Leicestershire County Council for the quality of care at a home it commissioned and for failing to respond adequately to concerns

Decision date: 20/12/19

What happened

Mrs C was an elderly lady who lived at home with no care needs up until suffering a fall in June 2017, which led to her admittance to hospital. She was then discharged to The Elms Care Centre, Ibstock, initially for 4 weeks’ respite care but she subsequently remained as a short-stay resident. She later moved to be close to a relative in March 2018.

During the period she was cared for at the Elms, Mrs C had capital above the upper threshold but was not considered by the council to have capacity to manage her financial affairs. It therefore agreed to pay for her care whilst another of her daughters, Mrs B, tried to obtain legal authority to manage her finances.

Mrs B complained to the Ombudsman about a number of aspects of the quality of care her mother received whilst resident at the care home, when the council was commissioning the care. These are set about below.

Care Planning

The care provider undertook a ‘short stay care plan’ for Mrs C upon her arrival. The plan was brief, incomplete and reviewed monthly but it was not ever amended. For example, it failed to record all of her medicine prescriptions.

Separate risk assessments were undertaken by the provider for Mrs C’s skin integrity and for risk of falls.

The first of these assessments was carried out in August 2017 and was again reviewed monthly but never amended.

Of the two falls risk assessments, neither actually recorded Mrs C’s name. Both were incomplete or inaccurate and contradictory of each other.

The Ombudsman was provided with two review sheets of the risk assessments but the date of assessment recorded differed on each. Both claimed that the original assessments were ‘still reflective’ of Mrs C’s risk levels.

Mrs C’s falls

Mrs C suffered a fall at the care home on 4 September 2017, which is when one of the above risk assessments was dated. She was X-rayed at a hospital the next day which revealed a fractured wrist. The care provider asked Mrs B to pay £102 as the fee of a member of staff accompanying Mrs C to the hospital but did not chase for payment when Mrs B refused to pay. In the following safeguarding investigation by the Council, the staff member claimed that it was a manager who had told her to try to bill Mrs B.

Mrs C suffered a second fall at the care home in February 2018 whereupon the provider communicated with the GP who advised medication for pain if there was any.

The safeguarding investigation

Mrs B complained to the Council in April 2018 about the quality of care her mother received at The Elms Care Centre and about the Council’s management of the case.

The Council had commissioned a social worker to investigate the complaint as a safeguarding matter in May and it was completed in October. They delay was purportedly due to separate delays in the exchanging of notes between Mrs C’s old GP practice and her new one.

The investigation found that a pharmacist had tried to prescribe Mrs C with a tub of aqueous cream for her skin but that the care provider had told them it was unnecessary. However, the Council recorded no other faults with the home and concluded their investigation. It wrote to Mrs B in October to relay the findings. Mrs B got in touch with the Council in December and it was only then that it directed her to the Council complaints team and explained why and apologised for how long the investigation took.

Record keeping

The Ombudsman was not provided with any evidence of the Council having assessed or visited Mrs C after she first entered the care home. There were brief recordings of the fall Mrs C suffered but no evidence of the Council considering the matter further. There was also no record of any contact from Mrs B. However, Mrs B was able to provide evidence that she had contacted the Council about her mother’s fall on 7 September. She voiced concerns via email to the correct address of a social worker that she has communicated with before and after. The Ombudsman also noted that every single other email sent by Mrs B was recorded by the Council.

What was found

A CQC report based on an inspection in July 2018 found that care plans at the home lacked sufficient detail to support person-centred care. It also found that the systems in place to monitor the quality of care were inconsistent and that clients’ access to activities were limited.

The care provider was mostly at fault for its poor record keeping and review scheduling. This was a factor in Mrs C not being provided with the medical treatment she required after falling from her chair. The Ombudsman could not conceive how or why the care home failed to obtain an X-ray for Mrs C on the day it acknowledged having clear evidence of her pain. The lack of any kind of review of the risk assessments for Mrs C’s last 3 months staying at the home and the fact that neither of her risk assessments were accurate or complete reinforced the idea of a wholly chaotic approach taken by the care provider to how it recorded and responded to falls.

The Ombudsman considered the care home to have failed to comply with the fundamental standard in Regulation 12. It was also brought into question whether or not the provider met the standards of good management, set out in Regulation 17.

There was some concern with the adequacy of the Council’s subsequent safeguarding investigation as it did not pick up on the deficiencies of the provider’s record keeping. There was no evidence that the Council made an effort to prevent another attempt by the care provider to bill patients or their families for hospital appointments. It should have alerted the CQC to the provider’s practice. However, this fault was not found to have led to any direct injustice as Mrs C was in a safe place by the time the investigation commenced.

The Council’s management of Mrs C’s case was assessed separately to their safeguarding investigation. In order to meet her needs when she moved into the care home, the Council needed to have assessed or at the very least reviewed them. It failed to do so and this is fault which resulted in injustice to Mrs C and to Mrs B.

The Council was also at fault for failing to consider how it could investigate all of Mrs B’s concerns (Mrs C’s activities at the home, for example) or to assess its own management of the case. The Council failed to direct Mrs B to its own complaint procedure or to the LGO after its safeguarding investigation which amounted to further frustration for Mrs B.


The Council agreed that it will, within 20 working days:

  • Apologise to Mrs B and Mrs C for the injustice caused to them
  • Write off 10% of the outstanding charges for Mrs C’s care
  • Pay Mrs B £500 to acknowledge the avoidable stress this has caused her

and within 3 months

  • Give its social work staff clear and consistent advice about its expectations of them when they are made aware of residents experiencing falls, in terms of record keeping and safeguarding referrals. Guidance on assessing the suitability of care home placements is also required.
  • Review care planning records for ALL residents of the care home

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Points for the public and services users, as well as care providers

This is a shocking case of what goes on in some care homes. It reveals how the monitoring of care plans of publicly funded clients can sadly sometimes do nothing further to improve the chances of a resident getting proper care. Here, the idea of asking a social worker to sort out the problem through the safeguarding function, before even trying to treat it as a complaint may have been well intentioned, but it did not impress the LGO.

We think that this report bodes poorly for the chances of clients during Covid-19 if they deteriorate in a home where it is similarly chaotic – eg for getting an ambulance or getting admitted to hospital.

The full Local Government Ombudsman report on the actions of Leicestershire Council can be found here: