Summary: We will not investigate Mrs X’s complaint about the Care Home providing poor care to her late mother, Mrs Y. This is because a further investigation would not lead to a different outcome and it is unlikely we would find fault with the Care Provider.

The complaint

1. Mrs X complained the Care Home provided poor care to her late mother, Mrs Y. The matter caused Mrs X distress and uncertainty. She wants the Care Provider to accept it acted with fault and provide her with a financial remedy. She also wants it to make service improvements to prevent a recurrence of fault.

Back to top

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.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

Back to top

How I considered this complaint

3. I considered information provided by Mrs X and the Care Provider.
4. I considered the Ombudsman’s Assessment Code.

Back to top

My assessment

5. Mrs Y was a resident at the Care Home. The Care Home had assessed Mrs Y as being at high risk of falls. The Care Home therefore provided Mrs Y with one-to-one support between 9am and 7pm daily.
6. Mrs Y also had a medical condition which required staff to administer her medication at specific times of the day with her last dose being at 10pm. Staff therefore kept Mrs Y awake until 10pm to administer her the last dose.
7. Mrs X complained her mother had experienced a fall which resulted in her sustaining multiple injuries. Mrs X said since her fall, her mother’s health had declined.
8. The Care Provider accepted that keeping Mrs Y awake until 10pm may have increased the risk of her falling as she did not have one-to-one support in place following 7pm. However, it said it kept Mrs Y awake for her last dose as previously, she would refuse to take her medication once in bed. It said since Mrs Y’s fall, she had been prescribed slow-releasing medication which meant staff were not required to keep her awake until 10pm.
9. We will not investigate this part of Mrs X’s complaint. This is because the Care Provider explained what may have contributed to Mrs Y’s fall and took appropriate action to reduce the risk of her falling again. It is unlikely a further investigation would lead to a different outcome.
10. Mrs Y moved into a new care home. The day before her move, she became unwell. The Care Home sought medical advice which resulted in a General Practitioner assessing Mrs Y and prescribing her with an antibiotic. The Care Home administered Mrs Y her first dose of antibiotic.
11. Mrs X said within 24 hours of Mrs Y being in the new Care Home, she deteriorated further and was admitted into hospital. Mrs X complained the Care Home failed to identify or act on signs of deterioration in her mother's health before her transfer, which may have contributed to her subsequent hospital admission.
12. We will not investigate this part of Mrs X’s complaint because it is unlikely we would find fault with the Care Provider. The Care Home recognised Mrs Y's condition had changed and responded by seeking medical advice and following it. We consider it took appropriate action at the time.
13. Mrs X said once her mother arrived at the new Care Home, staff noticed she had redness near her arms. Mrs X complained the Care Home failed to recognise this.
14. The Care Provider said staff had provided Mrs Y with personal care on the morning of her discharge day. Its records and staff confirmed there were no signs of redness or soreness near Mrs Y’s arms.
15. We will also not investigate this part of Mrs X’s complaint as a further investigation would not lead to a different outcome. We would not be able to establish that the Care Home failed to identify or respond to a skin concern without supporting evidence.

Back to top

Final decision

16. We will not investigate Mrs X’s complaint because a further investigation would not lead to a different outcome and it is unlikely we would find fault with the Care Provider.

Back to top

Investigator's decision on behalf of the Ombudsman