Summary: Mr X complains on behalf of the late Mrs Z that the Council failed to keep adequate records regarding a fall from a hoist. Mr X says the Council delayed in advising of and completing a Deprivation of Liberty Safeguards assessment and failed to consider or record safeguarding concerns. Mr X also says the Council denied access to Mrs Z’s records. Mr X says this has caused the family significant distress. We have found fault in the Councils actions for delay in completing a Deprivation of Liberty Safeguards assessments and completing a safeguarding investigation. The Council has agreed to issue Mr X with an apology.

The complaint

1. Mr X complains on behalf of the late Mrs Z that the Council failed to keep adequate records regarding a fall from a hoist. Mr X says the Council delayed in advising of and completing a Deprivation of Liberty Safeguards assessment and failed to consider or record safeguarding concerns. Mr X also says the Council denied access to Mrs Z’s records.
2. Mr X says this has caused the family significant distress.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service and use public money carefully. We do not start or continue an investigation if we decide any injustice is not significant enough to justify our involvement. (Local Government Act 1974, section 24A(6), as amended, section 34(B))
4. 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).
5. 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)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

7. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
8. Mr X and the Council were invited to comment on my draft decision. I have considered any comments before making a final decision.

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What I found

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision.
10. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences. Guidance on regulation 9 says each person and/or their representative must be involved in an assessment of needs and preferences as much or as little as they wish.
11. Regulation 12 of the 2014 Regulations says care must be provided in a safe way including assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks.
12. Regulation 17 relates to good governance. The Care Quality Commission’s guidance for care providers on how to comply with the Regulations requires them to “securely maintain accurate, complete and detailed records in respect of each person using the service”.

Deprivation of Liberty Safeguards (DoLS)

13. The Deprivation of Liberty Safeguards provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. The DoLS protect people from being deprived of their liberty, unless it is in their best interests and there is no less restrictive alternative. The legislation sets out the procedure to follow to obtain authorisation to deprive an individual of their liberty. Without the authorisation, the deprivation of liberty is unlawful. It is the responsibility of the care home or hospital to apply for authorisation. For people being cared for somewhere other than a care home or hospital, deprivation of liberty will only be lawful with an order from the Court of Protection. The DoLS Code of Practice 2008 provides statutory guidance on how they should be applied in practice.
14. The Supreme Court defined deprivation of liberty as when: “The person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements”.
15. If there is a conflict about a deprivation of liberty, and all efforts to resolve it have failed, the case can be referred to the Court of Protection.
16. Once there is or is likely to be a deprivation of liberty, it must be authorised under the DoLS scheme in the Mental Capacity Act 2005.
17. The ‘managing authority’ of the care home (the person registered or required to be registered by statute) must request authorisation from the ‘supervisory body’ (the council). There must be a request and an authorisation before a person is lawfully deprived of their liberty.
18. The application for authorisation should be made within 28 days.
19. There are two types of authorisation: standard authorisations and urgent authorisations. Standard authorisations are made by the council.
20. On application, the supervisory body must carry out assessments of the six relevant criteria: age, mental health, mental capacity, best interests, eligibility and ‘no refusals’ requirements. A minimum of two assessors, usually including a social worker or care worker, sometimes a psychiatrist or other medical person, must complete the six assessments. They should do so within 21 days, or, where an urgent authorisation has been given, before the urgent authorisation expires.
21. Urgent authorisations are made by the managing authority of the care home in urgent cases only, for seven days, pending application for a standard authorisation. In some cases, the supervisory body can extend an urgent authorisation up to 14 days in total.

Safeguarding

22. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

23. Mrs Z was admitted to hospital in late 2023 and returned to the care home where she lived following being discharged from hospital in November 2023.
24. The care homes notes record in mid-February 2024 that staff noted Mrs Z had bruising to her lower leg. The notes record the care home asked Mrs Z how this had happened, and she said she could not remember but that she does bruise very easily.
25. The care home completed a DoLS form in mid-February 2024.
26. The care homes notes record in mid-April 2024 that Mrs Z was seen by a medical professional to complete a mobility assessment. But this could not take place as she said she was feeling dizzy because of problems she was having with her ear. The notes record Mrs Z said she was afraid of being in the hoist as she nearly fell the previous week.
27. The care homes notes record bruising was noted again on Mrs Z in early May 2024. The care home staff again asked Mrs Z how the bruising occurred and she said she bruised like a peach so it could have been anything. The note goes on to say there was no history of trauma according to staff or the care notes.
28. The care home notes say Mrs Z’s daughter spoke to staff in early June 2024 and said she was concerned that Mrs Z was receiving all her care in bed. Mrs Z’s daughter said this was because Mrs Z said she felt unsafe in the hoist. The care home’s note refers to Mrs Z saying she preferred to be in her room.
29. The care homes notes say Mrs Z’s daughter spoke to it in early July 2024 and said she preferred to have female staff. The care home said some days only male staff were in the unit and Mrs Z’s daughter said this was ok.
30. The care home notes record in mid-July 2024 that Mrs Z said she was unhappy with the night staff and that staff reported this to the clinical lead. The same day Mrs Z also accepted the care home making a referral about the anxiety she reported feeling.
31. The care home notes from mid-July 2024 say Mrs Z cancelled an appointment she was due to attend as she was nervous about using the hoist.
32. The care home sent an email in early September 2024 to chase the DoLS assessment.
33. The care homes notes record staff noticing bruising on Mrs Z’s arms following detecting a rash the previous day in September 2024. The staff noted they asked Mrs Z about this, and she said the rash was itchy and she had been scratching it. The care home had a consultation with Mrs Z’s doctors’ surgery about the rash and bruising.
34. The Council spoke to Mrs Z’s daughter in early November 2024. The note records Mrs Z’s daughter said her mum did not get out of bed and will not use the hoist. She also said Mrs Z had a lot of bruising on her body possibly due to medication.
35. The care home notes from mid-November 2024 recorded that Mrs Z cut her leg while in the hoist. The notes say the staff cleaned and dressed the wound. It also recorded that Mrs Z understood the cut was a result of an accident.
36. The Council met Mrs Z in late November 2024 to attempt to complete a Mental Capacity Assessment however the notes record that Mrs Z would not co-operate.
37. Mrs Z’s Care Plan in relation to mobility recorded in December 2024 that she was afraid to use the hoist.
38. Mrs Z died in mid-December 2024.
39. Mr X raised a complaint with the care home in early March 2025. He said he had concerns over the rough handling of Mrs Z, restrictive bed confinement and a fall from the hoist.
40. The care home responded to say the rashes and bruising had been treated by a doctor, there was no evidence of a fall from the hoist and no unjustified restriction to bed. The care home said it had a record of an incident relating to Mrs Z using the hoist but there had been no unsafe practices.
41. Mr X raised a complaint with the Council in March 2025 and raised concerns about the rough treatment of Mrs Z. He also said she had been unjustifiably restricted to bed, and she had slipped or fallen from the hoist. Mr X said safeguarding concerns had not been resolved.
42. The Council began a safeguarding investigation in late March 2025 and emailed Mr X to say this had been allocated to an officer in early April.
43. The Council sent a further email to Mr X in early May 2025 to say the safeguarding investigation had been reallocated to another officer. Mr X responded to say he was unhappy with this and the delay it had caused.
44. The Council emailed Mr X in early May 2025 to ask him to provide further details concerning the allegations he had made about a fall from the hoist. Mr X responded to say there were multiple falls and the care home should have recorded these. But he believed one had taken place in September 2024.
45. The Council issued the outcome of its safeguarding investigation in early June 2025. It said there were no records of a fall from the hoist, no restrictions higher than expected were in place and advised that the care home had requested a DoLS assessment in February 2024. It said this was not allocated until December. The Council also noted that no safeguarding concerns were raised while Mrs Z was at the care home.
46. Mr X raised a further complaint in early June 2025 to say Mrs Z did fall from the hoist. He also said he had concerns about the DoLS assessment being requested in February 2024 but not allocated until December 2024. He said concerns about Mrs Z’s care were raised with the home.
47. Mr X also requested Mrs Z’s records.
48. The Council responded in early June 2025 and said no fall from the hoist was recorded. It also said the concerns made had been investigated under the safeguarding investigation and did not meet the threshold for further action. The Council provided a link to help Mr X get Mrs Z’s records. Mr X requested an internal review of the safeguarding investigation.
49. The Council issued a final response to Mr X in late June 2025 which said there had been a delay in completing the safeguarding investigation but once it was re-allocated it progressed as expected. It also said again the concerns raised did not meet the threshold for further investigation and it was satisfied the family had had a chance to engage with the investigation.
50. The Council emailed Mr X in June 2025 and confirmed what information would be required to allow it to release Mrs Z’s records.

Analysis

Record keeping

51. The care home has provided extensive notes detailing Mrs Z’s care. I have not been able to locate a record of a fall from the hoist. There are examples where it is noted Mrs Z was nervous of using the hoist and saying she had nearly fallen. The care home recorded an accident which happened in November 2024. But there is no record of a fall.
52. The care home has also noted concerns about bruising found on Mrs Z and questioned her about these. The care home also sought medical advice in relation to the bruising. Mrs Z’s daughter also raised this with the Council but suggested it was due to medication rather than raising it as a concern. I have not found fault in the way records have been kept.

Deprivation of Liberty Safeguards (DoLS)

53. The care home requested a DoLS assessment in February 2024, but this was not allocated until December 2024. This is fault and would have caused distress.
54. The Council has acknowledged there was a delay in completing the assessment which is fault. The Council say it is sorry for the delay, and it has now completed internal changes which have resulted in allocation times decreasing.

Safeguarding investigation

55. The Council has accepted there was a delay in beginning the safeguarding investigation following Mr X raising issues. This is fault and would have caused distress.
56. The delay was around four weeks and once the investigation was reallocated it progressed, and Mr X was provided with its conclusions quickly. I appreciate that Mr X is unhappy with the conclusions reached. However, the investigation considered relevant information and consulted relevant parties.

Releasing records

Mr X asked the Council to provide Mrs Z’s records in June 2025. The Council confirmed what information it would require in June 2025. The Council says it has not received the information it needed to release Mrs Z’s records. I have not found fault in the Council’s actions.

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Action

57. Within four weeks of this decision, the Council should:

• Write to Mr X to apologise for the distress caused by the faults identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.

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

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Decision

58. I find fault causing injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman