Summary: The Council was at fault in not taking into account Miss X’s comments in its draft safeguarding report in respect of a care home where her mother Mrs X had been a resident. The Council has apologised and agreed it should take Miss X’s comments into account. I have not asked for any further remedy.

The complaint

1. The complainant, who I shall refer to as Miss X, complained on behalf of her mother, Mrs X, about:
1. the way in which Adult Care Services carried out a safeguarding investigation into the standard of care Mrs X received in care home A from March to June 2015;
2. the way in which the Council carried out a safeguarding investigation into the care Mrs X received in care home B from August 2015 to February 2017;
3. social workers' actions in response to her complaints about the care agency providing domiciliary care to Mrs X after February 2017; in particular, in not identifying dates when the agency overcharged Mrs X through poor time recording, and in not ensuring that the agency refunded these sums;
4. delay by social workers between June and August 2015 and after February 2017 in finding a day centre place for Mrs X in accordance with her care plan;
5. inappropriate telephone conversations between her brother and a social worker in March 2017, when the social worker in question was no longer responsible for Mrs X's care and was the subject of an unresolved complaint by Miss X; and
6. a magazine article relating to a day centre which she received anonymously through her letter box. Miss X believes a member of Adults and Health staff must have posted this through her door since no one else knew of her interest in the day centre in question.

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What I have investigated

2. I have exercised the Ombudsman’s discretion to consider matters back to 2015. This is because of the time it has taken to work through all the issues Miss X complained about.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
5. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)

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How I considered this complaint

7. I have discussed with Miss X her complaint on behalf of Mrs X. I have also considered the information she provided in support of this, and the information the Council provided in response to my enquiries.
8. I have written to Miss X and the Council with my draft decision and considered their comments.

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What I found

9. Mrs X lived in care home A from early March to mid-June 2015. After leaving care home A, Mrs X lived temporarily with Miss X.
10. Mrs X moved into care home B in August 2015. But, a few weeks after she moved in, the same company which owned care home A took over this home too. Due to her concerns about the level of care Mrs X was receiving in care home B, Miss X told Mrs X’s social worker in August 2016 that she wished to care for Mrs X at home.
11. Mrs X moved in with Miss X in February 2017, and has lived with her since then.

Care home A

Miss X’s safeguarding concerns

12. In late June and early July 2015 Miss X told the Council about her concerns that the home:
• gave Mrs X her evening medication too early. She felt the home did this to make Mrs X drowsy and easier to manage;
• did not provide Mrs X with adequate care in relation to personal hygiene, bathing and clothing. Mrs X was only having a bath once a week. There was no record of her having a bath or shower at all between late April and late May 2015;
• although Mrs X liked to carry out her own personal care, carers did not prompt her to do this, or properly monitor the situation. Mrs X often looked dishevelled when Miss X went to collect her to go out. She would be wearing an odd assortment of clothes and often no bra. Miss X felt this was undignified; and
• did not maintain Mrs X’s dental hygiene. This had led to a severe deterioration in her dental health. Prior to a dental appointment, Mrs X had not brushed her teeth for several days.
13. The Council began a safeguarding investigation in July 2015. It completed its first report in February 2016 and its final report in May 2016. It held a final safeguarding case conference in September 2016.

Concerns about management of medication

14. In line with the notes of the strategy discussion, the enquiry report examined:
• Medication Administration Record (MAR) charts from Mrs X’s previous home and from care home A;
• the reasons why carers in both homes had administered medication at varying times; and
• the actions of pharmacy staff in dispensing the medication.
15. The report took account of the views of Mrs X’s GP and psychiatrist about the purpose of Mrs X’s medication and the effects on her of administering this at differing times.
16. The report also considered information provided by:
• an independent pharmacy technician dealing with medicine safety in care homes, and
• a clinical governance pharmacist from the pharmaceutical chain that dispensed Mrs X’s prescriptions while she lived in care home A.
17. The report found that:
• prior to Mrs X moving there, the previous care home provided a MAR chart to care home A showing that medication was administered at 5pm;
• as care home A routinely administered “tea time” medication at 4.30, staff asked the pharmacy to amend Mrs X’s prescription accordingly;
• the pharmacy could find no record of a registered pharmacist doing this. Thus, they were at fault for not adequately recording a decision relating to a change of medication time;
• Mrs X’s psychiatrist was happy with care home staff using their discretion to move medication within 30 minutes of the prescription time. This would not have impacted on Mrs X’s wellbeing;
• care home A had accepted information from the previous care home without consulting Mrs X’s GP about her medication regime or health conditions; but
• there was no record of staff concerns about Mrs X’s levels of drowsiness or other side effects from her medication. There was also no record of Miss X raising these with staff; so
• although there was poor communication and record keeping amongst all parties involved, there was no indication that a review of Mrs X’s medication and health conditions had been required; and
• there was no indication Mrs X had come to harm through the administration of her medication at the earlier time. This concern was not substantiated.
18. The safeguarding case conference concluded that:
• care home A had not decided to change the timings of Mrs X’s medication to sedate her so as to make her easier to manage. There was evidence of poor practice by the pharmacist. But, this was not the basis of the allegation; and
• the home had acted in good faith in continuing practices that were in place. The purpose of the drug was for Mrs X’s mental health, not to make her sleepy. The home had not acted neglectfully regarding the medication regime.

Concerns about personal hygiene, bathing and clothing, and dental care

19. The enquiry report found that:
• Mrs X was reluctant to allow staff to assist with all aspects of her personal care;
• she had a bath or shower around once a week. But, there were gaps in her care records indicating that carers did not offer or give a bath or shower;
• after her move to care home B, Mrs X was having a bath around three times a week. Carers worked around her preference for certain members of staff to minimise the number of times she refused a bath;
• Mrs X would often put on several layers of clothing, and discard these as she became warm. Carers sometimes found it difficult to get Mrs X to wear a bra. But, at other times she would put on more than one bra;
• at care home B carers were bringing Mrs X a set of clean clothes each day, and taking away her dirty clothes straightaway. She put on her bra each day with no issues;
• there were no entries in Mrs X’s care records showing that Mrs X was brushing he teeth regularly, although the manager believed this had been happening;
• as Mrs X would not accept assistance to clean her teeth, the quality of brushing was not sufficient. Consequently, the deterioration in Mrs X’s oral health would have been throughout her stay in care home A;
• there was reason to believe from unused toothbrushes and unopened toothpaste in her room, that Mrs X had not brushed her teeth for a period of six days shortly before she left care home A;
• staff at care home B were finding they needed to prompt Mrs X to brush her teeth twice per day, and to monitor her doing so; and
• Mrs X’s dentist considered there had been a “noticeable acute exacerbation of the deterioration of her oral health.” This indicated that regular twice per day brushing was not being achieved to the required levels.
20. The case conference concluded that the concerns about lack of personal care for both bathing and dental care were substantiated.

Miss X’s complaint

21. Adults and Health officers shared the minutes of the safeguarding case conference with Miss X, giving her the opportunity to add her amendments. But, the Council told me that the chair of the conference could not agree many of the amendments Miss X proposed. This was because the minutes were a record of what was said during the case conference. Miss X’s comments were not a reflection of this.
22. During November and December 2016, there were exchanges of emails between Miss X and the chair. In late November, the chair advised Miss X of her right of appeal through the statutory complaints procedure. Alternatively, Miss X could raise further safeguarding concerns.
23. In mid-December, Miss X said she wished to appeal on the basis that the pharmacy had not submitted written comments to the safeguarding investigation. She met with the complaints officer late in February 2017, and the officer prepared a draft complaint.

The Councils complaint response

24. A service delivery manager responded to Miss X’s appeal late in April 2017. She:
• noted that staff carrying out the investigation had amended their enquiries at Miss X’s suggestion to include a medication audit;
• explained that given Miss X’s concerns about the timing of the medication, there was understandably a focus on this area – how it came to be prescribed in the first place, and how it subsequently came to be given at 4.30pm;
• said the report demonstrated that the safeguarding investigation officer had thoroughly analysed all the MAR charts available to her. These were shared within the investigation, and further discussed at the case conference;
• clarified that while the officer had initially believed the clinical governance pharmacist was an independent regulator, he had corrected her on this point when he saw the draft report;
• confirmed that the investigating officer and the safeguarding coordinator had had verbal and written contact with the pharmacy technician and the clinical governance pharmacist. The report had included details of these contacts, including emails. The purpose of the enquiry did not require them to provide written reports;
• said both pharmacists were present at the case conference. So, they were available to clarify matters and respond to any queries that arose;
• said she was satisfied the pharmacy technician and the clinical governance pharmacist were the appropriate people for the investigating officer to consult. The chair of the case conference had confirmed this was usual practice;
• said she was further satisfied that the safeguarding enquiries had been thorough and detailed, and the principles of the Care Act followed in completing these enquiries;
• concurred with the conclusions of the safeguarding enquiry. Apart from Miss X, all those who had attended the case conference, and everyone whom the investigating officer had consulted – including Mrs X’s GP and psychiatrist, were of the view she did not suffer harm, and that care home A was not neglectful with regard to her medication regime;
25. Miss X subsequently attended a meeting with the Service Delivery Manager and Complaints Manager early in November 2017 to discuss her outstanding concerns. But, she did not provide new evidence which gave them cause to re-open the safeguarding investigation.

Care home B

Miss X’s safeguarding concerns

26. Miss X held Lasting Power of Attorney for Health and Welfare for her mother. But, in July 2016 she became concerned that:
• without consulting her, the home had asked Mrs X’s GP to prescribe a laxative for her. Although Mrs X did not present with symptoms that required the administration of a laxative, carers gave her this needlessly for a period of 48 consecutive days; and
• Mrs X became increasingly confused and agitated, and suffered from diarrhoea and dehydration.

The GP

27. The safeguarding report quoted comments from Mrs X’s GP as follows:
• she prescribed the laxative following a telephone consultation with care home B. She prescribed it again on two further occasions at the home’s request;
• Mrs X was not glucose intolerant, there were no contra indications with diabetes, and the laxative was safe to be given at the same time as Mrs X’s medication to control her diabetes. It was a drug that could be given on an ongoing basis, as opposed to just for five days.
• Mrs X was on a smaller dose than could have been prescribed, and there was not a high sugar content. The amount given would not amount to an overdose;

Case notes and observations

28. In examining the available evidence, the investigating officer found that:
• changes in Mrs X’s behaviour, including confusion and sleepiness were not exclusive to the period during which carers were giving her the laxative;
• Mrs X probably had loose bowels as a result of being given the laxative. But, there was no evidence of prolonged periods of diarrhoea. There were occasional bouts only;
• carers had given Mrs X three doses of the laxative in late May. She did not then take the laxative for another 16 days. It was unlikely therefore that these three doses had caused harm;
• by early July, carers had administered the laxative more consistently. So, this could have contributed to Mrs X having loose bowels at that time;
• after this date, carers did not administer further doses of the laxative. This might have been in response to the faecal matter around the toilet. But, MAR charts indicated that Mrs X was asleep at times when carers would have given the laxative. The investigating officer could not reach a view on whether carers would have administered this, had she been awake.
29. The report noted there was nothing to substantiate Miss X’s allegation that Mrs X had suffered five weeks of loose bowels. Weight loss would have been a cause for concern. But, during the six weeks when the laxative was prescribed, Mrs X weight remained at a range of 47.35kg to 47.8 kg.

Continence pads

30. In response to further concerns Miss X had raised, the report also noted:
• the care home’s explanation that Mrs X had run out of her own continence pads, as she would sometimes remove these herself; thus
• to maintain her dignity and continence, carers used an alternative product until they obtained further supplies for Mrs X; but
• when Miss X raised this issue with a carer early in July, the carer was able to provide her with the correct pad at that time.

Findings and recommendations

31. The report found:
• failures in the home’s recording of bowel care. Carers had not recorded concerns about Mrs Y having constipation. They had recorded loose bowels on only two occasions. It was not clear whether this was because there were only two incidents, or because other incidents were not recorded;
• carers should have also put in place a bowel movement chart so they had a clear indication of the effectiveness of the laxative they gave Mrs X;
• a qualified GP made the decision to prescribe the laxative. Carers administered only 33 of 97 possible doses. Mrs X had 10ml per dose when she could have had up to 15ml. So, she had not had an overdose;
• Mrs X’s notes did not indicate she was glucose intolerant. So, giving her the laxative should not have precipitated any such problem;
• it was acceptable for carers to use an alternative pad occasionally, thereby ensuring they met Mrs X's continence needs. But, the care home should have had in place better arrangements to ensure this was not happening as regularly as it was;
• Miss X’s concern was understandable; ie that is, the reason for running out of Mrs X’s pads was because her mother’s continence needs had changed, and might have been an indication of diarrhoea. But, the investigating officer had not found evidence this was the case;
• the care home was aware Miss X held Lasting Power of Attorney for health and welfare. It should have consulted with her about Mrs X’s symptoms of constipation and what should be done about these;
• the failure to consult her led to the associated allegations that the administration of the laxative had caused harm to Mrs X. But, while this was a failure in practice, it did not constitute an act of neglect towards Mrs X. So, the allegation was not substantiated;
• there were variations in Mrs X's mood, behaviour, tiredness, and enjoyment of life at care home B. The timeline showed no distinct correlation in relation to whether or not carers had given her the laxative. There was no evidence to indicate that the home acted with intent to harm Mrs X. So, this allegation was also not substantiated.

The Council’s comments

32. The Council at first told me that officers sent Miss X the draft safeguarding report to comment on in July 2017. But she did not provide any feedback, or respond to a reminder in January 2018. As they had still not heard from Miss X, officers finalised the report in March 2018.
33. However, Miss X was able to prove she had responded. Officers had acknowledged this in their complaint response in August 2018. (See paragraph 54 below.)

Domiciliary Care

What happened

34. In mid-June 2017, Miss X told Mrs X’s social worker of her view that the check in and check out facility the agency’s carers were using did not work. She questioned, therefore, whether timesheets and invoices were correct.
35. During a meeting between them in early July, Miss X told the social worker she had been dealing with a council recovery officer. She had told him she was liaising with the agency herself about the format of its invoices and the hours of care delivered.
36. The next day the social worker asked the agency for copies of relevant time-sheets. The agency provided these. It also confirmed it had received a complaint from Miss X, who had requested copies of the timesheets from February 2017 onwards. The social worker suggested that a member of the agency’s staff should meet Miss X to go through these to ensure its records were correct.
37. In mid-July Miss X emailed the social worker saying the agency had assured her it was dealing with matters. The social worker contacted the agency early in August asking if it had resolved the issues. Late in August the agency confirmed it would send the information she wanted to Miss X within the next few days.
38. Early in September, Miss X told a council finance officer she was pursuing the issues with the agency herself. The finance officer made the Council’s contracts team aware of Miss X’s concerns regarding the timesheets.
39. The Council said that once contracts and complaints officers were aware of the issues, they sent numerous emails to the agency about the outstanding hours and the reimbursement of these. In mid-September, the agency said it had agreed to refund 46 hours. But, Miss X had rejected this offer.
40. Two months later, a complaints officer asked for an update. The agency replied it was in contact with Miss X, and in the process of finalising its response to her. In late November, a complaints officer asked the agency if it had done this. In reply, the agency provided a copy of the response. It said it would refund:
• 67 hours and 34 minutes; also
• the hours Miss X had spent caring for Mrs X after she cancelled the agency’s services; and
• her accountant’s fees for calculating the invoices, as Miss X had not found the format clear.
41. A council recovery officer also created a further breakdown for each period as Miss X had requested.

The Councils complaint response

42. In her complaint response in January 2018, the Service Delivery Manager said:
• that in an earlier email in February 2017, the social worker had suggested that Miss X should try to address matters relating to care with the agency before making a complaint. She felt this was misleading, as Miss X had a right to complain to the Council at any point;
• she apologised for this lack of clarity, and said she would ensure all staff were reminded of statutory complaints requirements; but
• exchanges between the social worker and the agency, and with Miss X, in July indicated that the agency was keeping in touch with Miss X about reviewing the bill calculations;
• she felt, therefore, that the social worker had provided an appropriate level of support. She had taken Miss X’s concerns up with the agency, asked them to rectify the situation in terms of workers signing in and out, and contacted them for updates on their investigation of those concerns.

The Council’s comments

43. The Council told me that it would issue guidance to social workers that when they received a complaint, they must register this under the Council’s complaints procedure, even if a care provider was undertaking the initial investigation and response. This would enable it to monitor the provider’s investigation, and provide support and advice to both the complainant and the provider as necessary.

Delay by social workers in finding a day centre place

What happened

44. The Council has told me it has no record of correspondence and/or complaints from Miss X about lack of day care provision from June to August 2015. I have also seen no correspondence about this issue relating to the period after February 2017, when Mrs X returned to live with Miss X, and July 2017.
45. But, the Council said that from July 2017, Mrs X’s allocated social worker looked into agencies that could provide an escort service to take Mrs X out into the community. As Miss X had a young child, the social worker prioritised temporary cover over the six week school summer holiday period in 2017.
46. In mid-July, the social worker spoke to Miss X about the option of Mrs X attending day centre C, if an agency could not be found. The social worker said that if Miss X wanted to pursue this option, she would need to request additional hours and the relevant funding panel would consider this. But, in the short term, the best option would be to pursue temporary cover for the six weeks holiday period.
47. The social worker contacted day centre C in mid-July, and again in early August. On both occasions day centre C said they had no capacity to take on new referrals. But, according to the Council’s records, Miss X did not wish to pursue the day centre option until mid-September 2017 in any case. So, Adults and Health did not complete a support plan for Mrs X to attend a day centre until then.
48. At the beginning of October, day centre C told the social worker they could not provide all the requested hours. But, they would build these up over time. They could begin providing their service in mid-November. The social worker asked day centre C to contact Miss X to arrange to meet Mrs X. She also asked that they keep her up to date, so she could send the necessary paperwork to the Council’s home care commissioning service.
49. In a telephone conversation on the same day, the social worker confirmed to Miss X that the panel had approved funding for two days per week day centre support including transport. She had added this to Mrs X’s support plan. Miss X wanted the support in place straightaway. The social worker said this was not possible. But, she would expedite Miss X’s request and arrange the transport.
50. Also at the beginning of October, the social worker approached day centre D. This day centre advised her the next day that it was closed for refurbishment. Service users had transferred temporarily to day centre E. (This was usually a day service for the Hindu, Sikh and Muslim community).
51. In mid-November, day centre C updated the social worker that they and Miss X had agreed a start date for Mrs X in two days’ time.
52. The social worker asked Miss X to confirm that she still wanted Adults and Health to commission day centre C. When Miss X had not replied four days later, the social worker emailed again advising that Mrs X would be considered self-funding for day care.

The Council’s complaint response

53. In her complaint response in January 2018, the Service Delivery Manager:
• set out the social worker’s actions during the period July to October 2017;
• concluded that the social worker had tried to make referrals to day centre C on several occasions between July and October, only to find they did not have capacity. She had advised Miss X of this;
• early in October, when day centre C had part-capacity, she made the referral and provided all the information the day centre required;
• the social worker had suggested that, as Adults and Health had been unable to find a suitable day centre for Mrs X, Miss X might want to source and pay for day care herself; but
• said she believed it was clear from case notes and emails that Miss X was asking Adults and Health to commission the service from day centre C. She apologised for any distress and inconvenience this lack of clarity had caused;
• it was accurate to state the social worker was unaware, when she made the enquiry on Mrs X’s behalf, that day centre D was closed. But, she had referred Mrs X to day centre E as soon as she knew, within one day;
• as service users from day centre D had transferred to day centre E, this referral was not inappropriate for Mrs X. Day centre E had a diverse membership, and was not exclusively serving one BAME (Black, Asian, ethnic minority) community. Mrs X would have been in the company of white, black and Asian service users, and language would not have been a concern; and
• at Miss X’s request, she had arranged for a different allocated social worker to work with her and Mrs X, as the relationship with the current social worker had clearly broken down.

Other actions by social workers

Inappropriate telephone conversations between a social worker and Miss X’s brother

54. In March 2017 Miss X’s brother, from whom she was estranged, contacted social workers. He expressed concerns about Miss X’s care of Mrs X. Miss X complained to the Council early in June 2018 about what she believed a social worker had said in a telephone conversation with him.

The Council’s complaint responses

55. A service manager responded throughout the late summer and early autumn of 2018 to this and other outstanding issues. She said:
• the social worker would have needed to find information that she or the team manager had asked for to enable them to respond to Miss X’s complaints. Thus, it was legitimate for the social worker to access Mrs X’s file;
• she apologised for managers’ failure to acknowledge Miss X’s emails responding to the draft safeguarding report about care home B. (See my paragraphs 35 and 36 above.) She agreed both emails had been missed and this was unacceptable. So, she was upholding that part of Miss X’s complaint;
• she confirmed managers had the information Miss X had provided. It was important they took her view into account. So, hopefully the safeguarding investigation could now progress to a satisfactory conclusion;
• social workers’ contact with Miss X’s brother had been appropriate in that they had responded to his queries without breaching data protection requirements. He too had a right to confidentiality, and this was why they had not disclosed their contact with him to Miss X;
• Miss X’s brother had asked if there were concerns about care home B. Social workers had confirmed they were looking into the concerns raised. They had already shared these concerns with Miss X prior to her brother’s call;
• her brother had also raised concerns about Miss X having Lasting Power of Attorney, and about the way in which she was exercising this. Consequently, the safeguarding investigating officer had checked the status of the Lasting Power of Attorney with the Office of the Public Guardian; and
• it was regular practice for social workers to make such requests. It was not exclusive to Mrs X’s case. They had not consulted Miss X’s brother before undertaking this search.

Magazine article posted through Miss X’s door

56. The Council said:
• all staff undertake mandatory Data Protection Training and are aware of the importance of client confidentiality;
• the allocated social worker, her team manager and the Safeguarding and Risk Manager who were all involved with Mrs X at the time, were unaware of any articles being posted through Miss X’s letter box;
• this would not have been Adult Social Care’s usual approach. It was unlikely that a social worker would post an anonymous note through anyone’s door; and
• Miss X had advised them in January 2018 that she had disposed of the article and a note, which was with the magazine highlighting a page. In the absence of a copy of the article or the note, it had been unable to look into the matter any further.

Was there fault and if so, was there injustice requiring a remedy?

The Council’s safeguarding investigations

57. I have not reinvestigated Miss X’s safeguarding concerns. This is not the Ombudsman’s role. I have considered only the way in which the Council pursued its enquiries into the allegations Miss X made against care homes A and B.
58. There are no statutory timescales for carrying out and completing safeguarding investigations. The Council’s investigations of both homes took in excess of a year. But, I do not propose to pursue this issue of timeliness for the following reasons:
• Miss X did not complain about delay. Indeed, further information and comment that she continued to provide throughout the investigations contributed to their length;
• I am otherwise satisfied that the Council otherwise investigated matters diligently and in detail. Its enquiries were in line with statute and guidance;
• there was no ongoing risk to Mrs X. In both cases Miss X had already removed her mother from the homes in question;
• while I note Miss X’s dissatisfaction with the outcomes of the Council’s investigations, it is not open to me to question decisions it has made properly; and
• In the case of care home A, managers further considered Miss X’s views in response to her appeal. Miss X was also able to attend a meeting with them to further explain her concerns.
59. In the case of care home B, the Council was at fault in not realising Miss X had responded to the draft investigation report. However, it has apologised for this omission, and agreed to take her comments into account. I am asking the Council to provide evidence it has done this in its response to this draft decision.

The domiciliary care charges

60. The Council has accepted that Miss X was entitled to complain at any point, and has issued guidance to social workers on this point. I do not consider the Council was otherwise at fault in relation to charging. So, I see no need to pursue matters further.

Delay in finding a day centre

61. In its response to Miss X’s complaint about this issue, the Council has accepted there was a degree of fault. I share this view. But, as the Council has apologised to Miss X, I will not pursue matters further.

Other matters

62. In the light of what the Council has said in its complaint responses, I do not consider these points merit further investigation. Any animosity between Miss X and her brother is a private family matter. As Miss X’s brother had made allegations about the way in which she exercised the Lasting Power of Attorney for Mrs X, the Council was obliged to make checks with the Office of the Public Guardian.
63. Even if I had been able to find fault, I could not have concluded that Miss X suffered significant injustice. I consider this was also the case in relation to the posting of a magazine article through her front door.

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Decision

64. I have identified a degree of fault by the Council in relation to both the draft safeguarding report on care home B and domiciliary care charges. But, I do not consider either instance of fault has caused Mrs X or Miss X significant injustice. So, I have now completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman