Summary: Mr B complained that the Agency’s technicians who attended his home, did not properly test his electrical equipment and falsely certified that they had tested the equipment. We have found fault. The Agency has already remedied the injustice caused by the fault and has taken action to reduce the risk of the fault happening again.

The complaint

1. Mr B complains about NRS Healthcare (the Agency). The Agency carries out safety tests of equipment on behalf of a consortium of which the Council is a member. Mr B complains that the technicians from the Agency did not properly test his electrical equipment and then said that they had tested it and provided false readings. He also complains about the delay in responding to his complaint and he says the complaint response has not addressed all his concerns.

Back to top

The Ombudsman’s role and powers

2. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with an organisation’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)

Back to top

How I considered this complaint

4. I have discussed the complaint with Mr B and I have considered the information that he and the Council have sent.

Back to top

What I found

5. Mr B has an electric adjustable bed and an inflatable bath cushion.
6. Portable appliance testing (PAT) is the process of checking electrical appliances through a series of visual inspections and electronic tests.
7. The chronology of what happened is as follows.
• 1 August 2023. Two technicians of the Agency visited Mr B to carry out the PAT test on his equipment and certified that the equipment was safe.
• 4 August 2023. Mr B contacted the Agency as he was concerned that the test had not been conducted properly. He said the Agency’s technicians moved the bed up and down but did not use any electrical measuring equipment before certifying that the test had been done and the bed was safe.
• 4 August 2023. Mr B contacted the Council and informed them of his concern. The Council asked the Agency to investigate the complaint.
• 9 August 2023. Mr B contacted the Council as he had not received a response to his complaint from the Agency. All the Agency had done was to offer him a new test. He said the Agency did not take his complaint seriously. Mr B did not want to rebook the test until the Agency had investigated his complaint.
• 10 August 2023. The Council officer emailed the Agency again asking them to investigate the complaint.
• 21 August 2023. Mr B contacted the Council and said he had just called the Agency and they had told him that his complaint was being escalated. Mr B said it had been 3 weeks since he made his complaint and he had still not received a response.
• 24 August 2023. The Council officer responded and explained that they had tried to make enquiries on Mr B’s behalf but the Agency said it could not disclose the information to the Council, but could do so to the consortium which the Council was a member of. The officer gave Mr B the contact details for the consortium with an email address of a different council.
• 4 September 2024. An officer from the Agency spoke to Mr B and offered a further PAT test.
• 11 September 2023. Mr B told the Council officer that he did not agree with the Council’s suggestion to take his complaint elsewhere. He said he had provided the Council will all the information it needed to investigate his complaint and it had now been 5 weeks since he made his complaint and he had not received a response from the Agency nor the Council.

Complaint response – 22 September 2023

8. The Agency responded to Mr B’s complaint and said:
• It had interviewed the technicians and they had admitted that they did not use a PAT tester when they tested Mr B’s equipment. The Agency concluded that neither technician correctly undertook the work and fully upheld Mr B’s complaint.
• Disciplinary action had been taken with the technicians and they had also been retrained on the correct process of the PAT test.
• A full review of the activity and of communication had taken place and lessons had been learned, particularly regarding communication with service users and adhering to best practice.
• It would reach out to Mr B to undertake the test as part of the complaint feedback.

Mr B’s response – 30 January 2024

9. Mr B responded to the Agency’s email and said:
• The Agency had not addressed why the technicians chose not to use the PAT tester when they carried out the test on Mr B’s equipment and whether this only happened one time. Mr B suspected that more people may have been affected.
• In response to the comment that the Agency had reviewed its communications, Mr B said he had been contacted by an officer of the Agency on 30 January 2024 offering him a new appointment for the test. This officer knew nothing about the complaint so Mr B had turned down the offer of the test as he had not received any assurance that the test would not be done by the same technicians. The Agency then booked a test on the following day even though it knew that Mr B had not agreed to a further test.

Complaint response – 4 April 2024

10. The Agency responded to Mr B’s complaint on 4 April 2024 and said:
• It apologised for the delay in its response.
• When Mr B raised the complaint, the Agency carried out due diligence and found that this was a one-off incident and not a pattern of behaviour. The technicians were in a different van that day and did not have a PAT tester in the van.
• The Agency upheld the complaint that the actions of the technicians did not meet the Agency’s expected standards and core values. It apologised for what had happened.
• There had been no further complaints raised against the technicians since they had received re-training.
• The Agency apologised for the ‘blind booking’ on 31 January 2024 and accepted that the communication was ‘lacking’. This happened because the customer service centre had not been informed about the complaint. The service centre had now added a note so staff knew about the situation when they tried to rebook the test.
• The offer of a new test was still available.
11. Mr B responded and said he was still not satisfied on how the Agency knew that the same problem did not occur during the other PAT tests that the technicians carried out that day. He said the technicians told him they had carried out the test when they left, even though they knew that they had not. This was fraudulent misrepresentation and the Agency had not addressed this.

The Ombudsman’s investigation

12. The Council and the Agency have provided the following information in response to the Ombudsman’s enquiries.
13. The Agency interviewed the technicians on 6 September 2023 and it has provided the records of the interviews and the evidence of the re-training.
14. The Agency completed an investigation report. The report noted that the PPM (planned preventative maintenance) test they carried out for Mr B was the only PPM booked in for the technicians on that day.
15. I asked the Agency what actions it had taken to ensure that an incident like this did not occur again. The Agency said:
• Managers monitored technicians throughout the day via its internal system to ensure that all allocated jobs were on course to be finished daily.
• Frequent phone calls were made to technicians throughout the day to make sure they stayed on track to complete their allocated jobs.
• All technicians had been advised of the new ‘Authority to Fail’ process, meaning that it was mandatory for technicians to telephone their line manager, if they were unable to fulfil a job. The purpose of the telephone call was to seek approval to do so, following an explanation.
• Technicians were aware of the expectation to always follow this mandatory task. Failure to follow this reasonable request were managed internally via a formal process if necessary.
• Manager were spending time ‘out in the field’ with individual technicians, ensuring that all processes were followed.
• The technicians received ongoing training and, if issues were identified though the auditing of the quality of their work or via feedback, the relevant training was provided and recorded.
16. I asked the Agency how the actions it was taking were different from previous practices. The Agency said:
• The amount of time spent monitoring technicians and making telephone calls to technicians had significantly increased.
• The ‘Authority to Fail’ was a new process implemented at the beginning of the year.
• The programme of managers being out in the field and auditing work was introduced in April 2024.

Analysis

17. The Agency has already upheld Mr B’s complaint and I agree there was fault in the Agency’s actions. The Agency failed to properly conduct the PAT test. In addition, the Agency’s technicians falsely certified that the test had taken place which compounded the fault.
18. I note that the people using the equipment would often be vulnerable adults with mobility restrictions who would be more at risk of harm if the equipment malfunctioned. A PAT test should always be carried correctly obviously, but the consequences of not carrying it out properly could potentially be greater in this case so I understand why Mr B was so concerned and wanted to bring this to the attention of the Ombudsman.
19. The Agency has also already upheld the complaint about delays in the complaint responses and I agree there was fault in that respect. It was not only the delay but Mr B also felt that the Agency did not properly investigate the complaint as his main concern was that there may be a wider problem which the Agency was not properly addressing.

Injustice and remedy

20. I have considered the injustice suffered and the remedy that the Ombudsman can offer.
21. In terms of personal injustice to Mr B, Mr B suffered an injustice as his bed and the other equipment were not properly tested which could have exposed him to a risk if they had malfunctioned. In addition, he had the stress of pursuing the complaint to ensure that it was properly investigated.
22. I note, however, that the Agency has already remedied the personal injustice to Mr B. It has fully upheld his complaint and apologised several times and it has offered him a fresh test to ensure the equipment is properly tested.
23. I asked Mr B what outcome he wanted to achieve from taking his complaint to the Ombudsman as his personal injustice had been remedied. Mr B said the Agency had never properly dealt with the wider risk he had identified by its failures and he wanted this addressed. He said he wanted the dismissal of the technicians, the cancellation of the Agency’s contract and he wanted the Ombudsman to impose a large fine on the Agency.
24. I explained to Mr B that the Ombudsman would not be able to achieve those outcomes. I explained the way the Ombudsman considered remedies when there had been fault causing injustice. The relevant considerations are:
• If there has been personal injustice as result of a fault, then the purpose of the Ombudsman’s remedy is firstly to put the person into the position they would have been if the fault had not occurred.
• The Ombudsman does not impose punitive fines for errors or take action to punish people. It is an organisation focussed on individual justice and institutional improvement.
• The Ombudsman cannot get involved in disciplinary action against individuals.
• When the Ombudsman decides that the organisation needs to learn from the fault to prevent likely injustice to other in the future from similar fault, it can recommend a service improvement.
25. I note that the Agency has put in place service improvements (paragraphs 15 and 16) which should ensure that the risk of a similar incident occurring has been reduced. I therefore do not recommend further service improvements. I hope that this investigation and decision gives Mr B some assurance that his complaint was taken seriously and that the risk of a recurrence of the fault has been reduced.

Back to top

Final decision

26. I have completed my investigation and found fault, but the fault has already been remedied.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman