Summary: Mrs B complained about the care her mother, Mrs C, received at the Nursing Home and the lack of additional nursing care for which she received Funded Nursing Care (FNC). We found fault with how the Council communicated with Mrs B, it did not explain Mrs C had to be assessed before she would receive FNC. This caused uncertainty and left Mrs A feeling she was not listened to. We also found fault with the Care Trust’s complaint handling, it also did not explain Mrs C had to be assessed before the nursing home received the additional funding. This led to further uncertainty for Mrs B. We made recommendations and the organisations agreed to remedy this.

The complaint

1. Mrs B complains about the care provided to her mother, Mrs C, at The Coombs Nursing Home (the Nursing Home) for a short period before her death in early 2025. The Nursing Home is run by The Orders of St John Care Trust (the Care Trust). Gloucestershire County Council (the Council) helped Mrs C move to The Coombs after she left hospital. Specifically, Mrs B complains:
• Mrs C did not receive the nursing care she should have. She was receiving NHS-funded nursing care and should have received specific things with this, but she did not.
• Staff at the nursing home did not notice Mrs C’s catheter was strapped too tightly to her leg causing swelling.
• Mrs C was left for long periods sat in a chair which could not support her weight meaning she was slumped uncomfortably. Mrs B said whenever she visited and found her mother like this, her meals were also left out of her reach.
• Mrs C was not turned regularly when she was in bed.
• Mrs C’s carer continued to visit her, it was the carer who alerted staff she may have an infection.
2. Mrs B feels her mother’s final days were made much more uncomfortable than they needed to be. She feels she did not receive the basic care she was entitled to, much less the nursing care she received extra funding for. Knowing this caused extra distress to Mrs B, who lived many miles away, she received no reassurance when she raised issues the care would improve.
3. Mrs B wants reassurances lessons have been learned and explanations as to why her mother was treated the way she was. She wants financial redress as the family paid for the care, as well as for the added stress and distress caused by witnessing the events and chasing the nursing home for answers after her mother’s death.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended). If it has, we may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
6. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

7. I have considered information Mrs B provided in writing and by phone. I also considered documents and comments on the complaint from the Council and the Trust. I also considered relevant law, policies and guidance.
8. Mrs B and the organisations had the opportunity to comment on my draft decision. I considered the comments I received before finalising the investigation.

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What I found

Additional funding for nursing care

9. Mrs B complains Mrs C did not receive the nursing care she should have. She was receiving funded nursing care (FNC) from an NHS integrated care board (the ICB).
10. As part of my investigation, I asked the Council and the Care Trust to provide copies of the FNC paperwork for Mrs C. Neither organisation had a copy in its records. The Care Trust said the nursing home did not receive any funding from the ICB for additional nursing care.
11. I made an enquiry to the ICB and asked it to provide copies of the FNC paperwork for Mrs C. It explained a request for FNC had been received, but it did not assess Mrs C’s needs before she died. It confirmed it had not paid any funding to the nursing home to care for Mrs C.
12. In January 2025 before Mrs C moved to The Coombs, Mrs B emailed the Council about where her mother would go. In these emails the Council said she was assessed as having nursing needs, and FNC would be paid direct to the care home. Mrs B signed the paperwork.
13. In an email to Mrs B on 17 March, the Council told her “I have been in contact with the [ICB] who will be assessing mums ongoing nursing needs and eligibility for funded nursing care. They have advised that they are yet to allocate an assessor. [Mrs C’s] current plan ends tomorrow so I will extend this for a further 6 weeks while we wait for an assessor allocation.” The email does not make it clear there was no funding currently being paid.
14. Mrs B made a formal complaint to the Care Trust in April 2025. In this complaint, she raised the issue of Mrs C not receiving adequate nursing care. In its first response, the Care Trust did not respond to this issue. Mrs B asked to escalate the complaint further, and in its second response in June 2025, it said “The Coombs offers a nursing service. During the period … there was always a qualified nurse available… she was also receiving support from district nurses.”
15. The Council did not investigate the complaint because it was more appropriate for the Care Trust to respond.
16. Mrs B complained to the Ombudsmen about her mother not receiving nursing care. It is clear she did not know her mother had to be assessed for funding before it was received.
17. While I can see the Council told Mrs B her mother needed to be assessed, it is not clearly explained Mrs C was not receiving any additional nursing support during this time and FNC was not being paid. This is fault.
18. Mrs B felt her mother should have received more care and worried about the care she was receiving. She did not understand Mrs C needed to be assessed before she received FNC. This is an injustice to her which could have been avoided had the Council given Mrs B more information on how FNC worked. She was caused a further injustice during the complaints process, because the Care Trust at no time mentioned The Coombs did not receive FNC towards Mrs C’s care.

Care at the nursing home

Background

19. Mrs C was 101 years old when she went into the nursing home for respite care for six weeks. During this period, her longer terms needs were to be assessed. She sadly died before this could happen.
20. The Care UK website explains “nursing homes provide registered nursing care for those residents who need higher levels of care, whether that is immediate care following being discharged from a hospital or a long-term care need. As well as providing care for those with higher needs, nursing homes also offer social activities and in-home entertainment like residential care homes”.
21. It adds “the biggest difference between [a care home and a nursing home] is that nursing homes have a qualified nurse on site round-the-clock, supported by care assistants, so they can provide a higher level of care.”
22. My investigation has shown The Coombs did have registered nursing staff on site and Mrs C was also visited by a district nurse.

Wheelchair use and being unsupported.

23. Mrs B complains Mrs C was often left unsupported in a wheelchair and her meals were left out of reach.
24. Her care plan says she needs to be moved around the care home in a wheelchair and she tends to move forward when seated which leaves her unsupported, so she should be repositioned when this happens.
25. Mrs B complained directly to the nursing home four days after Mrs C’s admission about Mrs C being left for long periods sat in a chair which could not support her weight meaning she was slumped uncomfortably. The staff member explained there was an occasion when Mrs C needed to stay in a wheelchair, such as when she saw the hairdresser, but she was transferred to a chair soon after. Mrs B asked for a pillow to be placed behind Mrs C’s head when in a chair, and the staff member told Mrs B they would tell all staff of her wishes immediately. Mrs C’s care notes show a record of this conversation and all staff were spoken to the same day.
26. Mrs B told me after she raised the issue she, or Mrs C’s former carer who also visited, no longer had cause to complain.
27. While I appreciate it was distressing for Mrs B to see her mother looking uncomfortable, there is nothing specific in her care plan about how she needed to be positioned or for a specialist chair to be used. Staff at the nursing home responded to Mrs B’s concerns appropriately and changed how they cared for Mrs C when they knew Mrs B was unhappy. This is what we would expect and I can find no indication of fault.

Lack of turning in bed

28. Mrs B complains Mrs C was not turned regularly when she was in bed. Mrs B visited Mrs C and sat with her for several hours, she complains Mrs B was not turned when she was there.
29. I have reviewed Mrs C’s care plan and notes. She was on two hourly checks throughout her stay. Her care plan says “[Mrs C] is able to change her position when in bed”. There is nothing in her care plan which says staff need to re-position Mrs C.
30. Mrs C went from hospital to the nursing home with a grade II pressure ulcer on her sacrum. Her bed had a specialist pressure relieving mattress which means staff would be required to turn her less often.
31. Staff at the nursing home worked with a district nurse to dress and heal this wound. This is also an indication Mrs C was being repositioned regularly as it could not have healed so quickly if she was still for long periods.
32. I find no indication of fault with the actions of the nursing home staff.

Catheter, oedema and concerns over infection

33. Mrs B complains staff did not notice Mrs C’s catheter was strapped too tightly to her leg, she believes this may have led to swelling. She says staff did not elevate the leg as directed.
34. Mrs C’s care plan says she has an ‘indwelling catheter’, and it is to be strapped to one of her legs. The care plan also notes the catheter is only to be changed by a district nurse. The care plan adds “assist [Mrs C] to position and maintain their leg bag securely” and asks all staff to “observe for signs of infection”. She is also noted to be very frail due to her age with fragile skin.
35. Mrs C’s care notes show on the morning of 16 February, a carer noticed while washing Mrs C she had a bruise to her shin but there was no wound and she told staff she was not in pain.
36. The next day, her leg was swollen and was leaking fluid, staff called a district nurse and asked them to review her leg. The care worker on duty also spoke to the nurse on duty in the home at the same time. Staff were told to observe Mrs C carefully for signs of infection and to contact her GP if anything changed. The district nurse visited later the same day and noted the swelling had gone down, she was placed on an absorbent pad to make her comfortable and she would assess the leg again later in the week. There is nothing in the care notes about how the leg should be positioned and no indications there was an underlying infection.
37. On the 22 February, the district nurse came to dress Mrs C’s leg. She was concerned it had changed and spoke to the GP, who prescribed antibiotics for cellulitis, a skin infection which often shows itself as hot, painful or swollen skin. The notes show Mrs C was not reporting any pain or showing any outward signs of infection.
38. The notes do not show whether the district nurse believed the oedema may have been caused by the catheter bag being strapped too tight, although I do understand why this would have been a worry for Mrs B with it being in the same area. Therefore, in the absence of other evidence, I am unable to determine if it was fault by nursing home staff which led to the oedema.

Chest infection

39. Mrs B complains it was Mrs C’s previous carer who told staff she was worried of problems with Mrs C’s breathing, nursing home staff had not noticed. Mrs B told me the previous carer visited on 6 February and told staff she was concerned. The notes from that day do show the carer visited but only mention her labelling clothes.
40. Mrs C’s care notes show a friend visited on 12 February, but it gives a different name than her previous carer. Later that day, staff called Mrs C’s GP as they were concerned she was “chesty”. The GP prescribed antibiotics and care home staff noted they called Mrs B to tell her. Mrs C started on antibiotics the same day.
41. On 13 February, Mrs C’s care notes noted her previous carer visited, she remained chesty and was still taking antibiotics.
42. Mrs C’s care plan under the breathing section advises staff to “contact GP if [Mrs C] feels breathless, she may have developed a chest infection”. There is no mention in the care notes for the previous days of her reporting to be breathless.
43. While I do not dispute what Mrs B has said, the evidence I have reviewed shows events happened in a different order to those she has remembered. The staff noted Mrs C was chesty and called her GP for advice, who prescribed antibiotics. Her previous carer then visited the next day. Staff acted in line with Mrs C’s care plan. I can find no indications of fault.

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Action

44. I recommend within one month of the final decision on this complaint, the Council and the Care Trust separately apologise to Mrs B for the faults the Ombudsmen have identified.
45. Within three months of the final decision, the Council should complete the following actions.
• Prepare a briefing note and send it to all its social care staff to remind them of the importance of explaining complex processes such as FNC and CHC. The note should emphasise clear explanations could prevent complaints.
46. The Council and Care Trust should provide us with evidence they have complied with the above actions.

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Decision

47. I found fault by the Council and Care Trust and have recommended actions to remedy the injustice to Mrs B.

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Investigator's decision on behalf of the Ombudsman