Summary: We will not investigate Mrs X’s complaint about the standard of care provided to her mother by the Care Provider. The Care Provider has investigated Mrs X’s concerns, upheld parts of her complaint, apologised and taken action to improve. We could not add anything to the Care Provider’s response or achieve the outcome Mrs X wants.

The complaint

1. Mrs X complains the Care Provider did not immediately notify her or other family members when her mother, Mrs Y, was taken to hospital following a fall. She complains the Care Provider:

• initially gave her incorrect information about which hospital Mrs Y had been taken to;
• staff did not accompany Mrs Y to hospital;
• failed to complete a Deprivation of Liberty Safeguards (DoLS) assessment of Mrs Y, despite her diagnosis of dementia.

Mrs X says this caused Mrs Y and her family distress. She wants the Care Provider to take disciplinary action against the Care Home Manager.

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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, or
• further investigation would not lead to a different outcome, or
• we cannot achieve the outcome someone wants. (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.

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My assessment

4. The Care Provider has responded to the elements of Mrs Y’s complaint listed above. It has accepted staff did not follow its usual procedure of immediately notifying next of kin when a resident has a fall and/or is taken to hospital. It has apologised for this and the Care Home Manager’s mistake when they told Mrs X the wrong hospital for her mother. The Care Provider explained the action it had taken or will take to improve. This included speaking to staff members involved and reminders to all staff. The Care Provider also explained Mrs Y had capacity to decide to go to hospital unaccompanied by Care Home staff. It also explained Mrs Y’s recent dementia diagnosis did not suggest a DoLS assessment or measures were needed when she was admitted to the care home for a short respite stay.
5. Mrs X says she wants the Care Home Manager to receive a written warning for the way they dealt with the incident involving her mother. It is up to the Care Provider to decide how to deal with any internal disciplinary issues and this is not something we would interfere with as we cannot investigate personnel issues. We have no powers to insist the Care Provider takes the action Mrs X wants against the Care Home Manager.
6. The Care Provider has apologised to Mrs X and advised of the actions it has taken to improve and learn from her mother’s experience. We could not add to this or are likely to make a different finding even if we investigated and found evidence of fault.

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Final decision

7. We will not investigate Mrs X’s complaint because further investigation could not provide a different outcome to those already achieved.

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Investigator's decision on behalf of the Ombudsman