Summary: The Ombudsman will not investigate Mr X’s complaint about the care his mother received. This is because an investigation would be unlikely to add anything to the response Mr X has already received or achieve the outcomes he would like.

The complaint

1. The complainant, Mr X, complained about the residential care his mother (Mrs Y) received while recovering from an operation. The Council commissioned the care Mr X complained about. Mr X says Mrs Y’s condition deteriorated rapidly and she was admitted to hospital with severe dehydration. Mr X also complained about poor stoma care, a lack of communication, and that the Care Provider gave Mrs Y a first-floor room not set up for physiotherapy and without a television. Mr X says Mrs Y’s death was avoidable. He wants the Care Provider to accept the care was inadequate, to limit the number of residents, and to introduce improved training and processes.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse effect on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We may decide not to start an investigation if the tests set out in our Assessment Code are not met. (Local Government Act 1974, section 24A(6), as amended)
3. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them.

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How I considered this complaint

4. I considered information provided by the complainant and the Ombudsman’s Assessment Code.

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What I found

Background

5. Mrs Y was admitted to a residential care setting in October 2021 to recover from an operation. Mrs Y was admitted to hospital 20 days later and sadly died shortly afterwards. Mr X complained to the Care Provider about the care Mrs Y received. In response to Mr X’s complaint the Care Provider said:
• It was sorry to hear of Mr X’s negative experience and changes had been made. The Care Provider had been working with the Council and the Care Quality Commission (CQC) to make changes.
• The room offered to Mrs Y was the same as those on the ground floor. It did not provide televisions to residents.
• Not all staff were trained in stoma care and so it had arranged extra training.
• It was best practice to monitor food and fluid intake when a resident was admitted. It was sorry this had not happened, but no concerns had been raised when the home first admitted Mrs Y. A nurse who had said Mrs Y was dehydrated no longer worked for the Care Provider.
• Mrs Y had two falls the night before she was admitted to hospital. Staff had checked Mrs Y hourly but had found her on the floor at 1.15am and 7am. On both occasions Mrs Y had no injuries and did not seem confused. Staff had not called Mr X due to the time of the falls. However, the staff who had taken over when the day shift had started, should have called Mr X. This did not happen and the Care Provider apologised. It accepted Mr X only learnt of the falls when an Occupational Therapist visited Mrs Y at 09.30. New processes had been introduced to ensure a better handover between shift changes.

Assessment

6. In deciding whether to investigate a complaint we need to consider various tests. These include the alleged injustice and what an investigation could achieve. We do not investigate all the complaints we receive.
7. I understand how distressing the issues at the heart of this complaint must be for Mr X. But having considered the information available, we will not start an investigation into Mr X’s complaint. The reasons for this are as follows:
• Because Mrs Y has now passed away, we cannot do anything to remedy any injustice caused to her by the Care Provider’s actions.
• If we were to investigate, we could never say the Care Provider’s actions led to Mrs Y passing away.
• We cannot say how many residents the Care Provider should have.
• The Care Provider has responded to Mr X and accepted there were some issues with the care Mrs Y received. It has apologised and set out the changes it has made. It is unlikely we would recommend any further changes. It is therefore difficult to see what more an investigation would achieve.
8. But if Mr X has continuing concerns, he could approach the CQC as the regulator of care providers. The CQC regularly inspects care providers to make sure they are meeting the fundamental standards those registered to provide care services must achieve. It has far wider powers than the Ombudsman to act if it finds issues with a care provider.

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Final decision

9. We will not investigate Mr X’s complaint because an investigation would be unlikely to add anything to the response Mr X has already received or achieve the outcomes he would like.

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Investigator's decision on behalf of the Ombudsman