.
• There was conflicting evidence from Mr X and the care home.
• The allegations of neglect were serious and therefore it would conclude the safeguarding enquiry as partially substantiated. There was not enough evidence to substantiate Mr X’s concerns.

44. The Council said it would refer the safeguarding enquiry to its safeguarding adults board to request a safeguarding adults review. It said it would discuss with the care home about how it tells family members their loved ones have died. It also said it would discuss the need to complete light touch reviews of care and support discharge placements, even if the person has passed away.
45. Mr X emailed the Council in June and said he was unhappy with its findings. He provided further statements from him and Ms Z.
46. The Council’s referred the safeguarding enquiry to safeguarding adult board in July. Mr X asked for an update in August. The Council explained it was waiting for a response on whether the board had agreed to complete review.
47. Mr X contacted the Council for an update in October. The officer he emailed responded and said they had not received any updates.
48. The Council arranged a visit to the care home in December for January 2024 to look at the lessons learnt and changes to its practice following Mrs X’s death.
49. Mr X emailed the Council in January 2024 and said he was unhappy with the lack of communication. An officer who dealt with Mr X’s initial complaint responded and told him to contact the officer who was dealing with the safeguarding review.
50. Mr Z sent an email to the Council in February with Mr X’s concerns on how it had handled matters. The Council responded at the end of February and said Mrs X’s case did not meet the criteria for a full safeguarding review. However, it wanted the opportunity to review the safeguarding enquiry and the operational processes to ensure it had exhausted every line of enquiry.
51. The Council provided Mr X with its review of the safeguarding investigation in March. This said:

• The care records showed Mrs X regularly declined fluids, food and medication. However, there was no record of what the carers explored, and what the escalation process was. If staff did escalate matters, this was not recorded.
• There was no record of a referral to the speech and language team. The team could have potentially provided advice and guidance to care staff on how to encourage Mrs X with her food, fluids and medication. However, there is evidence some of the carers spent time with Mrs X to ensure she had someone to talk to and encourage her to take sips of her drink and food.
• The hospital made a referral to the GP surgery for palliative care. However, this did not reach the doctor for the care home until several days after Mrs X had been staying at the care home.
• The Council did not make direct contact with the manager of the care home to discuss additional 1:1 care following the safeguarding referral.
• The Council was sorry the distress its findings would cause Mr X.

52. The Council had meeting with Mr X and Ms Z in late April to discuss the findings of the safeguarding review. It sent a follow up email a few days later and provided Mr X with a copy of Mrs X’s care records. It also apologised for the delay he had experienced throughout the process.
53. Mr Z emailed the Council in late May and raised concerns about the care records. The Council responded in mid-June and said it had investigated the matter thoroughly and highlighted issues with the quality of the care home’s recordings. It said if Mr X remained unhappy, he could contact the Ombudsman.

Back to top

Analysis

54. The events in Mr X’s complaint start in October 2021. He did not refer his complaint to us until January 2025. Normally historical issues would be caught out by the restriction in paragraph six of this statement. However, the Council agreed to investigate the matters as a retrospective safeguarding enquiry after it responded to Mr X’s complaint in August 2022. It did not complete the review until March 2024, and then it issued it final response in June 2024. It was reasonable for Mr X to wait for the Council’s review and final response before referring his complaint to us. Therefore, I have exercised direction to investigate matters from October 2021.
55. Mr X says the care home failed to help Mrs X eat and drink. The records show some occasions where staff did try and help Mrs X to eat and drink. However, there are also other occasions where staff offered Mrs X food, she refused it, and it is not clear whether it encouraged her to eat or offered her food again later. This is fault, which leaves with Mr X uncertainty and upset about whether Mrs X health may not have deteriorated so quickly if the care home had taken better steps to support her with her eating and drinking.
56. Mr X highlighted some inconsistencies with the care home’s records. I have reviewed the records. On the day of Mrs X’s death, the entry from breakfast was made after the entry for lunch. This suggests the records were not contemporaneous. There are other inconsistencies with the timing of the entries onto the digital system. The Council highlighted the issues with the record keeping when it completed the safeguarding enquiry. Regulation 17 of the CQC guidance is clear that all care providers should maintain an accurate, complete, and contemporaneous record in respect of each service user. The care home’s faults with its record keeping leaves Mr X with significant uncertainty about the standard of care Mrs X received.
57. Mr X says Mrs X had two falls while she was at the care home, but staff failed to seek medical support or monitor Mrs X. He is concerned staff left Mrs X on her own most of the time.
58. Mrs X’s discharge summary from the hospital said she had a high risk of falls. The records of the first fall state it was an unwitnessed fall. The member of staff who found Mrs X called the team leader. The team leader checked Mrs X and did not find any injuries. The care home’s policy says if there was no injury, staff should tell the GP for their information and observe the service user for 72 hours. It is only if there was a change in condition then staff should contact emergency services.
59. The care home did not tell the GP about the fall which is fault. This fault has caused Mr X some uncertainty as the GP could have provided staff advice on how to prevent future falls. However, staff regularly observed Mrs X after the fall. The policy does not state how regular these observations should be. However, Mrs X was not left alone for most of the time as Mr X suggested.
60. Mrs X’s second fall was also unwitnessed. A member of staff completed an assessment and did not see any visual injuries. However, when staff changed Mrs X after the fall, they noticed a new bruise on her outer thigh. They agreed to monitor Mrs X every 30 minutes. The notes do not state how long the 30 minutes checks should continue for.
61. Staff initially checked Mrs X every 30 minutes, but this stopped a few hours after the fall. However, the records show staff still checked Mrs X regularly. While the doctor did visit Mrs X the following day, I cannot see staff told him about Mrs X’s fall. This is not line with the care home’s policy. I cannot say, even on the balance of probabilities, what the doctor would have done if he had known and whether it would have made any difference to Mrs X’s health. However, Mr X has some uncertainty about the outcome.
62. Mr X and the care home have conflicting accounts of what happened on the day of Mrs X’s death. The care home’s records do not clearly detail what happened. Therefore, I cannot, even on the balance of probabilities, reach a finding on this part of Mr X’s complaint. However, the care home apologised to Mr X if he considered its conduct was inappropriate and confirmed it would put in place training. The Council visited the care home in January 2024. The care home provided evidence it had updated its policy about telling families about a death of a relative.
63. Mr X says the Council’s safeguarding investigation was not comprehensive or detailed. It is not our role to carry out a safeguarding investigation. That is the Council’s role. Our role is to check if the council followed the correct process. Where a council has followed the correct process, considered all relevant information, and given clear and sound reasons for its decision, we generally cannot criticise it.
64. In this case the Council reviewed information from Mr X, Ms Z and the care home. It conducted an initial retrospective safeguarding enquiry and then reviewed matters at a senior level. The initial safeguarding enquiry is detailed. Mr X and the care home provided conflicting information about what happened when Mrs X was a resident. The care home’s records lack some content. Therefore, the Council reached a partially substantiated finding but highlighted several improvements and lessons to be learnt. This is a decision it was entitled to take, even if Mr X strongly disagrees with it. I am satisfied the Council conducted a detailed and thorough review of the matter. Therefore, I do not find fault.
65. While I do not find fault with the process the Council followed when completing the safeguarding enquiry and review, it was at fault for the length of time these processes took. It also failed to communicate with Mr X properly, and he had to constantly chase for updates. These faults caused Mr X frustration and distress at an already difficult time.
66. The Council apologised to Mr X for the distress its findings may have caused him and had a meeting with him. I do not know what apologies were shared in the meeting. However, I do not consider the Council’s written apology covers the significant uncertainty, frustration and upset Mr X experienced from the faults I have identified in the paragraphs above. Therefore, it should make a further written apology. It should also make a payment to Mr X to reflect his injustice.
67. The Council provided has visited the care home and provided evidence it has taken significant steps to improve its service. This includes involving individuals in their care planning and regularly completing daily records. The Council regularly spot checks the quality of the care home’s case records. I welcome this.
68. I recognise that Mrs X passed away during the COVID-19 pandemic. Care homes had to adapt to a different way of working. However, despite this being the case, I make a further service improvement for the Council to ensure care home staff are aware what to do and how to escalate matters if a resident consistently refuses to eat and drink.
69. The Council has confirmed it has put in place a process for family members to share any concerns they may have about care homes/care providers. It ensures hospital staff share with families at the point of discharge to a placement how to escalate concerns with the Council if they are not happy. It also ensures it reviews placements within six weeks. I welcome the improvements the Council has put in place. However, I make a further recommendation for the Council to improve how it responds to safeguarding investigations.

Back to top

Agreed action

70. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of the care home and the Council and make the following recommendations to the Council.
71. By 21 November 2025 the Council has agreed to:

• Apologise to Mr X for the injustice caused by fault in this statement.
• Pay Mr X £250 for the significant upset and uncertainty caused by the care home’s failings.
• Pay Mr £150 for the frustration and distress caused by the delays in completing the retrospective safeguarding enquiry and review and the poor communication.
• Issue written reminders to relevant care home staff to ensure they are aware of what they should do and how to escalate matters if a resident consistently refuses to eat and drink.
• Issue written reminders to relevant officers to ensure they complete safeguarding investigations without unreasonable delay and provide regular updates to the person who has reported the safeguarding concern.

72. The Council should provide us with evidence it has complied with the above actions.

Back to top

Decision

73. There was fault by the Council, which caused Mr X an injustice. The Council has agreed to my recommendations and so I have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman