The Local Government and Social Care Ombudsman upheld a complaint raised by a daughter over her mother’s care at Aria Court in March.
A care home in March “failed to provide a good standard of care” to a former resident, and lost some of their personal jewellery after they died. The Local Government and Social Care Ombudsman found that staff at Aria Court did not feed the woman in their care in the way they should have done, causing distress to her family.
The Ombudsman upheld a complaint against Cambridgeshire County Council due to the failings of the commissioned care provider. The county council said it is working with the care provider to ensure steps are taken to reduce the risk of something similar happening again. The management at the care home has also since changed.
The Ombudsman report said the woman, referred to as Mrs X, moved into the care home in October 2024. It explained that she had dementia and was no longer able to speak or feed herself.
The report stated that Mrs X’s care plan explained that she needed one-to-one assistance to eat and drink, and that each hour she should be encouraged to drink. Her care plan also set out that when being fed she needed to be carefully positioned sitting up in her bed with pillows at her sides to support her.
However, Mrs X’s daughter, referred to as Ms B, raised concerns after visiting her mother and noticing that in the two hours she was there no staff came to check on her mother or offer her a drink as required. The following day Mrs X was admitted to hospital with dehydration and suspected sepsis.
The family spoke about the issue with Mrs X’s social worker, who spoke to the team leader at the care home setting out the guidance for how to help Mrs X eat and drink when she was discharged. Mrs X was discharged back to the care home on October 29, but was readmitted to hospital the next day.
She later returned to the care home in November, where her family continued to notice ongoing problems with their mother’s care. The Ombudsman report said Ms B has photographic evidence of care workers trying to feed her mother with her head down, and said at times Ms B saw staff trying to feed Mrs X while she was lying on her side.
The report said Ms B raised these concerns with the care home. Mrs X’s social worker also went on to raise concerns, highlighting that they had noticed staff trying to feed Mrs X whilst she was in a “reclined side laying position” stressing that this was “unsafe”.
The care provider later replied to the social worker stating that staff were now making sure Mrs X was in the correct position before eating, and was being offered regular drinks. However, Ms B said that on a visit in December they found Mrs X “being fed on her side, head down” and that no one tried to offer her mother a drink while she was there.
Ms B also claimed staff openly talking in front of her mother about the end of life medication they were giving her, and saw staff giving Mrs X large spoonfuls of medication and not waiting for her to swallow before “pushing” in another.
Ms B said she also saw staff filling out a 30 minute observation sheet prospectively, and later saw a care worker enter her mother’s room at 8pm and fill out the observation for 7.30pm, when she knew they had not been there, as she had been in her mother’s room at that time.
Mrs X died in January 2025. After she passed away her daughter said rings her mother had worn on her left hand were missing and that the care manager had not been able to find them.
The Ombudsman report said the care provider acknowledged it had not always responded to Ms B’s contacts, and agreed that sight charts had been completed retrospectively and apologised for this. The report also said the care provider had acknowledged some of Mrs X’s jewellery remained missing.
After Ms B complained to the Ombudsman the issues were highlighted to the county council, which said it had not seen the complaint before, although the care provider was required to notify its contacts manager about any complaints.
The county council told the Ombudsman that the management at the care home had changed, and the home was also seeking to improve staff knowledge of the need to maintain proper records.
‘Family caused distress to see failings in mother’s care’
The Ombudsman report said: “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 Mr X [Mrs X’s husband] significant distress to see it continuing.
“The care provider acknowledges 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 missing jewellery is a further distressing event for Ms B and Mr X. While it may not be possible for the care provider to trace that now, there should have been an accurate record of where it was.”
The Ombudsman said the county council needed to continue to review with the home’s current management the concerns about adherence to the guidance for caring for residents and how training can be provided.
It also said the authority should offer £500 each to Ms B and Mr X in recognition of the “distress they suffered witnessing the care provider’s failures to treat Mrs X correctly”.
The Ombudsman also said a further £250 should be offered to Ms B in recognition of the time and trouble she had been through in making the complaint.
A spokesperson for the county council said: “We accept the findings of the Local Government and Social Care Ombudsman who has identified shortcomings in the service provided to this family and we are complying with all their recommendations.
“The care provider has acknowledged their responsibility for the issues and the council has actively worked with them to ensure that steps have been taken to reduce the risk of something similar happening again. A full update on progress towards this will be provided to the Ombudsman within the three-month period specified in the decision.”
Athena Care Homes (UK) Limited, which runs Aria Court, was contacted for comment.
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