Summary: We will not investigate Mrs X’s complaint about her late mother Mrs Y’s respite stay in a care home part-funded by the Council. An investigation would not lead to a different outcome nor achieve a worthwhile outcome and we cannot achieve the outcome Mrs X seeks from her complaint.

The complaint

1. Mrs X is the late Mrs Y’s daughter. Mrs Y went into Harper Fields Nursing Home for a respite stay in 2024, a placement part-funded by the Council. Mrs X complains Mrs Y was neglected during her time at the home.
2. Mrs X says Mrs Y suffered great distress resulting from her stay. She says she continues to feel great remorse and guilt for having trusted the home, and her late brother was devastated by Mrs Y’s treatment there. Mrs X is concerned for the care of others at the home.
3. Mrs X wants a full audit of Mrs Y’s documents and the home’s staff training records and a comprehensive visit from the Care Quality Commission (CQC).

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The Ombudsman’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service but must use public money carefully. We do not start or continue an investigation if we decide:

• we could not add to any previous investigation by the organisation; or
• further investigation would not lead to a different outcome; or
• we cannot achieve the outcome someone wants; or
• there is no worthwhile outcome achievable by our investigation.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

5. I considered information from Mrs X and the Ombudsman’s Assessment Code.

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My assessment

6. The care home and the Council responded separately to Mrs X’s complaint. The matters Mrs X raised included significant personal and medical care issues, monitoring of Mrs Y’s condition and medication, and lack of communication from staff. The care home investigated Mrs X’s concerns by speaking to staff involved, reviewing its care records and contacts with Mrs X. It accepted it did not always give Mrs Y appropriate care during her stay and could not confirm she had received some care because of a lack of staff record-keeping. The Council assessed the care home’s investigation and responses to the complaint and found it lacking. Officers considered there had been various errors and omissions in the home’s provision for Mrs Y, and that it was unlikely they could achieve a full retrospective investigation now. The Council confirmed it would be auditing the care home in relation to the various issues raised by Mrs X’s complaint, including care record-keeping, manager oversight of changes to residents’ needs and escalation to clinical referrals, and staff training.
7. The home gathered relevant information from Mrs X and its staff to investigate her concerns and provide its findings. We recognise the Council found the home’s investigation wanting but also found it unlikely they would now be able to investigate fully. There would be no new or additional evidence available to an investigation by us into Mrs X’s care provision which would allow us to add to the investigations already done by the care home and Council. An investigation by us would not lead to a different outcome here so we will not do so.
8. The injustices caused by failures in Mrs Y’s care were primarily to Mrs Y. We cannot provide a remedy to Mrs Y for that injustice as she has died. We also cannot remedy Mrs X’s late brother’s distress on his learning of Mrs Y’s experience at the home. We will not investigate where an investigation cannot provide a remedy because the person affected has died. We recognise Mrs X has been caused and continues to be caused feelings of remorse and guilt by the matter. But an investigation by us here could not stop or alleviate them. There would be no worthwhile outcome an investigation by us would now achieve.
9. Mrs X’s complaint about the care home has led to investigative action by the Council regarding the care home’s practices when dealing with its current and future residents. We note Mrs X also referred the matter to the CQC but was disappointed by its reply. We understand an outcome Mrs X wants from her complaint is for the CQC to visit the care home. But we do not have jurisdiction over the CQC so cannot order it to visit or inspect the home. It is for the CQC to decide how and where it uses its resources and how it responds to information it receives. That we cannot achieve a complaint outcome Mrs X seeks is a further reason why we will not investigate.

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Final decision

10. We will not investigate Mrs X’s complaint because:
• an investigation by us would not lead to a different outcome; and
• there is no worthwhile outcome an investigation would achieve; and
• we cannot achieve the complaint outcome she seeks.

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Investigator's decision on behalf of the Ombudsman