Summary: Mrs A complained about the care provided to her mother, Mrs B, before her death at Woodlands Care Centre. We will not investigate this complaint because it is unlikely we can add anything more to the investigation already carried out by the organisation.

The complaint

1. Mrs A complains about the care provided to her mother, Mrs B, while she was resident at Woodlands Care Centre (the Care Centre), which is run by RCH Homes (the Group). The placement was part funded by Cambridgeshire County Council.
2. Mrs A believes her mother’s care was inferior to those who were paying privately. She feels she was moved inappropriately which compromised her dignity and communication with the family was only when the family chased for updates.
3. Mrs A also feels the Care Centre manager should have addressed the complaints when the family raised them, she feels the manager showed no interest in her mother and didn’t know her.
4. Mrs A has been left feeling like her mother did not receive appropriate care, was treated without dignity and left in pain which should have been managed. Mrs A does not believe the changes promised in the RCH Homes complaint response letter have been implemented and fears other residents may be at risk. Some of Mrs B’s personal belongings which had sentimental value have been lost.
5. Mrs A wants service improvements and the Care Centre’s policies updated. She also wants financial redress.

Back to top

The Ombudsmen’s role and powers

6. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
7. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
8. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe it is unlikely we could add to any previous investigation by the bodies.
9. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)

Back to top

How I considered this complaint

10. I considered evidence provided by Mrs A, as well as the complaint response from RCH Homes. I asked it to provide evidence it had completed the improvements it said it would in the complaint response letter to Mrs A, and considered this.
11. Mrs A had the opportunity to comment on my draft decision.

Back to top

What I found

Mrs A’s complaint to the Care Centre

12. Mrs A complained to Woodlands Care Centre in early January 2025. The complaint was passed to RCH Homes to respond, and it did so in mid-March 2025.
13. The letter apologises for the delay in replying to Mrs A’s complaint and then addresses each of her complaint points. The letter apologises to Mrs A and admits fault in several areas. The letter commits to improve the service not just at the Care Centre, but across all the homes run by the group.

Ombudsmen assessment

14. While assessing Mrs A’s complaint, I spoke with her. She explained she did not believe the Group had made the changes it committed to and approached the Ombudsmen as she was concerned other residents may be at risk. She wanted reassurance she had done all she could.
15. I asked the Group to explain what it had done since it sent the complaint response letter, and to explain if it had made the changes it committed to in the same letter.
16. I will list what the Group said it would do and explain what action it has taken since.
17. The Group said it would:
• “Improve complaint handling procedures at the home and organisational level to ensure a more timely and thorough response, it is our aim to deal with most complaints within 28 days or receipt.” The Group explained it now manages all complaints through a digital system which sends an alert to managers 21 days after the complaint is received to remind them a response is due. The Group said now all complaints are now responded to within 28 days, or if this is not possible and update sent to the complainant explaining why.
• “Care planning must be more robust and track and monitor changes in the support, help and clinical oversight that a resident may need following a significant change in their health conditions”. The Care Centre now has a care plan tracker which allows managers to have oversight of all residents’ care plans. Care plan audits take place at the end of every month. Between June and September 2025, the Group worked with nurses and Team Leaders to help improve the overall leadership of the Care Centre, emphasising the importance of care planning, updating plans regularly and communicating with families openly and compassionately.
• “We could have done more to support you, explain our approaches and allay your concerns and this will be shared with the team so they can reflect on how we can do this better.” The Group said as part of the investigation into Mrs A’s complaint, the manager at the Care Centre was asked to complete a reflection and feed back how they thought things could be done differently in the future. The Care Centre manager Mrs A complained about has now left, but support was put in place for the new manager to ensure learning was taken from Mrs A’s complaint.
• “End-of-Life care planning must be completed with family members in a more timely and sensitive manner so we can ensure wishes and preferences are implemented as requested at this difficult time”. The Group said it now manages end of life care in a separate care plan, which has family input into both their and the resident’s wishes.
• “Care plan reviews with family members and power of attorneys should be completed as residents move in with updates monthly”. The Group said this area has become a focus at the Care Centre and families are now invited to attend monthly care review meetings. Before a patient moves into the centre, their family is asked if they want to be involved in the admission assessment and if so, the residents likes, dislikes and preferences are discussed in detail. When there is a change in the residents needs, families are also consulted before any changes in their care happen.
• “Following the passing of loved ones the home team must follow protocols to ensure that personal effects and items are stored safely to enable family member to collect at a later time.” The Group said it has changed the protocol at the Care Centre, now when a resident dies a team is asked to clean and tidy their room and lock the door until the family arranges to pack and collect their belongings. Staff will not do this without family permission.
• “Undertake a reflective supervision with the senior team at the home and some of the nurses and senior care staff to ensure that they learn what we need to improve and to understand the upset family members feel when things go wrong.” The Group said in March 2025 a Director met with the senior management team at the Care Centre to complete a reflection after Mrs A’s complaint. As part of the Care Centre’s development, in May 2025 an action plan was developed and weekly meetings took place to ensure the management team met the plan and improvements were made.
18. The Group has made service improvements to help prevent recurrence of the issues Mrs A complained about. It has put these in place across its service which is a benefit to anyone who uses any of its homes.
19. Mrs A wanted reassurance the Group had made the changes it promised it would. I acknowledge these improvements do not take away from the experience Mrs A had, and cannot restore to her family the sentimental items which were lost, but the action the Group has taken is what the Ombudsmen would expect and shows commitment to improving its service.

Back to top

Decision

20. We will not investigate this complaint because it is unlikely we could add anything further to what has already been done by the Group.

Back to top

Investigator's decision on behalf of the Ombudsman