Summary: A nursing home took too long to tell the complainant, Miss D, that her mother Mrs M had died, as the Home had not kept proper records about next of kin. It also did not manage Mrs M’s personal belongings or her finances properly. The NHS Trust responsible for managing Mrs M’s money failed to do this adequately or to safeguard her finances. We did not find failings in the way the Trust and the Council partly responsible for commissioning Mrs M’s placement at the Home handled Miss D’s complaint. Miss D said she suffered avoidable distress and inconvenience, and she believed the Home owed money to Mrs M’s estate. The organisations have agreed to apologise to Miss D and take action to prevent similar problems in future. They have also agreed to reimburse Mrs M’s estate with any money due to it.

The complaint

1. Miss D complains Rosedene Nursing Home (the Home) kept inadequate documentation about her late mother (Mrs M)’s next of kin. She said the Home delayed telling family members about Mrs M’s death and the funeral arrangements, and it failed in its documentation of and management of Mrs M’s personal belongings. Miss D also complains about the Home’s management of Mrs M’s money, including concerns the Home may have misappropriated some of Mrs M’s funds (wrongly taking money that belongs to another person). Miss D became aware of the issues after her mother’s death in 2019.
2. Mrs M’s placement at the Home was the joint responsibility of London Borough of Wandsworth (the Council) and Wandsworth Clinical Commissioning Group (the CCG), under section 117 of the Mental Health Act 1983.
3. Miss D also complains about South West London and St George’s Mental Health NHS Trust (the Trust), in its role as Mrs M’s corporate appointee to manage her benefits. She complains the Trust failed to adequately monitor Mrs M’s finances and this may have allowed the Home to misappropriate some funds.
4. Miss D complains about poor handling of her complaint by the Council and Trust, including avoidable delays and failure to acknowledge some significant failings. She complains the Council failed to tell her about actions taken as a result of her complaint. She says the Trust was unhelpful and obstructive, and the organisations failed to work together to jointly investigate her complaint.
5. Miss D says the failings meant Mrs M’s finances were not properly protected and the Home may have wrongly taken some money. She says she has experienced distress and inconvenience after learning of these matters following her mother’s death.
6. Miss D wants the organisations to acknowledge all the failings and apologise. She wants a payment for her time and trouble in pursuing the complaint, and a refund of money she believes is still owing to Mrs M’s estate.

Back to top

The Ombudsmen’s role and powers

7. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
8. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended) If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
9. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
10. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

Back to top

How I considered this complaint

11. I have considered information Miss D provided in writing and by telephone. I have also considered written information from the Council, Trust, CCG and the Home, as well as relevant law and guidance.
12. We have included the CCG in the investigation solely due to its legal responsibilities as joint commissioner of Mrs M’s care under section 117 of the Mental Health Act 1983. There are no specific complaints about the actions of the CCG.
13. Miss D and the organisations had the opportunity to comment on my draft decision, and I took their comments into account before making the final decision.
14. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, we have sent it a copy of our final decision.

What I found

Relevant law and guidance

Care Home standards

15. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (‘the CQC 2014 Regulations’) set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
16. Regulation 13 of the CQC 2014 Regulations says providers must protect service users from abuse, and must have robust procedures and processes in place to prevent abuse. Abuse includes theft, misuse or misappropriation of money or property belonging to a service user.
17. Regulation 16 says providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints. All complaints must be investigated thoroughly and necessary action taken where failures have been identified.
18. Regulation 17 says providers must have effective governance, including assurance and auditing systems or processes. Providers must also maintain accurate, complete and detailed records for each service user.

Mental Health Act 1983

19. Section 117 of the Mental Health Act 1983 imposes a joint duty on NHS clinical commissioning groups (CCG’s) and council social services to meet the health/social care needs arising from or related to a person’s mental disorder, when a person has been detained under specific sections of the Mental Health Act. This is known as section 117 aftercare, and it can include accommodation such as residential care.
20. The joint duty to arrange section 117 aftercare lasts for as long as the person needs the aftercare services. Section 117 aftercare can include services provided by the council, or which the council commissions from other providers. CCG’s will commission (rather than provide) these services.

Corporate Appointees

21. When a person lacks capacity to manage their financial affairs, a person or organisation can act as an “appointee” to claim their benefits from the Department for Work and Pensions (DWP). The appointee can manage and use that money on the person’s behalf in their best interests. In this case the DWP appointed the Trust to act as Mrs M’s corporate appointee.
22. The Trust’s Money Matters Policy (first issued in 2009, then updated in 2016 and again after January 2017) sets out its responsibilities and processes when acting as an appointee. The Trust was unable to provide a copy of its procedures for the period 2006 to 2009.
23. The Money Matters policy says the Trust should “make all the necessary [benefits] claims on the patient’s behalf and take any other action needed to safeguard the patient’s financial interests”. It also says the Trust should review the patient’s finances on a regular basis.

Personal expenses allowance

24. The Department of Health and Social Care issues annual guidance on Social Care – Charging for Care and Support. This guidance includes details about the Personal Expenses Allowance (PEA), the weekly amount that people receiving local authority-arranged care in a care home are assumed to need as a minimum for their personal expenses. The rate since this guidance was issued in 2015 has been £24.90 per week.

Complaint handling

25. In addition to Regulation 16 of the CQC Regulations, the complaints procedure for councils and NHS organisations is set out in the Local Authority Social Services and NHS Complaints (England) Regulations 2009 (‘the Complaints Regulations’).
26. The Complaint Regulations say there is a duty to investigate complaints properly and in a way that will resolve them efficiently. There is also a duty on organisations to cooperate when a person complains to one organisation but the complaint contains material relevant to another organisation. The Complaint Regulations say the organisations must ensure the complainant receives a coordinated response to the complaint.

Principles of Good Administration

27. The Parliamentary and Health Service Ombudsman’s Principles of Good Administration (‘the Principles’), which apply to NHS organisations, say that public bodies should have clear policies and procedures. They should also have accurate, complete and understandable information about the service. The Principles also say public bodies should follow their own policy and procedural guidance.

