Summary: Ms D complained about the care and treatment of her late father, Mr F, by Trinity Surgery and a care home commissioned by Norfolk County Council. We have not found fault by Trinity Surgery. There were some faults by the care home and Council relating to document management, care planning, communicating with Ms D and Trinity Surgery, and complaint responses. We have not upheld the other complaints about the care home and Council. We have recommended the Council apologises to Ms D. The Council accepts our recommendation, so we have completed our investigation.

The complaint

1. Ms D complains about her late father, Mr F’s, care at Chestnuts Residential Home in Wisbech (the Home) commissioned by Norfolk County Council (the Council) and by Trinity Surgery (the GP Surgery). Ms D says the following faults happened.
1. The Home failed to take appropriate and timely action in response to Mr F’s health problems and weight loss. The Home also failed to investigate whether Mr F had a urinary tract infection (UTI) or to refer him to other professionals for an investigation.
2. The GP Surgery failed to identify Mr F had a UTI, did not address his weight loss and did not visit him when requested.
3. The Home and GP Surgery did not work together and communicate effectively to ensure they both did what they needed to, for Mr F’s symptoms to be investigated and treated promptly.
4. The Home provided poor care to Mr F.
5. The Home failed to communicate with Ms D adequately.
2. Ms D says that Mr F lost a lot of weight while in the Home. She says he became very poorly and needed an emergency hospital admission, where he was diagnosed with a UTI and sepsis (a potentially life-threatening complication of an infection). Mr F died six days later. Ms D says she is left with a distressing uncertainty about whether earlier diagnosis and treatment could have saved her father’s life. This has affected her mental health.
3. Ms D would like the organisations to be open and honest about their mistakes and to take action to prevent them happening again. She also wants the organisations to be held accountable for their actions.

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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. The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended). The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services (Health Service Commissioners Act 1993, section 3(1)).
6. 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, section 25(7), as amended)
7. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
8. 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). If it has, we may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
9. The Health Service Ombudsmen may investigate, and question the decisions made in the exercise of clinical judgement.
10. We cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision the relevant responsible body has to make. Therefore, my investigation has focused on the way the body made its decision.
11. We cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
12. 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. 
13. If we are satisfied with the actions or proposed actions of the bodies 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)
14. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

15. Part of the complaint is ‘late’ because Ms D had concerns about Mr F’s care more than 12 months before first complaining to us in July 2023. We considered Ms D had good reasons for taking longer to complain to us. This is because she first tried to get her concerns resolved through various organisations’ local complaints processes, and through the Care Quality Commission (CQC, the adult social care regulator in England) and the coroner’s office. We have therefore decided to investigate her complaint despite parts of it being late.
16. 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. The Council commissioned Mr F’s place at the Home, so it remains responsible for the care he received there and for the actions of the Home.

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How I considered this complaint

17. As part of my investigation, I have considered:
• information Ms D has provided by telephone and in writing, including copies of medical and other records she has had access to;
• the Council’s and GP Surgery’s responses to my enquiries. These include their written responses to my questions and copies of relevant records;
• the Home’s comments and supporting evidence;
• clinical advice from an experienced GP, independent from the parties to this complaint; and
• relevant law, guidance and policy, which I have referred to below where applicable.
18. Ms D, the Council, the Home and the GP Practice have had an opportunity to comment on a draft version of this decision. I have considered their comments before making a final decision.

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What I found

A – The Home’s actions relating to Mr F’s health problems, weight loss and UTI

19. Ms D says the Home failed to take appropriate and timely action in response to her father’s health problems and weight loss. She also says it failed to investigate or refer him for investigation of a suspected UTI.
20. The Council and the Home provided us with copies of the available records relating to Mr F for the period we have investigated. However, they could not supply all the records we had asked for because the Home misplaced a file containing Mr F’s paper records. I have been able to find some of the missing information I needed by looking at Ms D’s own records (including photographs) and Mr F’s health records.
21. 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) has issued guidance on how to meet the fundamental standards which care must never fall below.
• Regulation 12 says care and treatment must be provided in a safe way. CQC guidance says that as part of this, care homes “must have arrangements to take appropriate action if there is a clinical or medical emergency”. It also says care homes must work actively with others to ensure care and treatment remains safe for residents. They should also share relevant information with other professionals involved in residents’ care.
• Regulation 14 says people must have enough to eat and drink to keep them in good health while they receive care and treatment. It also includes ensuring people get any prescribed dietary supplements and any necessary support with eating and drinking. CQC guidance says care homes must include residents’ food and drink needs in their initial needs assessments, and must act without delay to address any concerns about unnecessary dehydration or weight loss.
• Regulation 17 is about good governance. It says care homes must keep securely accurate and complete records of care and treatment provided to residents, and of decisions relating to that care and treatment.

What happened

22. In March 2022, the Home sought or followed up medical input for Mr F five times. It also asked for an extra district nursing visit on 1 April, the day Mr F was admitted to hospital.
23. In March 2022, the GP Surgery asked the Home to:
• contact the district nurses to organise a swab and to take a urine sample to the GP surgery for testing (17/3/22);
• refer Mr F to the dietitian urgently or to send the GP Surgery up-to-date weight information (17/3);
• chase the dietitian and look for other concerns e.g. swallowing difficulties, bleeding, pain (29/3); and
• document Mr F’s food and fluid intake, possibly ask Mr F’s family not to give him sweets, and ask his family if they could visit him at mealtimes to encourage him to eat.
24. Ms D reported her concerns about Mr F not eating and his weight loss to the Council in early March 2022. The Council:
• took Ms D’s concerns into account together with existing concerns about his weight loss;
• noted the Home had referred Mr F to a dietitian and that he was getting four calorie supplement drinks a day;
• contacted the Home and confirmed it would ask a GP to review whether any health conditions were contributing to Mr F’s weight loss;
• confirmed the Home was using food and fluid charts for Mr F and weighing him weekly;
• asked for an occupational therapist (OT) to review Mr F; and
• decided that because all these actions were happening, there was no need for a safeguarding enquiry under section 42 or the Care Act 2014.
25. However, the Council did not update Ms D about the actions. It apologised for this in its June 2022 complaint response to Ms D. In its further complaint response from September 2022, the Council apologised again and said, “there was room for further professional curiosity” and it could have explored Ms D’s concerns further by:
• speaking to the Home;
• asking to see the Home’s food and fluid charts; and
• asking questions about Mr F’s food preferences and his needs for support with meals.

Was there fault causing injustice?

26. The Home was providing Mr F with residential care, rather than nursing care. We would not therefore expect it to act as a health provider and investigate potential health problems, but rather to seek medical advice when appropriate.
27. The Home acted appropriately, in accordance with Regulations and without fault in:
• seeking external medical support with Mr F’s weight loss and other health problems;
• adequately documenting Mr F’s weight as well as his food and fluid intake;
• encouraging and helping Mr F to eat and drink but noting he would sometimes refuse this; and
• complying with most of the GP Surgery’s requests for information and samples.
28. The Home did not ask the district nurses to take a swab from Mr F’s penis, as requested by the GP Surgery. If the Home was not going to follow this request, it should have made this clear to the GP Surgery. Failure to do so was fault. We cannot say, even on balance, that doing so would have made a difference to Mr F as there are too many variables that could have affected his health. But this has added to Ms D’s sense of uncertainty about whether the outcome for her father might have been different.
29. The Home also acted with fault in misplacing some of Mr F’s paper records. This has not caused an injustice to Mr F as it happened after he died. It has also not prevented us from investigating this part of the complaint as we could get relevant records from other sources. However, it has added to Ms D’s sense of uncertainty.

B – The GP Surgery’s actions relating to UTI, weight loss and visits

30. Ms D says the GP Surgery failed to identify Mr F had a UTI, did not address his weight loss and did not visit him when requested.
31. Mr F’s medical records were accessible for viewing and updating to the key health providers involved in his care during the period of this investigation. These include:
• the GP Surgery, which as well as GPs employed a practice nurse specifically to visit and look after care home residents;
• the community nursing service (sometimes called district nurses). In Mr F’s case, they provided wound care, checked his skin for pressure ulcers and gave him vitamin injections;
• the nutrition and dietetics service; and
• the community rehabilitation and physiotherapy service.

What happened?

32. The records contain the following key information for the period of this investigation.
• District nurses saw Mr F seven times in March 2022, including on the day he was admitted to hospital in April 2022.
• The GP Surgery referred Mr F to the nutrition and dietetics service in February 2022 because of concerns about his weight loss. The service initially rejected that referral, but accepted it in early March 2022.
• Following a concern from the Home about weight loss on 10 March 2022, the GP Surgery’s practice nurse requested blood tests. The blood tests were for a variety of markers that would indicate some of the most common causes of weight loss in an older man.
• A week later, the Home told the GP Surgery Mr F has a discharge from his penis. Ms D also contacted the GP Surgery separately with concerns about weight loss. A GP from the Surgery reviewed Mr F’s case including the blood test results and asked the Home to contact the district nurses to take a swab of the discharge. The GP took the view there was no further action needed in response to the blood test results. The results were essentially normal with no indication of any underlying condition.
• On 22 March 2022, the practice nurse visited Mr F because he had a pain in his leg. The practice nurse advised the Home to give Mr F ‘homely medicines’ such as paracetamol. The nurse also asked the GP to consider a trial of a muscle relaxant medication for Mr F’s leg. The GP agreed and issued a prescription for the medication.
• On 28 March 2022, the Home emailed the GP Surgery with concerns about Mr F and asking for a visit or a call. The Home had concerns about Mr F not being his usual self and his continued weight loss, poor food and drink intake, vomiting and loose bowel movements, continued leg pain, and continued penile discharge. The Home also said it had not been able to get a urine sample. The GP Practice referred Mr F for a chest and abdomen X-ray.
• The following day, the GP Surgery informed the Home about the X-ray referral. It also asked the Home to chase up the dietitian and to look out for other concerns such as swallowing difficulties, bleeding and pain. The Home contacted the nutrition and dietetics service and gave it an update on Mr F’s weight loss. The service decided to place Mr F on ‘high priority’ with an appointment due within a month. The Home also contacted the GP Surgery to say Mr F’s family was becoming increasingly concerned about his weight loss and asking if he should be referred to hospital for support with fluids and nutrition. In response, the GP Surgery asked the Home to start documenting Mr F’s food and fluid intake. The GP Surgery also asked the Home to check if it was possible for Mr F’s family to visit him when he was eating to help encourage him to eat.
• On 31 March 2022, the GP Surgery’s practice nurse called Ms D twice. The first call was to discuss her concerns about Mr F’s weight loss. The practice nurse explained what the GP Surgery and Home had done so far and why it could take no further action other than referring Mr F to the hospital’s frailty consultant (a specialist elderly care doctor). Ms D was due to have a meeting with the Home about her concerns later that day and the nurse asked to have another call with her after this meeting. The GP Surgery’s note of the second call with Ms D says the practice nurse asked her “is she happy with what we have done so far and if there is anything we could be doing” and that she replied the GP Surgery had “done everything that has been requested to date and happy with this”. The GP Surgery made the referral to the frailty consultant and the community physiotherapy service on the same day.
• The GP Surgery also emailed the Home on 31 March 2022 to explain why it did not consider Mr F needed a hospital admission at the time. Its reasoning was that Mr F had no “acute symptoms” or pain and the ambulance service would therefore likely refuse to take him to hospital. The GP Surgery considered that even if the ambulance service agreed to take Mr F to hospital, he would probably not be admitted but would rather have blood tests in A&E. The GP Surgery’s view was that all this would be unnecessarily stressful for Mr F and that it was better to wait for the outcome of the frailty referral which would allow for a better planned assessment.
• On 1 April 2022, the GP Surgery chased up the X-ray referral. The district nurses saw Mr F in the morning to care for a wound on his arm, and in the early afternoon to check his sacrum for a pressure sore. A GP prescribed some barrier cream.

Was there fault causing injustice?

33. The General Medical Council (GMC) regulates doctors in the UK. The Nursing and Midwifery Council (NMC) regulates nurses in the UK. Both organisations have published guidance on standards and working with colleagues.
34. The National Institute for Health and Care Excellence (NICE) has published guidance on managing UTIs.
35. The GP surgery acted in accordance with relevant guidance when its GP and nurse:
• worked together or acted within their own capabilities, as appropriate, when managing Mr F’s care;
• treated Mr F as part of a multidisciplinary team of professionals with different specialisms;
• used their judgement to decide when it was appropriate to visit Mr F in person;
• worked with other professionals (dietitians and the Home) to investigate Mr F’s weight loss and treat it;
• referred Mr F to the frailty consultant and for investigations such as blood tests and X-rays;
• acted based on the symptoms Mr F had at the time and the results of recent blood and urine dipstick tests. Mr F did not show symptoms of a UTI until the day he went into hospital; and
• communicated with Ms D about Mr F’s health.
36. I have therefore not found fault with the GP Surgery in relation to this part of the complaint.

C – The Home and GP Surgery working together

37. Ms D says the Home and GP Surgery did not work together and communicate effectively to ensure that they both did what they needed to, for Mr F’s symptoms to be investigated and treated promptly.
38. There was no fault in the way the GP Surgery and Home worked together, except for the issues already identified in paragraph 28 above.
39. The GP Surgery acted in accordance with relevant standards and guidelines when working together with the Home. It has also implemented improvements following Ms D’s complaint by introducing GP visits to patients with complex needs to provide a second opinion. It is good practice for the GP Surgery to recognise and act on potential improvements, even where a complaint is not upheld.

D – Mr F’s care in the Home

Food

40. Ms D says the Home provided poor care to Mr F, for example: failing to chop up his food; not placing a call bell, drinks and snacks within reach; failing to properly monitor and record his food and fluid intake; poor continence care.
41. Ms D says she saw the Home giving Mr F meals such as egg and chips without them being chopped into small pieces. She says she later discovered that Mr F should have been on a soft diet. In its August 2022 response to Ms D’s complaint, the Home told her that Mr F was “on a soft diet in accordance with a level 6 IDDSI”. IDSSI is the International Dysphagia [swallowing difficulties] Diet Standardisation Initiative. IDSSI level 6 foods are soft and bite-sized.
42. In summary, the Home’s care plan for Mr F’s eating and drinking:
• described Mr F’s difficulties with eating and drinking, the support he needed, and that he would occasionally refuse to eat and drink;
• said Mr F needed support with cutting his food; and
• said Mr F had dentures but sometimes refused to use them. On those occasions, he needed a soft food diet.
43. While some records are missing, the Home did keep Mr F’s food charts from 18 March 2022. These show that Mr F was not on a soft diet permanently as they state he ate foods such as toast and sandwiches.
44. I consider the Home acted in accordance with Mr F’s food care plan and Regulation 14 in the way it provided his food and supported him with eating it. There was no fault by the Home in this respect.
45. The Home’s August 2022 complaint response to Ms D was inaccurate because it said Mr F was on a soft diet, when this is not supported by either Mr F’s care plan or his food chart. This was fault and has added to Ms D’s uncertainty about her father’s care.

Call bell

46. Ms D says the Home placed a call bell on Mr F’s bedside table where he could not reach it, and that the Home told her this is because Mr F did not know what it was for. In its August 2022 response to Ms D’s complaint, the Home disputed telling her this and said that it checked on Mr F regularly because he did not use the call bell. The Home also produced a statement following concerns Ms D raised with the CQC in April 2022. In it, the Home said that a staff member accidentally broke Mr F’s call bell resulting in there being no working call bell until it was repaired three days later. The Home said staff carried out regular checks as usual during this period.
47. The Home’s care plan for Mr F’s eating and drinking included a section about risk. It said Mr F had a buzzer but refused to use it as he believed he did not need help. To mitigate the risk, the Home said everything Mr F needed should be within reach from his bed to reduce the risk of him getting out of bed.
48. Where residents cannot use call bells, we would expect care providers to have alternative arrangements in place to ensure residents could seek help and ask to have their needs met. In this case, the care plan of having things Mr F might need within his reach and the practice of checking on him regularly were an appropriate alternative. The available food, fluid and repositioning charts indicate that most of the time, staff saw Mr F at least every two hours throughout the day and night. I have therefore not found fault in this part of the complaint.

Medication

49. Ms D also says the Home’s medication administration records (MAR) chart was inaccurate. In its September 2022 response to Ms D’s complaint about this, the Council said it had not seen those records but would expect all:
• residential care homes to have their own medication policies; and
• care home staff to have the training to complete medication duties safely.
50. The Council’s complaint response also apologised and said the Council should have explored Ms D’s concerns further to assess if it could provide any support or take any action.
51. The Home’s MAR charts for Mr F are part of the paper records it has misplaced. This means we cannot now investigate this part of the complaint. The loss of records is fault and has added to Ms D’s uncertainty.
52. The Council was responsible for Mr F’s care at the Home and should have been able to access his records there as part of its investigation of Ms D’s complaint. Failure to do so was also fault that has added to Ms D’s uncertainty.

E – Communication with Ms D

53. Ms D says the Home failed to communicate with her adequately. For example, it: did not inform her properly about her father being found on the floor; failed to involve her in developing his care plan; and failed to share his care plan with her.

Falls

54. Mr F’s medical notes say he moved into the Home on 4 February 2022 and mention a fall and readmission to hospital on 6 February. Mr F left hospital and went back to the Home on 19 February. The Home referred him to the community falls service on 22 February. The falls service accepted the referral on 28 February. The Home chased the falls service for an assessment on 11 March because Mr F kept getting out of bed and shuffling along the floor.
55. Ms D complained to the Home in June 2022. Part of her complaint included concerns about the Home not telling her Mr F had falls at some time between 3 and 5 February, and in the night of 27 February.
56. In its August 2022 response to Ms D’s complaint, the Home said that:
• it had conversations with Ms D about Mr F moving onto the floor from his bed;
• Ms D had emailed it asking it to allow Mr F to shuffle along the floor as that was what he had done at home (Ms D disputes this); and
• in one email from 5 March 2022, Ms D had clearly stated that the Home had informed her of Mr F falling but she disagreed with referring to this as falling and considered it was Mr F lowering himself out of his bed to crawl across the floor.
57. The Home has misplaced Mr F’s records for this period. Ms D’s and the Home’s recollections of communication about falls are significantly different. Together with medical records, the recollections are evidence that Mr F had several falls while at the Home. However, there is not enough in the available evidence for me to reach a view on whether the Home’s communication with Ms D about this was sufficient.

Care planning

58. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan. The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. If the adult cannot make their own decisions, the council must involve “any person who appears to … be interested in the adult’s welfare”. The Care Act 2014 also says the council must give the carer a copy of the care plan if the adult asks it to do so.
59. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs.
60. Government Care and Support Statutory Guidance (CSSG) says, “where a person has substantial difficulty in being fully involved in their care planning or lacks capacity to agree and consent to the care plan, they may be supported by family members or friends”.
61. The Council’s social care records show it:
• started to assess Mr F’s needs under the Care Act after he moved to the Home;
• involved Ms D and her sister in its assessment; and
• had not finished assessing Mr F’s care and support needs and finances by the time he went back into hospital on 1 April 2022.
62. The whole period was under two months, some of which Mr F had spent back in hospital, where it would not have been appropriate to continue assessing his needs. My view is therefore that there was no significant delay in the Council’s assessment of Mr F’s needs. The Council could not share the assessment and care plan with Ms D as it had not completed them before Mr F went back to hospital.
63. Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 is about person-centred care. It says care home residents must get care that is appropriate, meets their assessed needs and reflects their preferences. CQC’s guidance says assessments should include all the person’s needs including health and personal care. It says care providers should involve residents and their representatives as much or as little as they want to be in assessments. CQC guidance also says care homes must make clear care plans for residents and keep a record of all assessments and care plans.
64. The Home’s care plan for eating and drinking for Mr F is dated 5 March 2022. The care plan is written in line with CQC’s guidance. It includes detailed information about Mr F’s needs and preferences as well as references to information provided by his family. However, it was produced almost a month after Mr F first moved to the Home, and 13 days after he returned there following a re-admission to hospital. The Home should have produced the care plan much sooner, given it dealt with an essential part of Mr F’s care needs and Mr F was particularly vulnerable because of his weight loss and eating needs. The time taken to produce the care plan was therefore fault.
65. As the Home has misplaced Mr F’s paper records, we do not know if it completed care plans for all of Mr F’s other needs in line with Regulation 9 and CQC’s guidance.
66. There is no documentary evidence the Home shared any of its care plans for Mr F with Ms D. This corresponds with Ms D’s recollection that she did not get copies of care plans. The Home should have shared Mr F’s care plans with Ms D or explained its reasoning for not do this. Failing to do so was fault.
67. We cannot say what injustice, if any, the faults identified in this part of the complaint caused to Mr F. This is because there are too many other variables related to his care and health treatment. The faults have added to Ms D’s sense of uncertainty.

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Summary of findings

68. We have found no fault in the action of the GP Surgery.
69. 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. We therefore hold the Council responsible for the following faults relating to Mr F’s care at the Home.
• Failing to tell the GP Surgery that the Home would not comply with its request to ask the district nurses to take a swab from Mr F.
• Delay in completing the Home’s care plan for Mr F’s eating and drinking needs.
• Failing to share any of the Home’s care plans for Mr F with Ms D, without providing good reason.
• Misplacing Mr F’s paper care records.
• The Home’s complaint response incorrectly telling Ms D that Mr F was on a soft diet.
• The Council failing to consider the Home’s care records when responding to Ms D’s complaint.
70. We cannot say, even on balance of probability, that the faults caused Mr F an injustice. This is because there are too many other unknown variables that could have affected his health and wellbeing.
71. The faults have caused Ms D an injustice by adding to her distressing uncertainty about whether her father’s last illness could have been prevented or treated earlier.

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Agreed actions

72. Although we found fault with the actions of the Home, we have made recommendations to the Council because it remains responsible for the service it commissioned. The Home has already transitioned from a paper to an electronic records system, which means it is less likely to repeat the faults identified in this investigation. We have therefore not made service improvement recommendations.
73. To remedy the injustice to Ms D, the Council should write to her with an acknowledgement of and apology for the problems identified in our investigation. 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.
74. The Council should also share our findings with the Home.
75. The Council should provide us with evidence it has complied with the above actions within one month of the date of our final decision.

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Final decision

76. I uphold parts of the complaint as specified in paragraph 69. I do not uphold the rest of the complaint. The Council accepts my recommendation. I have therefore completed my investigation and closed the complaint.

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Investigator's decision on behalf of the Ombudsman