Summary: Mrs D complained on behalf of her mother, Mrs X, about faults in hospital discharge, residential care, community therapy services, equipment provision and complaint handling. The complaint is about the actions of London Borough of Bromley (the Council), Kings College Hospital NHS Foundation Trust (KCH Trust), Oxleas NHS Foundation Trust (Oxleas Trust); Bromley Healthcare CIC Ltd (Bromley Healthcare); and Sundridge Court Nursing Home. We upheld the complaints about the Council and Sundridge Court that relate to hospital discharge, residential care and complaint handling. The Council and Sundridge Court accepted our recommendations, so we have completed our investigation.

The complaint

1. The complainant, whom I shall call Mrs D, complains on behalf of her mother,
   Mrs X. Mrs D complains about the actions of London Borough of Bromley (the Council), Kings College Hospital NHS Foundation Trust (KCH Trust), Oxleas NHS Foundation Trust (Oxleas Trust); Bromley Healthcare CIC Ltd (Bromley Healthcare); and Sundridge Court Nursing Home (Sundridge Court). Mrs D complains that:
• Mrs X’s discharge from Kings College Hospital to Sundridge Court was inappropriate because she was discharged without a hoist, to a residential care setting that could not meet her needs;
• Mrs X received poor care at Sundridge Court. This includes poor continence care and being left to lie in bed;
• there was a delay in organising community physiotherapy and intervention from the moving and handling team from the time Mrs X could weight bear, around June 2021;
• there was a delay in moving Mrs X’s equipment from her flat to her residential care settings; and
• the Council and KCH Trust have failed to provide a coordinated joint response to Mrs D’s complaint.
2. Mrs D says the poor care caused Mrs X to become bed bound and incontinent. This has led to Mrs X losing her independence and is distressing for both her and Mrs D.
3. Mrs X would like to move to a setting that provides rehabilitation, or to receive more physiotherapy in her current care home, to enable her to regain her mobility and ability to bear weight. She would like this to be followed by a thorough assessment and, if appropriate, a move to the extra care housing scheme she was due to move to just before she broke her leg.
4. Mrs X wants reassurance that she will not be moved to another setting where there may be further delays in accessing physiotherapy.

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The Ombudsmen’s role and powers

5. 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).
6. 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.
7. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
8. The Ombudsmen may investigate complaints made on behalf of someone else if they have given their consent. (Health Service Commissioners Act 1993, section 9(3) and Local Government Act 1974, sections 26A(2) and 26A(1), as amended)
9. 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)

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How I considered this complaint

10. I have considered:
• information Mrs D has provided by telephone and in writing;
• the organisations’ written responses to my enquiries;
• relevant records from the organisations; and
• the law, national guidance and local policies, where they apply to the issues in this complaint. Where relevant, I have referred to these in the body of this decision statement.
11. Mrs D, the Council, KCH Trust, Oxleas Trust, Sundridge Court and Bromley Healthcare have had an opportunity to comment on a draft version of this decision. I consider any comments they made before reaching a final decision.
12. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

Organisational responsibilities

13. The Council was responsible for assessing Mrs X’s social care needs and then meeting those needs classed as ‘eligible’. This includes Mrs X’s residential care needs.
14. Because of the special funding arrangements for hospital discharge in force during the COVID-19 pandemic, Sundridge Court was acting both as a health provider and on behalf of the Council.
15. KCH Trust was responsible for Mrs X’s care in Kings College Hospital. Jointly with the Council and Sundridge Court, it was also responsible for ensuring her safe discharge from hospital to Sundridge Court.
16. Bromley Healthcare provides community physiotherapy in the Bromley area. Oxleas Trust provides community physiotherapy in a nearby council’s area.
17. Home B is another nursing home. Mrs X moved there in July 2021. Mrs X and Mrs D are not complaining about Home B. However, some of the things she is complaining about happened while she was in Home B.

Key background summary

18. In 2021, Mrs X was due to move from her flat into extra care housing (a self-contained home with on-site support for care needs). Shortly before the move could happen, Mrs X fell and broke her leg. This happened in March 2021. Mrs X needed hospital treatment including surgery and could not put weight on her leg for 12 weeks after the operation. Although she no longer needed to be in hospital by April 2021, she needed more care than could be provided in her flat or extra care housing. She was therefore discharged to Sundridge Court, under Pathway 2 of the Government COVID-19 discharge scheme.
19. Following another hospital admission, Mrs X moved to a different care home. Mrs X is dissatisfied with the care she received at Sundridge Court, delays in therapy to help her regain mobility, and delays in ensuring she had the right equipment in place to move her.

A – Discharge from hospital to Sundridge Court

Relevant guidance

20. National guidance called “Hospital Discharge Service: Policy and Operating Model” was in place for hospitals, councils and social care providers in April 2021. It said:
• hospitals should follow a “discharge to assess” model consisting of four pathways, 0-3 and using a “trusted assessment” model where one person or team carries out health and social care assessments on behalf of multiple organisations;
• pathway 2 was for people who no longer needed to be in hospital, but needed rehabilitation or short-term care in a “bed-based setting”, such as a care home;
• “Information essential to the continued delivery of care and support must be communicated and transferred to the relevant heath and care partners on discharge”;
• “Health and care systems should ensure effective information sharing, and full and carefully documented assessments of need, to ensure care providers can deliver the care and support people require”; and
• the guidance should be read alongside the National Institute for Health and Care Excellence (NICE) guideline NG27 “Transition between inpatient hospital settings and community or care home settings for adults with social care needs”.
21. NG27 says in section 1.5 that hospitals should have discharge coordinators who are responsible for coordinating people’s discharge from hospital. Discharge coordinators are the central point of contact for health and social care practitioners, the person and their family during discharge planning. NG27 says discharge coordinators should:
• be involved in all decisions about discharge planning;
• work with hospital- and community-based multidisciplinary teams and the patient to develop and agree a discharge plan;
• arrange follow-up care;
• ensure any essential specialist equipment is in place at the point of discharge.

What happened

22. After having an operation on her leg, Mrs X was ready for discharge from hospital in April 2021. KCH Trust completed a moving and handling risk assessment on
    8 April. This said Mrs X:
• needed bariatric equipment (specialist equipment for people living with obesity) including bed, pressure relief mattress, hoist, slings and slide sheets;
• did not need a riser recliner chair. Instead, she needed a bariatric ‘static tilt in space’, which is a specialist wheelchair which can be reclined; and
• needed four staff to help with turning, repositioning, help with using a bed pan, and hoisting.
23. On 12 April 2021, KCH Trust completed a ‘trusted assessor’ form which said that Mrs X:
• needed assistance from three to four carers with personal care and transfers using a hoist; and
• was fully continent, had a urinary catheter and used a bed pan for bowel movements.
24. On the same day, Sundridge Court completed a pre-admission assessment which shows that it was aware of:
• Mrs X’s continence needs;
• Mrs X’s weight; and
• the need for specialist bariatric equipment and extra staff to safely move and care for Mrs X.
25. Mrs X’s ‘discharge passport’, includes branding from the Council, KCH Trust and Bromley Healthcare. It:
• referred to the moving and handling report;
• said a hoist and specialist slide sheets had been ordered on 9 April 2021;
• said Mrs X was fully continent but had a urinary catheter in place; and
• stated Mrs X needed an interim nursing placement whilst non-weight bearing for 12 weeks after surgery. Non-weight bearing means that a person is not allowed to put any weight on a limb for a certain time, to allow it to heal.
26. On 15 April 2021, Sundridge Court told KCH Trust that it had ordered the specialist equipment. On 21 April, Sundridge Court told KCH Trust that Mrs X’s room was ready and the Home was ready to receive her.
27. In early May 2021, Mrs D contacted the Council about problems with Mrs X’s care and equipment at Sundridge Court. Later in May 2021, the Council held a review of Mrs X’s care at Sundridge Court. The Council also formally assessed Mrs X’s care needs at this time. Mrs X, Mrs D, Sundridge Court’s manager and Mrs X’s social worker were present. The Council’s record of the review says that:
• Mrs X is fully continent but wears pads in case of accidents;
• Mrs X complained she had to wait for up to 10 hours to have her pads checked and changed;
• the manager agreed there was a delay but said this was usually one to two hours, and asked Mrs X if she wanted the catheter which had recently been removed to be put back;
• Mrs D was concerned that Mrs X sometimes had to wait up to six hours for a bedpan and that the Home was not helping Mrs X with her physiotherapy exercises;
• the manager said that the Home had ordered a sling for Mrs X but it never arrived and another one was due to arrive from Germany later that month. Another part of the record says the original sling arrived but was too small;
• the manager also said the Home needed between four and six staff to care for Mrs X but was short-staffed and only had three permanent staff on duty at night. The manager said they were in trouble with Sundridge Court’s head office because of the cost of agency staff to help care for Mrs X. This meant Mrs X sometimes had to wait to use the bedpan because of a lack of staff; and
• the manager said the Home was struggling to meet Mrs X’s needs due to her size and wanted double the rate it was currently getting to carry on caring for Mrs X.
28. After the review, the Council recommended Mrs X was moved to a different care home as Sundridge Court was struggling to meet her needs.

