Summary: Mrs W complains on behalf of her late mother, Mrs Y, about the standard of care and support she received whilst at Oakham Grange Residential Care Home. In particular, she says the home did not appropriately manage and administer Mrs Y’s medication, did not ensure staff used safe moving and handling techniques and failed to monitor her weight and nutritional needs. The local safeguarding authority investigated the concerns and concluded with findings of neglect and organisational abuse. It made several recommendations for service improvements. The care provider will also apologise to Mrs W and make a symbolic payment in recognition of the uncertainty and distress caused by the failures.

The complaint

1. Mrs W complains about the care and support given to her late mother, Mrs Y, whilst resident in Oakham Grange Residential Care Home, which I will call ‘the home’. She says the home did not appropriately manage and administer Mrs Y’s medication, did not ensure staff used safe moving and handling techniques and failed to appropriately monitor Mrs Y’s weight and nutritional needs.
2. Mrs W also complains about the way the care home dealt with and responded to her complaints.

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The Ombudsman’s role and powers

3. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by their personal representative (if they have one), or someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
4. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C) If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide any injustice is not significant enough to justify our involvement. (Local Government Act 1974, section 24A(6), as amended, section 34(B))
6. If we are satisfied with an organisation’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)

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How I considered this complaint

7. During my investigation I discussed the complaint with Mrs W and considered the information she provided. This included complaint correspondence between Mrs W and the home, the findings of the care home’s investigation and the safeguarding papers. Mrs W also provided some of the contemporaneous records such as Mrs Y’s Medication Administration Record (MAR) showing the missed doses of medication and care records regarding her weight and nutrition.
8. Mrs W and the care provider had an opportunity to comment on my draft decision. I considered any comments received before making this final decision.
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Fundamental Standards of Care

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
11. Regulation 12 sets out the requirement for care providers to deliver safe care and treatment. It says that medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe. Those administering medication must be suitably trained and competent and kept subject to review.
12. Regulation 14 sets out how care providers should ensure service users have adequate nutrition and hydration to sustain good health. Where a person is assessed as needing a specific diet, this must be provided. Nutritional and hydration intake should be monitored and recorded to prevent dehydration, weight loss or weight gain. Action must be taken without delay to address any concerns.
13. Regulation 16 sets out how care providers should deal with complaints about their service. It says providers must have effective systems to make sure that all complaints are investigated without delay. This includes:
• Undertaking a review to establish the level of investigation and immediate action required, including referral to appropriate authorities for investigation. This may include professional regulators or local authority safeguarding teams.
• Making sure appropriate investigations are carried out to identify what might have caused the complaint and the actions required to prevent similar complaints.
• When the complainant has identified themselves, investigating and responding to them and where relevant their family and carers without delay.

Summary of key events leading to the complaint

14. This section of the decision statement does not list every event which happened during the period complained about. Instead, it provides an overall summary of the key issues relevant to the complaint.
15. Mrs Y and her husband, Mr Y, moved to Oakham Grange (‘the home’) on 8 November 2022 as a short-term respite resident. Mrs Y had dementia. Her care plan written dated 14 November said that the Mrs Y was at high risk of weight loss and malnutrition. To manage this, the care plan said the home would weigh Mrs Y on a weekly basis and monitor accordingly.
16. Two days after moving into the home Mrs Y fell and was later found to have sustained fractures to her left wrist and right femur. She remained in hospital for several weeks and had surgery to repair the damage to her right thigh. As a result of the injury, Mrs W said Mrs Y’s needs changed. She returned to the home on 23 November.
17. In early December Mrs W complained to the home about several concerns which I will summarise below.
• Mrs Y was in distress due to the way two male agency care workers had washed and dressed her. Mrs W said the carers did not know how to use Mrs Y’s mobility aid and raised their voices.
• Care staff had switched off Mrs Y’s bed which then deflated.
• Mrs Y received doses of paracetamol less than four hours apart.
• A female member of staff raised their voice at Mrs Y and had no knowledge of Mrs Y’s diagnoses and her needs.
• Trays and plates from leftover meals are being left in the room or corridor for hours.
18. Mrs Y suffered another fall on 30 December when she stood up from her wheelchair. Mrs Y sustained an injury to the skin on her leg needing medical attention.
19. The home responded to Mrs W’s complaint on 18 January 2023. In summary it said:
• The agency staff in question were spoken to. They will not return to the home. Since the incident, the home has recruited many staff and will rely less on agency staff.
• The mobility equipment was not being used as it was designed, and the provider spoke with all care staff to ensure they knew how to use the equipment.
• The home accepts “our values and good practices have not been adhered to and in this your complaint is upheld”.
• Throughout the recruitment process, staff are reminded of the importance of kindness and the need to respect residents’ and maintain their dignity.
• On occasion, medication is given a little later than planned. But the provider does not accept that the time is left uncorrected on the records leading to a potential overdose.
• Staff are reminded to clear dirty plates after each meal. The home has implemented a spot check to ensure this is done.
20. The care provider served notice on 7 February for Mrs Y and her husband to leave the home. They moved to a different home on 28 February.
21. Following an inspection in April 2023, CQC gave an overall rating of ‘Inadequate’ and placed the home into ‘special measures’. Following a re-inspection in July 2023, CQC found the home had made some improvements which prompted a change in the overall rating to ‘Requires Improvement’.
22. The following sections of this statement will set out how the home dealt with the areas of concern.

Fall on 10 November 2022

23. The home made a safeguarding referral to the local safeguarding authority, which I will refer to as ‘the Council’, on 14 November 2022 regarding the unwitnessed fall and subsequent injuries suffered by Mrs Y on 10 November. Mr Y raised the alarm when Mrs Y fell over whilst walking to the bathroom at approximately 4am.
24. Care staff called the NHS non-emergency line (111) for assistance. The home said that the 111 advisor told staff to hoist Mrs Y from the floor to her bed. Mr Y told Mrs W that Mrs Y screamed out in significant pain during the transfer.
25. The following morning, a member of nursing staff arrived on shift and shortly after noticed a distortion to Mrs Y’s thigh. The home called 999 and Mrs Y travelled to hospital by ambulance where she was found to have a broken wrist and femur. Mrs Y had surgery to repair the damage to her right thigh and was discharged before returning to the home on 23 November.
26. The Council considered the safeguarding referral and on 12 December decided to make enquiries into the events around Mrs Y’s fall.
27. During the enquiries, the home’s manager confirmed that staff used the hoist improperly because the legs did not fit under Mrs Y’s divan bed. This meant that staff lined the hoist parallel to Mrs Y’s bed before leaning the hoist and moving the sling to position. This practice was not in accordance with the moving and handling protocols and was found to be an “unsafe technique” which placed Mrs Y “at serious risk of harm and distress that could have been avoided”.
28. The Council examined the available evidence and found “… the allegation of neglect/act of omission has been substantiated. Following concerns around actions taken in response to [Mrs Y’s] fall… the enquiry found that whilst the carer took the correct course of action in contacting healthcare professionals the senior carer failed to use the appropriate moving and handling techniques putting [Mrs Y] at serious risk of harm and distress and pain resulted that could have been avoided. Furthermore they failed to follow the advice of the 111 professional who advised that they should have stopped the manoeuvre when [Mrs Y] expressed pain”
29. Following the incident Mrs W said that Mrs Y experienced significant psychological distress when being hoisted as she associated the hoist with the pain she felt on 10 November.
30. The home confirmed the staff member in question was suspended but re-instated following further training and assessment of their competency. In addition to the training for the staff member, the investigation concluded with the following recommendations for the home.
• Ensure staff are on shift morning and night and that they are trained to assess for injury and engage with healthcare professionals.
• Ensure that all staff know how to escalate any concerns.
• Communicate to all staff the importance of the correct moving and handling techniques and when to stop a manoeuvre.
• Undertake proportionate “environmental assessments” of the surroundings prior to starting any moving and handling techniques.
• Ensure all relevant training is up to date and recorded.
• Ensure all staff understand the whistleblowing policy and the procedure to report poor practice. Any breaches in these practices to be recorded and action taken.
• Implement training on clinical record keeping.
• Implement training on reporting incidents on the ‘RADAR’ system and recording the correct time and date of incidents.
• Implement the on-call procedure to ensure staff are aware to call for support.
• Complete appropriate supervision and monitoring of staff involved with the incident to ensure they can provide professional care.

Fall on 30 December 2022

31. Mrs Y sustained deep cuts to her leg on 30 December when she stood up from her wheelchair and fell forward. Multiple paramedics attended to join the skin together and applied a dressing to Mrs Y’s shin.
32. The home’s accident report says: “Agency staff went to assist [Mrs Y] with personal care and to put her to bed, they looked for stand aid outside the room. When they turned around [Mrs Y] was trying to stand from chair reaching for the bed, she then proceeded to slip from her chair onto the floor next to her bed”.
33. The home made a safeguarding referral to the Council on 16 January 2023.
34. The Council’s safeguarding enquiries found the home failed to ensure that Mrs Y’s care plan reflected her clinical needs; in particular around her changing mobility, moving and handling requirements. This meant that staff did not have suitable guidance about how to appropriately care for Mrs Y.
35. The investigation also found that, on some occasions, only one member of staff transferred Mrs Y, instead of two. On other occasions, staff did not always use the correct techniques and equipment.
36. Following the incident, poor communication at handover meant that a staff member tried to prematurely remove Mrs Y’s dressing which the paramedics had advised should remain in place for at least five days. Mrs W says the discharge notes provided by the paramedics remained in Mrs Y’s room and were not actioned by staff.
37. The safeguarding investigation concluded with the following outcome:

“… the concerns have been substantiated and that neglect and organisational abuse did take place. Found that staff did not have access to up-to-date support plans. [Mrs Y] was assigned 2 unfamiliar staff members who were not aware of needs. [Mrs Y] was left in considerable pain and distress and did not receive the safe clinical care in line with her needs and without robust systems in place for high quality and effective monitoring of care plans and then staff, particularly agency staff, could not deliver the care that [Mrs Y] required, considering her changing needs around mobility”.

38. The investigation concluded with the following recommendations for the home.
• Ensure all staff are aware of how and when to seek medical attention for a resident.
• Management to communicate the correct moving and handling techniques to staff.
• Ensure staff are aware of their responsibilities to seek support or escalate a situation to more senior colleagues when needed.
• Ensure relevant training is up to date and recorded.
• Ensure all staff understand the whistleblowing policy and the procedure to report poor practice. Any breaches in these practices to be recorded and action taken.
• Ensure staff are aware of record keeping protocols and to receive training and support if needed.
• Ensure training, competency and induction procedures for new starters are appropriate and updated if needed.
• Care plans and risk assessments to be shared with all staff and ensure they are followed, adhered to and implemented. Any breaches to be recorded appropriately and action taken.
• Agency staff to receive a thorough induction process.
• Staff to have adequate handovers to fulfil their role in a safe and timely way.
• Review care plans at regular intervals and amended when needed.
• Ensure that agencies are told in a timely manner about any incidents involving their workers.

Weight management and record keeping

39. Upon her admission, the home identified that Mrs Y was at high risk of weight loss, malnutrition, and dehydration. Her care plan said staff would weigh Mrs Y every week. During her time at the home, the records show that staff reviewed Mrs Y’s care plan on three occasions. Staff did not make any amendments to the agreed schedule of weekly weight monitoring.
40. Following her departure from the home, Mrs W made a Subject Access Request (SAR) to obtain data about Mrs Y. Mrs W said the data was needed to allow nursing staff at Mrs Y’s new home to identify any patterns in her weight loss.
41. The SAR response included one recorded weight in a care plan dated 1 January 2023. This was the only entry for the 16 weeks during which Mrs Y lived at the home. Mrs W made a further request, and the home later provided a copy of a redacted monthly weight chart on which Mrs Y did not appear.
42. Mrs W also received care notes. On 28 January an entry shows that Mr Y, who along with their children had Lasting Power of Attorney for Mrs Y, requested for Mrs Y to be weighed due to noticeable weight loss. The home refused to weigh Mrs Y because it said she was to be weighed only once per month. The only previous weight recorded by the home for Mrs Y was 28 days prior.
43. Mrs W asked for further care records about Mrs Y’s weight management. She received an email from the home to say, “… an unknown individual has deleted the weights off of recording sheet when [Mrs Y] was discharged from the service, this evidence was not archived as it should have been”.
44. The safeguarding enquiries found that Mrs Y lost 14.55kg in weight over 13 to 14 months. Due to the lack of records, it was not possible to say if Mrs Y’s weight loss was steady or whether there were periods of increased weight loss. Mrs W raised a complaint about these concerns.
45. The safeguarding investigation concluded with the following outcome:

“…. The allegation of neglect and act of omission has been substantiated. The care home failed to ensure that [Mrs Y] consistently received care in line with her needs and despite her care plan highlighting that she was at high risk of poor nutritional intake and therefore weight related issues, this was not monitored regularly. The care [Mrs Y] received in this domain did not reflect her identified needs”.

46. The minutes also noted that the home failed to act upon concerns raised by the Community Therapist and Mr Y about his wife’s weight loss.
47. The investigation concluded with the following recommendations for the home.
• Ensure care planning is robust and reviewed regularly to reflect residents’ needs.
• Staff to have access to care plans so that residents receive appropriate and safe clinical care.
• Care plans and risk assessments to be followed, adhered to and implemented.
• Staff to receive training on the new electronic system and have access to the handheld devices.
• Staff to record clinical and care tasks.
• Handovers to be done in a safe and timely way.
• Appropriate monitoring and supervision of staff following any incidents.
• Arrange a workshop for all staff about person led care and the role of LPA in relation to health and welfare.

Medication errors

48. After reviewing Mrs Y’s care records, Mrs W found the home had given Mrs Y only half the dose of the prescribed medication for the symptoms of Alzheimer’s Disease. This happened between 6 and 10 December. From 10 December the records showed that Mrs Y received none of the medication for the next six days. Mrs W said that Mrs Y was in a “confused state” during this period.
49. The home said the error happened when the prescriber changed the dosage from 10mg to 5mg per day. The tablets then ran out and were not in stock again for six days. The safeguarding notification raised by the home related only to a single dose of missed medication.
50. Furthermore, Mrs W reported the home did not properly administer Mrs Y’s steroid medication following her discharge from hospital in November. The steroids were given for pain and swelling in Mrs Y’s shoulder. Mrs W says Mrs Y came out of hospital on 10mg per day. Mrs W says the GP agreed for the dose to be reduced by 1mg each month whilst carefully monitoring Mrs Y’s pain levels.
51. Instead, Mrs W said Mrs Y received 10mg until 31 December and then 8mg for 11 days until decreasing to 7mg from 12 January. Mrs W complained the reduction in Mrs Y’s steroid medication was faster than discussed or agreed by medical professionals. Mrs W says Mrs Y complained about arm pain during this period.
52. In addition to the above, Mrs W also reported errors with other medication. Following Mrs Y’s discharge from hospital, Mrs W said that one of her mother’s prescribed medications for calcium and Vitamin D had been stopped due to Mrs Y’s high calcium levels. Mrs Y received a prescription for an alternative oral Vitamin D medication. From the MAR charts Mrs W found Mrs Y had received both the original and new medication between 25 December and 9 January until the new medication ran out. Mrs W says the home failed to recognise the two items were the same medication.
53. Mrs Y also missed two doses of her folic acid medication due to no stock between 21 and 23 January. The home’s system showed that staff booked in 28 tablets on 24 December. The home did not request a repeat prescription in a timely way.
54. The home investigated the reported errors and said the prescription for Mrs Y’s steroid medication stated that it was to be administered “as directed”. The home said the pharmacy then changed the regular dose to “as required” which resulted in the home entering a different dose on its system.
55. The home made a safeguarding referral on 24 February.
56. The safeguarding investigation identified “multiple medication errors”. The safeguarding papers summarise discussions with a GP, who said the following.
• The failure to consistently take the Alzheimer's medication may reduce the positive effect on Mrs Y’s memory problems. The GP expected any negative effect to disappear upon Mrs Y restarting the medication.
• There was no consultation during February 2023 about errors in the administration of the steroid tablets. Missing the tablets or implementing a “rapid withdrawal” can be a “risky error” due to the associated side effects.
57. The safeguarding investigation concluded with the following outcome:

“… the allegation of neglect and organisational abuse has been substantiated. The care home failed to ensure that Mrs [Y] consistently received safe clinical care in line with her needs. The homes failure to ensure medicines were managed and administered safely placed Mrs [Y] at increased risk of harm and deterioration in her health. Following a number of issues in this area, the home have taken the decision to only use qualified nurses to book in and manage medications. They have also employed three service managers for each unit to provide greater clinical oversight and direction. It is important to note that the regulatory body, The Care Quality Commission and the Integrated Care Board have also both visited the care home to ensure safe clinical care is provided within the care home and offered advice and recommendations to improve care and meet regulatory Standards”.

58. In relation to the errors with the Vitamin D medication, the minutes from the 11 January 2024 safeguarding meting said, “Oakham Grange didn’t show due diligence when booking in the medication and they didn’t have appropriately qualified staff or skilled staff undertaking the role [name removed] thinks this example illustrates because he clearly didn’t know that they were the same”.
59. The minutes also say, “Oakham Grange acknowledged the organisational failings towards [Mrs Y] and they’re truly sorry for those service deficiencies in the care that they received that wasn’t at the standard that should have been expected”. The home also apologised for the failures to respond to Mrs W’s concerns in a timely way and “… were sorry that they had been left feeling that the service dismissed the concerns that they raised”.
60. The safeguarding investigation concluded with the following recommendations.
• Medication to be booked in by appropriately qualified staff in a timely way.
• Prescriptions to be sought in a timely way to allow for standard operating procedures for dispensing.
• Prescription and medication issues to be addressed in a timely way.
• Management to notify the pharmacy in a timely way of any issues or concerns.
• Ensure the software company is notified of any issues with the app.
• Management to meet their obligation regarding duty of candour in reporting and accepting responsibility for errors.
• Staff to receive training in the clinical areas they are expected to work within.
• Ensure robust care planning for residents’ changing needs.
• Care plans and risk assessments to be shared with staff and ensure they are followed and implemented with any breaches in practice to be recorded and action taken.
• Ensure adequate staff handover to fulfil their role in a safe and timely way.
• Staff to receive training on the new electronic system.
• Management to arrange a programme of supervision and clinical supervision for the nursing team. To be continued at regular intervals and recorded appropriately.
• Ensure staff are aware of the need to inform the relevant person or representative of any incidents, such as medication errors, in a timely way.

Complaints not investigated under safeguarding procedures

61. Mrs W also raised complaints to the home about matters which were not considered as part of the safeguarding investigation, which I will summarise here.
• After doing a Subject Access Request (SAR), Mrs W received information relating to a Palliative Care Plan and Advanced Care Plan. She complained to the home that she, nor the other LPA’s, had been contacted or consulted about the contents of the plan. During her time at the home Mrs Y was not receiving end of life care.
• Mrs W also received information to show the home had applied for a Deprivation of Liberty Safeguard (DoLS) for Mrs Y without informing or consulting her or the other LPAs. Mrs W also said the home completed the DoLS application without first arranging a mental capacity assessment.

Was there fault causing injustice in the care provider’s actions?

62. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment.
63. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.
64. A decision about what a suitable remedy should be for a complaint is one for us to decide. Each case is considered on its own merits. Our Guidance on Remedies sets out the general principles that investigators should apply when deciding what recommendations to make.
65. As there has been a thorough safeguarding investigation of the issues complained about, it has not been necessary for us to review all the contemporaneous records because the concerns have been substantiated. Based on the evidence we have seen, we find fault for the following reasons.
• The home was responsible for significant errors with a number of Mrs Y’s medication. This includes some double dosing and rapid withdrawal. These errors did not happen in isolation. The GP reported the quick withdrawal of steroid medication may cause “risky” side effects. The risk caused by the error has been acknowledged by the local safeguarding authority who recorded a finding of neglect, acts of omission and organisational abuse.
• The home did not always ensure that staff used appropriate moving and handling techniques. The errors with the hoisting on 10 November likely caused Mrs Y significant and avoidable pain and distress. This is because staff did not follow the advice of 111 who said the hoisting must stop if Mrs Y called out in pain. It was not possible to halt the manoeuvre due to the unsafe way in which staff had positioned the hoist. The risk caused by the error has been acknowledged by the local safeguarding authority who recorded a finding of neglect, acts of omission and organisational abuse.
• The home did not weigh Mrs Y on a weekly basis, as agreed upon her admission to the home. Although one staff member asserted that Mrs Y needed monthly weighing, Mrs Y’s care plan was not updated to reflect this apparent change in need and to explain the rationale. The home also failed to explain why it did not act upon Mr Y’s request for his wife to be weighed. The family therefore have uncertainty about whether the home met Mrs Y’s nutritional needs and whether it made sure she maintained an appropriate weight. The risk caused by the error has been acknowledged by the local safeguarding authority who recorded a finding of neglect, acts of omission and organisational abuse.
• The care provider failed to consider and respond to Mrs W’s complaint in accordance with its complaints policy. Some of the complaints raised by Mrs W were wrongly logged by the manager as enquiries. Furthermore, the care provider’s complaint response does not include findings for all elements of Mrs W’s complaint. For example, it failed to respond to Mrs W’s complaint about Mr Y asking for his wife to weighed. It also made a contradictory statement about the Vitamin D error. These points were later addressed in the safeguarding investigation.
• The home acknowledged in its complaint response that it wrote a Palliative Care Plan for Mrs Y without first consulting the LPAs. While I appreciate that finding out about the care plan and reading the contents was distressing for Mrs W, in my view it did not cause a significant injustice because Mrs Y was not receiving palliative care and the plan was therefore not put into place during her time at the home. I would however suggest the Care Provider reminds staff to only complete any such paperwork when it is necessary and to always consult family members, representatives or LPAs about end-of-life care.
• The home acknowledged in its complaint response that it submitted a DoLS application without first arranging a mental capacity assessment. The home also identified that Mrs Y’s children, all of whom are LPA, were not consulted or informed about the application. The home said it had included Mr Y on the application as he also held LPA for Mrs Y. While I understand that finding out about the DoLS application was distressing for Mrs W, in my view the fault acknowledged by the home did not cause significant injustice because Mrs Y left the home before the authorisation and implementation of the DoLS. I would however suggest the Care Provider reminds staff to discuss important decisions, such as ones relating to DoLS, with family members or LPAs.
66. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened. In our view, we find the failures by the home caused significant distress to Mrs Y. This in turn caused significant and avoidable distress and uncertainty for Mrs W which the care provider has agreed to acknowledge with an apology and a symbolic payment.
67. We have also considered whether to recommend any service improvements in this case. The Council has already made wide-ranging recommendations to ensure the improvement of the care delivery, especially around the administration of medication. These recommendations are thorough and proportionate to the fault and so it would not be appropriate for the Ombudsman to recommend any further improvements. However, we will seek evidence that those improvements have been implemented.

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Agreed action

68. Within four weeks of our final decision, the care provider will:
• Issue an apology letter to Mrs W for the errors and the effect on Mrs Y. We publish Guidance on Remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• Make a symbolic payment of £1000 to Mrs W. This is in recognition of the avoidable distress and uncertainty caused by the care provider’s actions. This is in accordance with the range suggested in the Ombudsman’s Guidance on Remedies
• I have not recommended any service improvements for the reasons explained in paragraph 66 of this statement. However, the care provider will provide evidence to the Ombudsman to show the recommendations made during the safeguarding investigation have been implemented or are in the process of being implemented.
69. The Care Provider will provide us with evidence it has complied with the above actions.

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Final decision

70. I have completed my investigation with a finding of fault causing injustice for the reasons explained in this statement. The actions listed in the section above will provide an appropriate remedy for the injustice caused by fault.

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Investigator's decision on behalf of the Ombudsman