Summary: Mrs Y complained about the quality of care provided to Mr Y by Kibworth Court Residential Home, on behalf of the Council, and the Council’s response to, and investigation of, her concerns about his care. We have found fault by Kibworth Court in failing to keep accurate records, and properly assess Mr Y’s skin condition, causing injustice. The Council has agreed to remedy Kibworth Court’s faults by apologising to Mrs Y and making a payment to reflect her distress, and providing evidence of the action taken to improve Kibworth Court’s service.

The complaint

1. The complainant, who I am calling Mrs Y, complains about the quality of care provided to her late husband, who I am calling Mr Y, by his residential care provider, Kibworth Court Residential Home (KC), on the Council’s behalf. She is particularly concerned about his care during the period before his admission to hospital.
2. Mrs Y says KC failed to:

• provide Mr Y with good nutrition which led to his severe weight loss
• neglected Mr Y and failed to provide him with adequate personal care
• safeguard Mr Y
• properly implement and follow Covid-19 protection measures
• seek appropriate medical intervention and treatment for, and keep her informed about, Mr Y’s deteriorating skin condition

3. Mrs Y says these care failings affected Mr Y’s health and wellbeing. They resulted in such a severe deterioration in Mr Y’s physical condition, that on his admission, the hospital raised a safeguarding concern with the Council.
4. Mrs Y also complains about the Council’s response to the concerns she raised about Mr Y’s care. She says the Council failed to properly investigate her concerns or carry out a proper safeguarding enquiry.

The Ombudsman’s role and powers

5. 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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), 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, section 25(7), as amended)
7. If we are satisfied with a council’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

8. I made enquiries of the Council and read the information Mrs Y and the Council provided about the complaint.
9. I invited Mrs Y and the Council to comment on a draft version of this decision. I considered their responses before making a final decision.
10. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

What should have happened

Fundamental care standards

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards registered care providers must achieve. The CQC, as the statutory regulator of care services, has issued guidance on how to meet these standards below which care must never fall.
12. We consider the 2014 Regulations when determining complaints about poor standards of care. The following regulations, relevant to this complaint, require care providers to:

• provide appropriate and person-centred care and treatment based on an assessment of the person’s needs and preferences. (regulation 9)
• assess the risk to people’s health and safety during any care or treatment (regulation 12)
• ensure a person has enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. Nutrition and hydration intake should be monitored and recorded to prevent unnecessary dehydration, weight loss or gain (regulation 14)
• keep accurate, complete and contemporaneous records of care and treatment (regulation 17)

13. It is not our role to decide whether any failings in care or treatment by a care provider are breaches of the fundamental standards. These are matters for the CQC with which we share our decisions.

The Council’s role

14. A council may commission another organisation to provide care services on its behalf. However, the council remains responsible for those services and the actions of the organisation providing them.
15. The Care Act 2014 says a council has a duty to safeguard adults. Section 42 of the Act says a council must make necessary enquiries if it has reason to believe a person may be at risk of abuse and neglect, and, because of their need for care and support, cannot protect themselves.

What happened

Background

16. I have set out a summary of the key events below. It is not meant to show everything that happened.
17. In 2019 the Council commissioned KC to provide Mr Y with residential care. An independent relevant person’s representative (RPR) was appointed for Mr Y under the Deprivation of Liberty Safeguards (DOLS). Her role was to maintain contact with Mr Y and provide him with independent support in DOLS related matters. I understand Mr Y’s RPR maintained monthly contact with him.

Council’s response to Mr Y’s RPR’s referral

18. In January 2020, Mr Y’s RPR contacted the Council’s Adult Social Care team about concerns Mrs Y had raised with her about Mr Y’s care. Mrs Y told her she was finding it difficult to discuss concerns directly with KC. Mrs Y had many concerns and felt Mr Y’s care needs were not being met.
19. The Council’s Safeguarding Adults team investigated the RPR’s referral. The team’s records show they:

• called Mrs Y to discuss her concerns but were unable to speak to her. They asked the RPR for help contacting Mrs Y, and left messages with KC asking her to contact them. The team did not hear back from Mrs Y.
• gathered information from KC and the district nurses who visited Mr Y.
• concluded the concerns raised did not meet the threshold for undertaking a safeguarding enquiry under Section 42 of the Care Act.
• informed Mr Y’s RPR of the outcome of the referral.
• wrote to Mrs Y informing her of the outcome.