Was there fault causing injustice?

29. Because of the special arrangements in force during the pandemic, KCH Trust assessed Mrs X’s needs on discharge on behalf of both the NHS and social care. There was no fault in the way KCH Trust assessed Mrs X’s needs, recorded its assessments, shared them with the relevant organisations and checked with Sundridge Court that it was ready to accommodate Mrs X.
30. Sundridge Court’s records show it was fully aware of Mrs X’s needs in terms of staffing levels and specialist equipment before accepting her as a resident. It told KCH Trust it had the relevant equipment in place and was ready for her to move in. However, this was incorrect.
31. Records show that Sundridge Court then failed to meet Mrs X’s needs in terms of helping her with her toileting needs and supporting her with doing her physiotherapy exercises. Sundridge Court told the Council and the complainants this was because it had failed to ensure the correct equipment and staffing levels were in place. This was despite KCH Trust checking, and Sundridge Court reassuring it, that it would be able to meet Mrs X’s needs.
32. This was fault by Sundridge Court. It caused the following injustice.
• Mrs X missed out on the care she needed. For around six weeks, she had to suffer the indignity of soiling herself on pads even though she was continent and capable of using a bed pan. This also placed her at risk of harm through ‘holding on’, some days for hours, when she needed to use the bedpan and through being in soiled pads for longer than she should have been.
• Mrs X and Mrs D are concerned that the lack of appropriate care and support with toileting and exercises affected Mrs D’s mobility and worsened her constipation. There is simply not enough evidence for us to confirm whether this was the case. But the uncertainty is an injustice to Mrs X and her daughter.
• Mrs X and Mrs D suffered avoidable distress as a result.
33. We have made recommendations to remedy this injustice at the end of this statement.

B – Care at Care Sundridge Court

Relevant law and guidance

34. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. The following Regulations are relevant to this part of the complaint.
• Regulation 9 is about person-centred care. It says care and treatment must be appropriate, meet people’s needs and reflect their preferences.
• Regulation 10 says care providers must treat people with dignity and respect. This includes supporting people’s autonomy and independence.
• Regulation 12 is about safe care and treatment. It says care providers must assess the risks to people and “doing all that is reasonably practicable to mitigate such risks”. It also says care providers must ensure any equipment is safe, used in a safe way, and provided in sufficient quantity to meet a person’s needs.
• Regulation 13 is about safeguarding people from abuse and improper treatment. It says care must not be provided in a way that is degrading for people or significantly disregards their needs for care.
• Regulation 15 is about premises and equipment. It says all equipment must be suitable and appropriately located for the purpose for which it is used.
• Regulation 18 is about staffing. It says care providers must deploy enough suitably qualified, competent, skilled and experienced staff.
35. The Human Rights Act 1998 sets out the fundamental rights and freedoms that everyone in the UK is entitled to. This includes freedom from degrading treatment. The Act requires all local authorities, and other bodies carrying out public functions, to respect and protect individuals’ rights. Our remit does not extend to making decisions on whether a body in jurisdiction has breached the Human Rights Act – this can only be done by the courts. But we can decide whether or not a body in jurisdiction has had due regard to an individual’s human rights in their treatment of them, as part of our consideration of a complaint. We consider that Article 3, which includes the right to freedom from degrading treatment, is relevant to this part of the complaint.
36. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (Care Act 2014, section 42.)

