Derbyshire County Council (16 006 195)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 29 Nov 2019

Summary: Mr B complains about multiple failings in the care received by his late sister, Mrs C, when she was resident at the Grange Care Home between November 2015 and March 2016, which is owned and run by the Council. In particular, there were serious failings in its response after Mrs C died following a fall in the care home.


The Ombudsman has upheld the complaint and found fault causing injustice.


The Council has agreed to:

  • give an unreserved apology to Mr B accepting the findings of this investigation. It has said it will meet in person with Mr B to deliver this;
  • make a payment of £1,000 to a registered charity of Mr B’s choice;
  • offer to pay for a memorial for Mrs C such as a park bench or tree planted in her memory, subject to agreement with Mr B about matters such as his preferences and location.
  • undertake a further review to see what further lessons might be learned from this complaint. Full details are set out in the body of this report, but this will include the Council:
    • considering how it can ensure there is an audit trail of assessments left partially completed;
    • improve its record keeping in care homes using both electronic and paper records;
    • improve its capture of information when GPs visit its care homes;
    • reviewing several aspects of its current safeguarding procedures; and
    • how it can avoid gaps in service provision when undertaking restructuring of services.

Ombudsman satisfied with Council's response: 17 June 2020.

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