Worcestershire County Council at fault for inadequately dealing with complaints about the quality of care in a care home it commissioned

Decision date: 16/01/20

What happened

Mrs Y suffered from a variety of medical conditions including diabetes and dementia. She lived at home with her husband until he sadly died in June 2018. Worcestershire County Council arranged for Mrs Y to move to a care home (originally called Gold Hill, now called Blossom House) run by the provider Wishmoor Limited.

Her son, Mr X, complained to the Council about the quality of care his mother received at the care home, and later complained to the Ombudsman about the lack of support offered by the Council with regard to this matter.

Mr X began to raise concerns very early on in his mother’s occupation of the home. The care provider claimed that she repeatedly refused to get up or eat breakfast in the morning. Mrs Y’s legs swelled due to inactivity. In July, she was found with faeces all over herself and her room by family members who said they could not find any staff to help. When Mr X voiced his worries about her staying in her room and not eating or drinking properly, a staff member said that this was to be expected as the family had ‘dumped’ Mrs Y at the care home.

The family claimed that staff at the care home were regularly giving Mrs Y sugary food and drinks, which was highly inappropriate due to her diabetes. Staff said that they did this as Mrs Y was not eating or drinking very much. However, there is no record of this approach in any care plan. The family fought to move Mrs Y to a different care home that eventually accepted her at the same rate as Gold Hill/Blossom House. However, the Council failed to set out the correct responsibilities for the new care provider under the General Data Protection Regulation (GDPR) which meant that Mrs Y was at the care home for 7 weeks.

Within a day of being at the new care home, Mrs Y was admitted to hospital with malnourishment, kidney failure and dangerously high blood sugar levels. She sadly died two weeks later.

Mr X complained to the care provider in October that his mother’s health had rapidly declined during her residency there. He forwarded the complaint to the Council as it was responsible for commissioning the care. The Council responded by telling him that he did not have legal authority to act on his mother’s behalf and that he therefore was unable to go through the normal complaints process. Mr X found this very upsetting and an Officer from the Council wrote to him a week later to apologise and to say that it would pass his complaint to its quality assurance team. The Officer also told Mr X that some documents he had emailed were encrypted and therefore unable to read. He directed Mr X to provide any further information by post.

The care provider wrote to Mr X in December to offer its condolences. It said simply that it had undertaken an internal investigation and was happy to send all documentation to solicitors. When this was chased up, the care provider claimed that Mr X needed a grant of probate to evidence that he was executor.

What was found


The standard of records kept by the care provider was unacceptable and even some of Mrs Y’s needs that had been recorded were then ignored. Specifically, the risks regarding her type II diabetes were not mentioned in her care plan and her diet at the care home was inappropriate. There were no efforts to involve the family in her care, which could have helped reduce the injustices caused by this fault.

The care provider was also at fault for failing to consider the reasons behind Mrs Y’s difficult behaviours. It should have treated her incontinence and decrease in food/drink intake as a change in needs and referred the matter to the social worker and to Mrs Y’s GP.

These faults put Mrs Y at an increased risk of harm and probably had negative effects on her mental health. They also caused her family avoidable stress and uncertainty.

The Council’s complaints process

The Council applied an indiscriminate policy that people could not have complaints made on their behalf if they did not have legal representation. It did not consider Mrs Y’s best interests and refused to consider Mr X’s complaint because he was unable to share her information. This was fault and the Ombudsman noted that he could find nothing in her records or care plan that Mr X should not have known about

Furthermore, Mr X’s concerns could have initiated safeguarding procedures for all the residents of the care home but these were left unconsidered by both the Council and the care provider.

The Ombudsman had significant concerns about the Council’s approach to Mr X’s complaints and the implications for people who cannot speak for themselves. A copy of the final decision was sent to the CQC to assess the potential breaches of regulations 9, 12, 14 and 16.


The Council has agreed to:

  • Apologise to Mr X and pay him £500 to acknowledge its faults and the injustice they have caused.
  • Ensure every Gold Hill/Blossom House resident has an adequate care plan

Within three months:

  • Monitor the service at the care home and ensure the issues surrounding this case are being worked on.
  • Retrain its staff in how to handle complaints.

Points for the public, complaints officers, councils, advocates, family members and care homes

This is a shocking story of abject disregard for the legal framework. We find it hard to believe that the council thought that it could ignore the Complaints Regulations, in running something called a complaints system, and are surprised that the LGO does not say more about that.

Persons who may make complaints

5(1) A complaint may be made by

(a) a person who receives or has received services from a responsible body; or

(b) a person who is affected, or likely to be affected, by the action, omission or decision of the responsible body which is the subject of the complaint.

(2) A complaint may be made by a person (in this regulation referred to as a representative) acting on behalf of a person mentioned in paragraph (1) who

(a) has died;

(b) is a child;

(c) is unable to make the complaint themselves because of

(i) physical incapacity; or

(ii) lack of capacity within the meaning of the Mental Capacity Act 2005; or

(d) has requested the representative to act on their behalf.

(4) This paragraph applies where

(a) a representative makes a complaint on behalf of

(i) a child; or

(ii) a person who lacks capacity within the meaning of the Mental Capacity Act 2005; and

(b) the responsible body to which the complaint is made is satisfied that the representative is not conducting the complaint in the best interests of the person on whose behalf the complaint is made.

(5) Where paragraph (4) applies

(a) the complaint must not be considered or further considered under these Regulations; and

(b) the responsible body must notify the representative in writing, and state the reason for its decision.

But on top of that, there is the apparent unawareness on the part of the council that people for whom it commissions care are owed a non-delegable duty BY THE COUNCIL (regardless of the care provider being the way in which the council has chosen to meet the needs) to ensure that the care is adequate and appropriate and in accordance with a care plan.

Here it seems as if the care provider’s plan was at fault for not mentioning the diabetes, but the framework of the Care Act assumes and requires that any council doing an assessment will gather up ALL the needs, and ensure that they are ON the care plan, even if they are health needs that the council does not have to meet by way of arrangements IN the care plan. That care plan is the council’s responsibility under s25 of the Care Act.

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