Summary: Mrs C complains that her late mother’s jewellery went missing from the nursing home she lived in before her death. The Care Provider did a satisfactory investigation but could not find the missing jewellery. We cannot establish liability for its loss, so have found no fault with the Care Provider.

The complaint

1. The complainant, whom I refer to as Mrs B, was – until her death in January 2021 – a resident in a nursing home run by the Care Provider. The complaint is brought on behalf of her estate by her daughter, whom I refer to as Mrs C.
2. Mrs B lived in the nursing home for six years after suffering a stroke. As a result of the stroke her hand became a clenched fist, and her gold wedding ring was removed. At Mrs B’s request, the ring – along with a gold sovereign – was placed on a gold chain around her neck.
3. Mrs C complains that, when she visited the nursing home to collect Mrs B’s possessions after her death, the gold jewellery was missing. She says the room and the home’s safe were searched, but nothing was found.
4. Mrs C says Mrs B had only one functioning hand and therefore would not have been able to remove the jewellery herself. She also says Mrs B was not asked to complete an inventory of her possessions at any point in her six-year in the nursing home.
5. Mrs C feels the loss of the jewellery is the Care Provider’s responsibility.

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The Ombudsman’s role and powers

6. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
7. If we are satisfied with a care provider’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. I considered information from Mrs C and the Care Provider. Both parties had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Law and guidance

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 13

9. The intention of this regulation is to safeguard people who use services from suffering any form of abuse or improper treatment while receiving care and treatment.
10. Providers must have robust procedures and processes to prevent people using the service from being abused by staff or other people with whom they may have contact.
11. Where any form of abuse is suspected, the provider must take appropriate action without delay. This action must include investigation and referral to relevant external bodies.

Care Quality Commission (Registration) Regulations 2009: Regulation 18

12. The intention of this regulation is to set out a range of events or occurrences that must be notified to the CQC so that, where needed, it can take follow-up action.
13. Providers must notify the CQC of all incidents that affect the health, safety and welfare of people who use services. The list of incidents set out in the regulation includes “theft, misuse or misappropriation of money or property”.

The Care Provider’s safeguarding procedure

14. This procedure sets out the steps the Care Provider must follow when conducting a safeguarding investigation.
15. The home manager or person in charge must undertake an investigation and, if necessary, take action to protect the resident.
16. Statements should be taken from witnesses. Accurate written records of the situation should be kept in the resident’s records.
17. The CQC should always be informed if the incident involved any of the Care Provider’s workers.
18. If there are identified injuries or if fraud is suspected, the Police must be informed.
19. Where abuse has occurred, then, following investigation and completion of local procedures, the Care Provider will refer the matter to the Disclosure and Barring Service (DBS).

What happened?

20. Mrs B died in the nursing home on 31 January 2021. The following day Mrs C came to collect Mrs B’s possessions and noticed the jewellery was missing. She reported it to the home manager.
21. On 2 February the manager completed an incident form. On the form she recorded that she had searched Mrs B’s room, the home’s safe and the drugs cupboard, but to no avail. She said she would speak to staff members when several them returned to work following a covid-19 outbreak.
22. On 3 February the manager reported the matter to the Police. The Police acknowledged the report but said they would not take further action unless new evidence was found.
23. On 4 February the manager reported the matter to the CQC.
24. On 5 February the manager contacted a care agency who had provided the home with several staff members. She asked it to provide statements from staff who had worked in the home. She also asked it to provide details of the checks it conducted on people before hiring them.
25. On 10 February the agency provided statements from its staff. Nobody could remember Mrs B’s jewellery.
26. On 12 February the agency also told the home manager that it conducts DBS checks on all its staff.
27. Between 12 and 19 February the home manager gained statements from the Care Provider’s own staff members who had worked with Mrs B. Half the staff remembered Mrs B’s jewellery but could not remember when they last saw it. The other half said they could not remember the jewellery at all.
28. The Care Provider then responded to Mrs C, saying it could not find the necklace. It also said that, as Mrs B did not have total paralysis, it did not accept that she could not have removed the jewellery herself.

My findings

29. It is not my role to decide what happened to Mrs B’s jewellery, and I cannot establish liability for missing valuables. This is a matter which can only be properly decided by a court.
30. However, I must decide whether the Care Provider acted properly when Mrs C reported the jewellery missing.
31. The law and guidance set out earlier in this statement requires certain things of care providers when things like this happen. It requires that a proper investigation is undertaken (including getting statements from witnesses), and that the Police and the CQC are informed. If the investigation identifies that a member of staff is responsible, further action must be taken.
32. The records provided by the Care Provider show that it investigated Mrs C’s complaint about the missing jewellery, gained statements from both its own and agency staff, and reported the matter to the Police and the CQC.
33. In doing so the Care Provider acted in accordance with the Regulations and its own safeguarding procedure.
34. If the Care Provider had identified that a member of staff was responsible for the jewellery going missing, then it would have had to take action. But, as this did not happen, it had to decide how to respond to Mrs C.
35. The Care Provider decided that, as nothing had come of its investigation, it could not be held responsible for the jewellery going missing. Its reasoning was that, in its view, it would not have been impossible for Mrs B to remove the jewellery herself.
36. I understand why Mrs B is dissatisfied with the outcome of the Care Provider’s investigation, and it is certainly possible that the jewellery was stolen. But I have no grounds to conclude that it was, even on the balance of probabilities. Because of this, I do not consider the action the Care Provider took in response to Mrs C’s complaint – or the explanation it gave for its response – to be obviously incorrect or unreasonable.
37. As I cannot establish liability for the missing jewellery, and as the Care Provider acted properly in response to Mrs C’s complaint, I have found that the Care Provider did not cause Mrs B an injustice.

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Final decision

38. The Care Provider was not at fault for how it responded to Mrs C’s complaint about Mrs B’s missing jewellery.

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Parts of the complaint that I did not investigate

39. I did not investigate Mrs C’s complaint that Mrs B was not asked to complete an inventory when she moved into the nursing home. This is because there is no dispute about her possession of the jewellery before her death. An inventory would only be relevant if the Care Provider was denying that the jewellery was ever in her possession.

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Investigator's decision on behalf of the Ombudsman