A care home commissioned by Wandsworth Council failed on multiple levels to properly care for a vulnerable resident, leading to his deterioration and death in early 2024, a watchdog has ruled.
The Local Government and Social Care Ombudsman found that Sherwood Grange care home in Kingston Vale, run by Care UK, systematically failed to provide adequate care and repeatedly ignored family concerns about the resident’s declining condition.
The ombudsman’s investigation revealed fundamental breakdowns in the resident’s care across multiple areas:
- Inadequate medical care: The care home failed to consistently manage the resident’s pressure sores, with no robust care plan, inconsistent application of barrier cream, and poor record-keeping
- Ignoring family concerns: Staff repeatedly dismissed or failed to act on specific requests from the resident’s sister about his medical needs
- Poor communication: The care home failed to explain medical decisions to the family and provided misleading information about equipment orders
- Delayed medical intervention: Critical pressure relief equipment was only provided after the resident had already developed serious complications
- Council communication failures: Wandsworth Council closed the resident’s case without informing the family, leaving them without support when trying to raise concerns
In this case, the failure to provide an air mattress exemplified these broader failures: despite repeated family requests for pressure-relieving equipment, the care home delayed providing it for two months until blisters had already formed.
Council Left Family in the Dark
The family’s attempts to get help from Wandsworth Council revealed additional institutional failures. Mrs X claims she spent three months from October to December 2023 trying to get the council to respond to her concerns about her brother’s deteriorating care.
However, when she called for help, council staff told her they could not assist because Mr Y no longer had a social worker – something the council had failed to inform the family about when it closed his case after a routine review in October.
The ombudsman found no evidence in council records of Mrs X’s repeated calls during this period, but noted that the council’s failure to inform the family about closing the case was a clear fault that would have caused “shock.”
Confused Council Response at Key Meeting
In a bizarre twist, when a crucial safeguarding meeting was held in February 2024 to discuss the care failures, a Wandsworth Council officer attended but kept their microphone on mute “because they did not know what to say.”
The council later apologized for the officer’s attendance, claiming it was inappropriate since another local authority was leading the investigation. However, the ombudsman disagreed, noting that since Wandsworth had commissioned the placement, it was important for them to be involved in safeguarding issues.
The real problem, the ombudsman found, was that the officer failed to explain their role to the family, creating confusion about who was responsible for what – a failure that compounded the family’s distress during an already difficult time.
The ombudsman has ordered Wandsworth Council to pay the man’s sister £400 compensation for the “upset, distress and uncertainty” caused by the failings in care.
Timeline of Care Failures
The case centres on a man, referred to as Mr Y in the decision, who was placed at Sherwood Grange by Wandsworth Council in August 2023. His sister, Mrs X, had specifically requested an air mattress to prevent pressure sores after he returned from a hospital stay in October 2023.
However, a nurse at the care home instead ordered a static mattress, claiming Mr Y “did not have any wounds and was mobilising.” Crucially, the care home failed to explain this decision to Mrs X, who continued to chase for the air mattress she had requested.
When Mrs X contacted the care home again the following week asking about the pressure mattress, staff noted they had ordered an air mattress on 20 October. But the ombudsman found this was likely an error in the records, as only a static mattress arrived in early November.
It wasn’t until the end of November – when Mr Y had developed blisters and his urine had become cloudy indicating infection – that the care home finally ordered an air mattress, which arrived the same day.
Hospital Raises Safeguarding Concerns
When Mr Y was readmitted to hospital in early December 2023, nursing staff were alarmed by what they found. A nurse at the hospital “raised concerns about significant skin damage” and made a safeguarding referral.
The subsequent investigation by the local authority where the care home is located concluded there were “acts of neglect and omission” in Mr Y’s care.
The investigating council found the care home had “failed to consistently manage Mr Y’s pressure sores, it did not have a robust plan on pressure sore management and the records were inconsistent on whether care home staff applied barrier cream to the pressure area.”
Most significantly, the investigation concluded that “pressure relieving equipment was provided too late.”
Family’s Distress and Council Failings
Mrs X also faced difficulties getting support from Wandsworth Council during her attempts to raise concerns about her brother’s care. After a routine review in October 2023, the council closed Mr Y’s case and removed his social worker without informing the family.
When Mrs X called the council seeking help, she was told Mr Y no longer had a social worker and the council could not assist with his care concerns.
The ombudsman found this lack of communication was fault that would have caused Mrs X “shock” and confusion about who she could turn to for help.
Following the investigation, the care home has implemented improvements including refresher training for staff on pressure ulcer management, ensuring timely medical input for residents, and improving communication with families.
The ombudsman noted that “Mrs X asked for an air mattress because she wanted to prevent Mr Y’s bed sores” and found the care home’s failure to act on this request, combined with inadequate pressure sore management, caused the family significant distress.
Statements from the Parties
A Wandsworth Council spokesperson said: “We take the safety and wellbeing of our residents incredibly seriously. We accept the Ombudsman’s findings and have apologised to this individual, fully paying the compensation ordered. We regret the distress this has caused, and we are working with our partners to ensure that the learning from this experience is applied to improve outcomes for our residents.”
A Care UK spokesperson said: “We pride ourselves on offering kind and safe care to all residents in our homes and would once again like to apologise to the family for any shortcomings in our communication with them. While we were not part of the Ombudsman’s enquiry, we will take any learnings from the report to help us improve the service we provide to both residents and their families.”
The case highlights the critical importance of proper pressure sore prevention and management in care homes, particularly for vulnerable residents at high risk of developing these potentially serious complications.
The Local Government and Social Care Ombudsman investigates complaints about councils and adult care providers. The full decision (reference 24 014 250) is available on the ombudsman’s website.
This case was first reported by local democracy reporter Charlotte Lilywhite.
