A South London care home failed to consistently manage a resident’s pressure sores before he died, a watchdog has ruled.
Wandsworth Council, which placed the man in Sherwood Grange, run by Care UK, in Kingston Vale, has been ordered to pay his sister £400 for the distress caused by failings in his care.
A Local Government and Social Care Ombudsman report found fault with the care provided by Sherwood Grange to the man, referred to as Mr Y, and its communication with his sister, named Mrs X. It ruled the council was also at fault for its communication with Mrs X.
The council placed Mr Y in Sherwood Grange in August 2023. He was admitted to hospital in September with a severe urinary tract infection (UTI), before returning to the care home in October.
Mrs X asked the care home to order an air mattress for Mr Y to prevent his bed sores when he returned from hospital. A nurse ordered a static mattress instead, which arrived in early November, as she said he did not have any wounds and was mobile.
The report found the care home at fault for failing to tell Mrs X why it had not ordered the air mattress she had requested. A nurse ordered him an air mattress at the end of November, as he had developed blisters.
When Mr Y was admitted to hospital again in early December, a nurse raised concerns about major damage to his skin. The hospital made a safeguarding referral to the council, which sent Mr X’s case to another local authority where the care home is located, named Council X in the report. Mr X died in early 2024, while Council X was investigating the care home.
Council X found there were acts of neglect and omission in the care provided to Mr Y, including pressure-relieving equipment being provided too late.
The report said: “Mrs X asked for an air mattress because she wanted to prevent Mr Y’s bed sores. The conclusion from Council X’s safeguarding investigation was the care home 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.
“I have reviewed the care home’s records, and I agree with Council X’s comments. There was also a failure to consider whether to get an air mattress much sooner. These faults have caused Mrs X significant upset and distress. She also has uncertainty as to whether the deterioration in Mr Y’s health may have been prevented.”
The Ombudsman considered the care home’s actions were taken on behalf of the council, as it arranged for Mr Y to live there. The report found fault with the actions of the care home and the council, with the watchdog ordering the authority to apologise to Mrs X and pay her £400 for the distress and uncertainty she was caused. It said the care home had since made improvements to its services.
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. On the rare occasions where we do not meet our own high standards, we will always investigate any concerns as per the complaints policy which is published on our website. 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.”
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