London Borough of Sutton (17 008 278)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 22 Oct 2018

The Ombudsman's final decision:

Summary: Mrs B complains the Council failed to ensure her late mother was properly cared for during a stay in a nursing home, and failed to take appropriate safeguarding action. The Ombudsman finds there was some fault by the Council, in addition to that it has already accepted. The Council has now offered an improved remedy and the Ombudsman has made further recommendations for action, which the Council has agreed to implement.

The complaint

  1. The complainant, whom I shall call Mrs B, complains the Council failed to ensure her late mother (Mrs C) was properly cared for during a stay in a nursing home, and failed to take appropriate safeguarding action. Mrs B wants to know what happened to her mother in the care home, and considers the outstanding bill for her mother’s stay there should be waived.

Back to top

The Ombudsman’s role and powers

  1. 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)
  2. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
  3. 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)
  4. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share the decision on this complaint with CQC.

Back to top

How I considered this complaint

  1. I considered all the information provided by Mrs B about her complaint. I made written enquiries of the Council and took account of the information it provided in response. I provided Mrs B and the Council with a draft of this decision and took account of all comments received in response.

Back to top

What I found

  1. In August 2015, the Council placed Mrs C in Tordarrach nursing home when she was discharged from hospital. Mrs B says that during her stay in the home, her mother was not properly cared for. She says Mrs C was often left in wet clothes, put to bed too early, and poorly handled by staff: she suffered injury while at the home. In addition, Mrs B reports the home was cold and the lifts between floors often out of order.

Mrs B reports her concerns

  1. On 28 September 2015 Mrs B contacted the Council to raise concerns about her mother’s welfare at the home. She said her mother had not been out of her second-floor room the day before due to the lift being out of action, and reported that the lift had been out of action twice before in the previous few days. Mrs B said she had noticed a cut on her mother’s right arm, covered by a large plaster on it, and that staff said she had cut it on a wheelchair. Mrs B questioned this, since Mrs B had been in her room.


  1. The Care Act 2014 says 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.

The first safeguarding investigation

  1. Acting on Mrs B’s report, the Council contacted the home. About the lift, the home said there had been an intermittent fault but a new lift had now been fitted. About the cut to Mrs C’s arm, the home described this as a skin tear caused during a transfer using a hoist. It said Mrs B had been given incorrect information about the cause of the cut by a carer who had not been present at the time. The Council spoke to Mrs B and agreed to progress the matter to a safeguarding investigation: it considered there were manual handling issues which needed to be addressed. However, the injury was deemed minor and had been dressed, and therefore the severity level of abuse and risk of recurrence was deemed low and no immediate protection plan was required. The Council noted Mrs B was visiting her mother regularly at the home. On 9 October, relevant council staff held a strategy discussion and decided an investigating officer (IO) would visit the home to check care records, staff accounts, risk assessment, training records etc.
  2. On 12 October, the IO visited the home. She saw the cut to Mrs C’s arm, and noted it was three to four inches long, and seemingly a scrape which scored a flap superficially breaking the skin. The IO interviewed the manager of the home and the nurse in charge, and examined the accident report and the care notes
  3. The IO’s findings were that appropriate immediate attention had been given to the wound, the cause of which was inconclusive, and protective measures had been taken and reporting procedures followed. But the IO also found the home had not told Mrs B (as her mother’s next of kin) immediately as it should have done; had not raised the matter as a safeguarding alert with Council; had not informed the GP until his next visit to the home; and had not shown due attention to issues Mrs B had raised such as the problems with the lift, use of a wheelchair, and food issues. The IO considered a safeguarding case conference would be appropriate.
  4. A case conference was held on 6 January 2016. Mrs B attended. The results were:
  • The cause of injury was inconclusive;
  • Any accident report needs to note if GP is not called, and why;
  • An incident report needs to be sent to the Council for both major and minor injuries;
  • The home should ensure its policies are followed in respect of informing relatives of any incident; and
  • A risk assessment should be completed to plan what action will be taken in the event of the lift being out of order.

The second safeguarding investigation

  1. On 12 February 2016, as Mrs C was being taken to hospital, Mrs B noticed a bruise on her mother’s arm just above her elbow. A social worker raised a safeguarding alert, noting that Mrs B felt care in the home was rushed and rough. The Council made the decision to proceed to safeguarding as Mrs C was an adult at risk with care and support needs which prevented her from protecting herself from harm: the allegation was of neglect of care.
  2. A strategy discussion took place on 24 February and the Council decided to progress the matter to investigation. It was noted the home had been asked to provide an incident report which had not been forthcoming. The action plan included a request that Mrs C should not be discharged from hospital back to Tordarrach nursing home, pending investigation.
  3. The IO spoke to Mrs B, who also reported her mother had a plaster to a cut on her leg. Mrs B said she was very concerned her mother had bruises all the time, and raised additional concerns about issues with the heating and hot water in the home.
  4. On 29 February, the IO went to the home and spoke to the registered nurse, who was then acting as deputy manager. The home manager was not available. The nurse knew nothing about the cut to Mrs C’s leg, and said she had found out about the bruise when Mrs C was being prepared for going to hospital. It was noted she had previously said it had been reported to her by a carer: that did not tie in with the home’s records. The IO noted it was unclear if the incident had been reported to CQC; whether training for carers was up to date; whether the incident was properly investigated by the manager; whether there were any risk assessments or safety measures in place to prevent a repeat occurrence (such as reference to a tissue viability specialist or occupational therapist, or an updated care plan). More generally, the IO also noted resident’s bedrooms had extra heaters as the central heating was faulty and awaiting repair, and that two residents with restricted mobility were in their beds on a floor where there was no carer to assist them.
  5. On 2 March, the IO made an unannounced visit to the home, and carers interviewed and asked about their training and about procedures within the home. On 4 March, the IO informed CQC about the safeguarding in respect of Mrs C and two other residents at the home. On 10 March, the IO visited the home to interview the manager. The manager said bruising had been reported to Mrs C’s family the same day, and that it was impossible to avoid bruising due to the condition of Mrs C’s skin, her medication, and long history of smoking. The IO considered the manager had a superficial approach to the safeguarding alert and had not been able to show she had reported the incident to the Council or to CQC. The IO told the manager she would have to provide written reports of her internal investigations for the safeguarding conference. On 21 March, the IO also interviewed Mrs C’s carer who had been on duty at time of the bruising. The carer’s understanding was that her duty was to report the bruise to the nurse, who would then record it, and this is what she had done. The home’s training records showed this carer had not attended any training, though the carer at interview said she had done general care and end of life training. The carer reported that Mrs C would not have been able to stand up from lying down without first being assisted to sit by the carer, which she did by ‘catching / pulling’ her arm.
  6. A safeguarding case conference was held on 23 March 2016 and the allegation of abuse was deemed substantiated on balance of probability even though the cause could not be ascertained. It was noted that the outcomes of the previous safeguarding investigation were not being followed through by the home. The investigation had found that the history of Mrs C’s skin condition had not been properly assessed by the home; that information provided to social services and to Mrs B was inadequate; and that staffing levels in the home were inadequate, especially at night. The Council’s records state: “Ongoing work to continue with the home to ensure quality and standard of care in the home is improved”.
  7. In the meantime, alternative accommodation was to be investigated for Mrs C.

What happened next

  1. The Council completed a risk analysis for the home which led it to decide that with current issues in the home the level of risk was high and needed the implementation of control measures. An embargo on the placement of residents at the home was recommended until the home could show improvement actions had been completed. This was put in place from 30 March 2016. The Council wrote to tell the home of this and of what it needed to do to show the required improvements.
  2. On 19 April, following a meeting with the manager, the Council wrote to the home
    confirming the key areas of concern: the operational management of the home and related homes; low staffing ratios for a high-risk group especially at night and in the early mornings; the recording and reporting of accidents and incidents to the Council; and training for staff in moving and handling vulnerable people. The Council also advised what information the home was required to provide to it.

The current position

  1. Following further embargo on placement at the home, and several re-inspections by CQC, the home’s registration was cancelled by CQC in 2018 and all residents were relocated. CQC said: “The standard of care provided at Tordarrach Nursing Home fell way below the standard necessary to provide the quality of care required. The fact that the service could not sustain improvements at the service in response to our concerns led us to use our enforcement powers to cancel the home’s registration”.


  1. Regarding the safeguarding process, the Council acted properly when concerns were raised, making prompt decisions about the need for investigation and setting that process in motion. However, there were some faults in the investigation and what followed from it.
  2. There was a delay between the completion of interviews in October and the finalisation of the investigation report two months later, prior to the case conference on 6 January. Although no statutory timescale applies, it is in the interests of all concerned that safeguarding investigations are progressed to conclusion without undue delay.
  3. The first safeguarding investigation was not comprehensive. The IO noted she had not asked for the risk management policy at the home, or for Mrs C’s risk assessment or whether it had been updated since the incident: she said these should be requested but not by whom or when, and it is not clear if this was ever done. The carer had said at interview that she got Mrs C up from a lying position by ‘catching / pulling’ her arm, but no risk assessment for this was seen. A copy of the home’s moving and handling provided later was clear that a moving and handling risk assessment should be completed in all cases.
  4. There was a lack of follow up, or evidence of the same, of the protection plan actions listed to be taken as outcomes at the case conference in January 2016 and it was not made clear who would be following this up. All but one action were actions for the home to follow through on. The Council confirms such follow-up would usually be done by the commissioning management team: they were not at the safeguarding case conclusion meeting. Notwithstanding this however, the IO did feel Mrs C was adequately protected within the placement.
  5. To a degree, events were overtaken by the second safeguarding alert and the actions which followed from it. However, although the alert was raised on 12 February 2016 the home was not visited until 29 February (by the IO), and it was not until 2 March that the Council made an unannounced visit, accompanied by CQC. An internal Council document notes that the case conference on 23 March 2016 lacked a robust discussion about allegations that Mrs C had been ‘plonked’ back after using the toilet, that staff had laughed at her, and had been cruel; and it had focused on the bruise on Mrs C’s left arm and explored less about how the cut to her left leg had been caused.
  6. However, while Mrs B naturally remains dissatisfied and upset about the cause of her mother’s injuries being ruled inconclusive, in the circumstances of the case it is unlikely on balance that more could have been done to establish the facts.

Injustice to Mrs B and Mrs C

  1. The IO had noted the home seemed unprepared to assess incidents of injuries and to meet person-centred needs. In responding to Mrs B’s complaint, the Council accepted the care Mrs C had received had not been good enough and acknowledged the distress this had caused.
  2. The identified faults in the safeguarding investigations also led to injustice for Mrs B, as she had to wait longer than she might otherwise have done for an outcome and was not afforded the thorough investigation she was entitled to. She was then put to some time and trouble pursuing her complaint.

Back to top

Agreed action

  1. In recognition of the distress caused to Mrs B by the poor standard of care provided to her mother at Tordarrach, the Council has already waived fees of £860.84 which related to the last part of Mrs C’s stay at the home. The Council has now also confirmed to the Ombudsman that the remainder of the fees for Mrs C’s stay in the home, amounting to £3,022.09, is to be written off. This will provide a greater financial remedy than the Ombudsman would normally recommend to remedy distress in similar circumstances, and so I make no recommendation for further payment.
  2. However, as well as the above, I recommended the Council takes the following action:
  • Within four weeks of the date of the decision on this complaint, writes to Mrs B to confirm the write-off of the outstanding debt, for the avoidance of doubt; and
  • Within 12 weeks of the date of the decision on this complaint, reviews lessons learned from the complaint in terms of safeguarding, and takes steps to ensure so for as is possible that the faults identified are avoided in future.
  1. 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 there was fault with the service of the care provider, I have made all my recommendations to the Council. In this case in any event, the home is no longer registered.
  2. The Council has agreed to all my recommendations.

Back to top

Final decision

  1. I have completed my investigation on the basis set out above.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page