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City of York Council (21 012 834)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 07 Apr 2022

The Ombudsman's final decision:

Summary: We will not investigate this complaint about how the Council considered concerns Mrs X raised in relation to care her mother received whilst in a residential home. There is insufficient evidence of fault in how the Council considered the concerns to warrant further investigation. The Council was at fault for failing to explain the outcome of the investigation to Ms X. The Council has agreed to apologise to Mrs X and write to her with its findings. That remedies any injustice caused.

The complaint

  1. Mrs X complained about the care her mother, Mrs Y received when she was a resident at a care home (the Home) for a short period in 2021. She said that on Mrs X’s discharge home, she was inappropriately dressed, missing personal belongings and had bruising on her body. She also said the Home had discharged Mrs X with dressings for a skin tear when there was no sign of injury. She said the Home had not properly updated care records to reflect a change in Mrs Y’s medication.
  2. Mrs X said that despite raising this concerns through a safeguarding referral to the Council, its response failed to address her concerns. Mrs X remains worried that something untoward happened to Mrs Y at the Home.

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The Ombudsman’s role and powers

  1. The Ombudsman investigates 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 may decide not to continue with an investigation if we decide:
  • there is not enough evidence of fault to justify investigating, (Local Government Act 1974, section 24A(6))
  • we are satisfied with the actions a council has taken or proposes to take. (Local Government Act 1974, section 24A(7), as amended)

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How I considered this complaint

  1. I considered information provided by the complainant and the Council.
  2. I considered the Ombudsman’s Assessment Code.

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My assessment

  1. Mrs Y stayed at the Home for a week, as part of a discharge plan to return home from hospital. The Council funded the placement. Mrs X could not visit Mrs Y at the Home because of COVID-19 restrictions.
  2. When Mrs X collected her mother, she was concerned about the care she experienced at the Home for the reasons set out in paragraph one. Mrs X initially contacted the Care Quality Commission (CQC). The CQC redirected Mrs X to the Council’s Adult Safeguarding Service.
  3. The Council contacted Mrs X and discussed her concerns. It explained it would ask the Home to complete a safeguarding enquiry into the issues raised. Mrs X confirmed that Mrs Y did not want to be involved in the enquiry.
  4. The Home completed an investigation based on the Council’s instructions. Where the Home found practice fell short it set-out steps it would take to address the faults identified. The Council wrote to Mrs X setting out the what the Home agreed to do. As there were no outstanding risks to Mrs Y and the Home had identified actions to address the faults identified, the Council closed its safeguarding enquiries. It has continued to monitor the Home.
  5. I have reviewed the Council’s safeguarding investigation. It considered all the concerns Mrs X raised and there is insufficient evidence of fault in how it completed that enquiry to warrant further investigation. However, the Council did not explain the findings of its safeguarding investigation to Mrs X. Nor did it apologise for any shortcomings that the Home identified when in completed its investigation. That meant Mrs X felt the Council had not answered the concerns she raised and has caused her avoidable distress.
  6. During my enquiries the Council has agreed to my recommendation to address these faults. Therefore, we will not investigate this complaint further as I am satisfied with the actions the Council has agreed to take.

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Agreed Actions

  1. Within one month of my final decision the Council has agreed to:
    • Apologise to Mrs X for the avoidable distress caused by not initially providing a copy of the Homes findings; and
    • Write to Mrs X with the outcome of the Home’s findings and apologise where any shortcomings in the Home’s practice were identified.

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Final decision

  1. We will not investigate Mrs X’s complaint because there is insufficient evidence of fault in how the Council completed its safeguarding investigation and we are satisfied with the actions it has agreed to take where we did find fault.

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Investigator's decision on behalf of the Ombudsman

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