Was there fault causing injustice?

37. As set out in Section A above, records show that Sundridge Court:
1. was fully aware of Mrs X’s needs and preferences and what it needed to do to meet them, before Mrs X moved there;
2. admitted Mrs X despite being aware it did not have the equipment and staff in place that were needed to safely meet her needs for moving, toileting and bed-based exercises;
3. knowingly left Mrs X waiting for a bedpan or a pad change for hours at a time due to being short staffed on multiple occasions;
4. failed to provide Mrs X with person-centred care meeting her needs and preferences for moving, toileting and bed-based exercises; and
5. cannot show it properly took into account Mrs X’s right to freedom from degrading treatment when managing and delivering her care.
38. These were faults by Sundridge Court as a provider funded through the special NHS funding arrangements in force during the pandemic. We also hold the Council responsible for the faults set out in 36b) to 36e) above because Sundridge Court also acted on behalf of the Council in providing Mrs X’s care.
39. The Council became aware in early May 2021 of Mrs D’s concerns about Mrs X’s care. In mid-May, the Council met with Mrs X, Mrs D and the Home, where the Home confirmed that there were times it did not have the staff or equipment to meet Mrs X’s needs safely and even offered to insert a catheter in response to Mrs X’s concerns about having to wait a long time for help with toileting. I have seen no evidence the Council considered on either occasion whether this information should trigger immediate action to ensure Sundridge Court was supported to meet Mrs X’s needs, or a safeguarding enquiry. The Council should have considered these options because:
• Mrs X had needs for care and support which meant she could not protect herself from abuse and neglect;
• the problems Mrs X and Mrs D were complaining about could, if substantiated, amount to organisational abuse or neglect; and
• the Home had told the Council it was lacking staff and equipment to meet Mrs X’s needs safely.
40. There is no evidence that the Council did anything to help Sundridge Court resolve the staff and equipment problems, or considered a safeguarding enquiry, before Mrs X was hospitalised again at the end of May 2021. This was fault.
41. Mrs X left Sundridge Court at the end of May 2021 and was discharged to Home B in July 2021. The Council’s records indicate that it has invoiced her for care at Sundridge Court from 2 June 2021. This was fault as the Council had already established Sundridge Court was not meeting Mrs X’s needs and she was no longer resident there. However, Mrs X has not paid this invoice so the fault has not caused her a financial injustice.
42. As a result of faults by Sundridge Court and the Council:
• Mrs X suffered a lack of dignity around her continence care with potentially degrading consequences;
• Mrs X was at risk because of a lack of the right equipment and enough staff to meet her needs safely. This included risks of infection, pain and skin breakdown from waiting too long to use a bedpan or to have her pads changed. It also included the risk of delayed or failed evacuation if a fire or other emergency happened while Sundridge Court lacked appropriate equipment and enough staff to move her; and
• there was a missed opportunity for the Council to take action to improve Mrs X’s situation or make safeguarding enquiries.
43. Mrs X and Mrs D also suffered avoidable distress because of these problems.
44. These all amounted to injustice to Mrs X and Mrs D.
45. We have made recommendations to remedy this injustice at the end of this statement.

C – Delays by community physiotherapy and moving and handling teams

46. The complainants consider that Mrs X should have started getting services from community physiotherapy and moving and handling teams in June 2021.
47. Mrs X started receiving community physiotherapy services in October 2021. She had not received moving and handling services by April 2022, the end of the period I am investigating.

What happened

48. Mrs X had an operation on her leg in March 2021. The medical advice was that she should not put weight on her leg for 12 weeks, until around mid-June.
49. Trust records indicate that hospital doctors and therapists planned for Mrs X to get a community therapy assessment once she could put weight on her leg again. Before that, she was to do set exercises from a plan provided by hospital therapists. When it discharged Mrs X from hospital in April 2021, the Trust sent her and her GP a ‘rehabilitation prescription’ letter. This said that she would benefit from a therapy assessment once weight bearing restrictions were lifted, to establish the next steps in rehabilitating her. The letter asked Mrs X’s GP to “ensure follow up is actioned”.
50. When discharging Mrs X from hospital, the Trust advised Sundridge Court what equipment she needed and provided detailed moving and handling instructions. Sundridge Court confirmed it had what it needed to accommodate Mrs X. The problems Mrs X experienced while in Sundridge Court are set out in sections A and B above.
51. Mrs X was admitted to hospital again at the end of May, before she could start putting weight on her leg.
52. While in hospital, an orthopaedic doctor reviewed Mrs X as it had been 12 weeks since her operation. The doctor decided:
• Mrs X’s fracture had not healed enough;
• she needed to stay non-weight bearing for another three to four weeks;
• she could do leg exercises to strengthen her muscles; and
• in three to four weeks, she should have another x-ray to check if her leg had healed enough for her to start putting weight on it again.
53. In late June, the Trust decided Mrs X should be discharged from hospital as ‘bedbound’ because she would not use her specialist recliner safely and became distressed when asked to do so. The plan was for community therapy teams to assess Mrs X when she started being able to put weight on her leg again.
54. Mrs X moved to Home B in early July 2021. The orthopaedic clinic stated it was happy for Mrs X to start putting weight on her leg in mid-July.
55. Oxleas Trust received a referral for community physiotherapy services in mid-August 2021. It tried to visit Mrs X at Home B in early September. However, Mrs X had been readmitted to hospital. About a week later, Mrs D told Oxleas Trust that Mrs X had returned to Home B. Oxleas Trust made an appointment to see Mrs X the following week. However, by then Mrs X was back in hospital. Mrs X returned to Home B in October and Oxleas Trust made an appointment to see her a few days later.
56. Mrs X had her first community physiotherapy appointment in mid-October 2021. Oxleas Trust prescribed Mrs X a home exercise programme, agreed a care plan with goals with her, and booked further sessions. It also established her hoist sling had been lost during a hospital admission, so staff were not transferring her to her chair. Between then and April 2022, Oxleas Trust physiotherapists tried to see her every week to two weeks. Their sessions with Mrs X were usually short because her health and pain levels did not usually allow her to tolerate longer sessions. There were times when Home B or Oxleas Trust cancelled appointments, for reasons such as:
• Mrs X going back into hospital;
• Home B being closed to visitors because of infection outbreaks; and
• on one occasion, Oxleas staff being unable to attend.
57. Oxleas Trust referred Mrs X to another council’s moving and handling team in November 2021, after its physiotherapy service had been seeing her for about a month. The reason for referring to the other council’s moving and handling team is because Mrs X’s care home is in the other council’s area.
58. A professionals’ meeting in early February 2022 was attended by Mrs X, Mrs D, the Council, Home B’s clinical manager, and a physiotherapist. The Council’s note of the meeting says:
• Mrs X was yet to be seen by the moving and handling team despite a referral in November 2021; and
• the physiotherapy team was going to chase up the moving and handling referral and resume visiting Mrs X after a pause due to a COVID-19 outbreak.

Was there fault causing injustice?

59. KCH Trust’s hospital-based therapists conducted frequent and detailed assessments and provided reasoning for their plans. I have found no fault in their decision not to refer Mrs X for community therapy or moving and handling services while she could not bear weight on her leg.
60. Mrs X’s GP practice was responsible for referring her for community therapy services once she could start putting weight on her leg. Any delay in referral between mid-July 2021 (when Mrs X could start putting weight on her leg) and mid-August is not the fault of the organisations that are the subject of this investigation.
61. Oxleas Trust was responsible for Mrs X’s community physiotherapy since August 2021. Its records show it acted quickly when it received a referral and attempted to see Mrs X regularly. Any missed appointments during the period of this investigation (to April 2022) were not due to fault by Oxleas Trust.
62. Oxleas Trust referred Mrs X to the moving and handling team after three sessions with its physiotherapists. I do not consider the time Oxleas Trust took to make the referral to be fault. It was reasonable for the physiotherapy team to see Mrs X a few times to understand her needs and any issues with moving and handling before deciding that she needed a referral for specialist help with moving and handling.
63. I have not investigated the delays in the moving and handling team’s management of Oxleas Trust’s referral. This is because the moving and handling team is part of another organisation which is not the subject of this investigation.

D – Equipment

64. The complainants are concerned that a delay in moving Mrs X’s equipment from her flat to her residential care settings delayed her recovery and return to mobility.

What happened

65. Mrs X had a specialist recliner chair in her own home. When she was ready for discharge in April 2021, KCH Trust’s moving and handling assessment said she did not need this type of chair. Instead, she needed a bariatric ‘static tilt in space’, which is a specialist wheelchair that can be reclined. Sundridge Court did not hoist Mrs X out of bed so she could sit out. Therefore, this was never used.
66. When Mrs X went into hospital again in May 2021, therapists used a hoist so
    Mrs X could sit out in a specialist chair. Hospital records indicate Mrs X was often very anxious about repositioning, hoisting and sitting out and would sometimes decline offers to do this. Notes from a joint physiotherapy and occupational therapy review in late June 2021 say the following.
• Mrs X was using controls to place herself in an unsafe position in the specialist recliner chair. Mrs X was aware her position was unsafe but did not wish to change it and preferred to be in bed.
• Mrs X could only tolerate short periods of sitting out and felt very anxious when doing so.
• Mrs X would therefore be discharged from hospital as “bedbound”.
• Community therapy teams would need to reassess Mrs X’s transfer and mobility needs when she was allowed to start putting weight on her leg.
67. KCH Trust therefore decided that it would not supply Mrs X with a specialist recliner when it discharged her from hospital in early July 2021.
68. The orthopaedic clinic stated it was happy for Mrs X to start putting weight on her leg in mid-July.
69. In mid-August 2021, Mrs D told the Council that Mrs X’s own recliner needed to be transferred to Home B and asked for help with this. The Council agreed to arrange the move within 10 days.
70. Mrs X had not received her chair by early September 2021 and the Council chased this up. Its specialist equipment service said it had been unable to contact Mrs D to arrange access to Mrs X’s home, despite several attempts. The Council emailed Mrs D on the same day to ask her to contact the service direct to arrange a suitable collection time. Mrs X received her chair later that month.

Was there fault causing injustice?

71. Specialist assessments determined Mrs X should not be using her recliner after leaving hospital in April and July 2021, until she could put weight on her leg and be seen by community therapists. Those assessments are detailed, reasoned and based on relevant information available at the time. I have therefore found no fault in:
• KCH Trust’s decisions that a recliner was not appropriate equipment for Mrs X following the two hospital discharges;
• Mrs X’s own chair not being transferred to Sundridge Court; and
• Mrs X’s chair not being moved to Home B while Mrs X was non-weight bearing.
72. There was some delay between the Council agreeing to the complainants’ August 2021 request to move Mrs X’s chair from her flat to Home B. However, some of the delay can be explained by the equipment service’s difficulties in making an appointment to collect the chair. It is also unlikely that Mrs X would have been able to use the chair therapeutically until she started receiving community physiotherapy services in October 2021. I therefore consider there was no fault or injustice in the delay in moving Mrs X’s chair from her flat to Home B.

E – Complaint handling

Relevant law and guidance

73. The complaints procedure for councils and NHS organisations is set out in the Local Authority Social Services and NHS Complaints (England) Regulations 2009. Under the regulations, anyone who is dissatisfied with a decision made by the council or NHS is able to make a complaint about that decision and have the complaint handled by the council or NHS.
74. Regulation 9 is about complaints that concerns more than one organisation (‘responsible body’). It says responsible bodies must co-operate in handling the complaint. This includes duties to: establish who will lead the process; share relevant information; and provide the complainant with a coordinated response.
75. The Local Government and Social Care Ombudsman (LGSCO) has published guidance called Effective Complaint Handling for Local Authorities. It recommends that councils:
• speak to complainants where possible, to help them accurately define the complaint from the complainants’ point of view; and
• agree with complainants how their complaints will be handled.
76. The Parliamentary and Health Service Ombudsman (PHSO) has published guidance called Good Complaint Handling. This includes the following recommendations.
• Listen carefully.
• Confirm the complainant’s concerns and the issues to be investigated.
• Ask the complainant what they want to achieve.

What happened

77. In September 2021, Mrs D complained to the Council through its website. The complaint was about problems with Mrs X’s care and equipment in Sundridge Court and Home B, and lack of rehabilitation for Mrs X. Mrs D said what she had written on the complaint form was just a summary and asked for a discussion.
78. There is no indication the Council discussed the complaint with Mrs D before responding to her. The Council replied to Mrs X’s complaint in October 2021 and referred her to LGSCO if she remained dissatisfied. The Council’s complaint response identified that parts of Mrs X’s care were delivered by KCH Trust but did not arrange a co-ordinated response with the Trust.
79. Mrs D complained to LGSCO in November 2021. In December 2021, we asked the Council to reconsider the complaint, working together with KCH Trust to provide a response to Mrs D.
80. The Council attempted to coordinate a joint complaint response after our initial decision. The Council considered that Mrs D’s written complaint was clear enough and that it did not need to contact Mrs D for further clarification.
81. Having reviewed its records and Mrs D’s written complaint, KCH Trust decided the complaint was about Mrs X’s care outside hospital and so not a matter for the Trust. The Trust informed the Council of this. The Council therefore wrote to
    Mrs D on 29 April 2022 summarising its final position and confirming its complaints process had been concluded. It referred Mrs D back to us.

Was there fault causing injustice?

82. The Council had agreed with LGSCO to coordinate a joint response with KCH Trust to Mrs D. We would therefore expect the Council to have:
• contacted Mrs D to discuss her complaint and clarify the full extent of her concerns about both social care and health issues; and
• shared this information with KCH Trust to enable it to respond to any parts of the complaint that relate to its responsibilities.
83. The Council’s failure to do so was contrary to our guidance and therefore fault. As a result, it was not until Mrs D contacted the Ombudsmen for the second time that we were able to clarify the full extent of her complaints and the various organisations’ responsibilities. This has added avoidable time, trouble and frustration to Mrs D’s complaint experience. I have recommended a remedy for Mrs D and service improvements below.
84. I have not found fault in KCH Trust’s actions, as it considered it had no complaint to answer based on information provided by the Council.

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Agreed actions

85. Within a month of the date of my final decision, the Council will:
• write to Mrs X and Mrs D to acknowledge the problems identified in this decision statement and apologise for their impact on the complainants;
• pay Mrs X £1,000 in recognition of the injustice described in section B above;
• cancel any outstanding invoices for Mrs X’s contribution to her care at Sundridge Court; and
• pay Mrs D £100 in recognition of the avoidable time, trouble and frustration caused by flaws in its complaint handling.
86. Within three months of my final decision, the Council will:
• discuss with relevant staff the process for dealing with adult social complaints that may involve elements of health care and related guidance; and
• provide the Ombudsmen with documentary evidence of the discussion.
87. Within a month of my final decision, Sundridge Court will:
• write to Mrs X and Mrs D to acknowledge the problems identified in this decision statement and apologise for their impact on the complainants; and
• pay Mrs X £1,000 in recognition of the injustice described in sections A and B above.

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Final decision

88. We uphold the complaints against the Council and Sundridge Court relating to hospital discharge, care at Sundridge Court, and complaint handling. We do not uphold the other complaints. The Council and Sundridge Court have accepted our recommendations, so we have completed our investigation.

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Investigator's decision on behalf of the Ombudsman