Summary: Ms C complains the Care Provider, acting for the Council and ICB, failed to provide satisfactory care to Mrs D which resulted in her not receiving suitable health care and support. Ms C also complains the Council failed to investigate the Care Provider through safeguarding properly. There was service failure by the Care Provider which has caused uncertainty about whether Mrs D received suitable care and support. The Council, and Care Provider have agreed to make service improvements and a symbolic payment to Ms C for the distress caused by the service failure.

The complaint

1. Ms C complains about the care Mrs D received at Haldane House Nursing Home (the Care Provider) after she left hospital. NHS Frimley ICB (the ICB) and Bracknell Forest Council (the Council) commissioned the Care Provider under section 117 of the Mental health Act.
2. Ms C complains the Care Provider failed to provide suitable care to Mrs D when she left hospital. This included failing to manage a pressure sore, call an ambulance in good-time, and support Mrs D with her fluid and nutrition. Ms C says this caused Mrs D pain and discomfort and the family upset and anger.
3. Ms C also complains the Council’s safeguarding was inadequate and did not address all her concerns, leaving her frustrated and distressed.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
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, sections 24A(1)(A) and 25(7), as amended).
7. When investigating complaints, if there is a conflict of evidence, we 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
8. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

How I considered this complaint

9. I considered evidence provided by Ms C, the Care Provider, the Council, and the ICB as well as relevant law, policy and guidance.
10. Ms C and the organisations had an opportunity to comment on a draft decision. I considered any comments made before making a final decision.

What I found

What should have happened

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences. It has issued guidance on how to meet the fundamental standards below which care must never fall.
12. Regulation 10 says care providers must make sure they provide care and treatment in a way that always ensures people's dignity and treats them with respect.
13. Regulation 12 “Safe care and treatment” says care providers must assess risks to people's health and safety during any care and make sure that staff have the qualifications, competence, skills and experience to keep people safe.
14. Regulation 14 says care providers must meet service user’s nutritional and hydration needs. The associated guidance says care providers,
• “must include people's nutrition and hydration needs when they make an initial assessment of their care, treatment and support needs and in the ongoing review of these. The assessment and review should include risks related to people's nutritional and hydration needs.
• Providers should have a food and drink strategy that addresses the nutritional needs of people using the service.”
15. Regulation 17 says Care Providers should “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.”
16. NICE (National Institute for Health and Care Excellence) “Stroke and transient ischaemic attack in over 16s: diagnosis and initial management”, says for anyone with a suspected stroke call the emergency services immediately as the first four hours following a stroke are critical for effective treatment.
17. NICE, “Palliative care - oral” says, “When managing oral care in a person at the end of life, mouth care should be provided as often as necessary to maintain a clean mouth:
• The mouth can be moistened every 30 minutes to an hour with water from a water spray, dropper, ice chips, or sponge stick.
• Petroleum jelly on the lips may help to prevent lip cracking.
• A room humidifier or air conditioning can be used if needed.”
18. Pressure sores (also called pressure ulcers or bed sores) are wounds caused by pressure on part of the body interrupting the blood supply to the skin. Pressure sores are graded in severity from 1 to 4. Grade 4 indicates severe pressure damage, usually a deep wound that may go down to the bone and involve the death of underlying tissue.
19. Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.
20. Under section 117 of the Mental Health Act 1983, councils and ICBs have a joint duty to provide after-care services to people who have been detained in hospital for treatment under certain sections of the 1983 Act.
21. Since the events that have occurred a new owner has taken over the Care Provider. In response to the decision statement the new owners have said independent of our investigation they have made further improvements to the care provided.

What happened

Sequence of events

22. Mrs D went into Haldane House Nursing Home from hospital on 30 December 2024. Mrs D’s care was a joint ICB and Council responsibility as she had the benefit of care under section 117 of the Mental Health Act.
23. The Medical Administration Records (MAR) show from 10 January 2025 care staff provided Mrs D with a five-day course of antibiotics to treat her infected heel. The Care Provider says it was actively dealing with the infection and malodour (bad smell) it caused. The antibiotics finished on 15 January and the case records say there was some improvement in Mrs D’s heel. The Care Provider made a referral to a Tissue Viability Nurse on 16 January.
24. At 19.33 on 19 January the case records say,
25. “I saw Mrs D later in the morning and found her to be lying quite still, asleep, but the left side of her face looked a little drooped.…. I called the phone numbers on her file and her son responded, he was happy for the ambulance to be called and for active treatment in hospital.”
26. Supporting staff statements completed afterwards say care worker, X, noticed the drooping at 11.40 am and called the ambulance at 12 - noon.
27. X told both Ms C and the ambulance crew who attended that she thought Mrs D showed signs of a stroke the day before. The ambulance record says, “Paramedics not convinced about facial droop but has grade 4 necrotic foot ulcer (discharged from hospital with this) Pungent and dressing being changed every 2-3 days.” The ambulance service raised a safeguarding concern because of the delay in calling an ambulance and the lack of an active treatment plan for Mrs D’s pressure sore.
28. The Care Provider disputes there were signs of a stroke the day before. It questioned X who said they told ambulance staff, “she had heard these signs were there the day before”.
29. A GP visited Mrs D on 20 January and did not consider Mrs D had a stroke.

Pressure sore care

30. Mrs D entered the care home with a grade four pressure sore on her heel. Mrs D had a wound care plan. This detailed how care workers should treat Mrs D’s pressure sore. The daily case record dated 6 January says care workers should change Mrs D’s dressing every three days. The wound care plan says care workers changed Mrs D’s dressings on 6, 9, 13 and 16 January. During the safeguarding meeting, a senior worker from the Care Provider, Y, said care staff should have changed Mrs D’s dressing on 18 January. Y says when she was next on duty on 20 January she noticed the dressing unchanged and a malodour. Care staff on duty said the dressing did not need changing as there was no “strike through the outer bandage”. Y said the change was still necessary because of the high risk of infection. There is no record care staff changed the dressing until 20 January.

Food and nutrition

31. The Care Provider completed a nutrition support plan for Mrs D. This said staff needed to support Mrs D with food and drink. Care staff also completed a food and fluid chart. There is evidence of the Care Provider offering food and drink consistently through the day. Between 2 January and 18 January care staff record three days when Mrs D had more than 1000ml of fluid. From Sunday 19 January Mrs D stopped taking fluids. The Care Provider says this was because of Mrs D’s worsening condition; she was now at end of life care and could no longer swallow fluids. The Care Provider says that instead, to make Mrs D feel comfortable, they provided her with mouth care. The GP reported that when examining Mrs D there was no evidence of dehydration. Ms D disputes this and says the Care Provider did not properly support Mrs D with her hydration.

Safeguarding

32. The Care Provider completed an internal investigation and found no shortfalls in how it managed Mrs D’s care.
33. The Council completed a safeguarding investigation with an outcome of “Substantiated”. This was on the basis the Care Provider:
• did not have an effective staff handover system;
• there were gaps in communication;
• had inconsistent records.
34. Ms C was unhappy with the safeguarding investigation as she considered it failed to properly address the Care Provider’s failure to recognise Mrs D’s stroke symptoms earlier. Ms C was also unhappy about the accuracy of the meeting minutes. The Council apologised for these errors.

Care Provider response

35. The Care Provider accepted there were shortfalls in communication and recording and set up a written hand over system so staff coming on duty were aware of issues. The Care Provider says it also addressed shortfalls with individual staff members.
36. Following the events detailed in the complaint, ownership of the service transferred to a new provider in March 2025. The new Care Provider says it should not be liable for events that occurred before it took ownership. It says since taking over it has made several systemic changes to improve practice and has improved the quality of care.

Was there fault causing injustice?

37. We are aware of the Care Provider’s new ownership and welcome the independent service improvements. However we assume all liabilities transfer to the new ownership unless we are provided with a transfer deed/other evidence that proves otherwise.

Failure to act when there was a possible stroke

38. NICE guidance says treatment is most effective within the first four hours of when someone shows signs of a stroke. I therefore understand Ms C’s concern that Mrs D may have shown signs of a stroke the day before the Care Provider called an ambulance.
39. On balance, considering all the information available to me, including the case recording and staff statements, there is insufficient evidence to suggest Mrs D showed signs of a stroke on 18 January. I therefore find no service failure in the actions of the Care Provider on 18 January.
40. When Mrs D showed stroke symptoms on 19 January care staff acted according to her respect form and called an ambulance. Even if I were to find fault in the Care Provider’s actions I would be unable to say this caused Mrs D or Ms C injustice. This is because the case recording of both the ambulance crew who saw Mrs D on 19 January and the GP the following day did not consider Mrs D had a stroke.
41. However, the Care Provider communicated unverified information to both the ambulance crew and Ms C about Mrs D’s symptoms. This was service failure and caused Ms C distress, anxiety and uncertainty about Mrs D’s treatment.

Failure to properly support with a pressure sore

42. The Care Provider delayed in completing a wound care plan. It was not until 6 January, six days after Mrs D entered the care home that the Care Provider assessed and changed Mrs D’s dressing. The delay in completing the care plan and changing Mrs D’s dressing is service failure and a potential breach of Regulations 12 and 17.
43. Mrs D’s wound care plan was incomplete as it did not include the frequency of when care workers should change Mrs D’s dressing. While a case note records the frequency, unless care workers went back through the care records at every shift they would not know this information. The purpose of a care plan is to ensure staff are aware of what and when they should take actions, a clear record which care staff can refer to. The failure to have a properly completed care plan is service failure and not in line with Regulations 12 and 17.
44. Care staff did not follow the wound care plan consistently and there was a further delay of a day from 9 to 13 January. This was service failure and not in line with Regulation 12.
45. On 19 January both ambulance staff, care workers, and Mrs D’s family had concerns about the malodour and infection from the pressure sore. There are conflicting accounts about whether a dressing change was needed when scheduled on that day. There is no contemporaneous record about care staff checking the pressure sore and deciding the dressing did not need changing on that day. The failure to record the decision making is service failure and is not in line with Regulations 12 and 17.
46. I consider on balance, taking into account information from the ambulance service including the level of malodour, the case note about the frequency of dressing change needed, the explanation provided about why the dressing remained unchanged from Y; it is more likely than not Mrs D needed her dressing changed earlier. I consider this is service failure and is not in line with Regulations 10 and 12.

Food and fluid

47. Care staff completed Mrs D’s food and fluid charts. However, the fluid care plan does not say how much daily fluid Mrs D needs. The fluid chart shows several days when Mrs D drank little. There is no evidence care staff responded to encourage Mrs D to drink or get advice. The failure to properly monitor fluid intake is service failure and is not in line with Regulation 14.
48. Towards the end of Mrs D’s life she could not take any fluids. The Care Provider did not amend Mrs D’s care plan to reflect the changes in her fluid intake and how care staff should support Mrs D with mouth care. The failure to review and amend the care plan for Mrs D is service failure and is not in line with Regulations 12 and 17.

Safeguarding

49. A safeguarding investigation will not always get all the answers. Its purpose is to ensure safety measures are in place where a person is at risk and to protect others who may also be at risk.
50. The Local Government and Social Care Ombudsman cannot challenge a professional judgement where there is no procedural fault. I have considered the Council’s safeguarding process and find no fault in the way it considered the safeguarding alerts. It set up a meeting which included all the relevant parties and provided an opportunity to discuss the issues. Ms C is unhappy with the safeguarding minutes and the Council’s investigation. I have listened to a recording of the safeguarding meeting and recognise there are some discrepancies between the recording and the meeting minutes. I do not however consider they would make a significant difference to the outcome of the safeguarding.
51. A Council must be proportionate when undertaking safeguarding. I consider in this complaint it acted properly, apologising for some errors in the minutes and producing a plan of follow up steps the Care Provider had to take.
52. In response to a draft decision Ms C says the Council failed to carry out actions which it had agreed to do as part of the safeguarding. This included advising the family the outcome of the Care Provider’s internal investigation.
53. Following further enquiries of the Council, it has provided an email trail which shows Ms C was aware of the outcome of the safeguarding and the Care Provider sent the internal investigation directly to Ms C. While there was some delay in the Council providing the outcome to Ms C I do not consider this was significant. I therefore find no fault with the Council

Injustice

54. I am aware Mrs D was at end of life care and I cannot say on balance, but for the service failure I have identified, Mrs D would have lived longer. However, Ms C has the uncertainty, distress and frustration that Mrs D’s pain, quality of life and dignity for the last weeks of her life could have been better. In particular, the delay in assessing and treating Mrs D’s pressure sore which would have left her in pain and discomfort and the uncertainty caused by the failure to properly record the mouth care provided.

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Action

55. I have found service failure which has caused Mrs D and her family injustice. I cannot remedy Mrs D’s injustice as she has died. The actions below are therefore an acknowledgement of the distress caused by these failures to Ms C and to improve future practice.
56. In this complaint the ICB and Council jointly funded the Care Provider. The responsibilities for the fault are therefore separated.
57. 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 service of the Care Provider and make the following recommendations to the Council.
58. Within one month of the final decision, as part of its contract monitoring of the Care Provider, the Council will:
1. apologise to Ms C for the Care Provider’s failure to properly record and review Mrs D’s treatment and the uncertainty this has caused her;
2. make Ms C a symbolic payment of £150 in acknowledgement of the distress caused by the uncertainty and service failure.
59. Within three months of the final decision, as part of its contract monitoring of the Care Provider, the Council will review the Care Provider’s recording, in particular, daily case notes, reviews and updating care plans.
60. Within one month of the final decision the Care Provider (acting on behalf of the ICB) will:
1. apologise to Ms C for its failure to properly record and review Mrs D’s treatment and the distress this has caused her;
2. make Ms C a symbolic payment of £150 in acknowledgement of the distress caused to her because of the uncertainty and service failure.
61. Within three months of the final decision the Care Provider (acting on behalf of the ICB) will:
1. remind staff by a team meeting, training, staff circular or supervision about the need to follow care plans and evidence when action is taken; and to review and update care plans when there are changes in a person’s needs;
2. remind staff by a team meeting, training, staff circular or supervision about including the frequency of when action needs to be taken in care plans so staff members are clear about what actions are needed and when;
3. remind staff by a team meeting, training, staff circular or supervision about making contemporaneous records;
4. review how food and fluid is monitored in the care home, including how care staff monitor and analyse information recorded so there are triggers for review/further action when a person is not eating or drinking enough.
62. The organisations should provide us with evidence they have complied with the above actions.

Decision

63. I find service failure causing injustice. I consider the agreed actions above are suitable to remedy the complaint.
64. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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Investigator's decision on behalf of the Ombudsman