Summary: Mr X complains about the way the Nursing Home cared for his mother, Mrs Y, and her belongings. We will not investigate this complaint because the organisation has already admitted fault in several areas of Mrs Y’s care. It has apologised, made service improvements, and trained its staff to ensure the faults do not happen again. It has also accepted it has lost one of her rings. Further investigation by the Ombudsmen would not achieve anything more.

The complaint

1. Mr X complains about the care his late mother, Mrs Y, received at Homer Lodge Nursing Home (the Home). The placement was funded by Lincolnshire County Council and NHS Lincolnshire Integrated Care Board. Specifically, Mr X complains;
• Staff did not take a detailed inventory of Mrs Y’s possessions when she went to the Home which caused difficulties later when she was found to be wearing someone else’s clothes.
• When Mr X and his brother visited, they more than once found their mother sat in a soiled incontinence pad and had to ask staff to clean her.
• Mrs Y was asked to sign forms even though she had dementia. Mr X was the one managing this for her and he should have been asked to do so, or at least witnessed the signing.
• Mrs Y was moved to a funeral home without being fully dressed. Mr X says this shows a lack of respect for her dignity, even in death.
• When Mr X went to collect Mrs Y’s belongings after her death, including three rings, staff told him he could not have them because he doesn’t have lasting power of attorney, he had to explain that even if he did this ended on her death.
• A ring is missing and staff can provide no explanation as to what happened to it.
2. Mr X explains he and his brother have flashbacks to the poor condition they often found their mother in. Mr X in poor health and the experience has put a lot of stress on him and the rest of the family. The sentimental value of the lost ring cannot be replaced, and this has added increased distress to an already difficult time.
3. Mr X would like the Home to alter its procedures to make sure no other family goes through what they did. He wants service improvements and reassurances changes have happened. He wants to know what happened to the lost ring.

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The Ombudsmen’s role and powers

4. We have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting for both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
5. The Ombudsmen provide a free service but must use public money carefully. They may decide not to start or continue with an investigation if they believe:
• it is unlikely they could add to any previous investigation by the bodies.

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How I considered this complaint

6. I considered all the information provided to us by Mr X.
7. I considered the Ombudsman’s Assessment Code.
8. I considered the LGSCO and PHSO guidance on remedies.
9. Mr X comments on my draft decision, and I considered his comments before making a final decision.

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What I found

10. Mrs Y broke her hip in September 2023 and went into hospital. She also had dementia. When she was well enough to leave hospital, it was decided she would go to the Home for a period of reablement. This is a short period of care that allows the person to relearn how to do daily activities with support and can be for up to six weeks.
11. Mrs Y moved to the Home on 29 September. She died on 17 November.
12. While Mrs Y was at the Home, her two sons, one of which is Mr X, raised numerous concerns with staff about the care she was receiving. Some of the issues were resolved at the time, other issues were raised in a formal complaint by Mr X on 18 December 2023.
13. The Home provided its first response on 10 January 2024. In this response it admitted to fault in several areas, including;
• not taking a full inventory of Mrs Y’s belongings which led to her wearing someone else’s clothes.
• Not respecting Mrs Y’s dignity by not ensuring she was wearing her own clothing.
• Not keeping full and accurate records of what food Mrs Y was eating, what she refused to eat and why.
• Not dealing with the collection of Mrs Y’s belongings by Mr X appropriately.
• The transportation of Mrs Y to the funeral home after her death was not dignified as she was not fully clothed.
14. The Home upheld the above points. It also asked for further information from Mr X on two other points. The only points it did not uphold were related to care provided by District Nurses, which were not under its remit.
15. The Home apologised for each of the faults it identified and explained it had made improvements in several areas in recognition of the faults and to ensure the same issues do not happen again. This included training staff on record keeping, improving staff understanding on dignity in life and death, changes to procedure for family members collecting belongings and liaising with the local funeral homes for support and training to staff.
16. Mr X was not happy with this response and sent a second letter of complaint to the Home on 26 January. In this letter he also provided further information on the two points the Home had requested.
17. The Home provided another response on 8 February. In this letter it admitted further fault;
• After the evidence provided by Mr X, the Home agreed there were issues with Mrs Y’s continence care and said the evidence showed it was not at an acceptable standard.
• It admitted one of Mrs Y’s rings had been lost and could not explain how this had happened.
18. The Home upheld these points. It apologised and asked Mr X how he wanted to resolve the issue of the missing ring, which included working with the police. It also said it had sought advice for its staff from a community nurse on continence care and record keeping for the same issue.
19. It ended the letter by saying “Homer Lodge has most definitely reason to reflect on their practice going forward, learn lessons and understand the impact this has had.”
20. Mr X said he sent a further letter to the Home on 24 February, but he has not had a response.
21. I have considered what action the Home has taken and looked at the LGSCO and PHSO guidance on remedies. I consider the Home provided an appropriate remedy where possible. It has accepted it got things wrong, apologised, made service improvements, taken lessons to improve its service and said where it cannot remedy the injustice for the lost ring. An Ombudsmen investigation of the same issues is unlikely to achieve any more.

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Final decision

22. We will not investigate this complaint as an Ombudsmen investigation is unlikely to achieve more.

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Investigator's decision on behalf of the Ombudsman