Summary: Mrs X complained about the care her father, Mr Z, received in his home, in the lead up to his death. She complained carers failed to treat pressure sores on his body, and suffered unnecessary pain, as a result. We have found fault in the Care Provider acting on behalf of the Council’s actions for failing to follow Mr Z’s care plan, its procedures for recording and reporting skin integrity issues and for delaying in responding to Mrs X’s complaint. The Council has agreed to write to Mrs X to apologise, pay her a financial payment and complete service improvements.

The complaint

1. Mrs X complained about the care and support her late father, Mr Z, received from a Care Provider delivering domiciliary care to him, on behalf of the Council. She said the Care Provider failed to follow the care plan properly and allowed high pressure sores to develop on his body. She said the Care Provider failed to follow procedure and report the pressure sores appropriately. This meant Mr Z did not receive the proper treatment.
2. Mrs X said Mr Z was in significant physical pain because of the Care Provider failing to act.
3. Mrs X said the whole family suffered great distress watching Mr Z in pain.

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The Ombudsman’s role and powers

4. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
5. 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 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
6. 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(1), as amended)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

8. Mrs X first identified issues with Mr Z’s care in October 2024. Mr Z died in January 2025. The Care Provider made a final response to Mrs X’s in complaint March 2025. Therefore, I have investigated from October 2024 – March 2025.

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How I considered this complaint

9. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
10. Mrs X, the Council and the Care Provider were invited to comment on my draft decision. I have considered any comments before making a final decision.

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What I found

Law and guidance

11. 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.
12. Regulation 9 says the care and treatment of service users must be appropriate, meet their needs, and reflect their preferences.
13. Regulation 10 says people using care services should be treated with dignity and respect.
14. Regulation 17 says care providers should keep an accurate and complete record of the care they give to a person.
15. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

Care Plan

16. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.

Reviews

17. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.

Care providers complaints policy

18. The care providers complaints policy says complaints will be acknowledged within three working days and responded to within 20 working days.

Care providers Pressure Area Care Policy

19. The Care Providers policy says if staff notice any changes within the skin it must be reported immediately to a Health Professional and a body map must be completed recording the size, location and description of changes.
20. The policy also says for people with limited mobility, staff are to inspect the skin at least daily for signs of pressure damage.
21. The policy goes on to state a referral should be made to the local Safeguarding team if there is significant skin damage or where there is a concern that poor practice may be associated with the pressure ulcer.

What happened here

22. The following is a list of key events relevant to Mrs X’s complaint. It is not a list of everything that happened.
23. Mr Z was a vulnerable older man. He had several serious health issues and had a diagnosis of dementia. During the period I investigated, Mr Z received end of life care. He was bed bound. He could not communicate verbally. Mr Z lived with adult family members. One of those was his son, Mr W.
24. The Council commissioned a Care Provider (Provider B) to provide care at home for Mr Z. Two staff from Provider B visited Mr Z four times a day. A support plan completed in February 2024, by the Council, showed the care Mr Z needed.
25. Mr Z received help with all aspects of his personal care, and all aspects of daily living. He remained in one room in his house, during the period investigated.
26. At the end of October 2024, the carers told Mr Z’s family that he needed some cream to apply to sore areas of skin they had found. Over the course of a few days the medication was organised and ordered by the family. However, the carers said this could not be used as it was not prescribed.
27. At the start of November 2024 Mr W observed two carers holding Mr Z in a ‘drag lift’ while attending to his personal care. A drag lift involves lifting a person by putting an arm under theirs, often in the crook of an armpit.
28. Mrs X made a complaint to Provider B about this. She did not receive a response.
29. Shortly after the Provider B changed the care staff. The new carers identified two significant pressure sores on Mr Z’s body.
30. The care provider made a safeguarding referral to the Council regarding the ‘drag lift’ and confirmed the carers involved would not be attending Mr Z’s home again. The Council investigated this and decided to take no further action as appropriate action had been taken.
31. A nurse and Mr Z’s son found a further pressure sore on Mr Z’s heel in mid-November 2024.
32. Mrs X made a complaint to Provider B about the pressure sores, and told it she was also waiting for a response to the complaint about the moving and handling.
33. Provider B reviewed Mr Z’s care plan in mid-November 2024. Mr Z’s care plan was updated to include actions to take to treat the pressure sores and also regarding repositioning Mr Z at each visit.
34. A field supervisor visited Mr Z, and his family at home, in mid-December. His care plan was updated. Provider B decided, with permission of the family, to assign a small team of carers who were experienced in end-of-life care to care for Mr Z.
35. Mr Z died in January 2025.
36. Mrs X chased Provider B for a response to her complaint in mid-February 2025.
37. Provider B responded to the complaint in late February 2025 and said carers had attended a disciplinary hearing, it had implemented further training and was completing regular observations. Provider B also said it had held a workshop on safeguarding and skin integrity and apologised for the distress caused to Mr Z and his family.
38. Mrs X raised a further complaint towards the end of February 2025 and said Mr Z’s care notes did not show the carers had either noticed the severity of the sores or mentioned this. Mrs X also said that the notes recorded Mr Z’s skin condition as ‘good’ in the majority of notes. Mrs X said carers had not followed Provider B’s procedure about skin damage/pressure sores.
39. Provider B responded to Mrs X’s further complaint in mid-March 2025 and apologised for the delay in responding. It said there had been inconsistencies in its skin integrity records for Mr Z. It said it had held training to improve report writing and had reminded carers to report skin integrity problems immediately. Analysis

Delivery of home care

40. I find fault with the actions of Provider B about its moving and handling of Mr Z. Mr Z, at an extremely vulnerable time in his life, suffered degradation and a loss of dignity through actions of Provider B. Provider B acknowledged the fault in its carers moving Mr Z using a drag lift technique. It took appropriate action to respond to the incident which included formal processes for handling misconduct, and staff training. Mrs X was satisfied with the action it took. I am satisfied the response was thorough and proportionate. Therefore, no recommendations have been made about moving and handling.
41. I find fault with the actions of Provider B about its failure to properly record, respond to and address the pressure sores on Mr Z’s body.
42. Photographic evidence reviewed as part of this investigation showed the severity of the pressure sores on Mr Z’s body.
43. Provider B’s Pressure Area Care Policy says people with limited mobility are to be inspected at least daily and any changes to skin integrity should be immediately reported to a health care professional.
44. Mr Z’s care plan also recommended his skin be inspected at both morning and evening visits.
45. In the two weeks prior to Mrs X making her complaint the sores would have been developing. The care records show carers first logged the sores at the end of October 2024. But, this was not consistently noted by carers, some records refer to skin condition being ok after this time.
46. I find fault with Provider B for its record keeping. Staff failed to keep accurate and reflective records. Skin integrity was not properly assessed and recorded as it should have been. This fault likely contributed to the standard of care received by Mr Z. Had the care records held an accurate account of the pressure sores, opportunities to address the issue may have arisen sooner. Either family members, or other professionals visiting the home may have reviewed the care notes and acted.
47. I also find fault in Provider B’s actions for failing to follow its policy to report any changes in skin integrity to a Healthcare professional immediately. Had Provider B done this Mr Z’s pressure sores could have been assessed and treated more quickly.
48. In addition, Provider B further failed to follow its procedure by not making a Safeguarding referral in relation to significant skin damage being located.
49. Mr Z would have suffered significant distress in this period, the sores would have been causing him considerable pain and discomfort. In addition, once the sores had been identified Mr Z’s family would also have been caused significant distress at realising he had likely been in considerable discomfort which had gone undetected.

Care planning

50. In November 2024 Mrs X asked the Provider B to review the care plan urgently.
51. Provider B has shown Mr Z’s care plan was updated within seven days and was kept under review and updated several times until Mr Z sadly died.
52. I have not found fault in the Provider B’s actions in relation to this.

Complaint handling

53. Mrs X made her first complaint to Provider B at the start of November 2024. She made a second complaint around a week later. The contents of both complaints were serious, and about failure to care properly for Mr Z.
54. Provider B acted but did not reply formally to Mrs X. Provider B’s complaint procedure says a complaint will be acknowledged within 3 working days and a meeting will be organised to discuss the complaint.
55. It also says a complaint investigation will be concluded within 20 working days. If longer is needed, it says it will update a complainant every 7 days until the complaint response is made.
56. Only upon Mrs X contacting Provider B again, in February 2025, did it respond. Provider B made a formal written response to Mrs X in February 2025, 76 working days after the first complaint, 71 working days after the second. It made its final response in March.
57. I find fault with Provider B for failing to make a formal complaint response to Mrs X, in a timely manner, when she complained in November 2024. This failure exacerbated the distress experienced by Mrs X and caused her undue time and trouble in chasing the response.
58. The Council and Provider B has taken significant steps to ensure the improvement of the care, and I have no further service improvements to recommend in relation this.
59. Any injustice caused to Mr Z by the failings of Provider B cannot now be remedied. However, there was also considerable distress caused to Mrs X not only by the knowledge of the suffering caused to Mr Z, but also by the poor attitude of the care provider in its responses to her complaints.
60. Under Part 3 of the Local Government Act, we treat the provider’s actions as if they were council actions.

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Action

61. To remedy the injustice identified in this investigation, within four weeks of receiving a final decision, the Council should:

• Write to Mrs X and apologise for the distress caused by the faults identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• Pay Mrs X £500 to recognise the significant distress caused by the faults identified.
• Pay Mrs X £250 to recognise the time and trouble caused to her in making the complaint.

62. Within four weeks of receiving a final decision Provider B should:

• In writing, remind staff who deal with complaints of the importance of responding in line with its policy.

63. The Council should provide us with evidence both it, and Provider B has complied with the above actions.

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Decision

64. I find fault causing injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman