Summary: We have discontinued our investigation of this complaint. This is because we cannot add anything of substance to the outcome of Council’s own investigation.

The complaint

1. The complainant, to whom I will refer as Mrs C, complains on behalf of her late mother, to whom I will refer as Mrs P.
2. Mrs C complains about numerous aspects of Mrs P’s care in a residential care home. I will summarise these as:

• complaints about the home’s decision to move Mrs P from a single room to a shared room, including the reasons for this decision, the consultation about it, and hygiene and privacy issues created by the sharing arrangements;
• complaints about staff, including the home’s use of agency workers and that staff had been rude to her (Mrs C) on some occasions;
• complaints about the administration of Mrs P’s care, including reviews of care plans and that Mrs C had not been informed when Mrs P was prescribed antibiotics;
• complaints about the layout and development of the home, including that the owner had unlawfully occupied common land and that building works had been undertaken without notification;
• a complaint that animals had been allowed to visit the home; and
• a complaint the Council had not investigated a dispute about the payment of Mrs P’s financial contributions.

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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’. We provide a free service, but must use public money carefully.
4. We may decide not to start or continue with an investigation if we believe it is unlikely we could add to any previous investigation by the Council, or it is unlikely further investigation will lead to a different outcome. (Local Government Act 1974, section 24A(6), as amended)
5. 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)
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 reviewed Mrs C’s correspondence with the Council.
8. I also shared a draft copy of this decision with each party for their comments.

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What I found

9. Mrs P had been resident in a care home for several years, in a single room. In July 2017, the care home decided to move her to a different room, which she would be sharing with another resident.
10. In April 2019, Mrs C raised a complaint with the Council about the home. Around the same time, the home moved Mrs P to another shared room.
11. Between May and August, the Council investigated Mrs C’s complaint. This included agreeing a 36-point statement of complaint, covering numerous different issues. The Council visited both Mrs P and Mrs C as part of its investigation, and, after reallocating the complaint to a new investigator (as the original investigator had fallen ill), published its investigation report in September. It followed this with an adjudication meeting, where the Council agreed the investigator’s findings.
12. Mrs C initially approached the Ombudsman in July 2019, to complain the Council was taking too long to address her complaint. After initial enquiries, we referred her back to the Council, because we were satisfied it was investigating and the matter was premature for us. Mrs C later re-submitted her complaint after the Council’s response.
13. The Council’s report into Mrs C’s complaint gave an individual response to each of her 36 points of complaints. To summarise the Council’s responses:

• it did not uphold any complaints, or could make no findings because of a lack of evidence, about the home’s decision to move Mrs P to a shared room. It was satisfied the home had appropriate reasons for its decision, was not motivated by financial gain, and had taken appropriate steps to consult with Mrs C and the Council. It did accept there were any significant issues with hygiene and privacy arising from the fact Mrs P was now sharing with another resident;
• it did not uphold any complaints, or could make no findings, that the home was providing inadequate care to Mrs P;
• there was no fault in the home’s decision to employ agency staff;
• it could make no findings on Mrs C’s complaint staff had been rude to her;
• it partially upheld Mrs C’s complaints the home had not provided copies of Mrs P’s care plan reviews, and that it had not informed her when Mrs P had seen the GP, or when she had been on a course of antibiotics. The Council noted Mrs C did not hold Lasting Power of Attorney (LPA) for Mrs P, which limited which information the home could share with her, but accepted it was best practice and a matter of courtesy to share what information it could;
• it did not uphold complaints the home no longer stored Mrs P’s care notes in her room, for data protection reasons;
• it did not uphold a complaint Mrs C had not been invited to a care review in October 2018, as no such review had taken place then, but the records showed she had been invited to a review in July 2018;
• it did not accept a complaint the homeowner had wrongly occupied common land was relevant to Mrs P’s care;
• it did not uphold complaints the home had not notified residents’ families of building work, or that the position of Mrs P’s room meant she did not have privacy;
• the home had completed the proper risk assessment before the animal visit day, which was considered therapeutic for residents;
• the Council had requested financial information from Mrs C several times to help resolve the dispute about unpaid contributions. It noted Mrs C had said she would meet the Council to discuss this once her complaint was concluded. It made no finding on this complaint.

14. The Council made several recommendations with regard to the upheld elements of Mrs C’s complaint. These were:

• it should review its practices for sharing care plan and review paperwork, to ensure they were appropriate, and then ask care homes to ensure their practices were in line with the Council’s;
• the care home should ensure it has a means to obtain feedback from residents’ family members;
• the care home should ask Mrs P’s GP to assess her for any underlying health issues, given her frequent courses of antibiotics;
• the care home should review its practices for informing residents’ families of upcoming building works and similar;
• the care home should ensure it has a process for ensuring it informs family members when residents are prescribed antibiotics;
• the Council should now undertake Mrs P’s care needs review, which it had delayed at Mrs C’s request pending the outcome of the complaint investigation; and
• the Council should now meet with Mrs C to discuss her complaint about care contributions.

15. On 10 November, Mrs C responded with a detailed critique of the Council’s report. She complained the report was “haphazard” and poorly laid-out, and that the second investigator had not visited the home again after the case’s reallocation to him. She also provided responses to each of the Council’s findings on the 36 points of complaint, and included a new complaint that the home had neglected to take care of Mrs P’s fingernails and hands.
16. On the same day, Mrs C referred her complaint back to the Ombudsman, and we accepted it for investigation.
17. In March 2020, Mrs P passed away.
18. In August, Mrs C wrote to us again. This included a complaint she had not received a response from the Council with regard to her further complaint about Mrs P’s fingernails and hands, that it had not disclosed certain information about Mrs P to her, and that the dispute about care contributions had not been addressed because she had not considered the complaint resolved.

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Analysis

19. For several reasons, I have decided to discontinue my investigation of Mrs C’s complaint.
20. First, the initial events Mrs C has complained about – the home’s decision to move Mrs P the first time, and how this decision was made and communicated – are out of time. The law says a person should approach the Ombudsman within 12 months of becoming aware of an issue they wish to complain about. Mrs P’s first move of room was in July 2017, but Mrs C did not approach the Ombudsman until July 2019. This complaint is therefore late.
21. Second, and even putting the time consideration to one side, I do not consider the Ombudsman could reasonably add to the Council’s own complaint report. The Council undertook a detailed investigation, including making an unannounced visit to the care home. Its report provides an individual response to each of the 36 points of complaint Mrs C raised, and having reviewed these, I am satisfied they provide well-evidenced and cogent reasons for their findings.
22. I appreciate Mrs C does not agree with these findings. However, her reasons for disputing the Council’s findings are based largely on her own observations and recollections of visits to the home, and conversations she had with care staff and Council officers. While I do not dismiss Mrs C’s comments, they equally do not provide me with the type of objective evidence I could rely on to question the Council’s findings. The simple fact Mrs C does not agree with those findings does not give me grounds to investigate them further.
23. In other cases, Mrs C has disagreed on the merits of the Council’s decision – such as the appropriateness of the home’s use of agency staff, and of it allowing the animal visit day. But these are matters of professional judgement, and it is not for me to criticise this where there is no reason to believe that judgement has been taken improperly. I cannot uphold a complaint simply because Mrs C has a different view on these matters.
24. Third, I also cannot overlook the fact Mrs P has now sadly passed away. This, in itself, does not prevent us from completing an investigation, but we must remain conscious to what we are able to achieve under such circumstances. As I have said, I am satisfied the Council’s investigation was extremely thorough. But, even if I were to identify some flaw in the investigation process, it is likely the appropriate recommendation for me to make would be to ask the Council to reinvestigate the relevant points. With Mrs P having passed, this is no longer possible.
25. The Ombudsman is a publicly-funded body. While we are empowered to investigate a wide range of complaints, the law says our investigations should be proportionate. We retain wide discretion to decide when to start, discontinue or complete investigations; and one factor we must consider, as part of this decision, is whether there is reason to believe our investigation might add substance to the relevant authority’s own.
26. In this case, again, I am satisfied the Council has undertaken a thorough and diligent investigation. It has given clear, evidenced reasons for its findings, and upheld elements of the complaint where it considers it appropriate. There is nothing to suggest further investigation by the Ombudsman will draw any substantially different conclusions, and under such circumstances, an investigation by us is not appropriate.
27. I acknowledge Mrs C complains the Council has not responded to her follow-up comments on the original complaint. However, I note she resubmitted her complaint to the Ombudsman on the same day as she replied to the Council’s report, without indicating she expected further investigation by the Council, which may explain this. In any case, the law says the adult social care complaint process should consist only one of one stage, and so there was no requirement for the Council to allow Mrs C to escalate her complaint.
28. I cannot consider the Council’s handling of her separate, second complaint (about Mrs P’s fingernails and hands) as part of an investigation into the first complaint. If Mrs C wishes to pursue this further, and has still had no response from the Council, she will need to raise a separate complaint with the Ombudsman.
29. Mrs C has also complained the Council has not disclosed certain information about Mrs P to her. The Ombudsman would generally expect complainants to approach the Information Commissioner’s Office (ICO) with such matters, as the ICO is an expert body with a specific remit to investigate data protection. The ICO also has the power to enforce any decision it makes, unlike the Ombudsman.
30. I note Mrs C also says the issue about financial contributions remains unsettled. However, the point Mrs C raised about this in her complaint to the Council was simply to request it provide support in the dispute. In response, the Council said it would provide support upon resolution of the complaint, and so I am satisfied this was an appropriate way to address this point. Any complaint Mrs C has about the actual substantive dispute is new, and not something I can consider here.

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Final decision

31. I have discontinued my investigation.

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Investigator's decision on behalf of the Ombudsman