Summary: Mrs X made some serious complaints about neglect during her late mother’s eight week stay at the Council’s commissioned care provider, the sands care home, before she died. She said the Council failed to complete adequate safeguarding investigations. We find the Council was at fault. This caused significant distress to Mrs X. To address this injustice caused by fault, the Council has agreed to make several recommendations.

The complaint

1. The complainant, Mrs X, made serious complaints about neglect during her late mother’s eight week stay at the Council’s commissioned care provider, the sands care home, before she died. She said the Council failed to complete adequate safeguarding investigations. She also said her concerns were dismissed by the care home.

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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. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
4. We normally name care homes and other care providers in our reports. 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)
5. 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.
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
7. 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

8. I spoke with Mrs X about her complaint. I considered all the information provided by Mrs X and the Council.
9. Mrs X and the Council had an opportunity to comment on my revised draft decision. I considered their comments before making a final decision.

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What I found

10. 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.
11. Regulation 14 says care providers must make sure that people have enough to eat and drink to meet their nutrition and hydration needs.
12. 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.

Background

13. Mrs X’s mother, Mrs Y, was admitted to the care home in August 2023. The care plan stated:
• Mrs Y’s two sons were the next of kin;
• Mrs Y retains some awareness of her bladder and bowels and will ask to use the toilet. But most of the time she was unaware and experienced urinary and faecal incontinence;
• carers were to offer Mrs Y regular visits to the toilet to promote continence;
• carers were to ensure appropriate bedding was used and ensure the room was at a comfortable temperature. Mrs Y would request a blanket if she was cold;
• Mrs Y was to be supported to maintain a regular diet and she takes a normal consistency diet;
• Mrs Y required mobility assistance;
• Cream was to be applied twice a day; and
• Mrs Y would be supported to dress and undress as appropriate.
14. The support plan stated Mrs Y preferred female carers only.
15. An assessment completed in August 2023 listed the medication Mrs Y was prescribed. This included co-codamol for breakthrough pain as and when required. It was noted this was something she had been taking for years.

Daily notes in August 2023

16. The notes in August 2023 state Mrs Y did sometimes refuse meals. There are three days where there is no reference to whether Mrs Y had breakfast or not.
17. Mrs Y’s fluid intake ranged from around 700mls to 1300mls a day.
18. A risk assessment was completed due to poor dietary intake following the refusal of assistance at mealtimes and Mrs Y was referred to the GP. Carers were advised to continue to offer Mrs Y assistance.
19. Shortly after Mrs Y was admitted to the care home, it was noted her mobility was not good as she had been struggling to stand. The care provider spoke with an occupational therapist regarding Mrs Y’s mobility and the equipment used. She was placed on a waiting list as she was not assessed as needing urgent help.
20. Mrs Y was often assisted with using the toilet. Carers checked on Mrs Y every two hours throughout the night. The sensor mat was noted as being in place.
21. Mrs Y was seen by the doctor on the 17 August 2023 due to wrist pain. It was noted this was arthritis and a gel was prescribed. She was seen by the doctor again and no changes were noted.

Daily notes in September 2023

22. There are two days in September 2023 where there is no reference to whether Mrs Y had dinner or not. There are also two days where there is no reference to whether she had breakfast or not.
23. Mrs Y’s fluid intake ranged from around 570 ml to 1310ml a day.
24. The doctor saw Mrs Y as she had been eating and drinking less and sleeping a lot. Supplement drinks were prescribed. A new referral was also sent to the dietician as Mrs Y’s BMI was low.
25. On the 11 September 2023, Mrs Y had a fall which caused bruising and swelling to her wrist. She was seen by the doctor and an x-ray confirmed there was no fracture. It was noted as severe arthritis. The doctor saw Mrs Y a further two times and she reported no pain.
26. Mrs Y was often assisted with using the toilet. But there was one day where Mrs Y was assisted to use the commode in the morning. There is no further reference as to whether Mrs Y was assisted to use the commode again. But the notes state Mrs Y was incontinent in the evening and carers changed her pad.
27. Mrs Y was checked on every two hours throughout the night and the sensor mat was in place.

Daily notes in October 2023

28. On the 1 October 2023, Mrs X stayed with Mrs Y throughout the night. Mrs Y was assisted to the toilet in the morning. The call bell was rung by Mrs X 30 minutes later stating Mrs Y’s pad needed to be changed. Carers explained Mrs Y was wearing an absorbency pad and said they would change it after they had finished the care of another resident. The pad was changed 45 minutes later.
29. After Mrs X left, Mrs Y’s son visited and removed a blanket that Mrs X had put on Mrs Y as it was noted Mrs Y was very hot. Carers had noted Mrs Y was very hot previously, but said Mrs X had put the blanket back on Mrs Y.
30. Mrs Y sadly passed away on the 2 October 2023.

Care plan between August and September 2023

31. The care plan noted Mrs Y’s needs as being the same as detailed in paragraph 12. But it said whilst Mrs Y had a normal consistency diet, her appetite had decreased. It stated she was requiring more support when eating. It was noted a referral had been made to speech and language therapist and needed to be chased up.

Care plan between September and October 2023

32. The care plan noted Mrs Y was at risk of falls. It noted oversight was required when mobilising to minimise risks.

Mental capacity assessment

33. A social worker started to complete a mental capacity assessment with Mrs Y and her family. It was noted that:
• Mrs Y’s physical and mental health had deteriorated whilst at a previous care home and they were unable to continue care;
• Mrs X wanted to care for Mrs Y at home;
• the social worker met with Mrs Y in August and September 2023 to determine if she had capacity to make an informed decision; and
• the social worker spoke with Mrs Y’s sons and Mrs X about the types of care. They considered the views of all three siblings. But no decision was made as Mrs Y passed away before viable options were determined.

Safeguarding

34. Mrs X reported safeguarding concerns to the Council in September 2023. She said:
• Mrs Y’s arm was seriously hurting, and she should have been seen by a doctor straight away. Mrs X said Mrs Y was now unable to use a Zimmer frame. She said co-codamol was prescribed which she said affected Mrs Y’s eating and made her drowsy;
• Mrs Y was often left sat in a wheelchair scrunched up asleep all day with no recliner. She said there had been no occupational therapy input or physio;
• Mrs Y had nine urine infections in 12 months. Mrs X said carers were not fully supporting Mrs Y with her toilet needs. She said Mrs Y’s bottom was not cleaned properly and she was left in wet pads. She also said Mrs Y only uses the commode which debilitated her;
• Mrs Y was not eating much and refusing food. She was concerned that this was due to the co-codamol that had been recently prescribed; and
• She was concerned that Mrs Y’s sensor mat had not been plugged in. She also said she was concerned the call bell was out of reach so Mrs Y could not raise for help.
35. The Council’s investigation stated the concerns were unsubstantiated. It was noted that:
• Mrs Y had not been able to mobilise safely with a Zimmer frame since before admission. An initial assessment stated she needed assistance and had a history of falls;
• the care provider was informed of reports of pain and swelling to Mrs Y’s wrist on the afternoon of the 16 August, but it was not deemed as urgent. Mrs Y was seen by a doctor the following morning who stated it was arthritis and prescribed a gel and to continue the co-codamol. The co-codamol was not a new medication and Mrs Y had been on this pre-October 2022. Mrs Y’s sons confirmed this had been Mrs Y’s preferred pain relief medication for several years;
• the doctor confirmed they did not have any concerns around Mrs Y’s wrist which they assessed on two separate occasions;
• the wheelchair that Mrs Y sits in is her own from home which she liked to sit in;
• a cushion had been used on the wheelchair and Mrs Y’s son’s said Mrs Y did have curvature of the spine and was frail which is why it could look like she was scrunched up in the wheelchair;
• Mrs Y had been referred for physio and occupational therapy. She was on a waiting list but had not been deemed as urgent;
• Mrs Y had some awareness of her need to go to the toilet. But often it would be too late, and she had been incontinent;
• the pads used have the capability to hold between 1.3-2 litres and had absorbency indicators on the back which highlighted when changes were needed. They also have an acquisition layer which held the urine away from the skin;
• the commode was used as carers deemed this safe and appropriate for Mrs Y;
• Mrs Y was provided with personal care several times a day and offered a bath weekly which she sometimes declined;
• as the co-codamol is not a new prescription it is unlikely to have any affect on Mrs Y’s appetite and she does not take it enough to have a sudatory effect;
• the care provider had the appropriate care plans, risk assessments and action plans in place to support Mrs Y around her diet. The care provider monitored her weight weekly and will make a referral to the dietician if any further weight loss was noted; and
• a crash mat and sensor mat are utilised overnight as Mrs Y did not like the use of bed rails. The call bell is extended from the socket to within reach overnight. But this and the mats are stowed away during the day. This is because Mrs Y preferred to sit in the dining room during the day which is accessed by staff and therefore, she can be closely monitored.
36. Recommendations of the investigation included:
• the care provider to chase up the referrals made to physio and occupational therapy;
• the care provider to continue to ensure the sensor mat is always plugged in when needed and the call bell to be within reach;
• the care provider to continue to monitor Mrs Y’s weight and raise any significant concerns to the GP and dietician; and
• the care provider to continue to ensure they raise any safeguarding incidents that occur to the relevant professionals in a timely manner.
37. Mrs X raised further safeguarding concerns in October 2023. She said:
• Mrs Y had been left cold with no blankets;
• Mrs Y was barley eating. But the care provider gave her foods she could not eat, such as crackers and grapes;
• the care provider did not support Mrs Y with her toileting needs; and
• she had concerns the carers were doping Mrs Y up on co-codamol.
38. The Councils further investigation stated the concerns were unsubstantiated. It was noted that:
• Mrs Y was 96 with Alzheimer’s and she could not tolerate the duvet as it was heavy, and she became too warm. It was therefore replaced with blankets;
• Mrs Y’s sons had concerns when Mrs X had placed blankets on Mrs Y causing her to become too warm. It was noted that both of Mrs Y’ sons had no concerns around Mrs Y being left cold;
• Mrs Y refused all option of foods offered, including the softer options. Mrs Y had been referred to a dietician;
• the doctor stated Mrs Y’s nutritional and fluid intake was normal for a 96-year-old lady who was very poorly with the end stage of Alzheimer's dementia;
• Mrs Y’s son explained he, the staff and Mrs X tried to get Mrs Y to eat something with no success;
• within the final week of Mrs Y’s life, she was too frail to use the toilet or be hoisted out of bed onto a commode; and
• the co-codamol medication was only ever administered as per the medication care plan. There were some days when Mrs Y did not take co-codamol.

Complaint to the Council

39. Mrs X complained about the care Mrs Y received whilst in the care home. These included issues raised as part of the safeguarding referrals. She said Mrs Y was never given an advocate and her concerns were never heard. She questioned how the safeguarding investigation could take place without the Council visiting Mrs Y in the care home.
40. In response the Council said:
• when completing its safeguarding investigation, it sought input from the GP, the care home, Mrs X and her brothers and other involved professionals;
• it had asked the safeguarding support team to visit the care home to seek assurances around current care and practice. It said if any concerns were raised, a safeguarding alert may be raised if further enquiries were needed; and
• due to the fact Mrs Y disagreed with what her brothers and the GP had said, it agreed that a visit to the care home would have been appropriate to enable to social worker to form an independent view. It said it would complete a reflective session with the social worker to ensure any learning is captured.

Analysis- was there fault by the Council causing injustice?

41. In June 2023 the previous care home where Mrs Y had been since October 2022 referred her for a reassessment as they could no longer meet Mrs Y’s needs. The Council said the information gathered identified that Mrs Y and Mrs X had been estranged for 15 years and Mrs Y had not visited the previous care home. But Mrs Y disputes this. She said her and her mum had been in contact and has provided evidence that challenges that statement.
42. The Council got Mrs X’s details from her brothers and liaised with her to discuss the need to move Mrs Y into a new care home. Mrs X disputes this and said she had to contact the previous care home to get the Council’s details. Mrs X wanted Mrs Y to live with her where she said she would provide care. But Mrs Y’s sons wanted her to move to the new care home. After discussions it was agreed by the Council that Mrs Y would move into the care home for a short-term placement. But it was noted Mrs X wanted consideration to be given to Mrs Y moving in with her.
43. Due to deterioration of Mrs Y’s mental health and a diagnosis of Alzheimer's the Council started to complete a mental capacity assessment on the 1 August 2023. The assessment noted the social worker did not deem Mrs Y to have capacity around her care and support needs. But the assessment was ongoing due to fluctuations in Mrs Y’s capacity. I have seen evidence to support that Mrs X and her brothers views were considered in regard to where Mrs Y’s care would be provided. But sadly, Mrs Y passed away before a decision was made. The social worker also spoke with Mrs Y in September 2023. She said she was happy to stay at the care home and said she did not want to go back to her own home.
44. I do not consider there to be any fault in the process the Council has followed. An agreement was sought for the placement to be arranged on a short-term care basis in Mrs Y’s best interests. This was until a formal best interest meeting could be arranged. The Council then sought the views of the family to establish where Mrs Y’s care would be provided long-term. We could not criticise the Council for this.
45. The Council made a referral to an independent mental capacity advocacy service on the 18 August 2023. But the service stated it would not be appropriate as Mrs Y had family who could offer support. The Council then continued to ask the advocacy service for input due to the family differences. The family were informed on the 25 September 2023 that an advocate had been allocated. I could not criticise this as Mrs Y was not initially eligible for an advocate. But the Council pursued this due to the family differences. I also note that Mrs Y’s views were considered as part of the initial assessment and care plan.
46. I have reviewed the care notes and can see that Mrs Y was checked on every two hours during the night. It was often noted that Mrs Y’s sensor mat had been activated or she had rung her call bell. Therefore, I have not seen any evidence to suggest the sensor mat was not plugged in or that the call bell was out of Mrs Y’s reach. The safeguarding investigation also explained the sensor mat and call bell were only used during the nighttime as Mrs Y preferred to be in the dining room during the day.
47. Mrs X said Mrs Y was left cold with no blanket. The care plan stated Mrs Y would request a blanket if she was cold. I have not seen any evidence to suggest she did. From reviewing the care notes there is one occasion in October 2023 where Mrs Y’s son visited after Mrs X had left. It was noted he removed a blanket that Mrs X had put on Mrs Y due to her being very hot. It was also noted that carers had previously reported Mrs Y to be very hot, but Mrs X had put the blanket back on. The notes also often stated that Mrs Y was comfortable. We have two differing accounts of what happened, and I cannot say whether Mrs Y was left cold.
48. The care plan stated Mrs Y was to be offered regular visits to the toilet to promote continence. But Mrs X said this was not the case and said Mrs Y was made to wait and would be left in a wet pad. I have reviewed the notes and they indicate that Mrs Y was assisted to the toilet or commode often. But there was one day in September 2023 where the notes only mention Mrs Y being assisted to the toilet once. It is not clear whether Mrs Y was offered regular visits to the toilet, in line with the care plan. The failure to record this is fault and not in line with regulation 17. This caused uncertainty to Mrs X as to whether Mrs Y received the appropriate care on that day.
49. The notes are inconsistent around whether care staff applied cream to Mrs Y twice per day, as per the care plan. This is fault and not in line with regulation 17. This caused uncertainty to Mrs X as to whether this care was provided.
50. On the 1 October 2023, carers assisted Mrs Y to the toilet. But half an hour later Mrs X asked them to change Mrs Y’s pad as it was wet. The carers explained Mrs Y was wearing an absorbency pad which held the urine away from the skin and explained it would be able to change it once they had attended to the care of another resident. It is noted that the pad was changed 45 minutes later. Although this is not ideal, I cannot say this is service failure. I appreciate that Mrs Y would have been uncomfortable. But I also appreciate that carers must prioritise the service users and Mrs Y’s pad was changed within 45 minutes.
51. Mrs X said Mrs Y was not seen by a doctor quick enough when she reported wrist pain. She also said this pain affected Mrs Y’s ability to walk with the Zimmer frame. Mrs X told us she reported the concerns on the 14 August 2023 when she attended the home. The following day she sent an email to the Council detailing the same concerns. On the 16 August 2023, Mrs X wrote to the Council again and referred to care staff not taking any action on the 14 August 2023.
52. The care provider said it was made aware of the wrist pain on the afternoon of the 16 August 2023 and deemed it not to be urgent. Given that Mrs X reported these concerns to the Council shortly after, on balance, it is likely that Mrs X did raise these concerns to the care provider on the 14 August 2023. But there is no record of this in the notes. This is fault and led to a delay in Mrs Y being seen. The doctor saw Mrs Y on the 17 August 2023 and prescribed a gel for arthritis. The doctor saw Mrs Y a further two times and no changes were reported.
53. It is not for us to assess what should and should not be deemed as urgent. The care provider made a professional judgement which I cannot criticise. The doctor assessed Mrs Y and decided the pain was due to arthritis. I understand that Mrs X thinks the care provider should not have been giving Mrs Y co-codamol. But I have seen evidence to support that Mrs Y had been prescribed this prior to her admission to the care home. This is detailed in paragraph 15.
54. Mrs X also told us the doctor had advised her they had never prescribed co-codamol. But as stated above, there is evidence to support that Mrs Y had been prescribed this prior to her admission to the care home. It is also detailed in Mrs Y’s care plan.
55. The initial assessments completed upon Mrs Y’s admission noted Mrs Y’s mobility was not good and that she required assistance. Therefore, we could not say that Mrs Y’s wrist pain is what affected her ability to walk with the Zimmer frame. I also noted that Mrs Y was placed on waiting list for occupational therapy. Again, it is not for us to determine whether this should have been an urgent referral.
56. I note Mrs Y had a fall on the 11 September 2023 and was seen by the doctor. An x-ray confirmed her wrist was not fractured and it was severe arthritis. Mrs Y was seen by the doctor a further two times and no pain was reported.
57. Mrs X raised concerns about Mrs Y’s diet and fluid intake. The care plan stated Mrs Y was to be supported to maintain a regular diet and stated she had a normal consistency diet. From the evidence seen, Mrs Y did often refuse food, and this was evidenced from the beginning of her stay. In August 2023 shortly after Mrs Y was admitted, the care provider referred Mrs Y to the GP regarding her eating. They were advised to continue to offer her assistance.
58. In September 2023 supplement drinks were prescribed by the GP and a new referral was submitted to a dietician as Mrs Y’s BMI was low. In my view the care provider acted promptly and made the relevant referrals. There is also evidence Mrs Y was offered different foods, and the care plan stated she had a normal consistency diet which is what was offered.
59. Mrs X said she never witnessed Mrs Y being offered the supplement drinks. I acknowledge that Mrs Y may have been offered this when Mrs X was not there. But there is no record of when these supplement drinks were offered. This is fault and not in line with regulation 17. This caused uncertainty to Mrs X.
60. Whilst there is evidence the care provider did offer Mrs Y assistance with eating and drinking, there are a few occasions when the notes do not reference whether Mrs Y had food or not. This is detailed in paragraphs 16 and 22. The failure to record this is fault and not in line with regulation 17. This caused uncertainty to Mrs X.
61. Mrs X said there was one occasion where Mrs Y did not have her bottom dentures in. Staff said this was because she did not want them in. But Mrs X questioned how Mrs Y was supposed to eat. There is no evidence of this in the daily notes. If Mrs Y did not have her dentures in, we would expect this to be recorded in line with regulation 17. This is fault.
62. Mrs Y’s daily fluid intake differed each day. But I have not seen any evidence of a fluid chart that details the amount of fluids Mrs Y should have been drinking. Therefore, the care provider could not have compared Mrs Y’s fluid intake to what Mrs Y should have drunk. This is fault. The lack of proper record keeping is not in line with regulation 17. We also cannot say whether Mrs Y was offered enough fluids to meet her hydration needs. This is not in line with regulation 14.
63. The Council completed its safeguarding investigation, and this is detailed in paragraphs 35, 36 and 38. As part of the investigation, it considered evidence provided by the care provider. It also spoke with Mrs X, her brothers, the GP and other involved professionals. Mrs Y raised concerns about the Council not visiting Mrs Y in the care home as part of the investigation.
64. In the Council’s complaints response, it said due to the fact Mrs Y had disagreed with what her brothers and the GP had said, it agreed that a visit to the care home would have been appropriate to enable the social worker to form an independent view. I agree with the Councils findings and think a visit should have taken place. This is fault. Whilst I acknowledge that the Council did consider the care providers evidence and Mrs X’s comments, this did cause significant distress and uncertainty to Mrs X as to whether a visit would have affected the outcome.
65. Mrs X said Mrs Y was often left in a wheelchair all day. The care provider explained it was Mrs Y’s own wheelchair that she liked to be sat in. The notes state when Mrs Y arrived at the home, her son asked the carers to not leave her in the wheelchair for long spells. They also asked that the cushion was used when she was in it. The daily notes state Mrs Y was either in bed, her chair, or the wheelchair.
66. Mrs Y’s care plan fails to include any information around the length of time that Mrs Y should have been sat in the wheelchair. I acknowledge that the care plan does state Mrs Y sat on the cushion whilst in the wheelchair. But due to the lack of information, I cannot say whether Mrs Y spent too much time in the wheelchair as the care provider failed to include this in the care plan. This is fault and not in line with regulation 17. This caused further uncertainty to Mrs X.
67. Mrs X said Mrs Y did not want male care workers to provide care. But she said the care provider did not adhere to this. The support plan stated Mrs X preferred female care workers. But there is no evidence to suggest this was discussed further. We would have expected the care provider to consider this and decide whether this was something it could provide. Therefore, this is fault. The notes confirm that male care workers did sometimes provide care.
68. Mrs X told us she felt her concerns were dismissed as she said the care provider colluded with her brothers. The care plan stated Mrs X’s brothers were the next of kin and held lasting power of attorney for property and finance. But Mrs X said information about her mother’s care was kept from her and she was not invited to meetings. She also said she was the last to find out information about her mother’s care and said the care plan was never discussed with her.
69. Whilst we acknowledge it can be difficult when there are family disputes, it was for the care provider to make it clear from the beginning who it would be contacting. In my view, this was not clear. This is fault. The care plan stated the next of kin/family would be updated. Mrs Y is family. But from the evidence seen, she was not always kept up to date. This caused her significant distress.
70. Mrs X has provided us with several emails she sent to the care provider between August and October 2023 which she said were not responded to. Mrs X said she found this email address of the care providers website. The email address provided is now different to the one on the care providers website. Therefore, I cannot say for certain that these emails were received. The care provider also said it did not receive any concerns from Mrs X.
71. Mrs X has provided us with transcripts of recordings between her and Mrs Y. I acknowledge that Mrs Y had told Mrs X she wanted to be at home during these transcripts. But as stated in paragraph 45 Mrs Y’s views were considered as part of the initial assessment and care plan.

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Agreed action

72. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Care Provider, I have made recommendations to the Council.
73. Sadly, it is no longer possible to remedy the injustice to Mrs Z as she has died. To remedy the injustice to Mr X caused by fault, within one month of the date of my final decision the Council has agreed to:
• write to Mrs X with an apology that takes account of our published guidance on remedies and accepts the findings of this investigation; and
• pay Mrs X £350 to acknowledge the distress and uncertainty caused to her by the fault identified in this statement.
74. Within two months, the Council should review the care providers record keeping practices. This review should include:
• ensuring appropriate records of the care that should be provided to residents are kept. This should be in line with Regulation 17 of the CQC guidance; and
• ensuring there are clear fluid intake records to ensure the care provider is meeting the resident’s hydration needs, in line with Regulation 14 of the CQC guidance.
75. The Council should provide us with evidence it has complied with the above actions.

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Final decision

76. There was fault by the Council. The actions the Council has agreed to remedy the injustice caused. I have completed my investigation.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman