Summary: There was fault in the way the care home provided care to Mr B which meant Mr B suffered neglect in the last days of his life. This also caused- significant distress to Mrs B. There was also fault in the Council’s communication of its conclusion of the safeguarding enquiry adding to Mrs B’s distress. The Council has agreed to apologise and pay a symbolic financial remedy. The Home has been rated as inadequate by the CQC and I will share this decision with the CQC.

The complaint

1. Mrs B complains on behalf of her late husband, Mr B. She complains about the care provided to Mr B at Finch Manor Nursing Home in Liverpool. She also complains about the Council’s safeguarding enquiry into the care provided.

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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. 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)
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)

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How I considered this complaint

5. I considered evidence provided by Mrs B, the Council and the Home as well as relevant law, policy and guidance.
6. Mrs B and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

7. The Care Act 2014, the Care and Support Statutory (CASS) Guidance 2014 set out the Council’s duties towards adults who require care and support.
8. The Council has a duty to assess adults who have a need for care and support. If the needs assessment identifies eligible needs, the Council will provide a support plan which outlines what services are required to meet the needs.
9. Section 42 of the Care Act 2014 says that, if a local authority has reasonable cause to suspect that an adult in its area:
• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
10. The local authority must make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken.
11. The aims of safeguarding include, among other things:
• prevent harm and reduce the risk of abuse or neglect to adults with care and support needs
• stop abuse or neglect wherever possible
• address what has caused the abuse or neglect
12. The objectives of an enquiry include, among other things:
• establish facts.
• ascertain the adult’s views and wishes.

Care Quality Commission

13. 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.
14. 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. This says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).
• The nutritional and hydration needs of the service user must be met. Where a person is assessed as needing a specific diet, this must be provided in line with that assessment (regulation 14).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).

The care provider must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

Medication

15. The CQC has guidance on covert medication. Covert administration is when medicines are administered in a disguised format. Medicines could be hidden in food, drink or given through a feeding tube without the knowledge or consent of the person receiving them. 
16. Covert administration is only likely to be necessary or appropriate where:
• a person actively refuses their medicine and
• that person is assessed not to have the capacity to understand the consequences of their refusal. Such capacity is determined by the Mental Capacity Act 2005 and
• the medicine is deemed essential to the person’s health and wellbeing.
17. The process to decide whether to allow covert mediation is set out in the guidance and includes carrying out a mental capacity assessment, making a best interest decision, recording the decision making and frequently reviewing the decision.

What happened

18. Mr B was an older man who had Alzheimer's dementia. He lived at home until March 2025. Mrs B was Mr B’s carer and Mr B also received a support package from the Council. Mr B was admitted to hospital on 28 March 2025 and was ready for discharge on 23 May 2025.

Assessments and care plans

19. The Council assessed Mr B’s needs and it was decided that Mr B could not return home as his needs for care and support had increased and could only be met in residential care. Mr B moved to the Home on 28 May 2025.
20. Mr B was assessed by a speech and language therapist (SALT) on 4 March 2025 and 4 April 2025. The SALT said:
• Mr B needed full assistance with feeding. He was at risk of choking.
• He was unable to hold utensils.
• He needed to sit up fully.
• He had to drink small/single sips of thin fluid via a beaker.
• He needed one to one supervision for oral intake.
• Staff should encourage small sips/mouthfuls.
• He may require hand over hand assistance to slow pace of feeding.
• If staff observed any sign of struggle, staff should make an immediate referral to the SALT.
21. The Council's assessment of Mr B’s needs dated 28 May 2025 noted that Mrs B had to ensure that Mr B swallowed his tablets. If this did not happen, his tablets had ended up in his water cup. The Council’s reablement plan for Mr B did not mention medication administration.
22. The Home’s care plan for eating and drinking reflected the SALT recommendations but also said:
• His daily fluid intake ranged between 1200 and 1600 ml.
• It listed the actions the staff should take to reduce the risk of choking and said: ‘Carry out regular checks throughout mealtimes … Keep [Mr B’s] bedroom door open to allow for monitoring. Ensure a drink is always available to [Mr B].’
23. The care plan also said the following.
• Mr B was immobile and was unable to reposition himself in bed. Staff needed to use a slide sheet to reposition Mr B at least every 2 hours. Two staff members had to use the hoist for all transfers.
• Mr B could not mobilise independently. He could stand transfer and mobilise short distances with the assistance of two staff members.
• For medication it said ‘crush or use liquid medication only if prescribed’ and ‘confirm medication taken, check mouth if needed.’
• Mr B was compliant with his medication and he usually took them ‘all at once off a spoon with a beaker of juice or water.’

The Home’s records

24. The Home’s Medication Administration Records (MAR) showed that Mr B’s medication was given as prescribed.
25. The Home’s daily records showed the food and liquids that Mr B had consumed, but did not say what level of supervision Mr B received while he was eating or drinking.
26. Mr B’s fluid intake was within the recommended range in the first days of his stay.
27. On 1 June he drank 800ml and there was a gap between 00:30 and 10:30 where he did not drink and was not offered any fluids. Staff reported that Mr B was ‘very sleepy today when assisted at lunch time the drink was coming out of his mouth.’ The nurse was informed and took observations and said these were fine.
28. Mrs B’s last drink on 1 June was at 10:30 and he drank again at 10:20 on 2 June although he was offered fluids three times in between those times. His total intake was 750ml on 2 June. Staff informed the nurse (on 2 June) at 10:21 that Mr B was coughing while eating and at 13:55 that Mr B was not drinking or eating. At 17:48 the record says: ‘[Mr B] has been in his bed today as we think that he has had seizure…’
29. On 3 June Mr B drank 700 ml up until 12:00. The staff alerted the nurse at 13:45 that Mr B was not eating or drinking and Mr B was taken to hospital later that day.
30. Mr B was re-admitted to hospital on 3 June 2025 and died on 10 June 2025.

Safeguarding referral – June 2025

31. The CQC made a safeguarding referral to the Council on 9 June 2025 after Mrs B raised concerns. The Council spoke to Mrs B on 16 June to find out what her concerns were. Mrs B said the following.
• Mr B was at the Home for only 6 days when he was returned to the hospital. He was diagnosed with severe dehydration, aspiration pneumonia and sepsis. She said these were caused by the neglect he received at the Home.
• Mr B had been observed with a tablet in his hand which suggested he was not properly supervised during medication administration.
• Another resident with dementia was found in Mr B’s room.
• Mr B was found with food in his mouth because he was not properly supervised during meals.

Mrs B’s complaint to the Home – 4 July 2025

32. Mrs B complained to the Home on 4 July and said:
• The Home delayed providing its complaints procedure to her when she asked for it.
• The Home failed to provide sufficient liquids to Mr B leading to dehydration.
• The Home did not sufficiently supervise Mr B while he was eating which meant food was left in his mouth putting him at risk of aspiration.
• The Home did not properly administer Mr B's medication. Mrs B told the Home that Mr B’s medication should be crushed in yoghurt or other soft food and delivered on a spoon, but the Home failed to do this.
• Nurses found a seizure medication tablet in his hand when he was admitted to hospital. This suggested there had been a lack of supervision in the administration of the medication.
• Mr B had limited mobility, could not walk unaided and had to be supported by two people for transfers. The Home’s staff later said Mr B had been ‘up and walking’ which suggested the Home was not properly assisting Mr B.
• On 30 May 2025, Mrs B alerted staff to the fact that Mr B may have a temperature but staff dismissed her concerns and did not properly check Mr B’s temperature.
• Another resident was found in Mr B’s room on 3 June 2025, which suggested a lack of supervision of the residents.
• The Home failed to keep her informed of changes in Mr B’s health.

The Council’s safeguarding enquiry – 22 July 2025

33. The Council’s social worker asked the NHS Foundation Trust’s Safeguarding Adults Team to carry out the investigation into ‘neglect and acts of omission relating to alleged poor care’ at the Home.
34. The NHS’s safeguarding report dated 15 July 2025 noted the following concerns:
• The Home’s care plan clearly stated Mr B was unable to mobilise without support and he required support from two staff for transfers as it was not safe for him to mobilise. Despite this, Mr B was allowed to mobilise for very short distances unaided.
• The Home’s falls care plan failed to mention that Mr B was on medication for seizures which would have increased his risk of falls.
• There were contradictions in the care plan as some sections said Mr B was immobile, could not reposition himself and used a hoist for transfers and other sections said he could mobilise and transfer with the assistance of staff.
• No choking risk assessment was carried out despite Mr B’s risk of choking.
• The daily record dated 2 June 2025 said Mr B had a seizure on the day before but there was no record of this seizure on 1 June 2025.
• No review was carried out and no medical advice was sought following the seizure.
• There was no independent seizure care plan.
• The documents were not clear whether one or two seizures happened and whether staff observed the seizures or not.
• Mr B’s daily fluid intake was below the recommended 1200-1600 ml in the 3 days before his admission to hospital.
• The community matron advised staff on 2 June 2025 to seek advice from Telemed if Mr B’s presentation continued but staff failed to follow this advice and staff did not seek Telemed’s advice until 3 June 2025.
35. The social worker copied and pasted the conclusion section and the recommendations section of the NHS report into the Council’s report. The Council’s report concluded:
• ‘It did not appear there was neglect which had contributed or led to [Mr B’s] death.’
36. The report acknowledged the need for improvement at the Home and said that the CQC and the Council’s Quality Assurance Team had been informed.
37. The Council made the following recommendations for improvement.
• If plans were completed prior to residents being admitted to the care home, the plans should be reviewed on admission to ensure accuracy and should be updated to reflect any changes.
• Care plans should contain consistent and clear information.
• Care plans should contain all relevant clinical information.
• Staff should follow the guidance in care plans.
• All relevant care plans and risk assessments should be formulated on admission.
• Staff should ensure completion of all relevant risk assessments.
• If care staff sought advice from other health professionals, then they should follow the advice.

Mrs B’s complaint to the Council and its response – 14 August 2025

38. Mrs B complained to the Council on 14 August 2025 as she said the safeguarding investigation had been ‘inadequate and lacking in rigour’.
39. The Council responded to Mrs B and said that a thorough investigation was completed, but it was concluded that neglect did not contribute to Mr B’s death.

Clarification of Council’s position

40. As part of my investigation I asked the Council to clarify its conclusion of the safeguarding enquiry. I said it was not clear from the report whether the Council’s position was that there was no neglect at the Home or that there was no neglect which contributed to Mr B’s death. The Council’s response was:
• ‘There was neglect but the Council cannot confirm that the neglect contributed to [Mr B’s] death. This would be a determination made by clinical staff or the coroner’s office.’

Home’s stage 2 complaint response – 10 October 2025

41. The Home completed its second stage investigation into Mrs B’s complaint. I will not set out the detailed response as I rely upon it in my analysis and I want to avoid repetition. But I will set out the recommendations the Home made to improve in its performance.
• The Home’s policy will be followed and validated by the management team.
• There is a medicines reconciliation form that requires two trained members of staff to sign medications in to the Home on admission and this form will be reviewed to include management oversight and validation. This form includes information regarding medical history, allergies and hospital discharge letters.
• Staff training to be arranged for the 'deteriorating resident'. The training will incorporate the escalation process for residents whose physical condition deteriorates and appropriate actions to take.
• Staff will receive additional training on supporting residents with additional needs with diet and fluid intake.
• Staff will receive additional training for record-keeping and documentation.
• Training in seizures and the safe management of the resident will be arranged, this will include how to document in the seizure diary.
• Training in communication and inter-personal skills will be sought.
• Training will be arranged for the staff team to undertake further training in physical observations and interpreting the results.
• Training in ‘Martha’s rule’ has been scheduled to recognise that families and friends can know before others when loved ones are unwell.

Analysis

42. There was fault in care the Home provided to Mr B. Firstly, I refer to paragraph 37 which sets out in detail the failures the Council and the NHS found in their safeguarding enquiry. I agree these failures were fault and I shall not repeat them here.
43. In addition, there was further fault:
• The Home’s admission procedure said that all assessments and care plans should be completed before a resident moved in. This was not always followed and the care plans written pre-admission were not revisited to ensure they were accurate.
• The Home failed to put in place a seizure risk assessment or care plan after Mr B’s seizure on 2 June 2025.
• Staff noted that Mr B struggled with fluids on 1 June and coughed when eating on 2 June 2025. This should have triggered a full review of the risk choking assessment which did not happen.
• The Home’s care plan for eating and drinking was confusing as it said Mr B needed 1:1 supervision whenever he was eating and drinking but then also said his bedroom door should be kept open to allow monitoring and regular checks were needed during mealtimes. This suggested that Mr B was not always properly supervised when he was eating and drinking as it was not clear which plan the staff followed.
• The Home’s daily records did not record how Mr B was assisted to eat or drink and whether this was in line with the SALT recommendations so it was impossible to know whether the care plan and the SALT recommendations were followed.
• There was no risk assessment to inform staff that Mr B may have reduced fluid intake and what actions to take. The Home should have implemented a fluid plan when Mr B’s fluid intake declined and should have offered fluids frequently and encouraged him to drink.
• There were large gaps where Mr B was not offered or drank enough fluids. There was a 10-hours gap on 30 May and a 9-hours gap from 1 to 2 June.
• There was a delay in the referral to the SALT.
• Mrs B said the nurse dismissed her concern that Mr B may have a temperature on 30 May 2025. There was no record relating to this concern or any record that the temperature was taken.
• The Home failed to contact Mrs B and keep her informed even though Mr B suffered a seizure and his health declined.
• A resident with dementia was found in Mr B’s room which indicated there was a lack of supervision of residents.
• The Home failed to provide its complaint procedure to Mrs B after she asked for it twice.
44. In terms of the medication administration, the Home says neither the SALT report nor the hospital’s discharge documents recommended that Mr B’s medication should be crushed and put in food. The Home also said the covert administration of medication would require a process to be followed in line with the Mental Capacity Act.
45. Mrs B said she told the Home about the administration in food when Mr B first entered the Home. Unfortunately, I cannot say from the records what exactly was discussed. According to the Home’s records, the Home was told to provide the medication on a spoon.
46. I agree with Mrs B that it was fault that a tablet was found in Mr B’s hand. This showed that staff did not always follow the care plan which was that staff should check that Mr B had taken the medication. But I cannot say there was fault in the Home not administering covert medication.
47. In terms of the Council’s safeguarding enquiry, I note the Council delegated the enquiry to the NHS. The Council can delegate the enquiry to another agency if it is of the view that this agency is better placed to carry out the enquiry so there is no fault in that respect.
48. I note that the report did not address all the complaints Mrs B had made to the Home but that was because the Council was not informed, at the time, of the complaint Mrs B made to the Home.
49. I am of the view that both the Council and the Home carried out thorough investigations into the complaints.
50. However, there was fault in the Council’s communications with Mrs B about the outcome of its safeguarding enquiry. The Council concluded, in its safeguarding enquiry report that there was no neglect which led or contributed to Mr B’s death.
51. I do not understand why the Council phrased the conclusion as it did. It was never the Council’s role to determine the cause of Mr B’s death. The enquiry related to allegations of poor care and neglect which were upheld so why did the Council not simply say so in its conclusion? By phrasing its conclusion as it did, it left Mrs B with the impression that there was no neglect and no real fault in the way the Home provided care which was not at all the Council’s finding.

Injustice and remedy

52. Sadly, the person who suffered the greatest injustice from the fault, Mr B, has died so I cannot remedy the injustice he suffered. However, I do not underestimate the stress Mrs B suffered knowing that Mr B experienced poor care and neglect during the last days of his life and the uncertainty she will always have whether this contributed to his rapid decline.
53. In cases such as this one, where there is no financial impact from the fault, we can sometimes recommend a small symbolic sum to reflect the distress. I recommend the Council pays Mrs B £300.
54. Mrs B said she did not want any other person to go through what she and Mr B experienced at the Home. I have set out all the recommendations that the Council and the Home have made because of Mrs B’s complaint. I therefore do not think that adding any further recommendations would be helpful.
55. In any event, I note that the CQC has recently rated the Home as inadequate and the Home has been placed in special measures. I will share this decision document with the CQC as they are the Home’s regulator and therefore best placed to ensure that the Home makes significant improvements.

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Action

56. 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 Home and make the following recommendations to the Council.
57. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise to Mrs B in writing for the fault.
• Pay Mrs B £300.
58. The Council should provide us with evidence it has complied with the above actions.

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Decision

59. 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