Summary: The Ombudsman will not investigate Mrs B’s complaint about the poor standard of care her late aunt received from her care provider at the end stage of her life. This is because the Council has investigated the concerns, addressed the failings, and set up an action plan to minimise the risk of the same matters happening again in the future. It is unlikely further investigation could add to this or make a different finding even if the Ombudsman investigated.

The complaint

1. Mrs B complained about the poor care her late aunt, Mrs C, received from her care provider at the end of her life. Mrs B says Mrs C was 102 and had suffered a fractured hip. She was in pain, her pain was not monitored or managed and there was no end of life care plan in place to support her or her family. Mrs B has video evidence of Mrs C crying out in pain and the radio playing loudly. In addition, Mrs B is concerned the Council took over 12 months to respond to her complaint.

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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’. 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 Council, or
• it is unlikely further investigation will lead to a different outcome.

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

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How I considered this complaint

3. I discussed the concerns with Mrs B and considered information and documentation from Mrs B and the Council. I sent Mrs B a copy of my draft decision and considered her comments on it.

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What I found

4. Mrs B complained to the Ombudsman that her concerns about Mrs C’s care at the end of her life had not been considered by her care provider or the Council and her complaint was not responded to.
5. The Ombudsman asked the Council to respond to the concerns raised and provide Mrs B with a formal response.
6. The Council responded to Mrs B’s concerns in September 2020. It apologised her complaint received in November 2019 had not been responded to and that she had not been kept informed about the investigation.
7. It explained it met regularly between February and July 2020 with staff from the Care Quality Commission (CQC), Safeguarding, NHS Continuing Health Care (CHC) and Adult Social Care to set up a robust Quality Improvement Management programme (QUIM.
8. The Council says the meetings had a clear directive to ensure action plans were drawn up and followed to improve standards of care. It says the Manager of the home left and a senior manager was put in post to address and improve the quality of care provided to its residents. It explained following the implementation of the quality improvement notice, standards have significantly improved and a Quality Assurance Office will monitor the home when COVID restrictions permit. The Council attached a copy of the actions taken from QUIM detailing the additional processes and measures now in place regarding pain monitoring, medication, and end of life care plans.
9. The Council has apologised for the anxiety and distress caused to Mrs B and has acknowledge the standard of service she received from it was not adequate. It has assured Mrs B it will learn from the mistakes identified, improve its practices and communication. It has advised Mrs B of the actions and processes it has put in place to minimise the risk of risk of similar occurrences happening to other residents and their families. Sadly, Mrs C is deceased so any injustice caused to her from the Council’s actions cannot be remedied.
10. Mrs B is concerned the care provider will not follow the actions outlined and that she will not know whether they have done so. The Council has explained its Quality Assurance Officer will monitor the home when restrictions allow. The Ombudsman could achieve no more than this. Mrs B can ask the Care Quality Commission (CQC) to consider her concerns. As the regulator of care providers, the CQC can assure itself the actions identified in the plan have been implemented. While Mrs C may not know what has happened or be told the outcome, it is not the role of the Ombudsman to provide Mrs C with the answers. The Ombudsman is satisfied additional processes and procedures have been implemented to minimise the risk of similar occurrences happening again in the future.

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Final decision

11. The Ombudsman will not investigate this complaint. This is because it is unlikely any further investigation by the Ombudsman could add to the Council’s response.

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Investigator's decision on behalf of the Ombudsman