Date of decision
17 December 2025
Summary
The Council’s commissioned care provider failed to provide an acceptable standard of care for the late Mrs X. Failures included keeping proper records in accordance with the regulations and providing her nutrition in accordance with the hospital discharge instructions.
What happened
Ms B, the adult daughter of Mrs X, raised concerns with Cambridgeshire County Council about her mother’s treatment at Aria Court care home throughout October 2024 to January 2025. Mrs X’s degree of dementia meant she could no longer feed herself, and required significant assistance. Despite Mrs X’s care plans and hospital discharge instructions, the care home failed to meet her nutritional needs and correctly position her head and body during feeding.
Mrs X moved into the care home on 16 October 2024. On 19 October Ms B visited her mother and was with her for at least two hours. She said that during that time no care workers checked Mrs X or offered her fluids despite the requirement in the care plan for Mrs X to be encouraged to take a drink during each hourly sighting aiming for a target of 1200ml of fluid per day. Ms B witnessed care workers neglecting to follow proper procedures.
On 20th October Mrs X was admitted to hospital with dehydration and suspected sepsis. Ms B spoke to the social worker about her concerns and the social worker spoke to the team leader at the care home, giving her the SALT guidance for Mrs X’s return. Mrs X was discharged back to the care home on 29 October but readmitted to hospital the next day.
Ms B said there were ongoing problems regarding positioning whilst feeding after her mother’s return to the care home on 14 November. Ms B had photographic evidence of care workers trying to feed Mrs X with her head down. She said care workers were also trying to feed Mrs X while she was lying on her side. Ms B said she emailed the care provider twice in the next few days but did not receive a reply. The care manager told her she never received the email. In December 2024, after a meeting to assess Mrs X’s needs for NHS Continuing Healthcare (CHC) funding, Ms B found her mother in a dire state. It was evident she had not been weighed for a month. Ms B said that after the meeting she went into her mother’s room with the social worker and there was dried liquid food-supplement on her mother’s face and her positioning was ‘appalling.’ The social worker emailed the care provider after the DST meeting to set out the concerns, including the fact that Ms X was supposed to be getting 1200 mls of fluid a day but was often only getting 800mls. As the social worker did not receive a reply he followed up his e-mail a fortnight later, and received assurances from the care provider. However Ms B and her father visited two days after the social worker’s email and found that her mother was being fed on her side with her head down, without any offer of a drink. One carer left after feeding the main course and another came for the pudding. Her mother was not repositioned and there was still no offer of fluids.
She said that staff openly talked in front of Mrs X about the end of life medication they were giving and were giving large spoonfuls of the medication without waiting for her to swallow before pushing another. Ms X said that on 10 January she saw a member of the nursing staff completing a 30 minutes observation sheet prospectively that Mrs X was asleep. Ms B says she knew he had not been in at 7.30pm as she was in the room herself.
Mrs X died on 11 January 2025. Ms B also reported that the rings her mother wore on her left hand were missing, and that the care manager could not find them.
What was found
There were concerns voiced by Ms B about Mrs X’s positioning for feeding from her readmission to the home in November. Despite the care plan and the discharge note from the hospital, care workers continued to try and feed Mrs X when she was poorly positioned. That was a potential breach of the regulations: it was not treating Mrs X with dignity. It failed to meet her nutritional needs properly and it was not appropriate for her needs. It caused Ms B and her father significant distress to see it continuing.
The care provider acknowledged that it failed to maintain records properly, or communicate properly with Mrs X’s family. That was also a potential breach of the regulations. Inaccurate records for one resident cast doubt on the entirety of the care provider’s recording system. The Council says it had not seen the complaint prior to the relative going to the Ombudsman; the care provider had not complied with the clause in its contract which required it to notify its contacts manager about complaints.
The missing jewellery was a further distressing event for Ms B and her father. While it might not have been possible for the care provider to trace that now, there should have been an accurate record of where it was.
The Ombudsman recommended that the Council should continue to review with the current management the concerns about adherence to SALT guidance for residents and how training could be improved. That should include knowledge about repositioning. After a three month’s review the Council should let the Ombudsman know the position then.
Since Mrs X had died it was too late to remedy any injustice she suffered as a result of the poor positioning. However the Council was to offer £500 each to Ms B and her father in recognition of the distress they suffered witnessing the care provider’s failures to treat Mrs X correctly and a further £250 to Ms B in recognition of her time and trouble in registering the complaint.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
We think that the Ombudsman could have gone further in considering whether more forceful action could or should have been taken by Cambridgeshire as the commissioner, at an earlier stage. Ms B noted concerns within three days of her mother’s first admission to the care home, and reported these to the social worker. The social worker did speak to the team leader of the care home at that stage, but two months later after the DST meeting when the social worker witnessed Mrs X’s poor positioning and the dried food-supplement on her face himself. He emailed the care provider and followed this up two weeks later. Given the seriousness of the concerns the social worker should have raised a safeguarding alert. Both the Council and the provider owed human rights to the woman and this was sufficiently bad care as to amount to inhuman and degrading treatment, in our view.
It would also have been a potential breach of Regulation 10 for CQC purposes – the regulation says service users must be treated with dignity and respect.
The report was passed to the CQC, and the report indicates that Aria Care had appointed a new manager.
The report makes no mention of whether an urgent or standard authorisation should have been in place. Mrs X had dementia and could not speak, so it seems likely she lacked capacity. The care arrangements may well have constituted a deprivation of liberty meaning that DOLS safeguards should have been in place. The DOLS process if applicable could have led to proper scrutiny of Mrs X’s care arrangements with serious consideration of the family’s concerns.
We would like to see families being routinely given information about the legal framework surrounding their loved ones placement in a care home, and the range of avenues for raising concerns, if as is so often the case, the complaints procedure does not lead to a speedy or effective outcome.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Cambridgeshire County Council (24 021 792) report. If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
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