Summary: Ms X complains about the quality of care her parents received during a respite stay in September 2022 and the way in which her complaints about this were handled. The Care Provider has investigated Ms X’s concerns, apologised and is taking action to improve. We could not add to the Care Provider’s responses or make a different finding of the kind Ms X wants.

The complaint

1. Ms X is making this complaint on behalf of her late parents, Mr Y and Mrs Y. Ms X complains about the quality of care her parents received from the Care Provider during a respite stay in September 2022. Ms X says the Care Provider failed to:

• follow her mother’s diet plan, causing significant weight loss;
• ensure her mother had easy access to a commode, which caused a fall;
• make sure both her parents maintained adequate hydration during their stay, and;
• respond properly to Ms X’s complaints about the quality of it care.

2. Ms X says the Care Provider’s handling caused significant distress to her parents and the rest of their family.

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The Ombudsman’s role and powers

3. 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)

4. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
5. 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)

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How I considered this complaint

6. I have spoken to Ms X about her complaint and considered the information she has provided.
7. I have considered the information the Care Provider has sent in response to my enquiries.
8. Ms X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant guidance

9. The International Dysphagia Diet Standardisation Initiative (IDDSI) provides guidance to speech and language therapists and other healthcare professionals on the diet and fluid textures best suited for people with dysphagia (difficulties swallowing). Levels 7 to 3 describe the textures of food as follows:

• 7 – Regular
• 7* - Regular easy chew
• 6 – soft and bite sized
• 5 – minced and moist
• 4 – pureed
• 3 – liquidized

(Fluids are described from levels 4 to 0).

What happened

10. This overview of key events does not cover everything that happened.
11. Ms X’s parent, Mr and Mrs Y, lived in their own home and received domiciliary care and support from carers they had privately employed. In September 2022, Mr and Mrs Y’s regular carers were due to have leave from work. Mr and Mrs Y’s family, including Ms X, arranged for them to receive residential respite care at a Care Home owned by the Care Provider for a period of eight days from in late September 2022. Ms X’s sister met with the Care Provider before Mr and Mrs Y’s admission to discuss their needs. The Care Provider noted before admission that Mr and Mrs Y both had capacity to make their own decisions.
12. The Care Provider completed a falls risk assessment for Mrs Y after being informed she was at risk of falls. The Care Home implemented hourly wellbeing checks for Mr and Mrs Y. It also installed a sensor mat to detect Mrs Y getting out of bed and placed a commode near her bed to minimise the risk of falls at night.
13. On the fifth night of their stay, Mrs Y had a fall in the early hours of the morning while trying to access the toilet. The nurse on duty completed a full assessment of Mrs Y and sought guidance from a doctor’s out of hours service.
14. Mr and Mrs Y’s family decided to remove them from the Care Home placement two days early as they were unhappy with the quality of care provided.
15. Mrs Y sadly passed away in early October 2022 and Mr Y died in Spring 2023.

Mrs Y’s weight loss and diet plan

16. Ms X complained to the Care Provider about the Care Home’s failure to follow her late mother’s diet plan. Ms X says 22 of the 24 bottles of fortified drinks provided for Mrs Y on admission were returned when she left the Care Home early. Ms X alleges Care Home staff failed to ensure Mrs Y did not lose any further weight.
17. The Care Provider responded to this element of Ms X’s concerns during its internal complaint investigation. It explained that it could not force Mrs Y to consume the fortified drinks supplied if she declined. Mrs Y had capacity to express her wishes and the Care Provider explained it had to respect these wishes. The Care Provider explained to Ms X it had provided alternatives in the form of fortified milkshakes to Mrs Y during her stay, which she had preferred.
18. I have reviewed the food and fluid records the Care Home made while Mrs Y was a resident. These appear to confirm the Care Home offered Mrs Y the foods suggested in the diet plan provided by her family. The records also clearly show the need for thickener in all of Mrs Y’s drinks.
19. Ms X alleges her mother lost approximately four kilograms during her stay at the Care Home. The Care Provider’s explained it had been unable to measure Mrs Y’s weight when she left the Care Home. It had sought to provide the foods suggested in Mrs Y’s diet plan and in line with her wishes.
20. The Care Provider’s responses to this element of Ms X’s complaint appear cogent and thorough based on my review of the case records compiled at the time of Mrs Y’s stay. There is nothing further I can investigate nor add to the investigation the Care Provider has already undertaken in this respect.
21. The Care Provider has accepted that its record keeping for Mr and Mrs Y could have been better and I would agree with this. The Care Provider says it is already taking steps to address this issue. I am satisfied there is nothing further I could add to the Care Provider’s investigation that would lead to a different conclusion to the one already reached.
22. Ms X believes her mother’s death was hastened by the weight loss she experienced while at the Care Home. Any issues surrounding Mrs Y’s death would be a matter for a coroner to determine. We have no remit in establishing or deciding the cause of death in such cases.

Commode access and Mrs Y’s fall

23. Before admission, the Care Provider recorded Mrs Y was at risk of falls. It completed an assessment of Mrs Y’s needs and that a commode should be placed near her bed so she could easily access this at night. The assessment recorded the need for grab rails around the toilet and a sensor mat by Mrs Y’s bed to alert Care Home staff when she got out of bed at night. The Care Provider also undertook hourly wellbeing checks on Mrs Y during her stay.
24. Mrs Y had an unwitnessed fall at night while trying to access the toilet. She was examined by the nurse on duty and further guidance was sought from her GP practice (out of hours service).
25. In response to Ms X’s complaint about her late mother’s fall, the Care Provider was unable to explain why the commode and sensor mat were not in place on the night of the incident. The Care Provider was able to address Ms X’s complaint about the length of time Mrs Y spent on the floor before being discovered. The wellbeing check records showed Mrs Y’s fall occurred between 1:30am and 2:45am.
26. The Care Provider apologised to Ms X for its lack of records to confirm exactly what had happened when Mrs Y fell. It also apologised that neither Ms X nor any other family members were contacted about Mrs Y’s fall at the time.
27. I have reviewed the Care Provider’s records for Mrs Y and its responses to Ms X’s complaints about this issue reflect the information recorded within its wellbeing checks and incident report following Mrs Y’s fall.
28. The Care Provider has given Ms X a cogent and thorough response to her concerns about her mother’s fall. I have not seen anything to suggest the Care Provider sought to dismiss or downplay Ms X’s concerns. Even though I recognise Ms X disputes what the Care Provider has said or the evidence it has relied on, we would have access to no more information than the Care Provider had. I find the Care Provider’s handling of this element of Ms X’s complaint appropriate and reasonable given my review of its records.

Hydration for both parents

29. In response to my enquiries, the Care Provider accepts the records of fluid intake for Mrs Y were not completed as thoroughly as they should have been. The Care Provider has confirmed it is taking action to address this issue at the Care Home.
30. The Care Provider has also explained it does not hold records of Mr Y’s fluid intake during his stay at the Care Home. It did however try to reassure Ms X in its earlier complaint responses that Mr Y had free access to as many drinks as he wanted. There is little more I can add to the Care Provider’s previous responses to Ms X on this element of her complaint as these appear to reflect the records I have reviewed.

Complaint handling

31. Ms X believes the Care Provider has not responded to her complaints properly. Ms X told me she felt the Care Provider had not fully addressed her concerns with the responses it had provided. She has said she would like us to consider whether the Care Provider should issue a full refund of the fees her parents paid for their respite stay.
32. The Care Provider’s responses to Ms X’s complaints appear to reflect the records I have now seen. It has explained that it could not interview all the Care Home staff involved as some had since left their employment.
33. The responses to Ms X’s complaints took a considerable time to complete. Ms X made her formal complaint on 8 January 2023 and did not receive a response until 27 March 2023. The Care Provider did however inform Ms X of the delay in its response and apologised for the impact of this in its substantive reply.
34. Ms X’s second complaint was submitted on 11 July 2023. The Care Provider’s response was delayed until 7 September 2023. Again, it apologised for the delay and updated Ms X before this to explain its response would be delayed.
35. I find the Care Provider gave cogent and thorough responses to the concerns Ms X raised about her parents’ care. The Care Provider appears to have considered the evidence available to it and it would not be reasonable to expect it to seek information from former employees in these circumstances.
36. The Care Provider’s terms and conditions for short respite stays are clear that fees for this type of stay are payable in advance. They are unlikely to be refundable given the short period of time covered.
37. Based on the evidence I have seen and the Care Provider’s responses to Ms X, I am not persuaded a full or partial refund of fees paid by the late Mr and Mrs Y is required in these circumstances.

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Final decision

38. I have completed my investigate and uphold Ms X’s complaint. The Care Provider has already investigated, apologised and taken appropriate action to remedy the distress caused to Mr and Mrs Y’s family. We could not add to that action, nor can we provide Mr and Mrs Y with a remedy for any injustice they may have experienced as they have now both sadly passed away.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman