Moat House Surgery (18 001 953c)

Statement Not upheld General practice 06-Sep-2019

Summary: The Ombudsmen found no fault by a Council and GP Practice in terms of the care provided to an elderly woman in hospital and a nursing home. The Ombudsmen found fault with the Trust’s failure to arrange a heart scan but are satisfied this did not have a significant impact on the woman’s care.

St George's Nursing Home (17 015 066a)

Statement Upheld Other 04-Sep-2019

Summary: The Ombudsmen found North Somerset Council’s flawed safeguarding enquiry into Mrs D’s care and support caused Mrs C distress and uncertainty. St George’s Nursing Home’s (the Home) poor record keeping of Mrs D’s fluid intake and pressure sore care caused Mrs C uncertainty. The Home should remedy the distress Mrs C suffered when she found an antibiotic next to Mrs D’s bed. The Ombudsmen also found Bristol, North Somerset & South Gloucestershire Clinical Commissioning Group compounded Mrs C’s distress by significantly delaying handling her complaint.

Care Quality Commission (17 015 066b)

Statement Not upheld Other 04-Sep-2019

Summary: The Ombudsmen found North Somerset Council’s flawed safeguarding enquiry into Mrs D’s care and support caused Mrs C distress and uncertainty. St George’s Nursing Home’s (the Home) poor record keeping of Mrs D’s fluid intake and pressure sore care caused Mrs C uncertainty. The Home should remedy the distress Mrs C suffered when she found an antibiotic next to Mrs D’s bed. The Ombudsmen also found Bristol, North Somerset & South Gloucestershire Clinical Commissioning Group compounded Mrs C’s distress by significantly delaying handling her complaint.

Weston Area Health NHS Trust (17 015 066c)

Statement Not upheld Hospital acute services 04-Sep-2019

Summary: The Ombudsmen found North Somerset Council’s flawed safeguarding enquiry into Mrs D’s care and support caused Mrs C distress and uncertainty. St George’s Nursing Home’s (the Home) poor record keeping of Mrs D’s fluid intake and pressure sore care caused Mrs C uncertainty. The Home should remedy the distress Mrs C suffered when she found an antibiotic next to Mrs D’s bed. The Ombudsmen also found Bristol, North Somerset & South Gloucestershire Clinical Commissioning Group compounded Mrs C’s distress by significantly delaying handling her complaint.

NHS Bristol, North Somerset & South Gloucestershire Clinical Commissioning Group (17 015 066d)

Statement Upheld Other 04-Sep-2019

Summary: The Ombudsmen found North Somerset Council’s flawed safeguarding enquiry into Mrs D’s care and support caused Mrs C distress and uncertainty. St George’s Nursing Home’s (the Home) poor record keeping of Mrs D’s fluid intake and pressure sore care caused Mrs C uncertainty. The Home should remedy the distress Mrs C suffered when she found an antibiotic next to Mrs D’s bed. The Ombudsmen also found Bristol, North Somerset & South Gloucestershire Clinical Commissioning Group compounded Mrs C’s distress by significantly delaying handling her complaint.

North Somerset Community Partnership (17 015 066e)

Statement Not upheld Other 04-Sep-2019

Summary: The Ombudsmen found North Somerset Council’s flawed safeguarding enquiry into Mrs D’s care and support caused Mrs C distress and uncertainty. St George’s Nursing Home’s (the Home) poor record keeping of Mrs D’s fluid intake and pressure sore care caused Mrs C uncertainty. The Home should remedy the distress Mrs C suffered when she found an antibiotic next to Mrs D’s bed. The Ombudsmen also found Bristol, North Somerset & South Gloucestershire Clinical Commissioning Group compounded Mrs C’s distress by significantly delaying handling her complaint.

Oxford Health NHS Foundation Trust (18 005 323a)

Statement Upheld Mental health services 04-Sep-2019

Summary: The Ombudsmen found faults in safeguarding Mrs D’s mother Mrs F, assessing Mrs F and her husband, and in responding to Mrs D’s complaint. The Council and Trust have already accepted there were faults and apologised. This is an appropriate way to address the injustice to Mrs D’s family. The Council and Trust have also improved services since Mrs D’s complaint. Some of their process and information remain flawed, so we have recommended service improvements. The Council and Trust accept our recommendations, so the Ombudsmen have completed their investigation.

Oxford Health NHS Foundation Trust (18 018 977a)

Statement Upheld Mental health services 04-Sep-2019

Summary: The Council and Trust have already acknowledged they failed to assess Mr F as a carer and failed to provide him with support. The Council has accepted our recommendation to provide an apology. The Trust has accepted our recommendation to issue staff guidance. The Ombudsmen have therefore completed their investigation.

Royal Devon & Exeter NHS Foundation Trust (18 013 412a)

Statement Closed after initial enquiries Other 02-Sep-2019

Summary: The Ombudsmen will not investigate Mr and Mrs Y’s complaint about the way the Trust and the Council carried out a safeguarding enquiry. This is because an investigation is unlikely to add to the responses Mr and Mrs Y have already received.

Pennine Care NHS Foundation Trust (19 003 456a)

Statement Closed after initial enquiries Mental health services 02-Sep-2019

Summary: The Ombudsmen will not investigate this complaint about the circumstances surrounding the detention of the complainant under the Mental Health Act. This is because some of the matters the complainant raises do not fall under the Ombudsmen’s jurisdiction. The complainant’s other concerns relate to care provided more than 12 months ago. These matters are late for the Ombudsmen’s consideration.