Summary: Mrs X complained about the way Rosedale Care Services (Yorkshire) Limited responded to her concerns about the incident which happened to her mother when she was receiving residential care in the Sycamores Care Home. We found fault with the Council for not ensuring the care provider, delivering services on its behalf, kept proper records. This caused injustice to Mrs X and her brother. The Council has agreed to apologise and request some service improvements from Highgate Care Services Limited, which succeeded Rosedale Care Services (Yorkshire) Limited.

The complaint

1. Mrs X complains about the way Rosedale Care Services (Yorkshire) Limited (the Care Provider) responded to her concerns about the incident which happened to her mother (Mrs Y) in the Sycamores Care Home (the Care Home). Mrs X says the Care Provider failed to investigate and share information.
2. Mrs X says the Care Provider’s failings caused her and her brother (Mr Z) significant distress at the very difficult time after their mother’s death.

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The Ombudsman’s role and powers

3. 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)
4. 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)

5. 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)
6. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
8. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

9. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
10. Mrs X 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

Legal and administrative framework

Fundamental standards of care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) issued guidance (the Guidance) in March 2015 on how to meet the fundamental standards.
12. The fundamental standards are the standards below which the care must never fall. Everybody has the right to expect the following standards:
1. Person-centered care – you must have care or treatment that is tailored to you and meets your needs and preferences;
2. Dignity and respect – you must always be treated with dignity and respect while you are receiving care and treatment. This includes making sure you have privacy when you need and want it.
3. Safety – you must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Providers must assess the risks to your health and safety during any care or treatment and make sure their staff have the qualifications, competence, skills and experience to keep you safe.
4. Safeguarding from abuse – you must not suffer any form of abuse or improper treatment while receiving care. This includes neglect and degrading treatment.
5. Food and drink – you must have enough to eat and drink to keep you in good health while you receive care and treatment.
6. Premises and equipment – the places where you receive care and treatment and the equipment used in it must be clean, suitable and looked after properly.
7. Good governance – the provider of your care must have plans that ensure they can meet fundamental standards. They must have effective governance and systems to check on the quality and safety of care. These must help the service improve and reduce any risks to your health, safety and welfare. The records kept for you should be accurate, complete and contemporaneous.
8. Staffing - The provider of your care must have enough suitably qualified, competent and experienced staff to make sure they can meet these standards. Their staff must be given the support, training and supervision they need to help them do their job.

What happened

13. Mrs Y received treatment in hospital for a few months before she was discharged to the Care Home at the beginning of September 2024. Mrs Y was capable of taking decisions about her care and she could communicate them.
14. The next morning after arriving at the Care Home Mrs Y was transferred by hoist and sling from her bed to a chair. There are several versions of how this happened:
1. Mrs X’s statement based on what Mrs Y told her; during the morning transfer from her bed to a chair the care staff banged Mrs Y’s leg. She screamed out in pain. This resulted in an internal injury and Mrs Y had to be re-admitted to hospital.
2. Care notes; four members of the Care Home staff helped Mrs Y to move from her bed to a chair. She was content. An hour later she had a drink. Before midday the Care Home staff called hospital about Mrs Y’s medication. After midday the staff called the medical team about an internal injury to Mrs Y’s leg.
3. Incident report prepared shortly after the incident by the Care Home’s Manager (the Manager); two members of the night staff (Care Worker 1 and Care Worker 2) helped Mrs Y to transfer from her bed to a chair using a hoist and a sling. Mrs Y received morphine before the transfer. Although the care notes stated there were four people involved, two of them did not take part in the transfer. Care Worker 1 was not aware that Mrs Y caught her leg on the hoist and there was no sign of her being in pain. Later that day Mrs Y told the Manager that during the transfer the night staff caught her leg on the hoist. There was bruising and a lump on Mrs Y’s leg. The Care Home contacted the medical team. A General Practitioner (GP) assessed Mrs Y’s overall condition and noted concerns with certain aspects of her health. Later in the afternoon the GP recommended taking Mrs Y to hospital for a review.
4. Incident investigation report sent as part of a safeguarding referral; Mrs Y needed an extra-large sling for transfers. The night staff brought a medium sling to the office and was told this was correct as had been used the previous night for Mrs Y. It seemed obvious the night staff did not want to transfer Mrs Y to her chair so the day staff intended to do that. Half an hour later Care Worker 1 said she hurt her shoulder when moving Mrs Y. The notes stated there were four members of staff involved in this process. The Manager went to talk to Mrs Y and found her upset. She said the care staff caught her leg on the hoist and there appeared a lump. The Care Home contacted medical staff and later in the afternoon Mrs Y was taken to hospital.
5. Care Home’s complaint response provided by the Regional Manager: a large sling was the right size to be used for Mrs Y and the care staff used it to move Mrs Y from her bed to a chair. The right sling was found in Mrs Y’s wardrobe. It was not correct the night staff did not want to help Mrs Y to transfer to a chair. The night staff were not aware that any injury happened during the transfer, therefore they did not report anything. Although there were four people in Mrs Y’s room during her transfer to a chair, only two of them helped her.
15. A few days after the incident the Care Provider sent the incident report to the Council’s safeguarding team and notified CQC of what it called a “serious injury”.
16. After investigating what had happened, at the end of September 2024 the Care Provider completed an Incident investigation report.
17. Mrs Y died in hospital in mid-September 2024.
18. Mr Z repeatedly tried to get information from the Manager and Care Provider about what had happened. Mr Z and Mrs X were increasingly frustrated by the lack of clarity and confusing information.
19. At the end of September the Care Provider sent to the Care Home an action plan following the incident. It told the Care Home to:
• complete a full body map of any resident on the day of admission to the Care Home;
• ensure when hoisting a resident one staff member guides their legs so they are not caught or banged against the hoist.
20. After receiving from the Care Provider a list of proposed actions, in mid-November 2024 the Council closed the safeguarding referral.
21. In the third week of October 2024 Mr Z complained to the Care Home. At the end of November 2024 the Regional Manager replied. They said the Care Home had completed a full investigation and decided there was no evidence an incident had taken place. The Care Home carried out moving and handling observations and confirmed there were no concerns about practice. The Care Home reminded all senior staff about the need to complete body maps when admitting new residents.
22. Mr Z was not satisfied with the Regional Manager’s response and queried it further. He also asked for copies of witness statements obtained during the Care Home investigation. The Regional Manager provided a further response at the beginning of December. They refused to provide witness statements.
23. In response to my enquiries I was informed that since January 2025 the Care Home has operated under a different registered provider Highgate Care Service Limited. The new Care Provider has accepted the Care Home’s investigation and subsequent incident report were of poor standard and highlighted the need for timely reporting that is detailed and specific.

Analysis

24. Councils are responsible for the care arranged for their residents with eligible care needs even if these residents pay for this care from their own funds. As explained in paragraph five of this decision we hold councils into account for any failings of the care providers delivering services on councils’ behalf.
25. The Care Home’s inadequate record-keeping made it impossible to find out what exactly happened a few hours before re-admitting Mrs Y to hospital. I consider Mrs Y’s care notes inaccurate and misleading because:
• there is no mention of Mrs Y’s upset following her transfer from her bed to a chair as described in some reports;
• care notes are not consistent with other reports.
26. The Care Home’s failure to keep accurate and complete records of care breaches the fundamental standard of good governance. This made verifying details and quality of care provided to Mrs Y impossible.
27. The Council failed to ensure the Care Provider, commissioned to deliver residential care services to Mrs Y, met all fundamental standards of care. This is fault. It caused injustice to Mrs X and Mr Z as they were distressed by the contradicting reports of the incident and the lack of accountability. They spent much time and effort to find out what happened to their mother before she got re-admitted to hospital.

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Action

28. 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 provider and make the following recommendations to the Council.
29. We recommend the Council within four weeks of the final decision apologise to Mrs X and Mr Z for the injustice caused to them by the Council’s failure to ensure the Sycamores Care Home providing services to Mrs Y on behalf of the Council met all fundamental standards of care. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology I have recommended.
30. We also recommend the Council within four weeks of the final decision request from Highgate Care Services Limited to complete within three months of the final decision the following:
• ensure the Sycamores Care Home care records are accurate, complete and contemporaneous by training the care home staff and conducting checks;
• consider what changes are needed to ensure timely, detailed and specific reporting of the incidents and implement them.

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

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Decision

31. I find fault causing injustice. The Council has accepted my recommendations, so this investigation is at an end.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman