Privacy settings

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

City of York Council (17 015 821)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 23 Mar 2018

The Ombudsman's final decision:

Summary: The Ombudsmen find no fault in the way a care home and GP practice responded to a resident’s declining health, or in the way the home tried to manage the resident’s personal care needs. However, the Ombudsmen find fault in way the care home managed the resident’s pressure area needs. This caused an injustice. The Ombudsmen recommend an apology and an action plan to address this.

The complaint

  1. Mr A complains about the care, support and treatment his late mother, Mrs R, received from September 2015 until January 2016. He complains about:
  • Tuxford Manor Care Home (the Care Home), which City of York Council (York Council) arranged and funded while Mrs R stayed there
  • Tuxford Medical Centre (the Practice)
  • Nottinghamshire County Council (Notts Council), which investigated Mr A’s concerns.
  1. Mr A complains:
  • The Care Home failed to investigate Mrs R’s complaint of being attacked in her bedroom. Mr A said Mrs R complained about this shortly after she moved in to the Care Home. Mr A said, because the Care Home failed to investigate, Mrs R lost trust in the professionals involved in her care. He said this, in turn, meant she stopped sharing things with them, such as the pain she was in.
  • The Care Home and Practice failed to address Mrs R’s deteriorating health during December 2015 and January 2016. Mr A said there were clear signs that Mrs R’s health was deteriorating due to treatable medical problems. Mr A complains his mother’s death was painful and undignified and could have been avoided had appropriate care been provided in a timely manner. In particular, Mr A complains the Care Home and Practice failed to take proper account of Mrs R’s:
    • Inability to eat and associated weight loss
    • Inability to drink and severe dehydration
    • Increasing abdominal pain
    • Inability to pass stool
    • Increasingly restricted movement.
  • The Care Home failed to provide proper personal care for Mrs R. Mr A said Mrs R needed help with elements of her daily personal hygiene needs. He complains the Care Home failed to provide this help. Mr A said, as a result, his mother was unable to use the toilet when she wanted to and was left in urine soaked underwear. Mr A complains this, in turn, meant Mrs R developed avoidable urine acid burning between her legs.
  • The Practice failed to recognise signs the Care Home was not providing proper personal care for Mrs R. Mr A said the Practice should have noticed evidence of poor care during their examinations of Mrs R.
  • The Care Home failed to provide proper pressure area care. Mr A said Mrs R developed an avoidable pressure sore on her heel because of this.
  • Notts Council failed to investigate his concerns adequately or objectively. Mr A complains Notts Council accepted the professionals’ versions of events without any scrutiny or analysis.

Back to top

The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
  2. The Ombudsmen will not generally investigate a complaint unless they are satisfied the matter has been brought to the relevant organisation’s attention and that organisation has had a reasonable opportunity to investigate and reply to the complaint (Local Government Act 1974 section 26(5), as amended and Health Service Commissioners Act 1993, section 9(5)). However, in the case of joint complaints (i.e. those deemed suitable for investigation by the Joint Working Team operated by both PHSO and LGSCO), if one organisation has investigated and replied to the complaint but another organisation has not, the Ombudsmen may decide to exercise their discretion to investigation the complaint against all organisations, so that the issues can be considered in the round.
  3. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen 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).
  4. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened.
  5. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i)).

Back to top

How I considered this complaint

  1. I read the correspondence Mr A sent to the Ombudsmen and asked him about his concerns via email. I wrote to all the organisations to explain what I intended to investigate and to ask for comments and copies of relevant records. I considered all the comments and records they provided. I also got copies of records from Mrs R’s previous GP surgery, and from her hospital admission in January 2016.
  2. I read relevant legislation and guidance and got advice from a clinical adviser: a GP with relevant knowledge and experience.
  3. I shared a confidential copy of my draft decision with Mr A and all the organisations to explain my provisional findings. I invited their comments considered the remarks and additional information I received in response.

Back to top

What I found

  1. Until August 2014 Mrs R lived with one of her sons, Mr C, who supported her. York Council also arranged for carers to visit Mrs R three times a day. In August 2014 Mr C went into hospital and Mrs R moved in to a care home in York (the York Home) as a temporary, respite measure. However, Mr C remained unwell and Mrs R stayed in the York Home. She was registered with a local GP (the York GP) throughout this time.
  2. Mr C sadly died in July 2015. Mrs R’s family and professionals agreed she would not be able to cope at home on her own. Mrs R wanted to move closer to her family. Her grandson spoke to York Council and noted Mrs R wanted to move to the Care Home. The Care Home told York Council it could meet Mrs R’s needs.

York Council’s assessment of Mrs R’s needs

  1. York Council completed an assessment of Mrs R’s social care needs and a support plan in August 2015. This noted, among other things:
  • Mrs R had some short term memory loss but could communicate her needs and preferences. However, it said:
    • She underestimated the amount of care she needed
    • Had difficulty retaining information and needed to be reminded.
  • Mrs R experienced some incontinence and wore pads, and needed prompting to change the pad during the day if it was wet.
  • Staff needed to prompt and assist Mrs R with personal care and hygiene tasks, including:
    • To assist her in the shower with appropriate equipment
    • To monitor her skin.
  • Mrs R needed to receive a healthy, varied diet, and staff should:
    • Include low fat options
    • Encourage her to eat healthier options
    • Monitor her weight.
  1. Toward the end of August 2015 Mrs R’s grandson told York Council he was happy with its assessment. York Council sent copies of its assessment and support plan to the Care Home the following day.

Mrs R’s move to the Care Home

  1. Mrs R moved to the Care Home on 1 September 2015. The Practice registered Mrs R as a patient two days later.

Complaint that the Care Home failed to investigate Mrs R’s complaint of being attacked in her bedroom

Arrangements at the Care Home

  1. The Care Home said Mrs R’s room was on the first floor of the building. It said at night there are normally three carers working, plus a senior. The Care Home said two of the carers work on the first floor.

Care Home’s night time care plan

  1. The Care Home completed a range of care plans for Mrs R at the start of September 2015. This included one about night care. The Care Home recorded that Mrs R wanted staff to check on her every two hours during the night. The plan also said Mrs R could let staff know when she needed support and could use the call bell.
  2. The Care Home records state that night staff regularly checked on Mrs R at midnight, 2am, 4am and 6am.

Care Home records about events on 8 September 2015

  1. The Care Home’s records state Mrs R pushed her call bell shortly before midnight on 8 September 2015 as she was uncomfortable. Staff went to her room and inflated her mattress while Mrs R sat in a chair. Staff then helped her back to bed. Staff returned at 4am and found Mrs R to be sleeping.
  2. At 6am Mrs R told a staff member that someone had come into her room in the middle of the night and pushed her to the floor. The staff member checked Mrs R for injuries and did not find any. They also told Mrs R that a carer had been upstairs all night and would have heard something if it had occurred. Later in the morning Mrs R told a different carer that somebody had been in her room at night and hit her on the back of the head and she had fell and hit the front of her head. The staff member checked the back of her head and face but did not find any marks or wounds.

Contact with York Council

  1. York Council’s records show the Care Home called it the next day. The Care Home told York Council what Mrs R had said, and noted that her recollection of events had changed. The Care Home noted that Mrs R’s grandson’s wife had checked Mrs R and it said there was no sign of any bruising or injury. The Care Home also said its staff had not heard or seen anything.

Care Home records about events over the following days

  1. The records from the following days do not have any further reference to this incident, or any other concerns from Mrs R about her safety. There are entries about Mrs R asking staff to take her to her room. There are records that staff continued to regularly check on Mrs R throughout the nights and found her to be sleeping. In addition, there is evidence that Mrs R used the call bell to ask for assistance when she wanted it – for a drink, or to go to the toilet, or to complain that her bed was uncomfortable.
  2. The Care Home records do not contain references to Mrs R showing any anxiety about going to bed, or about staying in the same room. There is evidence to show that staff locked the door when she asked for this.

Guidance about patient safety

  1. There are standards for safety and quality care homes need to meet, which I will call the Regulations (The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). The Care Quality Commission (the CQC) has written guidance to help care homes meet these standards, known as the Fundamental Standards (Guidance for providers on meeting the regulations, March 2015). This includes keeping people safe from risk or harm (Regulation 12).


  1. The Care Home’s records show staff talked to Mrs R about this incident and regularly checked on her. There is also evidence that Mrs R was capable of, and willing to, ask for help when she wanted it, and of telling staff about her concerns. Mrs R did report said she had trouble sleeping after this incident, but this related to the comfort of the bed rather than any anxiety about a risk of harm. Records from later in the year show Mrs R did tell staff when she was in pain at times. Overall, given the absence of any evidence of a physical injury it was reasonable that the Care Home did not carry out an investigation of this incident. Therefore, I have not found any evidence of fault.

Complaint that the Care Home and Practice failed to address Mrs R’s deteriorating health during December 2015 and January 2016

Mrs R’s health before she moved to the Care Home

  1. Mr A said Mrs R had Chronic Obstructive Pulmonary Disease (COPD) and was a little overweight, but was otherwise in good health. Further, he said before her move to the Care Home Mrs R had a good appetite and ate normally. He also noted that, before the move, Mrs R had complained of pains in her lower left abdomen.

Events while Mrs R was in the York Home

  1. The York Home contacted the York GP in July 2015 and asked for indigestion treatment for Mrs R. The York GP prescribed medication and said the York Home should ask for a medical review if the symptoms persisted. A couple of days later Mrs R’s family asked for a medical review as Mrs R had been burping and having discomfort in her stomach. The York GP saw her the following week and noted the problem had been ongoing for some time but was getting worse. They advised Mrs R to stop taking a medication and asked for an abdominal ultrasound.
  2. Mrs R had the ultrasound scan in late August 2015. However, the sonographer said it had been difficult to perform the examination so the scan had limited use as a diagnostic tool.

Records the Care Home kept

  1. The Care Home weighed Mrs R the day after she moved in and found her to be 104.1kg. It recorded this on a ‘Weight Monitoring Chart’ which it updated during Mrs R’s admission.
  2. The following day the Care Home started a ‘Food and Nutrition Record’ for Mrs R. This recorded information about the food and portion sizes it offered, and what Mrs R ate. It recorded this information for: breakfast; morning snack; lunch; afternoon snack; tea; and supper. Staff completed this each day.
  3. Staff also made regular entries on the Care Home’s ‘Daily Notes’. These notes included entries about:
  • Mrs R’s mood
  • What she did during the day
  • Whether she had eaten well or not had much to eat
  • The type of care and support staff gave (or offered) Mrs R
  • Concerns Mrs R or staff had about her health.

Relevant events in September 2015

  1. The Practice saw Mrs R for the first time in the middle of September 2015. It did not yet have the records from the York GP, other than some the Care Home provided. The Practice noted Mrs R was belching a lot and that this was an ongoing issue.

Relevant events in October 2015

  1. A GP from the Practice saw Mrs R again at the start of October 2015. They noted Mrs R had occasional spasms of stomach pain and had not opened her bowels for a few days. The GP examined Mrs R and thought she might be constipated and have colic (pain in the upper abdomen). The GP prescribed Buscopan (a medication to ease stomach cramps). They also asked the Care Home to see how things developed over the next few days and, if Mrs R got more unwell, to ask for another review.
  2. The Care Home weighed Mrs R again in early October 2015 and found her to be 96.9kg (a decrease of 7.2kg over 34 days).
  3. On 12 October 2015 staff in the Care Home felt Mrs R seemed unwell, was not moving as well and was not eating or drinking much. They asked a GP to see her. The GP examined Mrs R but did not find anything unusual. They prescribed a laxative and asked for a blood test. A couple of days later Mrs R complained of pain in her abdomen and told staff it felt ‘like her insides were twisted’.
  4. On the same day Mrs R’s grandson contacted York Council and said Mrs R had not settled in well. He said she had been confused at times, as well as paranoid and fearful. He also said her mobility and balance had deteriorated. Mrs R’s grandson said he felt Mrs R may need an updated assessment at some point.
  5. The Care Home weighed Mrs R again the next day and recorded her weight as 93.7kg (a decrease of 3.2kg over nine days, and 10.2kg over 43 days).
  6. Mrs R complained of similar pain again the following week and staff noted she had not eaten much and her mobility seemed poor. Staff spoke to a GP at the Practice and said the Buscopan had helped a lot. The GP approved another prescription.
  7. Toward the end of October 2015 the Care Home contacted the Practice again. They noted Mrs R had lost weight and said the Buscopan did not seem to be working anymore.

Relevant events in November 2015

  1. A GP visited at the start of November and noted the amount of weight Mrs R had lost between the start of September and middle of October. They also noted Mrs R was still complaining of wind and belching and was refusing to eat. The GP examined Mrs R but did not find anything to explain her symptoms. The GP referred Mrs R to a geriatrician for further investigation, to help find a cause of her continued abdominal pain and weight loss.
  2. On the same day Mrs R’s grandson spoke to York Council. He noted Mrs R was eating very little. He also said she was paranoid and yelped and flinched and put her hands up to her face if anyone came near her. Mrs R’s grandson said Mrs R had deteriorated significantly, including her mobility and mental health.
  3. York Council also spoke to the Care Home. The Care Home noted it had food and fluid charts in place and were in contact with the GP who had, in turn, referred Mrs R to a geriatrician. York Council spoke to Mrs R’s grandson again and he said he felt it was appropriate to wait for the outcome of the referral to the geriatrician to see if this ruled out a clinical cause and, if it did, they could then consider a mental health assessment. York Council also noted that Mrs R’s grandson was happy with the care at the Care Home and felt a move would be detrimental to Mrs R’s health.
  4. The Care Home weighed Mrs R again on 6 November 2015 and she weighed 91.1kg (a decrease of 2.6kg over 22 days, and 13kg over 65 days).
  5. At the end of November 2015 York Council spoke to the Care Home which advised that things were pretty much the same. The Care Home said it was continuing to monitor how much Mrs R ate and drank. It also noted that Mrs R had not yet seen the geriatrician.

Relevant events in the Care Home in December 2015 and early January 2016

  1. Mrs R continued to eat only small amounts of food in December 2015, and sometimes refused to eat anything. This was in the Care Home and when Mrs R went out: Mrs R’s grandson took Mrs R out in early December 2015 and told staff they had encouraged her eat at their house but she had not eaten anything.
  2. A couple of days later the Care Home called the Practice due to their concerns about how little Mrs R was eating. A GP said Mrs R needed to see the geriatrician as they had done as much as they could to investigate her symptoms locally. The GP said they would chase the referral.
  3. On 13 December 2015 staff asked for a GP review because of general concerns about Mrs R’s health. The staff member recorded in the Care Home notes that Mrs R was ‘not right’. They also recorded in the daily notes that Mrs R was still complaining of pain in her stomach and still not eating. The GP saw Mrs R the next day. They noted Mrs R’s breathing was ‘not as good’ and examined her. They did not find anything to explain Mrs R’s symptoms and noted again that she was due to have an outpatient appointment with a geriatrician. Over the following days the Care Home noted that Mrs R periodically threw herself back and forth and complained of pain in her stomach.
  4. On 21 December 2015 the Care Home called an ambulance which took Mrs R to hospital. The hospital diagnosed Mrs R as suffering from urinary tract and kidney infections and noted she was dehydrated. It gave Mrs R a course of antibiotics, encouraged her to drink and discharged her the same day.
  5. The Care Home weighed Mrs R again on 23 December 2015. She weighed 82.5kg (a decrease of 8.6kg over 47 days, and 21.6kg over 112 days). The following day staff advised the Practice that Mrs R continued to eat and drink very little.
  6. The Care Home updated its care plans for Mrs R on 28 December 2015. It noted she continued to have the mental capacity to tell staff what she liked and did not like. The care plans noted Mrs R had minor problems with chewing and swallowing. It advised staff to encourage and assist Mrs R to eat.

Admission to hospital on 3 January 2016

  1. Mrs R went to stay with her family on 2 January 2016. They called an out of hours doctor the following evening due to Mrs R’s abdominal pain. Mrs R went to hospital which noted she had an acute kidney injury and treated her with IV fluids.
  2. Mrs R had a CT scan on 6 January 2016 and this showed her to be faecally loaded. The following day medics noted concerns about Mrs R’s ability to swallow safely. They said she should not be given food or drink orally and asked Speech and Language Therapy (SALT) to review her. This review happened the next day and SALT recommended a pureed diet and thickened fluids.
  3. Mrs R remained in hospital until she sadly died on 21 January 2016.

Relevant guidance

  1. Health and social care staff should presume people have the mental capacity to make choices about their own care unless there is proof to the contrary. People should not be treated as lacking capacity just because the decisions they make are unwise ones (Section 1, Mental Capacity Act 2005).
  2. Care homes need to provide personalised care, respect peoples’ wishes and ensure they only provide care and treatment with the person’s consent. As part of this, care homes should assess peoples’ needs, taking account of their own views and preferences, and keep these assessments under regular review (Regulations 9, 10 and 11).
  3. Care homes also need to make sure their residents get enough to eat and drink. As part of this requirement, care homes need to keep a person’s food and drink needs under review. When things change, and when a person is not eating or drinking enough, staff need to act (Regulation 14).


  1. The Care Home’s records show staff regularly checked on Mrs R and noted changes to her health and eating habits. They also show that staff were conscious of, and concerned about, Mrs R’s weight loss.
  2. Mrs R was never considered to lack the mental capacity to make her own choices, including about what she would or would not eat. The Care Home needed to respect Mrs R’s own choices and could not force her to eat. There is evidence to show that staff tried offering different types of food, and encouraged Mrs R to eat and drink. The Care Home also sought help from medical professionals to try to find a cause for Mrs R’s behaviour and pain, by involving the Practice.
  3. The Practice records show GPs reviewed Mrs R in good time when the Care Home asked for this. Mrs R’s weight loss was significant. There was a basic explanation for this – that Mrs R was not eating. Mrs R was also noted to be constipated and this can sometimes make people less inclined to eat. The GP requested blood tests to try to find an explanation for what was happening, but the results did not provide an answer.
  4. The significance of Mrs R’s weight loss meant further action was necessary. The Practice did act by referring Mrs R to a geriatrician. This was appropriate.
  5. It is established practice to allow secondary care to consider whether to undertake different types of investigations. Some can be invasive and be stressful, both physically and mentally, and it is appropriate for a consultant to weigh up the pros and cons with the person (and their family) as they have more specialist experience. Therefore, it was reasonable for the Practice to have left it for secondary care to have considered these matters.
  6. However, Mrs R did not get to see a geriatrician. The Practice had asked for an appointment ‘soon’, as opposed to urgently. This was appropriate in the circumstances, as physical examinations and blood tests had not suggested anything sinister as a cause for Mrs R’s weight loss. There are no set standards for how long it should take to get an appointment following a ‘soon’ referral. It can vary around the country and between disciplines. As a general guide the referrer might expect the person to be seen within four to eight weeks.
  7. The Practice said when it made the referral to the geriatrician there was nothing to indicate there was likely to be a wait of more than a few weeks. It said the hospital asked it to email the original referral letter to them on 27 November 2015, and it did so. The Practice said it chased things up on 8 December and again on 29 December 2015. It said that it was at this point that the old age service indicated the waiting time was likely to be eight to ten weeks. During the complaints process the hospital noted there had been a ‘clinic capacity issue’ which meant it could not offer an appointment earlier than 6 January 2016. The hospital apologised for this.
  8. A month after the Practice made the referral Mrs R had not shown any signs of improvement. In addition to asking the secretaries to chase things up a GP could have written a letter to geriatrician asking for the referral to be expedited as Mrs R had not improved after a month. However, throughout this time, there was nothing in the GP’s examinations or the blood tests which indicated Mrs R needed an urgent, acute admission. At one point blood tests showed some renal impairment but this improved at a later test and returned to an acceptable level. A test also suggested Mrs R might be slightly anaemic but, again, this returned to a normal range at the next test. It is also notable that Mrs R went into hospital toward the end of December 2015 but it did not find she needed to stay in hospital. Therefore, there had been no indication Mrs R needed an acute hospital admission before she went at the start of January.
  9. If a GP had written to the geriatrician after a month I do not know whether this would have sped things up as the geriatrician’s caseload was out of the Practice’s hands. Further, the investigations the geriatrician could have asked for were done during Mrs R’s hospital admission and did not identify a clear cause for her problems. Mrs R was found to be constipated, but scans and examinations did not identify any other explanation for Mrs R’s deterioration and weight loss. The Practice had known Mrs R was constipated in the community and they had prescribed an appropriate treatment for this. As such, while the Practice could have been more proactive in chasing the referral it made to secondary care, it is not clear this would have led to a different outcome.
  10. Overall, there is evidence to show the Care Home monitored Mrs R’s health appropriately and asked for suitable medical help. The Practice completed relevant examinations and tests and, again, made a suitable referral. Therefore, I have not found evidence of fault.

Complaint the Care Home failed to provide proper personal care for Mrs R

Records the Care Home kept

  1. The Care Home completed care plans for Mrs R a couple of days after she moved in. It noted she was occasionally incontinent of urine and may need a carer to help her to use the toilet.
  2. Staff recorded the ways they supported Mrs R in the Daily Notes. This included entries about:
  • Helping with personal care
  • Helping to get dressed
  • Washing
  • Helping Mrs R to the toilet
  • Changing continence pads.
  1. On 21 December 2015 staff noted another full body wash and reported that Mrs R was sore and red. They applied a cream and informed a senior member of staff.
  2. The Care Home updated its care plans on 28 December 2015. It noted that two members of staff needed to help Mrs R to the toilet due to poor mobility. The Care Home also noted that Mrs R needed full assistance with general bathing and personal hygiene. On the same day staff noted they were checking all of Mrs R’s pressure areas every day and would report any concerns to the senior member of staff on duty who would then inform the community nurses if necessary.
  3. The following day staff noted that Mrs R was still looking red and they applied more cream.

Relevant records from Mrs R’s hospital admission

  1. On 4 January 2016 hospital staff noted two stage two sores to Mrs R’s left and right buttocks, and a stage three sore on her natal cleft. A couple of days later staff noted a ‘significant moisture lesion to sacrum, both buttocks’.


  1. The Care Home records show that Mrs R’s need for help and support increased during her time in the Care Home. There are entries from the early part of her stay which report her going to the toilet on her own but, later, she could not manage this. The records also show that staff regularly checked on Mrs R and offered to help her wash, dress and go to the toilet. There were a number of occasions when Mrs R told staff she did not want any help. In keeping with the Regulations, staff were right to respect Mrs R’s wishes.
  2. Pressure sores and moisture lesions can occur very quickly, over a matter of hours. This means the evidence from the hospital does not automatically show Mrs R’s sores came from her time in the Care Home. Nevertheless, Mrs R’s mobility was known to have reduced, she was incontinent, sometimes refused to let staff change her pads or wash her, and had a poor diet. These are known risk factors for the development of pressure sores and moisture lesions. Therefore, on the balance of probabilities, the sores the hospital found related to the time she was in the Care Home.
  3. However, this is not to say the sores only arose because of poor care by the Care Home. Entries in late December 2015 provide evidence that staff did wash Mrs R thoroughly. They took note of changes to her skin and responded to this. The Care Home updated the relevant care plan and there is evidence that staff were aware of the need to check on areas of Mrs R’s skin which were susceptible to pressures sores. There is also evidence to show the Care Home used a pressure relieving mattress and pressure cushions. Therefore, there is sufficient evidence to show the Care Home offered appropriate support for Mrs R’s needs, but she did not always want to accept it.

Complaint the Practice failed to recognise signs the Care Home was not providing proper personal care for Mrs R.

Response from the Practice

  1. In response to this complaint, the Practice said the Care Home, Mrs R and the family did not advise it of any pressure sores or moisture lesions. It said GPs always saw Mrs R for a defined problem and undertook relevant examinations. It said its GPs limit their examinations to areas of the body which are relevant to the clinical concerns they are dealing with at the time.


  1. The Practice’s response is in line with established good practice for GP visits. When GPs complete home visits the person who requested the visit advises of a problem and the GP completes a targeted examination. There is no expectation for a GP to undertake a complete, head-to-toe examination of patients every time they see them. Also, GPs generally do not get very involved in issues around skin integrity and pressure areas. Nurses have the relevant skills and expertise for these issues. Therefore, I have not found any evidence of fault here.

Complaint the Care Home failed to provide proper pressure area care

Relevant events while Mrs R was in the Care Home

  1. The Care Home recorded that a community nurse saw Mrs R on 24 December 2015 and looked at a wound on her left foot. The notes said the nurse thought it looked like a blister and, as it was dry, advised against putting a dressing on it. A couple of days later a member of staff noted a ‘bruised looking circle on [Mrs R’s] left heel’. They notified a senior member of staff.

Relevant records from Mrs R’s hospital admission

  1. On 4 January 2016 the hospital noted a stage three pressure sore (measuring 2.5cm by 2.5cm) on Mrs R’s heel. It described this as 100 percent necrotic. A member of staff called the Care Home which said this related to a slipper.

Guidance on pressure area care

  1. All adults are at risk of developing pressure sores and there is guidance about helping to prevent them. The National Institute for Health and Care Excellence (NICE) issued its guidance in April 2014, which I will refer to as the NICE Guidance (NICE Clinical Guideline 179 – Pressure Ulcers: prevention and management (April 2014)). This includes advice that staff should discuss ‘with adults who are at high risk of developing a heel ulcer a strategy to offload heel pressure’ (section 1.1.15).


  1. I have not seen evidence in the Care Home records to show that it took sufficient proactive steps to help prevent this sore from forming. Records show staff were aware of a mark on Mrs R’s heel. The hospital notes provide evidence that staff felt it related to her slippers. However, I have not found any entries in Mrs R’s notes or care plans about taking steps to alleviate pressure on this area. This is fault. A plan, which could have included the use of specific equipment or advice about regular repositioning of this area, could have helped to prevent the sore Mrs R had. The sore was painful and distressing for Mrs R, and distressing for other to see. Therefore, on the balance of probabilities, this fault led to an injustice.

Complaint that Notts Council failed to investigate his concerns adequately or objectively

Notts Council’s investigation of Mr A’s concerns

  1. Mr A contacted the Care Quality Commission (the CQC) and raised concerns about the way the Care Home had cared for his mother. In early April 2016 the CQC referred these concerns on to Notts Council as a safeguarding matter.
  2. Notts Council checked whether its social care team had any previous contact with Mrs R, and checked if any safeguarding concerns had been raised earlier. It checked with its Quality Market Management Team and noted they did not have any current concerns about the Care Home. Notts Council also checked the CQC website and found the last inspection had rated the Care Home as ‘Good’.
  3. In the middle of April 2016 a Safeguarding Social Worker visited the Care Home. Later in the month she spoke to a GP at the Practice and asked about their involvement in Mrs R’s care. The Social Worker went to the Care Home again in early May and looked at the records and spoke to the manager. The Social Worker also visited a hospital and read through the records of Mrs R’s admission to hospital in January 2016.
  4. Notts Council closed its safeguarding enquiry as ‘inconclusive’ and said it had not identified any risk.


  1. Evidence shows Notts Council obtained information from an appropriate range of sources to form an understanding of what happened while Mrs R was in the Care Home. The case notes show the Social Worker used her judgement to analyse this information. Therefore, there is evidence to show the Council followed the process appropriately and I have no reason to question the professional judgement of the Social Worker. I find no fault.

Back to top

Agreed actions

  1. Within one month of the date of the final decision York Council (as the organisation responsible for arranging Mrs R’s care) should write to Mr A to acknowledge they did not provide suitable pressure area care in respect of Mrs R’s heel. They should also acknowledge that, as a result, Mrs R developed a pressure sore to her heel which caused her and her family distress. York Council and the Care Home should apologise for this distress.
  2. Within two months of the date of the final decision York Council should arrange for the Care Home to complete an action plan to ensure lessons are learned from this complaint, and to help prevent recurrences. The Care Home should share this with York Council and the Ombudsmen.

Back to top


  1. I have completed my investigation on the basis that:
  • There was no fault in the actions of the Care Home after Mrs R complained of being attacked in her room.
  • There was no fault in the way the Care Home and Practice responded to Mrs R’s deteriorating health during December 2015 and January 2016.
  • There was no fault in the Care Home’s management of Mrs R’s personal care needs.
  • There was no fault on the part of the Practice in relation to Mrs R’s personal care needs.
  • There was fault in the pressure area care Mrs R received in the Care Home and this led to an injustice. I have recommended an apology and action plan to address this injustice.
  • There was no fault in the process Notts Council in investigating Mr A’s complaint.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page