The Safeguarding Adults team’s further enquiries in February 2020

20. Mrs Y contacted the team after receiving their letter informing her of the outcome of the referral. She said there were serious issues with KC’s care of Mr Y and other residents. She wanted the team to look at this again and provided them with her notes about these issues.
21. The team made further enquiries. Its records show it reviewed the notes Mrs Y provided. It contacted KC for additional information. It carried out a visit to KC.
22. The team concluded, after completing its further enquiries, the concerns raised did not meet the threshold for a safeguarding enquiry. But they felt there was a breakdown in the relationship between Mrs Y and KC’s manager, there was a risk KC would end the placement and further work was needed. Mr Y’s case was transferred to the Council’s Older Adults team.

The Older Adults team’s review March 2020

23. The team contacted Mrs Y in March. They asked how they could support both her and Mr Y. Mrs Y said she was unhappy with Mr Y’s care, in particular his poor diet.
24. The team contacted KC. They said Mr Y’s needs had not changed. He was on a supplemented diet to increase his calorie intake.
25. On 23 March the team carried out a review of Mr Y’s care and support plan (by phone due to the Covid-19 restrictions in place at the time) with Mrs Y and separately with KC’s manager. The review confirmed:

• Mrs Y had recently raised concerns about standard of care. These had been referred to the Safeguarding Adults team. The concerns had not triggered an investigation but recommendations about record keeping had been made to KC.
• Mr Y’s RPR would maintain monthly contact with all parties.
• Mrs Y had been visiting Mr Y daily but could not do so now because of Covid-19 restrictions. Their daughter was having skype calls with him.
• Mr Y needed to be weighed regularly to make sure he maintained a healthy weight.
• Mr Y needed support with all personal care, and help getting dressed to make sure he was dressed appropriately. Occasionally he would not sleep well and needed support at those times

July 2020

26. Mrs Y contacted the Council again in July. She said she felt Mr Y’s health had gone downhill over the last 12 weeks. She was buying him additional food. She asked about moving Mr Y to a different care home.
27. The Council’s records show its Older Adults team tried to contact Mrs Y a number of times in July and August by phone and email to discuss her concerns but were unable to speak to her.

September 2020

28. Mr Y developed a rash on his arm. KC’s records confirm one of the local medical practice’s paramedics attended Mr Y on 1 September and prescribed cream to treat the rash. In a case note, KC said Mr Y had a raised area, what looked like a rash to his left and right elbow and forearms, which looked red and raised and was itchy.
29. The Older Adults team called KC on 9 September to ask how Mr Y was and for the documentation required from KC to complete the review. KC confirmed this would be sent.
30. On 23 September Mrs Y contacted the Older Adults team. The record of her call says Mrs Y told the team she was not looking to move Mr Y at the moment. Things had improved and she was happy with Mr Y’s care workers, although not with KC’s management. She was still concerned about Mr Y’s weight loss. The team noted KC had not yet sent the updated care plan needed to complete the review.

October 2020

31. Mrs Y told the Older Adults team she was concerned again about Mr Y’s care. He now had eczema in addition to his existing conditions of asthma and COPD. Mrs Y said she was considering moving Mr Y to another care home or caring for him at home. The team told her they were still waiting for the review paperwork from KC and Mrs Y said she would remind them on her next visit.

Mr Y’s health issues in October and November 2020

32. KC’s records show:

• Mr Y had been prescribed cream for his rash. This was being applied every day.
• Mr Y was wheezy, breathless and lethargic on 10 October. KC called 999, paramedics attended and liaised with the out of hours GP. It was thought to be an exacerbation of Mr Y’s existing COPD, which could turn into a chest infection. Mr Y was prescribed antibiotics and steroids.
• KC called the local medical practice on 19 October as Mr Y was lethargic. The nurse practitioner called to discuss his condition and medication was started.
• The nurse visited Mr Y on 21 October. His temperature and pulse were fine, oxygen a little low but the nurse was not overly concerned. She prescribed stronger antibiotics and KC were to continue to monitor him. The nurse also prescribed nutritional drinks because Mr Y was slowly losing weight although he was still eating his meals well.
• Mr Y’s skin integrity was checked on 3 November. His skin felt warm and there was an area of redness. A photo was taken with a note to inform a senior.
• Mr Y had a fall on 8 November. KC reported this as:

“Answered emergency call bell found staff with Mr Y. He has a graze on his head left hand side forehead, and skin tear to left elbow. Head not bleeding it is just a graze and dressing applied to elbow. Will follow minor head injury route with hourly checks and if condition changes will ring 111. Mr Y seems his usual self and able to move all limbs as usual with no pain. And weight bear assisted back into bed with pressure mat in place…..An unwitnessed fall, monitoring for injury in their room.”

• KC called the GP on 9 November. Mr Y was lethargic and being physically supported to eat and drink. His temperature was recorded as 36.6, pulse 92bpm and oxygen level 96%. The nurse called the home and spoke to staff. It was likely Mr Y had another chest infection. She prescribed antibiotics and a change of inhalers. KC carried out a Covid-19 test on Mr Y.

Mr Y’s admission to hospital on 10 November 2020

33. KC called 999 because Mr Y was having difficulty breathing. He was admitted to hospital and found to have Covid-19. Sadly, Mr Y died in hospital on 15 November. His cause of death was recorded as Covid-19, dementia and COPD.
34. The ward sister attending Mr Y on his admission contacted the Council about him on 12 November. She said Mr Y had scabies, with a very itchy red rash all over his body and tested positive for Covid-19 on admission. She was concerned about his condition which she felt was evidence of neglect.
35. The Council contacted the hospital’s safeguarding team. The hospital safeguarding officer told the Council:

• Mr Y was brought into hospital due to shortness of breath, a rattle in his throat and not responding.
• He was diagnosed with sepsis, Covid and scabies on admission.
• Mr Y had several bruises and a bump on his head from an unwitnessed fall. The care home was unable to tell her when this happened.
• He had a bruise with a wet laceration to his left elbow and a bruise with a wet laceration to the left side of his forehead. (Photos taken by the hospital of these injuries were sent to the Council).
• Mr Y also had an all over rash which had been diagnosed as scabies. The hospital could not say for how long he had had this. Sepsis would not have been triggered by scabies.

36. In response to the hospital’s referral, the Council initiated a safeguarding enquiry on 16 November, under the category of neglect.

The safeguarding enquiry

37. This enquiry was carried out by Mr Y’s case officer in the Older Adults team. The report says she liaised with hospital and KC staff, and Mr Y’s family. The officer completed the enquiry in February 2021. She concluded allegations of neglect by KC were not substantiated. No risks were identified and KC appeared to have taken appropriate action regarding its care for Mr Y, as evidenced by its records.
38. The enquiry report said:

• Mr Y’s admission to hospital was not connected to his fall, but due to the general deterioration in his breathing. This was consistent with the hospital information recording his admission was due to shortness of breath, rattle in throat and not responding.
• KC said Mr Y had been undergoing treatment for a chest infection and exacerbation of his COPD.
• KC were aware of his fall as documented by its incident record. Mr Y was assessed as low risk of fall. He fell on to the sensor mat by his bed which alerted KC to the fall.
• The hospital’s report appeared to be due to a miscommunication with KC.
• Mr Y’s medical notes show he was receiving treatment for eczema. KC’s manager had vehemently stated the care home had not had an outbreak of scabies as supported by the fact they had not had to take any measures concerning this.
• The hospital records said Mr Y was being treated for Covid-19 and sepsis. His cause of death was recorded as Covid-19, dementia and COPD.
• Mr Y was tested by KC for Covid-19 on 9 November. His positive test result came back on 13 November, after his admission to hospital on 10 November.

KC’s contact with the Council about other residents with skin conditions

39. KC’s manager spoke to the Council’s infection prevention and control senior nurse advisor on 4 January 2021. KC has provided the nurse’s email to the manager confirming their conversation and that the manager had advised:

• Eight residents had been identified as possibly having scabies
• None of the residents had had skin samples sent for testing/confirmation
• Six of the residents had the first treatment on 24 December 2020 and another two had their first treatment on 1 January 2021.

Mrs Y’s complaint to the Council.

40. Mrs Y complained to the Council about KC and Mr Y’s care. The Council responded to her complaint on 8 February 2021. It confirmed the outcome of the safeguarding enquiry and said:

• Its safeguarding team had spoken to the hospital. The deterioration in Mr Y’s breathing was linked to COPD. The rash, initially thought to be scabies, was now thought to be exacerbation of eczema.
• KC’s records documented the fall and showed it had consulted the GP about Mr Y’s skin condition, which had been diagnosed as eczema. It had applied the prescribed cream.
• The safeguarding investigation had concluded the concern as unsubstantiated, with no evidence of neglect or failure of care.

The safeguarding enquiry review

41. Mrs Y was unhappy with the enquiry conclusion and pursued her complaint with the Council. In response to this, the Council arranged for another of its officers to carry out an independent review of the enquiry.
42. The Council’s records confirm the reviewing officer spoke to:

• KC’s manager. The manager was also asked to send records of Mr Y’s food intake, interactions with health professionals, consultations about Mr Y’s rash and application of the prescribed cream.
• the medical practice’s nurse practitioner who attended Mr Y. She said Mr Y’s rash was examined by their practice paramedic on 1 September who prescribed hydrocortisone cream. Mr Y had not been diagnosed with scabies (while at the home). But there were some residents at KC who had been treated for this. Mr Y appeared to be a happy man and she had not noted anything when she attended him which might appear to be neglect or poor care. He was at high risk of developing complications from Covid-19.
• KC’s manager again, about a staff member who had tested positive for Covid-19, the dates of Covid-19 tests for residents, and other residents with rashes. The manager was asked to provide details of its Covid-19 infection control prevention measures.

43. KC provided the following information about its Covid-19 prevention measures:

• PPE was purchased through its directors and usual sources and masks purchased and provided by the Council. Uniforms were not worn out of the building and staff who had to travel on buses were given extra PPE for the journey.
• Temperatures taken as staff arrived and residents daily by senior in charge.
• Staff were tested regularly. Their tests were negative on 6 September 2020, 9 and 10 October and 2 November.
• All KC’s residents were tested on 11 July and 9 October 2020 and all results were negative.
• A member of staff, care worker A, tested positive on 7 November. Her last working day at KC was 3 November. Care worker A did not work at the home on 6, 7, 8, or 9 November.
• Staff were tested again on 9 November and were negative.
• Residents who had been supported by care worker A the last time she was at work were tested initially and were negative.
• Another group of residents were tested, including Mr Y, whose results were positive.

44. The reviewing officer completed her review in May 2021. She reported:

• Regarding the concerns Mr Y had scabies on his admission to hospital, he had been seen by the medical practice paramedic on 1 September who assessed the rash on his skin and prescribed hydrocortisone cream.
• Mr Y continued to be supported by care workers who reported that the rash did not get worse.
• Mr Y was last seen by the nurse practitioner on 21 October. There was no mention of a rash on his skin. It was noted Mr Y’s health was deteriorating and concerns mentioned of progressive dementia and reoccurring chest infections.
• KC’s manager had provided information on the Covid-19 prevention guidelines followed for staff members and residents and testing staff members and residents.
• The nurse practitioner reported that there was no evidence of neglect in Mr Y’s care when she attended to him.

45. The officer concluded the safeguarding threshold of Neglect and Acts of Omission at a higher level did not appear to have been met. However, there were some lessons learnt especially around escalating skin condition concerns which had been fedback to KC’s manager.

The Council’s complaint response

46. Two of the Council’s managers met with Mrs Y to discuss her complaint and the outcome of the enquiry review on 7 May 2021. The managers considered the breakdown in her relationship with KC’s management team had a serious impact for Mrs Y, leading to a failure in effective communication and trust at certain points.
47. The Council sent Mrs Y its final response to her complaint on 11 May. This said:

• The initial safeguarding investigation had been reviewed, together with additional information. The decision was the concern was unsubstantiated and the safeguarding threshold not reached.
• The breakdown in Mrs Y’s relationship with KC’s management team had been identified as a significant factor in the course of events.
• The Council would waive Mr Y’s care fees from 21 October 2020 when his deterioration was first noted.
• It enclosed KC’s response to specific questions raised by Mrs Y.

Mrs Y’s complaint to us

48. Mrs Y first contacted us about her complaint in January 2021. At this stage the Council had not completed its safeguarding enquiry or its complaints process. She brought her complaint back to us in June 2021.

My findings – was there fault by the Council or KC causing injustice?

KC’s day to day care of Mr Y

49. I have reviewed the records provided by KC of its day- to- day care of Mr Y. These set out details of his care needs, including his medication, skin integrity, sleeping and personal care needs.
50. The care notes record the personal care provided, including the regular application of the skin cream prescribed in September 2020, monitoring of and response to any sleep issues and his daily life at KC. I do not consider these indicate care failings by KC in these areas.

Mr Y’s nutrition and hydration needs

51. I have reviewed KC’s meal charts and nutrition records for Mr Y. These give details of his meals and snacks, and how much he ate and drank. I consider they show KC was monitoring Mr Y’s food and fluid intake, and he was generally eating and drinking well, until shortly before his admission to hospital. I do not consider these records indicate a failing by KC to provide Mr Y with enough to eat and drink.

Mr Y’s weight records

52. There are, however, inconsistences in KC’s records of Mr Y’s weight. Mr Y’s weight chart records him as being weighed on the first of every month in 2020 until 1 October, and a gradual loss of weight – 2.kg – over a period of nine months.
53. But information recorded in KC’s hospital pack shows Mr Y lost 6.3 kg in the six months between December 2019 and June 2020.
54. One of Mrs Y’s main concerns was that Mr Y was losing weight. In a photo she sent me Mr Y looks gaunt. But I note KC says Mr Y was a very active man who walked with a purpose every day and only sat for limited time. His weight loss started as his health deteriorated and his dementia became more advanced.
55. I consider, the significant inconsistencies in the information KC recorded about Mr Y’s weight, mean there is no reliable record of his weight loss during 2020. In my view this was a failure to keep accurate records, and fault by KC. This may not be in line with the fundamental standards.
56. This fault means it is not certain how much and how quickly Mr Y was losing weight and what steps should have been taken in response to this.
57. I do not consider I can say how this fault affected Mr Y. Having considered the evidence provided (including KC’s care notes and the nurse practitioner’s comments), my view is Mr Y appeared to be fairly well, happy and active until the deterioration in his health in the period leading up to his admission to hospital.
58. But, in view of Mrs Y’s ongoing worry about Mr Y’s weight, this fault has left Mrs Y with uncertainty as to whether her concern was justified.

Other paperwork

59. According to the Council’s records, KC did not return the paperwork the Council needed to complete its review of Mr Y’s care and support needs or respond to the Council’s requests for this. I consider this was a failure by KC to keep accurate records and fault by KC, although it does not appear to have caused any actual injustice in this case.

Mr Y’s fall

60. My understanding, based on KC’s report, is Mr Y fell onto the pressure mat beside his bed. He was said to have sustained a graze to his left forehead and left elbow. My view, based on the care notes, is Mr Y did not appear to have been seriously injured and KC took appropriate action to monitor Mr Y in the immediate period following the fall.
61. I have not seen any reference in KC’s care notes to any further checks on Mr Y’s injuries. The hospital described these as lacerations, bruising and a bump on his head. This description, together with the photographs, indicate the injuries were still very apparent on his admission, four days later, and part of the reason for the safeguarding concern. My view is KC’s failure to monitor and note the condition of Mr Y’s injuries was a failure to keep accurate records and assess any risk to Mr Y’s health, and fault by KC. This may not be in line with the fundamental standards.
62. I consider this fault may have caused missed opportunities to alleviate any discomfort Mr Y suffered. Sadly, we are unable to put this right for Mr Y now. But, in my view this fault also caused Mrs Y uncertainty about the seriousness of Mr Y’s fall.

Mr Y’s skin condition

63. The records of the interventions by medical professionals in the period from September 2020 confirm Mr Y was prescribed treatment for a skin condition thought to be eczema, initially on his arms. There is no reference in these records of the skin condition spreading or any all over rash. The care notes show staff were regularly applying the prescribed cream to Mr Y’s skin.
64. The hospital’s description of Mr Y’s skin condition on admission, which it diagnosed as scabies, is very distressing. I have considered the evidence provided so far about Mr Y’s skin condition in the days before his admission. KC’s care notes show Mr Y was provided with personal care and support dressing and undressing in the days before his admission to hospital. There is no reference to an all over rash, or a rash as serious as that seen by the hospital.
65. The care notes for 3 November refer to redness to Mr Y’s back which felt warm, a photo taken and the senior informed, although there is no record of any follow up action. The notes also show care workers were now applying the cream to Mr Y’s groin and legs as well as arms in the days before his admission to hospital. This indicates, in my view, a deteriorating and spreading rash.
66. Based on the evidence I have seen, my view is I am not able to make a finding Mr Y’s skin condition, while he was still at KC and being provided with personal care, had deteriorated to the extent of the serious condition recorded on his admission to hospital. Mr Y was very unwell by then and it is possible his rash may have deteriorated acutely. I do not consider I can make a finding KC failed to take appropriate action to address Mr Y’s serious skin condition as recorded on his admission.
67. But, in my view, the evidence shows Mr Y had a long standing and deteriorating skin condition. I consider KC should have done more to monitor this and seek further medical advice (as the Council found in its review). My view is this was a failure to properly assess the risk to Mr Y’s health and fault by KC. This may not be in line with the fundamental standards.
68. I consider KC’s fault in failing to properly assess the risk of his skin condition to Mr Y’s health, may have caused missed opportunities to treat it and alleviate any discomfort Mr Y suffered. Sadly, we are unable to put this right for Mr Y now. But, in my view this fault also caused Mrs Y uncertainty about whether more could have been done for Mr Y before his admission to hospital.

KC’s Covid-19 prevention measures

69. The information provided indicates KC put in place Covid-19 prevention and protection measures in line with government guidance, including testing for staff members and residents.
70. Mr Y was assessed as being at risk of complications from Covid-19, because of his respiratory illnesses. I do not consider the evidence I have seen indicates KC failed to properly assess the risk of Covid-19 to Mr Y’s health or failed to take appropriate action to safeguard him from this risk.

The Council’s response to concerns about Mr Y’s care

71. I consider the Council properly responded to Mrs Y’s concerns in early 2020. It reviewed the notes she provided, and made appropriate enquiries, including a visit to KC, before concluding her concerns did not meet the safeguarding threshold. It then arranged for its local Older Adults team to contact Mrs Y to discuss her and Mr Y’s support needs.
72. I have not found fault by the Council in the way it responded to and investigated Mrs Y’s concerns in January and February 2020.
73. My view is the Older Adults team properly initiated a review of Mr Y’s care and support needs in March 2020. It noted KC had not yet returned the updated care plan and chased this, although I understand KC did not respond to the requests for the required paperwork.
74. I consider the team responded properly to the further concerns Mrs Y raised with the Council in July 2020 by discussing these with her. It tried to contact Mrs Y to talk further about her concerns and the possibility of moving Mr Y to another placement.
75. In my view, the Council responded appropriately to the hospital’s concerns following Mr Y’s admission to hospital by promptly initiating a safeguarding enquiry.
76. I consider the initial safeguarding enquiry, taken together with the enquiry review, shows the Council made appropriate enquiries and a detailed investigation of the hospital’s concerns. It set out in its reports the reasons for its conclusion the concern was not substantiated, and explained the outcome to Mrs Y. I have not found fault in the way the Council carried out the safeguarding enquiry in response to the hospital’s concerns.

How the Ombudsman remedies injustice caused by fault

77. The Ombudsman’s guidance on remedies makes the following points:
• for injustice such as distress, harm or risk, the complainant cannot usually be put back in the position they would have been, but for the fault. Therefore, we usually recommend a symbolic payment to acknowledge the impact of the fault
• there must be a clear and direct link between the fault identified and the injustice to be remedied
• distress can include uncertainty about how the outcome might have been different

Agreed action

78. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I have found fault with the actions of Kibworth Court, I made recommendations to the Council.
79. To remedy the injustice caused by the above faults, and within four weeks from the date of our final decision, the Council has agreed to:

• apologise to Mrs Y for the distress caused by Kibworth Court’s failure to keep accurate records and properly assess the risk to Mr Y’s health of his skin condition.
• pay Mrs Y £250 to acknowledge the distress caused by the uncertainty about aspects of Mr Y’s condition due to Kibworth’s Court failure to keep accurate records and properly assess the risk to his health.
• This figure is a symbolic amount based on the Ombudsman’s published Guidance on Remedies.

80. And within three months from the date of our final decision, the Council has agreed to arrange for its Quality Improvement team to:

• review and assess the improvements in practice and record keeping KC put in place in response to the safeguarding enquiry.
• consider with KC whether any further changes should be made in light of the findings in this decision.

81. The Council should provide us with evidence it has done this.

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Final decision

82. I have found fault by Kibworth Court causing injustice. I have completed my investigation on the basis the Council will carry out the above actions as a suitable way to remedy the injustice

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Investigator's decision on behalf of the Ombudsman