A government watchdog ordered Cambridgeshire County Council to pay the widow of a 74-year-old man who died in care £5,000.

The local government and social care ombudsman found the council’s commissioned provider – the Elms in Whittlesey – guilty of “very poor care and treatment”.

He said the council’s safeguarding investigation found that HC One – who own the Elms- had “failed in multiple aspects” of care.

£5,000 was in “recognition of the considerable anxiety and distress she was caused by the actions of the care provider it (the council) commissioned”.

A spokesperson for The Elms said: “Our priority is to deliver the best possible care for each resident we serve.

“So, we deeply regret that in this historic incident mistakes were made.

“They led to us falling short of the standards residents and their loved ones rightfully expect and deserve.”

The spokesperson added: “As noted by the ombudsman’s report, significant progress has been made at the home.

“This is thanks to the extensive action we immediately undertook at the time to improve record keeping, complaints procedures, and to implement enhanced training for colleagues.

“We have a new home manager and new area team in place since the time period covered by the report.

“We are continuing to work closely with our local authority partners to ensure that we are consistently providing the best possible care.”

The ombudsman says the widow complained that:

1: The Elms failed to give her husband his medication which resulted in impaction of the bowels and consequent frequent enemas

2: The Elms failed to give him adequate hydration and nutrition so he became dehydrated and malnourished.

3: The Elms failed to follow speech and language therapy (SALT) advice about food preparation.

4: The Elms altered records and threatened to evict residents whose relatives complained.

The man went into the Elms in September 2018.

He had Parkinson’s disease, dementia and deemed to be at high risk of choking.

The ombudsman says his wife provided a 6-page care plan for him which she says was included in the Elms’ own care plan, but later removed from his records.

Mrs X alleged staff frequently gave her husband an unsuitable diet.

“She says they gave him biscuits, toast, whole chicken breasts, shredded pork and other foods not able to be mashed,” says the ombudsman’s report.

“In an effort to prevent carers giving him biscuits she made a notice for his room but it was confiscated by staff.”

The report says prescribed supplement drinks which should have been given twice daily, often weren’t.

The widow said a dietician advised in September 2018 that her husband should weigh 63kgs

“By January 2019 his weight had fallen to 47kg.”

The ombudsman says that on occasions her husband went up to 11 hours without fluids.

Mrs X says in February 2019 the area manager told relatives they expected a standard of service they were not going to get.

“She says she was personally told Mr X would be evicted if she did not stop complaining,” says the report.

A second safeguarding alert came after her husband was admitted to hospital on February 18, 2019 with sepsis and a chest infection.

He had kidney failure and impacted bowels and was malnourished.

“Mrs X says he was so dehydrated the hospital staff could not insert a canula,” says the report.

“She contacted the council to raise a further safeguarding alert. She said she did not want the care home to know which ward her husband was in.”

The ombudsman says a social worker met Mrs X on the hospital ward on February 25 to discuss the safeguarding alert.

The wife said the Elms – which offers residential nursing and special dementia care for 37 people - had neglected her husband’s needs over a period of time.

“She said she had often visited and found him lying in urine and faeces,” says the report.

“She said the care home was neglecting basic care such as washing, changing and giving sufficient food and drink.”

Her husband was discharged to another care home at the beginning of March.

He died on March 24, shortly after his 74th birthday.

Records obtained from the home supported the widow’s claims, including the home’s failure on two occasions to act on Mrs X’s requests to call for medical help on the day her husband was admitted to hospital.

The ombudsman said the council had upheld the widow’s complaints of multiple breaches.

“The council also upheld the complaint that a former area manager had threatened residents with eviction if relatives continued to complain,” says the ombudsman.

The ombudsman says Cambridgeshire County Council implemented a Home Improvement Plan (HIP) following the investigation.

The ombudsman concluded, however, that there were “undoubtedly serious failings in the care and treatment provided by the Elms care home to Mr X.

“The failures were potential breaches of the regulations”.

He said there were other failings of concern in the way area managers tried to prevent complaints, threatening relatives with residents’ eviction.

“That showed a culture which had set its face against improvement and was willing to use fear to prevent exposure of its failures,” he said.

“It is significant that Mrs X did not want the care home to know which ward Mr X had been admitted to.

“The care provider says it has made major improvements in its complaints system since this time.”

The ombudsman said that since the resident had died, it was not possible “to remedy the injustice which he was caused by the actions of the care provider”.

The ombudsman says that publication of the HIP was followed by routine monitoring contact on a virtual basis until the Covid19 restrictions were lifted and a full monitoring visit was completed in April 2021.

It identified the progress made respect of the areas of concern identified following Mrs X’s complaint.

“The council says that food, fluid, elimination and postural charts were now being completed appropriately and there were clear reasons given for charts being used,” he concluded. “It says daily records were also properly kept.”

The council found that medication records were now being appropriately kept and a monthly audit completed.

There had been no reported concerns about moving and handling practice at the Elms in the six-month period monitored.

The ombudsman said the council reimbursed the cost of the independent social worker Mrs X employed to assist her.

“It says Mrs X was very clear that the principal aim of her complaint was to avoid the same things happening to another family,” he added.