Summary: Miss X complained about aspects of care provided to her relative Mr Y in a residential care home which she said caused Mr Y physical and psychological harm. We have ended this investigation because further investigation would not achieve anything more.

The complaint

1. Miss X complained about aspects of care provided to her relative Mr Y from early April to mid-June 2024 in a residential care home. Miss X was concerned about another resident, Mr Z, entering Mr Y’s bedroom, poor record keeping and poor communication. Miss X said the family decided to remove Mr Y for his personal safety after he was attacked by Mr Z which caused him physical and psychological harm. She said this caused distress.

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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 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 continue an investigation if we decide we could not add to any previous investigation by the organisation, further investigation would not lead to a different outcome, or there is no worthwhile outcome achievable by our investigation (Local Government Act 1974, section 24A(6), as amended, section 34(B)).

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How I considered this complaint

3. I considered evidence provided by the care provider and by Miss X and spoke to her on the telephone. I also considered relevant law, policy and guidance.
4. Miss X and the care provider had an opportunity to comment on my draft decision. I considered comments received before making a final decision.

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What I found

5. Mr Y has a diagnosis of dementia and lived independently. In early April 2024 Mr Y resided at a residential care home. His care was funded privately, also known as a self-funder.
6. In early May 2024, a male resident, Mr Z, moved into a bedroom next door to Mr Y’s bedroom. Miss X said immediately there were issues with Mr Z wandering into Mr Y’s bedroom. Miss X says the family repeatedly expressed concerns to the care staff. Miss X was concerned these incidents were not recorded on Mr Y’s daily care records.
7. Later in May 2024 and in early June 2024 the family were increasingly concerned about the escalating behaviour of Mr Z to Mr Y and other residents at the care home. In mid-May and early June 2024 there was a verbal and physical altercation between Mr Z and Mr Y. Following these incidents the care home placed sensor tape across Mr Y’s bedroom with the aim of preventing Mr Z’s access. Sensor mats were put outside both Mr Y’s and Mr Z’s bedrooms and the care home later relocated Mr Z to a different bedroom away from Mr Y’s bedroom. The care home also made referrals to a mental health team and the Deprivation of Liberty Safeguards (DoLS) team (DoLS are a legal procedure to protect people who are unable to make decisions for themselves to ensure any restrictions on their liberty are legal and in their best interests).
8. In early June 2024 the care home made a referral to the local Council’s safeguarding team about the altercations between Mr Z and Mr Y. The Council was satisfied with the actions taken by the care home and closed the referral.
9. In mid-June 2024 Miss X submitted a safeguarding referral to the Council. She was unhappy it had been closed by the Council without being involved in the safeguarding process. The Council’s safeguarding team contacted the care home again and it provided a full report to the Council including staffing levels, which it said were sufficient and which also considered communication with Miss X. There was a discussion about moving Mr Y and Mr Z to different floors. In mid-June 2024 Mr Y’s family decided to remove Mr Y from the care home and the Council closed the safeguarding investigation on the basis the risk had been removed and it did not consider the incident required further investigation.
10. Miss X continued to have concerns about Mr Y’s stay at the care home and complained to the care provider. It did not uphold Miss X’s complaints. Miss X also complained to the Council about its safeguarding investigation. In its complaint response the Council said ‘the fundamental safeguarding principles (Care Act 2014, West Midlands Safeguarding Policies and Procedures) of proportionality and prevention was demonstrated. It was felt that the actions by the home were appropriate to the situation without being restrictive to or risk adverse to Mr Y or other residents concerned’. Miss X remained unhappy and complained to the Ombudsman in Autumn 2024 about the Council’s safeguarding investigation (case reference 24 012 326). That Ombudsman investigation found no fault in the way the Council conducted its safeguarding investigation.

Analysis

11. The Council considered the concerns about Mr Z’s behaviour through the safeguarding process. As we found no fault in the way that investigation was conducted it would not be appropriate or proportionate for me to reinvestigate those issues now. In addition, as Mr Y no longer lives at the care home, there is nothing more I can achieve by investigating these issues further.
12. Miss X was unhappy with the care home’s record keeping and communication with her and the family. The care provider’s complaint response said its records showed regular ongoing communication with Miss X, it arranged a multi-disciplinary meeting in mid-June 2024 and offered to meet with Miss X. The care provider said Mr Y’s privacy, dignity and respect was consistently maintained and throughout Mr Y’s stay it documented his care needs and health observations. An investigation by us would be unlikely to add anything to what the care provider concluded or achieve a different outcome on these issues.
13. Miss X was unhappy with the care home response to her complaint and said it did not answer all her specific questions and concerns. The care provider responded in detail about Miss X’s concerns. It did not respond to every point but it did cover the main issues raised. There was not enough evidence of fault to justify further investigation on this point.

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Decision

14. I have ended my investigation. There was nothing worthwhile I could achieve by investigating further.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman