Summary: We will not investigate Mrs X’s complaint about the care and support provided to her late mother by her care home. This is because there is insufficient evidence of fault. In addition, an investigation would not lead to any further findings or worthwhile outcomes.

The complaint

1. Mrs X complains about the care and support provided to her late mother by her care home. She complains:
• Residents were allowed to wander into her mother’s room.
• Medication inappropriately administered.
• Staff failed to notice a growth on her mother’s leg
• Poor wound care.

She also complains about the Council’s poor management of her mother’s transfer to a new care home.

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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:

• there is not enough evidence of fault to justify investigating, or
• 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 information provided by the complainant and the Council.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. In March 2024, Mrs X contacted the Council to request a review of her mother, Mrs Z’s, care placement. Mrs X also asked the Council to consider moving her mother to a care home that was nearer to her.
6. At the end of March 2024, the Council noted Mrs Z’s needs could be met in a residential home and that nursing care was not needed.
7. In April 2024, the Council met with Mrs Z and Mrs X and explained the need to have input from a medical professional regarding whether Mrs Z was fit to move. A paramedic saw Mrs Z in May 2024 and gave view that Mrs Z was not well enough to move to an alternative care home.
8. In June 2024, Mrs Z was seen by her GP who expressed their view that they had no clinical concerns regarding a move.
9. In July 2024, the Council review Mrs Z. During this meeting, the social worker asked the care home to give 4 weeks notice on the placement. Records show that throughout July, the Council was working to source a different placement that was nearer to Mrs Z.
10. Mrs Z moved to a new care home at the end of July 2024.
11. In total it took around four months for Mrs Z to move to a new care home from when Mrs Z first requested it. However, an investigation is not proportionate for the following reasons:
• Between March and June 2024, the delay was due to the necessity of seeking medical opinion on whether Mrs Z was fit to move to a different care home. The initial medical opinion was that Mrs Z was not fit to move, and an alternative view was only received in June 2024. Therefore, we are not likely to find fault with the Council because it was appropriate for the Council to wait until there was clear evidence Mrs Z was fit to be moved.
• It is apparent from the case records that once confirmation that Mrs Z was fit to be moved was received, it took the Council around a month to review Mrs Z. we would usually consider a month to be a reasonable timeframe for assessments and reviews to be completed. Therefore, we are not likely to find fault.
• From July 2024, once notice was given by the care home, case records show the Council was appropriately working to source Mrs Z an alternative placement. It is noted there was initially some issue with funding due to the cost of the alternative placement found and there being no third party available to fund a top up. However, we are not likely to find fault as it was appropriate for the Council to ensure any alternative placement was cost effective given Mrs Z’s current placement could meet her needs at a lower cost.
12. The case notes show the care home had investigated the incident involving incorrect medication being given to Mrs Z. The care home acknowledged the error had occurred and appropriately sent a safeguarding referral to the Council. The care home took action to address the fault by holding disciplinaries with the staff involved, apologising, and giving staff medication training.
13. The care home also accepted an incident occurred where another resident entered Mrs Z’s room, which caused her distress. The care home noted it could not put in place any barriers to prevent their residents from moving freely around the home. Mrs Z was offered the option to move to another room to prevent the issue from reoccurring, but Mrs Z declined.
14. An investigation is not justified on these two points as it would not lead to any further findings as fault has already been acknowledged. I am also satisfied an investigation would not lead to any further outcomes as the remedies put in place by the care provider was appropriate.
15. Finally, Mrs X complained about the care home failing to notice a growth and the poor care of that wound. I note there is no reference to this matter in the Council’s complaint response. However, the case records detailed there was discussion around this matter with the Council and care home in June 2024. It was noted by Mrs Z’s family that wound care had improved and the dressing was now being changed daily.
16. An investigation is not proportionate on this point as there are no worthwhile outcomes achievable. This is because even if we were to find fault with the care home for failing to notice the growth earlier, it would not be possible to say whether this would have led to better outcomes for Mrs Z.

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Final decision

17. We will not investigate Mrs X’s complaint because there is insufficient evidence of fault. In addition, an investigation would not lead to any further findings or worthwhile outcomes.

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Investigator's decision on behalf of the Ombudsman