What happened

28. This chronology includes key events in this case.
29. Mrs M started living at the Home in 2006, after a psychiatric hospital arranged to place her there under section 117 of the Mental Health Act. She remained at the Home until her death in January 2019.
30. When Mrs M moved into the Home in 2006 it did not record any next of kin details for her on its admission documentation. The first dated entry in the Home’s records about next of kin was in 2013, when the Home updated its admission form and noted Miss D as Mrs M’s next of kin. Between 2013 and 2017 the Home’s documentation contained inconsistencies about whether Mrs M had children or a next of kin. However, the Home’s relative contact sheets from 2017 included details of Miss D as next of kin.
31. Miss D said she first contacted the Home in 2009, arranged a visit to her mother, and when she visited, made a point of ensuring the Home added her contact details to her mother’s file. She also said she contacted the Home several times between 2009 and her mother’s death in 2019, to provide new address details and contact telephone numbers. The Home disputes that Miss D made these further contacts after 2009.
32. In 2017 the Home documented that it tried seven times to contact Miss D by phone, without success, to update her about Mrs M and her care. The Home also said the GP Practice linked to the Home tried several times to contact Miss D in January 2019 as Mrs M was nearing the end of her life, but did not manage to make contact.
33. During Mrs M’s time at the Home the Trust was her corporate appointee and it received and managed her welfare benefits on her behalf. From November 2006 the Trust paid £50 each week to the Home by standing order, to cover Mrs M’s spending on personal items such as clothing, hairdressing and cigarettes. The Trust had set up a Lloyds Bank account to receive Mrs M’s benefits, and it then transferred £50 per week from this account to the Home’s account.
34. The Home first told us the £50 weekly payment went into its ‘main clients account’ between 2006 and 2016. It later told us the payment went into the Home’s ‘current account’.
35. The Home kept a running spreadsheet of Mrs M’s incoming money from the Trust and her outgoing expenses. It also kept copies of some receipts for items it had bought, such as clothing.
36. In 2016, after recommendations from an external consultant, the Home set up a separate bank account on behalf of Mrs M, to receive the weekly payments from the Trust. By that time Mrs M had built up around £13,700 in credit from the £50 weekly payments from the Trust since 2006, after taking off the money spent on her personal expenses.
37. The Home transferred £11,805.47 into the new bank account for Mrs M, and kept £1,985.60 of her money in the Home’s main current account. It told us it kept some money in the Home’s main account to cover sundries, and it would then transfer any balances over £2,000 to the resident’s own account periodically throughout the year.
38. The Home transferred £1,863.60 into Mrs M’s bank account in January 2018, leaving £1,983.50 of her money in the Home’s main current account. The Home continued to keep a running spreadsheet of incoming money for Mrs M from the Trust, and outgoing expenses.
39. Mrs M died in late January 2019. Between then and 5 February the Home tried to contact Miss D by phone several times but was unable to get hold of her. The Home said it also sent two letters to Miss D to two different addresses, and contacted Mrs M’s social worker about trying to get in touch with Miss D. The Home’s last attempt to contact Miss D was on 5 February. The Home then contacted the Police on 11 February to ask them to help in finding Miss D and telling her Mrs M had died. On 12 February the Police attended Miss D’s address and told her of her mother’s death.
40. After Mrs M died Miss D contacted the Home to discuss her mother’s funeral arrangements and to arrange collection of her personal belongings. Miss D said the Home told her it had already made the funeral arrangements, and it would box up her mother’s belongings ready for her to collect. Miss D said when she went to the Home to collect the belongings they were in a black binbag and contained some items belonging to other residents.
41. After Miss D knew her mother had died, she contacted the funeral directors and made some changes to the funeral arrangements. Miss D said on the day of the funeral, staff at the Home travelled to the funeral in a limousine which her mother’s money was used to pay for, as part of the funeral package. She said the Home had not given Mrs M’s family the option of using the limousine.
42. Miss D was the executor of her mother’s will. She contacted the Trust and the Home to arrange for her mother’s estate to receive the money the Trust and the Home held on Mrs M’s behalf. Miss D became concerned that the Home and/or the Trust may not have managed her mother’s money appropriately, and the Home may have wrongly taken some of her mother’s money.
43. Miss D complained to the Home and the Trust in Spring / Summer 2019. The Trust responded to her complaint in July 2019. The Home provided several responses during 2019 but as Miss D was unhappy with how the Home responded, she then complained to the Council in late 2019. As the Council had joint responsibility with the CCG for Mrs M’s placement at the Home, it agreed to investigate the complaint. The Council met with Miss D to discuss her complaint in February 2020 and said it would investigate her complaints and try to work jointly with the Trust to provide a combined complaint response. The Council sent a draft complaint response in March 2020, and a final response two weeks later after receiving comments from Miss D. The complaint response did not cover the issues about the Trust. The Trust had already responded in July 2019, and it provided a further response to Miss D in May 2020.
44. Miss D was still unhappy after receiving responses to her complaints and complained to the Ombudsmen in July 2020.

Next of kin information

45. The Council accepted there was fault in the way the Home documented information about Mrs M’s next of kin in her records. The Council could not work out when the Home had made some of the changes to Mrs M’s records about her next of kin, and there were inconsistencies in the records. Even when there were entries in the Home’s records about Mrs M having children, the Home made little effort to locate Miss D and her sister, or to reconcile the differing information about next of kin.
46. The Council said Mrs M's recorded resistance to family involvement in her life made issues about next of kin more difficult. The Council also said there had been many changes in the Home’s management and its documentation during Mrs M’s time there, which had led to some inconsistencies.
47. The Council upheld this part of Miss D’s complaint, which means it found there had been mistakes and/or a poor service by the Home. It apologised for Miss D’s the anxiety and distress due to the Home not keeping her updated or involved in her mother’s care. It also apologised for the delay this caused in Miss D learning of her mother’s death.
48. The Council said the Home had already made some changes and improvements to its policies and documentation for recording information about residents and their next of kin, following a CQC inspection in 2016. The Council also recommended the Home should take further action in this area, by:

• regularly updating next of kin details
• having written arrangements for telling family members when a resident has died, if the resident has indicated they do not want family members involved in their care
• making sure changes to records are initialled and dated [to provide an audit trail]

