Summary: Mrs X complained the Council failed to act when she contacted it with concerns about her late brother’s care and it was difficult to get in contact with anyone. She also complained the care home the Council commissioned failed to get an air mattress for her late brother before he went into hospital and the care home failed to treat his urine infection. We find fault with the care home’s communication with Mrs X and the care it provided to her late brother. The Council was at fault for its communication with Mrs X. These faults have caused Mrs X upset, distress and uncertainty. The Council has agreed to our recommendations to apologise to Mrs X and make a payment to her.

The complaint

1. Mrs X complained the Council failed to act when she contacted it with concerns about her late brother’s (Mr Y) care and it was difficult to get in contact with anyone. She also complained it closed Mr Y’s case to adult social care without telling the family and an officer failed to offer any support at a meeting and then failed to get in contact with her.
2. Mrs X also complained the Council commissioned care home (Sherwood Grange) failed to get an air mattress for Mr Y until 24 hours before he went into hospital and the care home failed to treat Mr Y’s kidney/urine infection.
3. Mrs X says the matter has caused severe distress and upset to the whole family.

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The Ombudsman’s role and powers

4. 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)
5. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by their personal representative (if they have one), or someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
6. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
7. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
9. 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

10. I considered evidence provided by Mrs X and the Council well as relevant law, policy and guidance.
11. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Care services regulation and guidance

12. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which 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.
13. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards.
14. Regulation 9 says care and treatment must be appropriate and meet service users’ needs.
15. Regulation 12 says care and treatment must be provided in a safe way for service users.
16. 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”.

What happened

17. Mr Y became a resident of Sherwood Grange (the care home) in August 2023. The Council commissioned the placement.
18. Mr Y went into hospital in September with a severe urinary tract infection (UTI). He was discharged back to the care home in October. The discharge summary said Mr Y would need antibiotics for 14 days, a district nurse referral for catheter care in the community and barrier cream for moisture skin damage.
19. Mrs X emailed the care home and said Mr Y had a mattress when he was in hospital which helped the prevention of bed sores. She asked it to sort out a mattress for him. The care home spoke to a nurse on 10 October and asked her to order a pressure relieving mattress for Mr Y. The nurse ordered a static mattress rather than an air mattress because she said Mr Y did not have any wounds and he was mobilising.
20. Mrs X emailed the care home the following week and said Mr Y had not received his pressure mattress. The care home’s notes state it ordered an air mattress for Mr Y on 20 October.
21. A social worker reviewed Mr Y’s care and support needs at the end of October. Mrs X was aware the review was taking place. He decided the care home was meeting Mr Y’s long-term care and support needs. The Council decided to close Mr Y’s case and remove his assigned social worker.
22. Mrs X called the care home in early November and chased the air mattress. The care home chased the matter up with the nurse.
23. The care home received a static mattress for Mr Y in early November.
24. Care home staff noticed at the end of November Mr Y’s urine was cloudy and he had developed blisters. The GP visited Mr Y, and they prescribed antibiotics for a urine infection. The care home started repositioning charts because of Mr Y’s skin and made a referral to the district nurse. The nurse visited the following day and ordered an air mattress for same day delivery. The mattress arrived that day.
25. Mr Y went back into hospital at the beginning of December. The nurse at the hospital inspected Mr Y’s skin and raised concerns about significant skin damage. They made a referral to the Council. The care home is in a neighbouring authority (Council X). Therefore, the Council sent the referral to Council X.
26. Mrs X phoned the Council and asked for an urgent call back to discuss Mr Y’s case. She said the care home had failed to provide Mr Y with an air mattress. She phoned the following day and asked it to assign a social worker to his case. The officer explained they had transferred Mr Y’s case to the relevant team who would be in touch with an update.
27. Mrs X called the Council the following week. The Council said a social worker would review Mr Y’s care needs before he was discharged from hospital. Mrs X had a further phone call with the Council a few days later about Mr Y’s discharge plans.
28. Mrs X attended a safeguarding meeting at the care home in February 2024. A Council officer attended, staff from the care home and an officer from Council X. Mrs X detailed her concerns about the care Mr Y had received. Mr Y sadly passed away shortly after the meeting.
29. Mrs X called the Council and said she was trying to find a colleague who had taken over the investigation of the care home. The officer she spoke to referred the matter to Mr Y’s previous social worker’s manager. The manager phoned Mrs X and agreed to send a copy of the social worker’s review of Mr Y’s care and support needs from October 2023. Mrs X she had no issues with the review, but the issues came after the review.
30. Council X completed its safeguarding investigation. It concluded the care home failed to consistently manage Mr Y’s pressure sores, it did not have a robust plan on pressure sore management, the records were inconsistent on whether care home staff applied barrier cream to the pressure area, there was no evidence of a consistent skin integrity assessment and pressure relieving equipment was provided too late. These were acts of neglect and omission.
31. Mrs X complained to the Council in July. She said the care home failed to get an air mattress for Mr Y to prevent his bed sores. She also said she contacted the Council from October to December 2023 and it told her Mr Y no longer had a social worker and so it would not help with his care. She told the care home Mr Y had a urine infection, but it failed to get medical help. Finally, she said the Council officer who attended the safeguarding meeting in February 2024 promised to meet with her to discuss her concerns. However, despite her chasers, the officer was never available. When he eventually answered, he passed her concerns to another officer.
32. The Council responded to the complaint. It said it was the responsibility of the NHS to provide pressure relieving items. The officer who attended the meeting in February 2024 should not have attended as Council X was dealing with the safeguarding issues. It apologised for the error. It also said its case recordings did not show it explained the next steps after its review of Mr Y’s care and support needs. It apologised for this. It said it was sorry to hear about her frustrations about lack of contact. It said as a service improvement it would work with its communications team to improve responsiveness from staff.

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Analysis

33. The events in this case start from August 2023, but Mrs X did not refer her complaint to us until November 2024. Events before November 2023 would usually be caught by the restriction in paragraph seven of this statement. Mrs X says she was dealing with the safeguarding process which took time, and she was also raising the issues relating to Mr Y’s death with the hospital. These are good reasons why Mrs X did not refer her complaint to us sooner. Therefore, I have exercised discretion to investigate matters from August 2023 onwards.
34. Mrs X says she could not get in contact with anyone at the Council to discuss her concerns about Mr Y’s care from October to December 2023. She says she told the Council about the air mattress issues, but it said it could not help as Mr Y no longer had a social worker. I have reviewed the Council’s case notes and its records of communication with Mrs X during this time. I have not seen any evidence of Mrs X’s calls during this period or her communication with the Council. Therefore, I do not uphold this part of her complaint.
35. The Council failed to tell Mrs X it was closing Mr Y’s case to adult social care and that he would no longer have a social worker. This is fault, which would have caused Mrs X some shock. I welcome that the Council apologised for this and it now has regular case audits in place to prevent a recurrence of this fault. I do not recommend anything further.
36. In the Council’s response to Mrs X’s complaint, it said it was inappropriate for the officer to have attended the safeguarding meeting in February 2024. The officer kept their microphone on mute because they did not know what to say. The meeting was to discuss Mrs X’s concerns about the care the care home had provided and the steps of the safeguarding investigation. While I agree with the Council that Council X was the authority responsible for leading the safeguarding investigation, I do not agree it was inappropriate for an officer from the Council to also attend. The Council commissioned the placement and therefore it was important for it to be involved with any potential safeguarding issues. The officer should have clearly explained their role to Mrs X, and the distinction from Council X’s role. The failure to do so is fault, which caused Mrs X confusion.
37. I have not seen any evidence the Council officer from the February 2024 safeguarding meeting offered Mrs X a meeting or that Mrs X had to repeatedly call to chase it up. The case records only show one phone call from Mrs X to the Council when she asked to speak to the officer who had taken over the safeguarding investigation. The Council’s failure to clarify its role caused this confusion. I welcome that the Council apologised for this confusion when it responded to Mrs X’s complaint.
38. The hospital discharge notes do not state the care home had to provide an air mattress for Mr Y. However, when Mr Y went back to the care home after his stay in the hospital, there was a discussion about a pressure relieving mattress. The nurse decided this would be a static mattress, rather than an air mattress. I have not seen any evidence the care home communicated this decision to Mrs X. This is fault.
39. The care home’s notes state it ordered an air mattress on 20 October and then chased this up in early November. I consider it is more likely than not the care home wrongly referred to an air mattress when it should have stated static mattress. This is because a static mattress arrived in early November after the care home chased it up again. It is clear from Mrs X’s complaint she was expecting an air mattress. The nurse ordered an air mattress at the end of November, and it arrived on the same day. As I have stated in paragraph 38 above, the care home should have explained to Mrs X why it had not ordered an air mattress when she had requested it. This fault caused Mrs X upset and distress.
40. Mrs X asked for an air mattress because she wanted to prevent Mr Y’s bed sores. The conclusion from Council X’s safeguarding investigation was the care home failed to consistently manage Mr Y’s pressure sores, it did not have a robust plan on pressure sore management and the records were inconsistent on whether care home staff applied barrier cream to the pressure area. I have reviewed the care home’s records, and I agree with Council X’s comments. There was also a failure to consider whether to get an air mattress much sooner. These faults have caused Mrs X significant upset and distress. She also has uncertainty as to whether the deterioration in Mr Y’s health may have been prevented.
41. Council X recommended for the care home to implement refresher training to its staff on pressure ulcer management, to ensure timely medical input is provided to its residents and to ensure it puts in place a process to improve on effective communication with families. When I sent my draft decision, I recommended that the Council provided evidence the care home has put in place these service improvements. The Council provided me with this evidence in response to my draft decision. I have therefore removed this recommendation.
42. Mrs X says her daughter had to point out Mr Y’s urine infection to the care home and after a week it had failed to treat him. I have reviewed the care home’s notes which do not support Mrs X’s assertions. Care home staff noticed the change in Mr Y’s urine and contacted the GP. The GP prescribed Mr Y with antibiotics the same day.

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Agreed action

43. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of the care home and the Council and make the following recommendations to the Council.
44. By 11 July 2025 the Council has agreed to:

• Apologise to Mrs X for the injustice caused by fault in this statement.
• Pay Mrs X £400 for her upset, distress, and uncertainty.

45. The Council should provide us with evidence it has complied with the above actions.

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Final decision

46. There was fault by the Council, which caused Mrs X an injustice. The Council has agreed to my recommendations and so I have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman