Summary: Mr B complains on behalf of his partner, Ms C, about the quality of care she received between August and November 2018. We uphold the complaint finding fault in the care arranged by the Council and delivered by TLC Sheffield Home Care Ltd. We also find fault in how the Council responded to Mr B’s service requests and complaint. This caused injustice to Mr B and his partner as distress. The Council accepts these findings. At the end of this statement we set out the action it has agreed to remedy the injustice caused to Mr B and Ms C and improve the service it provides to others.

The complaint

1. I have called the complainant ‘Mr B’. He complains on behalf of his partner ‘Ms C’. Mr B’s complaint concerns social care provided to Ms C by TLC Sheffield Home Care Ltd (the ‘Care Provider’), arranged for by the Council. Mr B complains the Care Provider was at fault because:

• care workers arrived too early in the evening; before Ms C was ready for assistance in going to bed;
• it sent male care workers to support Ms C, contrary to her wishes and what was in her support plan;
• its care workers did not transfer Ms C correctly;
• one of its care workers nearly gave Ms C wrong medication on one occasion but for Mr B’s intervention;
• its care workers left Ms C alone while Mr B was at the shops;
• its care workers failed to keep adequate records.

2. Mr B says the Council was also at fault for how it responded to service requests he made drawing its attention to the above. And for how it then responded to his complaint about these matters.
3. Mr B says all these events caused distress to him and Ms C. He says the poor practice by care workers in transferring Ms C resulted in a serious risk to her health and safety. While carrying out visits at the wrong time and sending male workers to Ms C compromised her dignity. Mr B also considers delays in answering his complaint and poor customer service put him to unnecessary time and trouble in pursuing his complaints.

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The Ombudsman’s role and powers

4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
5. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. We normally name care providers in our decision statements. However, we will not do so if we think someone could be identified as a result. (Local Government Act 1974, section 34H(8), as amended)
7. If we are satisfied with a council’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

8. Before issuing this decision statement I considered:

• Mr B’s written complaint to the Ombudsman and any supporting information he provided. This included information gathered in a telephone conversation with him.
• Exchanges of correspondence between Mr B and the Council pre-dating our investigation into the complaint.
• Information provided by the Council and Care Provider in response to enquiries.
• Relevant law and guidance as referred to in my proposed findings below.
• Comments made on a draft decision statement from Mr B and the Council.

9. Under an information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC. The CQC is the regulator of care services in England.

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What I found

Key facts

10. Mr B and Ms C are partners. Ms C has a long term brain injury. This has resulted in short term memory loss and problems with mobility.
11. In 2018 Ms C suffered a fall which resulted in a spinal injury. After a spell in hospital she was discharged to residential care but wished to return home. In May 2018, while Ms C was in residential care the Council completed a care review questionnaire with her. This noted Ms C’s memory loss left her at “risk of attempting to mobilise without constant supervision”.
12. The Council assessed Ms C’s needs under the Care Act 2014 and decided she had a need for social care in several areas when returning home. These included help with:

• personal hygiene;
• safety in her own home;
• maintaining adequate nutrition and hydration;
• being appropriately clothed;
• accessing the community;
• managing her toileting needs.

13. From 10 August 2018, the Council arranged for the Care Provider to visit Ms C at home four times a day. A support plan said the Care Provider would help Ms C with transfers in and out of bed, personal care tasks and giving medication. At the end of September 2018, in response to representations from Mr B and Ms C the Council reduced these visits to twice a day.
14. I checked the Council’s records and noted the following reports from Mr B raising concerns about the quality of care Ms C received from the Care Provider. I also summarise below the actions recorded by the Council in response to those concerns.

• On 13 September 2018 the Council received a referral from an Independent Mental Capacity Advocate (IMCA) working with Ms C who reported concerns raised with her by Mr B. First, that on or around 10 September 2018 a care worker had transferred Ms C inappropriately causing her to fall into her chair. Second, that on or around the same day a care worker also failed to provide the correct medication to Ms C in the evening, until alerted to this by Mr B. The IMCA said they had checked the records in Ms C’s home and found the medical record (MAR) sheets incomplete. I could not identify what investigation the Council undertook into these concerns.
• On 28 September 2018 a review of Ms C’s care took place. While the Council kept some contemporaneous record of this, I could not identify this covered the matters raised in the referral on 13 September recorded above. However, a social work note made on 14 December 2018 says these matters were raised at that meeting.
• On 17 October 2018 Mr B reported care workers leaving Ms C unattended while he went to the shops. The Council made checks with the Care Provider. It said that Mr B left the house at the same time as the care workers, who had visited Ms C for 15 minutes. It said this had happened before.
• On 19 and 26 October 2018 Mr B reported care workers arriving significantly early for the evening visit to help Ms C to bed (an hour early on one occasion and an hour and a half early on the other). I could find no record of the Council raising this matter with the Care Provider. Mr B also mentioned this matter in letters written to the Council on 3 and 27 November 2018, which it recorded receiving.
• On 25 October 2018 Mr B reported the Care Provider had sent a male care worker to meet Ms C’s needs contrary to her wishes. His letter of 3 November also raised this matter. He said this was the third time this had happened. The Council checked with the Care Provider the next day who said this was unacceptable. The Council checked with the Care Provider again on 26 November 2018 who said the incident on 25 October was the only time it sent a male care worker to meet Ms C’s needs. In his letter of 27 November, Mr B said this had happened ‘four times’.
• On 21 November 2018 Mr B reported that a different care worker had used Ms C’s hoist improperly when transferring her, risking injury to Ms C. The Council raised this with the Care Provider on 26 November 2018 who said it would investigate. On 6 December 2018 the Council received a general assurance from the Care Provider that its care workers received appropriate training in moving and handling users of its services.

15. I checked the care planning documents kept by the Council that summarised the care it expected the Care Provider give to Ms C. I saw no record that referred to whether Ms C had a preference to receive care from female care workers. I saw no record that discussed if Ms C could be left at home unattended. Case notes clearly showed there was concern about Ms C being able to transfer safely given her spinal injury. This was especially in the days and weeks immediately after she left residential care.
16. I also checked the Care Provider’s records as follows:

• First, a series of records of contacts connected to Ms C’s case. None of these were dated. But they show that on one occasion Mr B reported to the Care Provider directly that care workers had arrived too early for the evening call. He also told the Care Provider of his dissatisfaction with the incident on 21 November 2018 when he alleged poor practice by a care worker in transferring Ms C. The Care Provider did not record any other concerns raised about its care. There is no reference to the telephone calls with the Council which I have referred to in paragraph 14.
• Second, a logbook of visits to Ms C’s home covering the period 10 August to 30 September 2018. The Care Provider says it has been unable to locate any other logbooks. The Council notes these logbooks show that Ms C did not always receive visits at the correct time because of staff shortages and/or care workers running late. I checked entries around 10 September 2018. None of these record any incidents involving the transfer of Ms C or in giving her medication. Nor does the record for 17 September 2018 (a date on which Mr B later reported Ms C almost received the wrong dose of medication - see paragraph 25) contain anything of note.
• Third, a record showing that on three occasions a male care worker visited Ms C. This was on 18 October, 25 October and 1 November 2018.
• Fourth, a log of the scheduled timings for visits to Ms C and the times recorded by its care workers on arriving at and leaving Ms C’s home. On 17 October 2018 the record shows care workers arriving 35 minutes late for the morning visit and staying only 15 minutes instead of 30 minutes scheduled. The record also shows that on 19 October 2018 care workers should have visited Ms C’s home at 8:30pm (two hours after Mr B said they arrived). They do not record their actual time of attendance. There is no record for 26 October 2018. The time sheets frequently show care workers attending up to an hour early or late. There are also numerous records of visits being shorter than arranged.
• Fifth, a record of an investigation undertaken in June 2019 by the Care Provider into the allegation its care workers failed to transfer Ms C safely on 21 November 2018 (although the Care Provider recorded the date of the incident as unknown). The care workers interviewed said that Ms C would sometimes release her hold on the hoist early causing her to fall back into her chair. They said they were unaware of Mr B raising any concern about this and had no record of Ms C reporting any pain.

17. I also noted the incidents recorded above took place against the backdrop of other developments in Ms C’s case. These included:

• A disagreement about the extent of care Ms C needed. As early as 17 August 2018 Mr B said Ms C did not need a teatime call. As noted, the Council agreed to reduce care visits to Ms C from four times a day to twice a day on 28 September 2018. It received reports from an Occupational Therapist that Mr B could transfer Ms C safely on his own using the hoist provided. But in between 17 August and 28 September I noted multiple contacts about this matter.
• Concerns about the degree to which Mr B could meet Ms C’s needs without support or respite. There were concerns at tensions in Mr B’s contacts with care workers and occasions when he refused access.
• Concerns Ms C experienced falls after returning home.

18. From 23 November 2018 Mr B refused the Care Provider further access to the home until it could guarantee it could meet Ms C’s needs safely. The Council met with Mr B and Ms C and assessed from 11 December 2018 that Mr B could continue to meet Ms C’s care needs without support from a care agency.
19. Mr B told me that at first, when he complained, he wanted the Council to reinstate some home care for Ms C subject to assurances care workers were properly trained with the hoist. But with the passage of time Mr B says he no longer sees any need for this as he manages Ms C’s care alone.
20. I asked the Council about its contacts with the Care Provider to assure itself of the quality of its service. The Council provided me documents showing that in February 2019 it had several concerns about the Care Provider’s practice. This included that not all its staff had up to date training in medication administration and moving and handling techniques. It also had concerns about the management and supervision of care workers. It drew up an action plan with the Care Provider to address these concerns and in June 2019 recorded steps taken by the Care Provider in addressing these.
21. I noted the Council then carried out further visits to the Care Provider in July 2019 and February 2020. The note of the latter visit implied the Care Provider had made further progress to allay the Council’s concerns. The Council says that it had also intended this year, before the onset of COVID-19, to view the Care Provider’s moving and handling training. It has instead asked the Care Provider to give it more information about the training it provides.

Mr B’s complaint

22. In January 2019 Mr B submitted a complaint to the Council. He said it had failed to answer four letters he sent it. These included the two letters he sent in November 2018 I recorded in paragraph 14. It also included letters sent in September and December 2018 which the Council has no record of receiving. I note the September 2018 letter was not concerned with the matters covered by this investigation. While in the December 2018 letter, Mr B chased the Council to reply to his letters of November 2018.
23. The Council began an investigation into Mr B’s complaint, carried out by one of its contract managers. They spoke to Mr B in March 2019 and clarified the scope of his complaint. In late May 2019, the Council wrote to Mr B with its reply. It said:

• The record kept by the Care Provider of the timing of its visits to Ms C “were not of a standard we would expect”.
• The Care Provider wanted to review all the records of the care it gave to Ms C but Mr B had not returned logbooks and MAR charts left in the home.
• It could find no record of any incidents where Ms C may have almost received the wrong medication.
• It found that all care workers were “fully trained to the required standards”.
• It had no record of Ms C requesting female care workers. It believed the issue resolved further to its call to the Care Provider on 26 October 2018.
• That there was “no evidence” of care workers not using equipment correctly and the Council received assurance on 6 December 2018, they received suitable training.

24. The Council’s contract manager then met with Mr B and Ms C at the end of May 2019. The meeting notes record Mr B telling the Council the Care Provider had taken the logbooks monthly. So, he only had one logbook. The Council says Mr B showed its contract manager the logbook for November 2018. They did not consider the notes in there “as detailed as they would expect”.
25. Following the meeting, the Council agreed to further investigate:

• A concern the Care Provider almost failed to provide Ms C with the correct medication on 17 September 2018.
• Concerns about the two incidents reported by Mr B where care workers did not use Ms C’s hoist correctly. In the notes of this meeting the incidents are said to have taken place on 13 October and 18 November 2018 (as opposed to 10 September and 21 November 2018 as recorded above).
• The concern care workers left Ms C alone on 17 October 2018.

26. In February 2020, the Council gave its final response to Mr B’s complaint. The Council has apologised for the delay in sending this letter. It said there was a breakdown in communication between its commissioning service and its adult care social work service.
27. In this further reply the Council said:

• It was still working with the Care Provider (whose management had changed) to try and locate logbooks. It promised to investigate further “once these are located”.
• It would look to observe the Care Provider’s moving and handling training to “check it is of the required standard”.
• It had not identified any records which indicated Ms C could not be left alone unattended.

28. The Council also agreed to look at charges made to Ms C for the home care she received from the Care Provider. Before we began our investigation into this complaint it agreed to cancel those charges and refund any sums she paid. These totalled around £2400.

My findings

29. My starting point for investigating this complaint is to note that where the Council commissions a private company to provide care to a user of services, the actions of the Care Provider come within our jurisdiction. In these circumstances, a complaint about the quality of care engages two key questions. First, what is the evidence for any poor care or practice by the Care Provider and how did it respond to any allegations of any poor care or practice. Second, what did the Council do when presented with those allegations or any evidence of poor care. I will address each in turn before considering the Council’s complaint handling.
30. In considering the first question, when we consider any complaint about quality of care we take account of the ‘fundamental standards’ which all care providers should meet in delivering care (see Health & Social Care Act 2008 (Regulated Activities) Regulations 2014). Of relevance to this complaint are the following.

• Regulation 9 – “Person-centred care”. This regulation aims to ensure those who receive care services do so in a way that is personalised specifically for them. Care Providers should use all reasonable efforts to deliver care in a way that reflects their personal preferences.
• Regulation 10 – “Dignity and Respect”. This regulation aims to ensure those who receive care do so in a way that respects their dignity and individual expectations around such matters as privacy. The Care Quality Commission (CQC – which regulates care providers) publishes guidance which says “when providing intimate or personal care, providers must make every reasonable effort to make sure that they respect people's preferences about who delivers their care and treatment, such as requesting staff of a specified gender”. Also, that “people using the service must not be neglected or left in undignified situations”.
• Regulation 12 – “Safe care and treatment”. This regulation aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. It includes guidance on managing medication.
• Regulation 13 – “Safeguarding service users from abuse and improper treatment”. The intention of this regulation is to safeguard people who use services from suffering any form of improper treatment while receiving care and treatment. The CQC says providers must take appropriate action without delay through having ‘robust procedures’ in place to investigate incidents.
• Regulation 17 – ‘Good governance’. This regulation requires providers have systems and procedures in place to meet other regulatory requirements. Providers must also maintain accurate, complete and detailed records for each person using their service.

31. I find on balance the evidence suggests the Care Provider failed to always meet these standards in caring for Ms C. In particular, I find:

• It failed to keep adequate records of why there was such a mismatch between times care workers arrived to help Ms C to bed compared to the agreed time for such visits. I consider this a potential breach of Regulation 9 as this was not respecting the times agreed for visits in line with Ms C’s wishes. I also find Regulation 10 of the fundamental standards engaged as arriving so early to carry out Ms B’s night-time visit risked leaving her too long without support with toileting. This could compromise her right to receive dignified care.
• It sent male care workers to support Ms C contrary to her wishes. I have seen no record of either the Council or Care Provider recording Ms C’s preference for female care workers at the outset. However, this appears implied by most visits being undertaken by female care workers before 26 October 2018. And if there was any doubt before, there could be no longer after the conversation between Care Provider and Council on that date. But despite this, the Care Provider again sent a male care worker to Ms C on 1 November 2018. I consider this a breach of Regulation 10. I accept that in exceptional circumstances the Regulation may not be breached if a carer of a different gender to that preferred attends to provide care. This is because the over-riding priority will be to ensure the users of services receives care. But all reasonable efforts must be made to avoid this. In this instance there are no records which would lead me to reach such a conclusion.
• It failed to carry out a contemporaneous investigation into the report that care workers transferred Ms C inappropriately on 21 November 2018. The Care Provider knew of this report within a few days but did not carry out any investigation for seven months. This suggests the Care Provider does not have ‘robust procedures’ in place to investigate incidents in line with Regulation 13.
• It failed to keep adequate records. In particular there is no record of the many disparities between the times care workers were due to visit Ms C and when they actually visited. There was also no record of the conversations between Council and Care Provider where they discussed Mr B’s concerns around Ms C’s care. This shows a failure to keep adequate records in line with the expectation of Regulation 17.

32. These failings on the part of the Care Provider justify a finding of fault.
33. I can make no finding the Care Provider was at fault in September 2018 for its handling of Ms C or in its administration of medications. There is no record the Care Provider knew of the concerns expressed about its conduct in these areas. Meaning there was no investigation of what happened from which I could draw any conclusions.
34. Nor I do not find the Care Provider at fault for leaving Ms C unattended on 17 October 2018. I note the evidence of the assessment questionnaire the Council completed with Ms C in May 2018 which suggested she needed ‘constant supervision’ to avoid mobilising. But there is no evidence I have seen which shows the Care Provider was aware of this. It would also be inevitable in the course of a day that Ms C would be left unattended for short periods of time, for example while Mr B cooked meals or attended to his own personal care.
35. However, both these findings lead me to go on to consider the second key issue in this case, which is how the Council responded to the concerns expressed by Mr B about Ms C’s care. I find the Council failed to follow basic good administrative practice when Mr B first made its service aware of concerns for Ms C’s care. In particular, I find the Council:

• Did not ensure there was any investigation into the concerns raised via Ms C’s IMCA on 13 September 2018. The Council did not ensure the Care Provider investigated these or that it did so itself under its own safeguarding procedures. The concerns raised were serious and credible. I can find no explanation for why the Council would not want to ensure they were investigated both in the interests of Ms C’s welfare and potentially other users of the Care Provider’s service.
• Did not ensure it kept an adequate record of the meeting on 28 September 2018. If, as it later recorded, the concerns raised on 13 September were raised at this meeting then it should also have noted the detail of that discussion. Again, this would be to ensure there was a satisfactory investigation into what Ms C’s IMCA reported.
• Failed to complete an investigation into Ms C being left unattended on 17 October 2018. It should have reported back to Mr B what the Care Provider told it. It should also have explored with Mr B, Ms C and the Care Provider the wider question of if Ms C could be left alone safely and if so, for how long, especially bearing in mind the questionnaire completed in May 2018. This could then have informed both the Care Provider and Mr B in their practice in caring for Ms C moving forward.
• Failed to ensure there was any investigation into why care workers attended so early for Ms C’s evening calls despite Mr B raising this on four occasions. It missed an opportunity at an early stage to identify the multiple instances when care workers failed to arrive at Ms C’s home on time.
• Failed to find out the facts about how often Ms C received calls from male care workers. The Council received incorrect information from the Care Provider, which it passed on to Mr B. It also failed to re-investigate this matter when Mr B indicated the Care Provider had again sent a male care worker to Ms C in his letter of 27 November 2018.
• Failed to ensure an adequate investigation into a report from Mr B of care workers not transferring Ms C properly on 21 November 2018. It alerted the Care Provider to the report but failed to follow this up to ensure the Care Provider undertook an adequate investigation.

36. These failings by the Council justify a finding of fault.
37. I find the Council then compounded these failings through poor complaint handling. First, I find the initial reply to Mr B’s complaint in May 2019 was potentially misleading. What it said about the Care Provider’s training of staff appears inconsistent with its own records of engagement with the Care Provider from February 2019. Those records show the Council clearly had concerns about this issue.
38. Second, it also failed to properly investigate the individual concerns Mr B raised about Ms C’s care. Over 12 months elapsed between Mr B making a complaint to the Council and him receiving its final response. But in this time, he received no adequate reply to his concerns about how the Care Provider transferred Ms C. Nor his concerns about medication administration. The Council also failed to check the Care Provider’s records on how many times male carers attended Ms C. It also failed to press the Care Provider on what logbooks it kept further to its meeting with Mr B in May 2019, where he contradicted its account that he had retained all the missing logbooks. While I recognise the Council was engaging with the Care Provider on some of its general policies and procedures in these areas, it did not address Mr B’s specific concerns relating to the care Ms C received.
39. These failings by the Council also justify a finding of fault.
40. I consider the failings by both the Care Provider and the Council caused both Mr B and Ms C injustice. I consider but for the faults identified it is unlikely Ms C would have again had a male carer visit on 1 November 2018. I also consider earlier and more effective intervention by the Council would not have led to the Care Provider attending so often at the wrong time to meet her needs. These matters will have caused distress to Ms C.
41. I also consider further distress arises from the Council’s failure to properly ensure contemporaneous investigation of the concerns around Ms C’s transfers. I cannot say the Care Provider’s practice was flawed here. But both Mr B’s account and the care worker’s account agree that Ms C fell back into her chair, which I find concerning given her spinal injury. So even if care workers were not at fault, a more thorough investigation may still have resulted in improved practice. I consider the uncertainty that more might have been done to improve practice around Ms C’s transfer is another form of distress.
42. I also consider distress arises from the Council’s failure to respond adequately to Mr B’s requests for a service or his complaints. I consider the Council’s failure likely to have undermined Mr B and Ms C’s confidence in the Council’s capability to resolve their concerns. Mr B was also put to unnecessary time and trouble in pursuing concerns.
43. I note that both Mr B’s service requests and the complaints covered more ground than I have summarised in detail in this statement (see paragraph 17). Further, that at times the Council had reason to raise concerns with Mr B about his ability to cope with caring for Ms C. I recognise this context put the Council under extra pressure in dealing with the concerns he raised. But I do not consider this provides mitigation for the injustice set out above.
44. But in considering a suitable remedy for this complaint, I give credit to the Council for refunding to Ms C all fees paid for the care given by the Care Provider and writing off any balance due. Because of this action, and given Mr B’s own wishes, I do not propose a financial remedy in this case. However, but for this action by the Council I would have recommended this.
45. I am pleased the Council has accepted these findings and agreed action to remedy Mr B and Ms C’s injustice. In deciding the scope of action needed, I gave thought to whether the Council should carry out further investigation into specific concerns raised by Mr B. In particular, his concerns about medication administration which were never investigated contemporaneously. Nor the concern he raised in September 2018 about how a care worker transferred Ms C. However, I consider those events are now so long ago that an effective investigation could not be safely carried out. This is after noting it is nearly two years since the Care Provider gave care to Ms C; its records are clearly incomplete; its personnel may have changed and the memories of all concerned may no longer be reliable.

Agreed action

46. To remedy the injustice I have identified above the Council has agreed that within 20 working days of a decision on this complaint it will provide a written apology to Mr B and Ms C accepting the findings of this investigation.
47. It has also agreed to take further steps to learn lessons from this complaint. While I note the Care Provider has a different management team and has improved practice since February 2019 I have not seen enough evidence to satisfy me that it has resolved all the concerns highlighted by this complaint. So, within three months of a decision on this complaint the Council will write to this office and clarify what further steps it has taken to assure itself the Care Provider:

• has satisfactory procedures in place to ensure the safe administration of medication to users of its services;
• has satisfactory training in place to ensure the safe moving, handling and transfers of users of its services;
• keeps adequate records on its client files of such matters as the user of services’ preference for care workers of a specific gender; how it records concerns or complaints from users of services including those brought to its attention by the Council;
• undertakes prompt investigation into any concerns raised about the practice of individual care workers.

48. In addition, I also consider there are useful lessons the Council can learn about its practice. In particular, in its handling of complaints. Within three months of decision on this complaint it has agreed to write to this office and clarify what further steps it has taken:

• to ensure that its social care staff ensure investigation of concerns raised by users of services which allege serious failings in a Care Provider’s service;
• to ensure that its social care staff maintain oversight where they have asked a Care Provider to look into a user of service’s concern;
• to ensure that officers asked to respond to complaints are reminded of the need to respond to the individual concerns around poor care raised by complainants; as well as considering broader questions of care provider’s policy and practice;
• to ensure timely responses to complaints and set out what steps it has taken to avoid a repeat of the communication breakdown between its social care and contracts team that it says caused delay in replying to Mr B’s complaint.

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Final decision

49. For reasons set out above I uphold this complaint finding fault by the Council causing injustice to Mr B and Ms C. The Council has agreed action that will provide a fair remedy for that injustice and to ensure it learns wider lessons from the complaint. Consequently, I am satisfied I can now complete my investigation.

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Investigator's decision on behalf of the Ombudsman