Summary: We will not investigate Mr X’s complaint about the Care Home providing poor care to his mother. This is because we could not add to the Care Provider’s investigation, a further investigation would not lead to a different outcome, it is unlikely we would find fault and some personal injustice is not significant enough to warrant an investigation.

The complaint

1. Mr X complained the Care Home provided poor care to his mother, Mrs Y. He said the matter also caused him distress. He wants the Care Provider to provide his mother with a financial remedy.

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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
• any injustice is not significant enough to justify our involvement, or
• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome.

(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 Mr X and the Care Provider.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. Mrs Y was a resident at the Care Home. Mr X complained to the Care Provider about the care and support she had received during her stay. He said:
• despite the Care Home being aware Mrs Y was allergic to red peppers, on her first day, staff served her a meal which contained red peppers. Mr X said he was present and removed the red peppers from her meal;
• staff did not provide Mrs Y with adequate personal care. He also said staff delayed informing him Mrs Y did not have any toiletries;
• Mrs Y appeared upset. She felt as if she had done something wrong because staff left her on her own;
• he and his family were unable to get into the Care Home to visit Mrs Y as staff were not available to open the doors. He said this caused Mrs Y to become upset;
• staff did not properly record what Mrs Y had to eat;
• Mrs Y’s medication was not in her room. Mrs Y therefore left the Care Home without her medication. Mr X had to return to the Care Home to collect her medication; and
• staff had not updated the duty board.
6. The Care Provider investigated Mr X’s complaint. In its response it said:
• its records stated staff did not serve Mrs Y red peppers. It also said it had no evidence Mr X was present at the Care Home at the time;
• it accepted it had not provided Mrs Y with good personal care, that it delayed informing Mr X she had no toiletries and it failed to document and escalate the matter. It apologised to Mr X and explained it had taken action to address the matter with staff;
• staff had left Mrs Y on her own for a period of ten minutes;
• its records stated staff reassured Mrs Y and that she was content during her stay. It accepted Mrs Y may have expressed distress to Mr X and the family;
• staff are not always able to open the door to the Care Home at weekends as they prioritise taking care of the residents. It apologised to Mr X for the delay in answering the door;
• as there were no concerns with Mrs Y’s appetite and weight, the Care Home was not required to keep a chart of everything she ate. It said Mrs Y ate well and staff had no concerns;
• staff stored medication in a locked cupboard situated in secure room for the safety of residents. Mrs Y had left the Care Home suddenly which did not give staff enough time to prepare the medication. It said staff had apologised to Mr X when he returned; and
• it accepted its duty board had not been updated. It addressed this with staff.
7. We will not investigate Mr X’s complaint because we are unlikely to add to the Care Provider’s investigation. The Care Provider accepted that it had failed to provide Mrs Y with adequate personal care and that its communication and record keeping in this respect had been poor. It apologised to Mr X and explained the action it would take to prevent similar issues recurring. This is an appropriate response and what we would expect the Care Provider to do.
8. We are unlikely to find fault with the Care Provider in relation to the other matters raised. Its records indicate that staff did not give Mrs Y red peppers and Mr X was not present when this was said to have occurred.
9. In addition, there is no general requirement for care homes to keep detailed records of every meal where there are no identified concerns about a resident’s nutritional or hydration needs. Providers are expected to monitor and record intake where this is necessary based on the resident’s individual needs and risks.
10. The Care Provider’s records do not indicate that Mrs Y was distressed. In the absence of further evidence, it would be difficult to establish that staff failed to recognise or respond to distress. A further investigation is therefore unlikely to reach a different conclusion.
11. We recognise Mr X’s concern that Mrs Y was left alone. However, there is insufficient evidence that this caused her significant harm.
12. We also recognise Mr X’s concerns about delays in answering the door, Mrs Y’s medication not being provided when she left and the staff duty board not being updated. However, any personal injustice is not significant enough to warrant an investigation. In any case, the Care Provider apologised to Mr X and explained what matters it had addressed with staff which was appropriate.

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Final decision

13. We will not investigate Mr X’s complaint because we could not add to the Care Provider’s investigation, a further investigation would not lead to a different outcome, it is unlikely we would find fault and some personal injustice is not significant enough to warrant an investigation.

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Investigator's decision on behalf of the Ombudsman