49. We asked the Council and the Home what actions the Home had taken to make the changes and improvements the Council had identified. The Council said the Home had completed the recommendations from the CQC inspection in 2016 about updating resident record folders, person-centred care plans and risk assessments, by February 2017. The Home sent us a copy of its current Admission Pack for new residents, and its Policy on Admissions (January 2021). These documents make it clear that referral information for new residents should include a short social report including the person’s social history. The Admission Pack includes space for details of Next of Kin, Other Contacts, End of Life Information, and Funeral Details. The Home said its activities co-ordinator has responsibility for funeral arrangements, and the staff nurse on duty deals with contacting relatives. If no next of kin information is available on the Admission Form, the Home will contact the resident’s social worker about this when a resident has died.
50. We found the Home did not meet the requirements of Regulation 17 of the CQC 2014 Regulations, and this was fault. It did not maintain accurate, complete and detailed records for Mrs M, and did not have systems in place for effective governance in this area. This fault caused an injustice to Miss D. She suffered avoidable anxiety and distress, particularly through the delay in the Home being able to contact her to tell her about her mother’s death and the funeral arrangements.
51. We are satisfied the Home has taken appropriate action to address this problem, following the 2016 CQC inspection and the Council’s complaint investigation and recommendations in 2019. It has made appropriate changes to its procedures around admission and next of kin information, and the Council has apologised to Miss D for the distress and anxiety she has experienced. We are satisfied these actions remedy this part of the complaint.

Delay notifying family of death and funeral arrangements

52. The Council accepted there was fault by the Home in its delay in successfully contacting Miss D to tell her of her mother’s death and about the funeral arrangements. The Council said it could not find out whether the Home had sent letters to Miss D after her mother’s death, as it had not sent them by recorded or signed for delivery. The Home had not produced a copy of the letters during the Council’s investigation. The Council said there were entries in the Home’s records about its attempts to contact Miss D by telephone, but there was no log of outgoing calls detailing the date and the phone number called.
53. Miss D said the addresses and contact telephone numbers used by the Home were wrong. She said she had provided regular updates to the Home when she had changed address or telephone number so the Home could update its records. She also disputed the Home had successfully contacted her home telephone number and had been told she was out, when trying to contact her after her mother’s death.
54. The Council said it has methods of finding a person’s next of kin, but it could not find any records of the Home making this request to the Council. The Home said it tried to contact Mrs M’s social worker after Mrs M’s death to discuss next of kin details. The Home said the social worker was away for six weeks and there was no contact information or next of kin details on the Council’s system so it could not help. The Home said it contacted the Police on 11 February as a ‘last attempt’ to tell Miss D of her mother’s death.
55. The Council upheld Miss D’s complaint there were unnecessary delays in contacting her after her mother’s death.
56. The Council said the Home should:

• keep a telephone log of outgoing calls, including the date and number called
• keep copies of correspondence with families on file
• make sure it sends important letters or documents by recorded or signed-for delivery, with the postal service label attached to the copy of the letter

57. The Home said it now documents outgoing phone calls or emails about residents in their care file. It also has a post book and records all outgoing post – standard post and recorded delivery items. The Home says it now has a robust system which can easily identify outgoing correspondence.
58. As outlined in the previous section, the Home also has nominated specific staff with responsibility for contacting relatives when a resident has died and for making funeral arrangements. The Home also said it will contact the resident’s social worker if a resident has died and there is no next of kin information on the Home’s file.
59. We found the Home did not meet the requirements of Regulation 17 of the CQC 2014 Regulations, and this was fault. It did not maintain accurate, complete and detailed records for Mrs M, and did not have systems in place for effective governance in this area. This fault caused an injustice to Miss D, as she suffered avoidable anxiety and distress through the delay in telling her of her mother’s death, and her lack of involvement in the early funeral arrangements.
60. We are largely satisfied the Council and Home have taken appropriate action to address this issue. The Home has made appropriate changes to its procedures about resident admission and next of kin information, and about logging telephone and written correspondence with relatives / carers. It also has nominated staff with responsibility for contacting relatives after a resident’s death, contacting social services where there is no next of kin information, and for making funeral arrangements. The Council has apologised to Miss D for the distress she and her family experienced while grieving for the loss of Mrs M.
61. We recommend the Council takes further action to fully address this issue. This is to ensure relevant staff know and understand the escalation procedure where there are difficulties in finding next of kin after the death of a resident, and can advise care providers about this.

Poor documentation and management of personal belongings

62. The Council accepted there was fault by the Home in its documentation and management of Mrs M’s personal belongings. It said it could not identify which personal belongings Mrs M had on her admission to the Home in 2006 as the documentation at the time did not provide a full inventory. The only item listed then was £30 in cash.
63. The Council said:

• some clothes given to Miss D after her mother’s death were items the Home had bought for her with her allowance
• the Home has a practice of redistributing belongings when a resident leaves and does not take some items with them
• it believed Mrs M had admired several items which then became her property
• there was a lack of consistency in the Home recording information about Mrs M’s personal possessions

64. The Council also said it was wholly unacceptable for Mrs M’s belongings to be treated with a lack of respect, such that they were in a black binbag when Miss D arrived to collect them. It said the Home should have a practice for recording personal items, and for cleaning and storing them securely before collection. It should also have an inventory for relatives / carers to sign for on collection. The Council upheld this complaint and apologised to Miss D for her distress.
65. The Home said it now completes an inventory when a resident goes into the Home, and it updates this annually as a minimum. It sent us a copy of its New Clients Admission documents including the Inventory Form.
66. The Home has offered a further apology to Miss D that it did not package her mother’s belongings appropriately for her to collect. It said it has trained staff on how to appropriately pack belongings for collection.
67. We found the Home did not meet the requirements of Regulation 17 of the CQC 2014 Regulations, and this was fault. It did not maintain accurate, complete and detailed records for Mrs M’s personal belongings, and did not have systems in place for effective governance of this. It also failed to ensure it packaged Mrs M’s belongings in a suitable manner for her daughter to collect after her death. These faults caused an injustice to Miss D as she suffered avoidable distress.
68. We are satisfied the Home has taken appropriate action to address this. It has made appropriate changes to its procedures around resident admission and documentation of personal property. It has also trained staff on how to appropriately pack personal belongings for collection. The Home and Council have apologised to Miss D for the distress she experienced. We are satisfied these actions remedy this part of the complaint.

Poor management of finances and possible misappropriation of funds

The Home

69. The Council accepted there was fault by the Home in its management of Mrs M’s finances. It said there was a lack of clarity and evidence about how the Home managed Mrs M’s money. It upheld this complaint.
70. The Council said the Home should have a clear finance transaction policy to record all expenses, keep receipts, and enter corresponding numbers in the transactions records.
71. Miss D remained unhappy after receiving the Council’s complaint responses, as she felt the Home may have wrongly misappropriated some of her mother’s money. She said she had not had any explanation about what had happened to the interest on her mother’s money that would have accrued over the years, She said the Council or Home had not offered her any compensation to resolve this part of the complaint.
72. We asked the Council and the Home what actions the Home had taken to improve. The Home sent us a copy of its Policy on Financial Procedures (2021) which says it has open, transparent and robust accounting and financial procedures, which will be independently audited annually. It said it records and dates all financial transactions on its system. The Home also said it opened a separate bank account in 2016 to keep most of Mrs M’s money in, rather than keeping them in the Home’s main account, following advice from an independent consultant who reviewed the Home’s processes.
73. We asked the Home how it regularly accounted to the Trust as Mrs M’s corporate appointee, about the Home’s management of Mrs M’s money. The Home said it gave telephone updates to the Trust’s Cashier’s Department roughly quarterly. It could not provide any documentary evidence of this.
74. We found the Home did not meet the requirements of Regulation 13 of the CQC 2014 Regulations, and this was fault. It did not have adequately robust procedures or safeguards to protect Mrs M’s financial interests, or to protect her from the risk of financial abuse. It is important that all transactions involving a resident’s money are transparent and clearly recorded, and the Home did not meet this standard here. A resident should not be exposed to the risk of harm or the risk of loss of money or property because of theft, misuse or misappropriation.
75. We also found the Home did not meet the requirements of Regulation 17 of the CQC 2014 Regulations, and this was fault. It did not have adequate procedures for effective governance, assurance and auditing in terms of its management of Mrs M’s money. It also failed to maintain sufficiently complete and detailed records.
76. We have not seen any evidence the Home deliberately mismanaged Mrs M’s money or misappropriated her funds. However, the lack of clarity about how the Home managed Mrs M’s money has created an understandable concern for Miss D about whether the Home has wrongly taken some funds.
77. We are not satisfied the Council or home have taken sufficient action to address this fault or fully remedy the injustice to Miss D.

The Trust

78. The Trust told Miss D how it had calculated the money due to Mrs M’s estate, including the money the Home transferred back to the Trust from the account it held for Mrs M, and the money the Trust held on Mrs M’s account as her corporate appointee. The Trust said it had allowed a further three standing order payments of £50 to go to the Home after Mrs M’s death, due to an oversight by the Trust’s cashier. The Trust said the Home included this £150 in the £14,493 it transferred to the Trust on 25 March 2019, so there were no further monies owing by the Home. The Trust apologised about its failure to cancel the standing order soon enough and said it would speak with the member of staff.
79. The Trust said all money owing to Mrs M’s estate had been paid in full.
80. The Trust told us during our investigation that it takes its role as corporate appointee very seriously. It says this includes safeguarding a person’s financial interests and making sure they have enough money for their everyday needs. The Trust said for a long time it had met regularly with the Home, but had not continued doing this in more recent years. The Trust said it recognises that more oversight on its part of how the Home was using Mrs M’s money on her behalf would have prevented concerns the Home may have misappropriated some funds.
81. The Trust said it estimated the Home spent an average of £23 a week on Mrs M’s personal expenses such as clothing, dental expenses, opticians and podiatry. It said this spending appears reasonable based on the amount of Mrs M’s benefits and what the Home spent the money on.
82. The weekly Personal Expenses Allowance set by the Department of Health and Social Care has been set at £24.90 since guidance on this in 2015. The Home’s spending on Mrs M’s behalf is in line with this.
83. The Trust said there was no direct evidence the Home had misappropriated any funds, or that any further funds were due to Mrs M’s estate from either the Home or the Trust.
84. In its responses to us, the Trust explained how it had calculated the funds due to Miss D’s estate. It said its bank account statement for 25 March 2019 showed a balance of £68,759.90, including the £14,493.60 the Home had transferred. The sum paid to Mrs M’s estate was £68,603.15, which was £129.87 less than the figure provided on 25 March. The Trust said the final figure was less because of three transactions that took place after the 25 March 2019 date. The delay in the payment out to Mrs M’s estate was because of the time taken for probate to be granted. The Trust gave us the following information:

85. The Trust said it recognises it can improve its processes in this area, and has already made several changes. It commissioned an independent audit of its Patient Monies processes and procedures, which listed three improvement actions which have all been completed:
• to put formal arrangements in place with residential homes setting out the processes for notification of patient death
• to make patient discharge / death listings available to the Trust Cashiers Department from the Trust Information Management system
• to update the Patient Monies policies and procedures around withdrawal of personal money for capable and incapable patients
86. The Trust said it no longer agrees to regular standing orders for residents in care homes. Instead, it transfers a sum of money when the resident starts their placement. The Home then contacts the Trust when it needs more money for the resident and provides evidence of what the money has been spent on.
87. The Trust said it is very unusual for a resident to accrue the amount of money that Mrs M did during her time living at the Home. The Trust also said it would be working with care homes to make sure if there were any residents who had accrued relatively large sums like Mrs M did, those funds were transferred back to the Trust to be held in their patient account managed by the Trust as corporate appointee.
88. We found fault in how the Trust managed Mrs M’s funds as her corporate appointee. It did not act in line with its own Money Matters Policy which says it should act to safeguard the patient’s financial interests and should review the patient’s finances regularly. We have not seen any documentary evidence of how the Trust safeguarded Mrs M’s financial interest in terms of the large sums of money held by the Home, or that it reviewed her finances regularly. The Parliamentary and Health Service Ombudsman’s Principles of Good Administration say that public bodies should follow their own policy and procedural guidance. The Trust failed to do that in this case. This has caused an injustice to Miss D as she is concerned about whether the Home has wrongly taken some of her mother’s money, and this has caused her distress.
89. We are not satisfied the Trust has taken sufficient action to address this fault or fully remedy the injustice to Miss D.

Complaint handling by the Council and the Trust

90. The Complaints Regulations for councils and NHS organisations include a duty to cooperate when a person complains to one organisation but the complaint includes material relevant to another.
91. Miss D complained to the Trust on 4 June 2019 and it responded on 9 July. Miss D wrote to the Trust almost six months later, in late December 2019, explaining why she remained dissatisfied. The Trust offered to reopen Miss D’s complaint. Miss D replied saying she had raised the complaint “with the appropriate departments” and the Trust was likely to be “contacted and brought into this investigation with all parties involved”. On that basis the Trust did not reopen the complaint. Miss D’s complaints to the Trust in June 2019 are mostly about payments from the Trust to the Home after Mrs M died, and about the attitude of a member of the Cashier’s Team. The Trust apologised to Miss D for the tone its Cashiers Department had used in emails to her when dealing with queries about her mother’s finances. The Trust said this could have been more helpful and empathetic.
92. We have not seen fault in the way the Trust investigated the complaint without involving the Council, as it was not clear at that stage that a coordinated response was appropriate.
93. Miss D complained to the Home in 2019, and when she remained unhappy with its responses she complained to the Council in November and December 2019. When the Council became involved in late 2019 it thought it would be helpful to provide a coordinated complaint response. It tried to approach the Trust and the Home about the complaint, but the Trust said it had already investigated and responded to the complaint in 2019. The Trust told us it was not aware of any request from the Council to work on a coordinated complaint response. It said it will always work with other providers in this way when appropriate, in line with the Parliamentary and Health Service Ombudsman’s Principles of Good Complaint Handling. The Trust said two members of its Cashiers Department no longer worked at the Trust, so if the Council had contacted them this may not have been dealt with.
94. There is very little information about this other than the Council investigator’s telephone notes, but on balance of probabilities the Council did approach the Trust about a coordinated response.
95. As the Trust had already responded to the complaint the Council’s response was solely about the Council and the Home’s involvement. Although it might have been better to give a coordinated response, we do not consider there was fault here because of the circumstances and timescales involved.
96. We have not seen evidence of unreasonable delays in investigating and responding to Miss D’s complaints by either the Council or the Trust.
97. Miss D said she is unhappy the Council has not told her about the actions the Home took as a result of her complaint. The Council told us its usual processes for following up complaint recommendations have been disrupted by the COVID‑19 pandemic and lockdowns. The Council asked the Home for an update on its actions in November 2020, and the Home has sent this information to us as part of our investigation. We have not seen any fault in the Council’s actions about following up compliance with its recommendations, because of it stopping its visits and audits temporarily due to the COVID-19 pandemic.

Back to top

Agreed action

98. To remedy Miss D’s distress and inconvenience due to the failings we have identified, and to address the potential that money may be due to Mrs M’s estate, the Council, the Home and Trust have agreed to:
• write to Miss D to apologise for the faults we have identified and for her avoidable distress and inconvenience, within one month of our final decision
• pay Miss D £300 in total (split between the three organisations) to recognise her distress, and her time and trouble in pursuing this complaint, within one month of our final decision
• work together to establish what amount of interest Mrs M would have accrued on her money held by the Home between 2006 and 2019 if the organisations had managed her money appropriately, and
• agree which organisations(s) are responsible for payment of this money to Mrs M’s estate, and then make that payment within three months of our final decision
99. The Council has agreed to:

• write to Miss D (with a copy to us) to explain what action it has taken to ensure all relevant staff know and understand the escalation procedure where there are difficulties in locating a service user’s next of kin after their death. The Council should also ensure there are processes in place to tell care providers about the escalation processes when needed. The Council should complete this within three months of our final decision

100. The Trust has agreed to:

• write to Miss D (with a copy to us) to explain what action it has taken to ensure that, where the Trust is a corporate appointee, any large sums of money accrued by care home residents are transferred back to the Trust to be held in their patient account. The Trust should complete this within three months of our final decision

Back to top

Final decision

101. There was fault by the organisations which caused Miss D an injustice. The organisations have agreed to take the actions we recommended to remedy the injustice to Miss D. I have therefore completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman