Summary: Miss C complained about the service provided to her mother Mrs D by the Council’s adult social care team. We uphold two parts of the complaint. First, that there is an ongoing service failure by the Council, because it cannot secure a residential care home placement for Mrs D in its area. Second, we find there have been some failings in the personal care Mrs D has received while living in a care home out of Borough. The Council accepts these findings. At the end of this statement, we explain what action the Council has agreed to take to remedy the injustice caused by these faults.

The complaint

1. I have called the complainant ‘Miss C’. Miss C’s complaint concerns the service provided to her mother, Mrs D, who since March 2021 has lived in a residential care home outside the Council’s area. Miss C complains:

• she did not receive adequate support in caring for Mrs D, when she lived with her between January and March 2021 before moving to residential care;
• that since it was agreed Mrs D’s needs should be met in a care home, the Council has been unable to offer her a place in a care home in its area;
• that the care home where Mrs D lives, Springview (operated by Springdene Nursing and Care Homes Ltd – whom I will refer to as ‘the Care Provider’) has not always met Mrs D’s needs because of failings in the care provided.

2. Miss C says as a result Mrs D is living in a care home that is too far away for her to visit more often than at weekends. Nor can other friends visit Mrs D because the care home is too far away from her former home. Miss C says this causes both her and Mrs D distress. Miss C says both have also suffered further distress, and Mrs D has twice been admitted to hospital, because of poor care by the Care Provider.

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The Ombudsman’s role and powers

3. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
4. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

7. Before issuing this decision statement I took account of the following:

• Miss C’s written complaint to the Ombudsman and supporting information she provided, including that gathered in a telephone call and via emails;
• correspondence between Miss C and the Council about the matters covered by the complaint which pre-dated our investigation;
• information provided by the Council in reply to enquiries;
• any relevant law or Government guidance referred to in the text below;
• any relevant guidance issued by this office, including the Ombudsman’s guidance on remedies.

8. I also gave both Miss C and the Council a chance to comment on a draft version of this decision statement and to provide me with any further evidence considered relevant to the content. I took account of any comments or new evidence they provided before issuing this final decision statement.
9. Miss C and the Council should note that under an information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share the final decision statement with CQC. This will be in advance of publication on our website.

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What I found

10. Below I set out what I consider are the key facts forming the events covered by this complaint. This is not intended to be exhaustive and so it does not mention every interaction between Miss C, Mrs D and the Council or the Care Provider. I have only referred to those facts I consider necessary to reach findings on the complaint.

Key facts

The complaint about events January – March 2021

11. I note at the outset that Mrs D is a single woman in her mid-nineties. During the events covered by this complaint she has been diagnosed with dementia. She is also registered blind and deaf, having only limited sight and hearing. She also has a health condition that means she must eat a low-fat diet. At the beginning of the events covered by this complaint (January 2021) Mrs D had lived in the Council’s area for nearly seventy years and in the same flat for over sixty years.
12. In January 2021 Mrs D suffered a fall at home and was admitted to hospital. Miss C alerted the Council Mrs D was in hospital and when a social worker called the following day, Mrs D had been discharged to Miss C’s care.
13. On discharge, Mrs D moved in with Miss C. This arrangement was not suitable for anything other than short-term care for Mrs D. The property was too small, being a one-bed flat Miss C shared with her partner. She was also, at the time, working from home. The property was therefore too cramped and not suitably adapted for Mrs D's limited mobility.
14. In February 2021 the Council assessed Mrs D’s needs and by the middle of the month it had agreed, in principle, that she should move on a short-term basis into a care home. In the meantime, the Council provided some home care for Mrs D. Care workers visited her at Miss C’s flat once a day to help with her personal care. The Council offered more visits and the option of a night-sitting service, but Miss C declined these. She could support her mother with other care needs and the flat was too cramped to accommodate an extra person overnight.
15. The Council’s case notes indicate that in February 2021 it told Miss C that it could not place Mrs D in a residential care home close to her former home. Its notes say this was due to reasons "mostly about the quality of care”, although Miss C says she was not given an explanation at the time. The Council told Miss C that it would need to look at funding a placement for Mrs D out of the Borough. Soon afterwards, it identified a placement in a neighbouring Borough. But Miss C when visited that care home, she rejected it as unsuitable.
16. Around a week later, Miss C identified Springview instead as a suitable placement and the Council agreed. This care home is also out of the Borough, being between nine and ten miles from Miss C’s home and Mrs D’s former home (which are located nearby each other). However, it was close to the home of Miss C’s sibling, meaning that Mrs D would receive regular visits.
17. Mrs D moved to Springview in mid-March 2021.
18. In January 2022 Miss C made a complaint and part of this included that she did not receive more support in caring for Mrs D between January and March 2021. In its reply the Council said it had done what it could to support Miss C in caring for Mrs D when she moved into Miss C’s flat, offering up to three calls for care workers a day and a night-sitting service.

Complaint about lack of accommodation in Borough from March 2021 onward

19. Miss C found it hard to visit Mrs D in her care home due to the distance involved, her own work commitments and her own health needs and those of her partner. After several months, Miss C bought a car because she found using public transport took so long and to cut the journey time. She also needed to support Mrs D attending appointments. But she was still unable to visit during the week because of the distance involved and her work commitments.
20. The Council’s notes show that from March 2021 onward, its officers recorded the Council was not commissioning "any standard residential beds" within Borough (the term ‘commissioning’ refers to when the Council contracts with care providers). So, it could not accommodate within Borough any person whose needs met this description. I found in April 2021 the Council recorded telling Miss C that it could not provide a bed for Mrs D in a particular care home within the Borough, as that care home did not offer ‘standard’ residential care beds.
21. Information provided in reply to my enquiries by the Council shows that there are four residential care homes in its Borough who specialise in care for older residents. Three of these are run by a single operator out of buildings which are owned by the Council. The fourth is run by a charity which gives preference to those whom it already accommodates in other charitable accommodation.
22. Around April 2021 Miss C also began communicating directly with the care provider that runs the three residential homes within Borough. It told her that it could not accept new placements because it needed to carry out essential building repairs on the care homes. In subsequent communications the care provider gave Miss C different dates for when the care homes may once again accept new placements arranged by the Council. All of those dates have subsequently passed but all the care homes are currently advertising they are not accepting new residents. Miss C says that when she spoke to the care home over the telephone she was led to believe that it may be able to accommodate Mrs D if she was self-funding her own care.
23. The Council provided information showing it suspended placements in these care homes until building works, related to fire safety improvements, completed. An inspection of one of the care homes, available on the CQC website, also refers to this work. The Council says there was delay initially in agreeing the scope of the works with the care provider.
24. By June 2021 Mrs D had been provisionally diagnosed as suffering dementia. The following month the Council agreed it should place her on a waiting list for a ‘dementia residential’ bed. This is a different category of placement, as the care home must be registered with the CQC as suitable to provide residential care for those with dementia. However, there are no further homes in the Borough that offer this type of accommodation.
25. In September 2021 Miss C reported a potential placement within the Council’s area. In November 2021 the Council reported explaining to Miss C that Mrs D could not have a placement at that home, because it was a nursing home and not a residential care home. Sadly, also in September 2021, Miss C’s sibling who lived close to the care home died.
26. In January 2022 Miss C made a complaint to the Council that Mrs D was still living out of its area. Miss C explained the difficulties she experienced visiting Mrs D and why it was in Mrs D’s interests she move.
27. In its reply, the Council said it had very few available beds in its area in ‘normal times’ and the COVID-19 pandemic had increased pressure on beds. It said that it could not offer a placement in its area at that time.
28. In February 2022, when Miss C escalated her complaint, she said she had received different explanations for why the Council could not offer Mrs D a care home placement in its area. After chasing, the Council replied in May 2022. It said it had made more enquiries to see if there was a suitable vacancy for Mrs D in its area but there remained a shortage, with places dependent on high standards of safety and quality as well as cost. The response also said the Council could help Miss C to visit Mrs D more often, although it did not say how.
29. In July 2022 Miss C contacted another nursing home in the Council’s area, which suggested that if Mrs D was referred by the Council it may have a bed available. The Council explained it could not refer Mrs D’s case as the care home was a nursing home and that it had assessed Miss C as needing a residential care placement.
30. The Council says the current position is that expects all three of the residential care homes undergoing building works to be ready to accept new placements arranged by it, by the end of summer 2023. This is subject to satisfactory ‘sign off’ of works by building control inspectors and the London Fire Brigade. It has a waiting list for those in care homes wanting to move back into the Borough and it says Mrs D’s name is on that list.

Complaint about standards of care at Springview

31. I noted that when Mrs D entered the care home, the Care Provider drew up its own care planning documents for her care. The versions I am provided with were initially drawn up in March 2021 and most recently updated in September 2022. The current care planning documents include a specific part covering Mrs D’s nutrition needs and this says she needs a low-fat diet. It says Miss C will make menu choices on Mrs D’s behalf. She will also provide additional snacks for Mrs D which she should be offered. Miss C says because Mrs D’s diet is limited, there is only ever a limited menu (in effect) that she can choose from.
32. The care planning documents also refer to Mrs D being offered the choice of a shower and hair wash each day. And that at night Mrs D’s routine has always been to go to bed around 10:00pm and this should be maintained.
33. In early April 2021 Miss C made the Council aware of concerns she had for Mrs D’s care at the care home. She told Mrs D’s social worker that the care home was not ensuring Mrs D received food in accord with her dietary needs and nor was it providing Mrs D with regular showers. The Council took these matters up with the Care Provider which said that Miss C’s allegations were incorrect. In response, the Council agreed to arrange an urgent placement review.
34. Later in the month, Miss C made the Council aware that she understood Mrs D was being put to bed much earlier than expected; or else was left sitting in her room in a state of undress as she had not got into bed. The Council contacted the Care Provider to express its concern at this. Next, Miss C reported that the care home left Mrs D’s hair unwashed and made her use a commode when she could use the toilet. In response to these concerns the care home arranged for Mrs D to have her hair washed and removed the commode.
35. In August 2021 Mrs D was on the telephone to Miss C who told her she had been left sitting in her room, in her underwear, as she did not want to go to bed early. Miss C said that she tried to speak to staff at the care home about this, but they terminated her calls. So, Miss C telephoned the police. When the Council learnt of this it was concerned by the events Miss C described. So, it told the care home to contact the local adult social care team where it is based and report the incident as a safeguarding concern. This, the Care Provider went on to do. Later in that month, Miss C reported further concerns about Mrs D’s personal appearance indicating a lack of personal care and that she had twice visited to take her mother for lunch to find the care home had already provided this.
36. In November 2021 Mrs D was admitted to hospital for treatment for an infection. Miss C said the Care Provider was not ensuring Mrs D received the correct diet related to her health needs and this resulted in the infection. This was something denied by the Care Provider which said that Miss C would make dietary choices for Mrs D each week. Around this time Miss C also raised a concern the care home did not always answer when Mrs D rang a call bell alarm, meaning she required assistance.
37. In December 2021 the Care Provider shared records with the Council showing how it had responded to any call bell alarms from Mrs D.
38. Later that month, Mrs D was admitted to hospital a second time for the same reasons. This led Miss C to again ask more questions about Mrs D’s diet. In January 2022 the Care Provider agreed to keep a photographic record of the food given to Mrs D.
39. Also, in December 2021 the Council received an update on the safeguarding investigation. It was brief, with the social worker from the neighbouring authority commenting only that Miss C wanted Mrs D to move to the Council’s area and asking if the Council would support such a move.
40. As part of her complaint in January 2022, Miss C also raised concerns about the quality of care Mrs D received. The Council said it had liaised with the Care Provider over Mrs D’s care to address concerns and said it considered the care she received was “not unsuitable”.
41. As part of her complaint escalated in February 2022, Miss C reiterated her concerns. In its reply, sent in May 2022, the Council said it had received further assurances from the Care Provider that Mrs D remained well cared for at the care home. But that it was looking at what extra support she might need and would convene a care review meeting shortly.
42. While waiting for this reply, in March 2022, Miss C had raised a further concern about staff not replying to Mrs D’s call alarm. This followed an occasion when she was on the phone to Mrs D who said she was pressing the alarm and no-one answered. The Care Provider investigated and again found no evidence it was not answering Mrs D’s alarm calls, sharing those records with the Council.
43. This led Miss C to question if Mrs D knew how to use her call alarm bell and she asked for the Care Provider to provide support to her in this area. She also requested that staff provide more verbal prompts to Mrs D in view of her limited vision.
44. Following Mrs D’s diagnosis of Alzheimer’s, she was found not to have capacity to consent to make choices about her living arrangements. Consequently, the Council has to obtain authorisation under the deprivation of liberty safeguards, that her placement with the Care Provider is in her best interests. In June 2022 that authorisation was reviewed (and later renewed in September 2022), with the assessor finding Mrs D was well looked after and settled at the care home.
45. However, it is also recorded on Mrs D’s care records that an NHS professional who is part of the team that assessed Mrs D as having Alzheimer’s disease symptoms, believed it would be in her best interests to move back to the Council’s area. This is also a view the Council holds but says it cannot move Mrs D at this time due to the ongoing shortage of suitable beds.

My findings

The complaint about events January to March 2021

46. I did not find fault in the Council’s actions during this period. First, I found no evidence that any NHS body alerted the Council to Mrs D’s admission to hospital in January 2021, which was brief. The Council was afforded no opportunity therefore to assess Mrs D’s social care needs when she was in hospital, meaning it had no part in the decision to discharge Mrs D to Miss C’s care.
47. I recognise that Miss C’s home was not a suitable long-term arrangement for Mrs D’s care. But I found there was never any dispute on this point from the Council. And once the Council completed its assessment of Mrs D’s social care needs, it quickly found a care home placement for her. While I understand Miss C’s reasons for rejecting this, there is a lack of evidence to show the initial care home it offered was unsuitable.
48. When, within around a week, Miss C found a care home she considered more suitable, the records showed the Council did not delay in agreeing that placement with the Care Provider.
49. The only potential delay therefore arose in the time taken from the Council learning of Mrs D moving in with Miss C and it completing its social care needs assessment. I found this took around a month. This was less than ideal given the pressure on Miss C and Mrs D caused by their cramped living conditions. But I do not consider it sufficient to find fault. This is because we consider it reasonable for councils to take around a month to complete such assessments, where satisfied that care needs are being met in the interim. So, this takes account that during this time Mrs D’s care needs were met through a combination of Miss C’s efforts and some outside support from a care agency.
50. I noted also the Council offered Miss C more support with home care in this time. I understood Miss C’s reasons for rejecting this, but I did not find the Council should have offered anything different. This was after taking account of the narrow window of time under consideration and that it was still assessing Mrs D’s long-term needs. So, for example, I did not think it was fault that there was no discussion of Mrs D receiving respite care during this time.

The complaint about a lack of residential care accommodation in Borough after March 2021

51. In considering this part of the complaint I began by studying the statutory care and support statutory guidance given to councils by Government. This tells councils that they must “have regard to ensuring a sufficiency of provision – in terms of both capacity and capability – to meet anticipated needs for all people in their area needing care and support – regardless of how they are funded”. This means councils should plan for how many people in their area are likely to need different types of social care, including residential and nursing care, and look to ensure there are enough places to meet that need.
52. The Council sent me a copy of its ‘market position statement’ which demonstrates how it looks to fulfil this duty. It notes there are eight care homes within the Borough providing residential or nursing care. It says the Council currently has a ‘block’ contract with five of these homes, meaning that it commits to buying a certain number of placements a year from the providers. In other cases, it will enter 'spot contracts’ with providers, which means it will buy care on a one-off basis for individuals who need care. The Council says it is committed to continuing with existing block contracts and working with those other providers, so long as they receive a positive CQC inspection report.
53. Neither the law nor its policy therefore places an obligation on the Council that it will always be able to ensure that someone who needs a residential care bed will be provided one in its area. I consider there are factors which may always impact the Council’s ability to do this. For example, if there is an unexpected demand when a council may have to look outside its area for beds.
54. However, the guidance still places an onus on the Council to do what it can to secure enough residential and nursing home placements in its area for those who need one. So, it should be the exception and not the rule if the Council finds it cannot meet demand in its area. It is therefore a service failing if the Council finds itself in the position where it cannot purchase residential or nursing home beds in its area for a prolonged period of time.
55. That is the case here. Because for nearly two years now, the Council has had no beds it can offer Mrs D, whom it has assessed as needing a residential care placement (up to July 2021) and then a residential care placement specialising in dementia care (from July 2021). Our investigation found only four care homes in the Borough, which offer such care (one of which is small and run by a charitable institution that prioritises residents it already supports in another housing scheme). The Council has a block contract with the three larger homes, with the care provider contracts to run three care homes which are in the Council’s ownership. That contract has effectively become suspended while the care homes undergo building renovations.
56. I cannot find fault with the Council requiring these building works. But it is deeply concerning this suspension of available beds has now gone on for so long. However much the position may be unavoidable it creates an ongoing service failure, as Mrs D is not being provided with accommodation where the Council has said her needs will best be met.
57. I also found the Council had communicated poorly with Miss C about the reason for the shortage of beds. While Miss C became aware that building works were a possible explanation for why Mrs D had not been moved back into the Borough, this was one of several reasons put to her. Neither her communications with Mrs D’s social worker nor the replies to her complaint made the position clear.
58. It is one of our key principles of good administrative practice that councils be open and transparent with citizens when they complain. I considered the Council fell short of that explanation here and that was a fault.
59. I also considered the Council could have been clearer at times in explaining the different categorisations of need when someone needs a ‘care home’ placement. Each care home will be registered by the CQC to provide a particular kind of care (or a combination). So, when an individual’s needs are established, they should be matched with a care home suited to those needs. I can see that in this case confusion surfaced because Miss C identified care homes with vacancies in the Council’s area. But these were care homes providing nursing as opposed to residential care, which up to now the Council has not assessed Mrs D as needing. I found the Council had sought to explain this to Miss C, but I thought it could have set this out more clearly at the outset. So, there was some fault in these communications also.
60. As a result of the service failing and faults, I found Miss C and Mrs D suffered injustice because:

• Mrs D had missed out on accommodation where she would see more of her daughter and friends;
• Miss C had missed out on time spent with her mother and suffered inconvenience in the travel time taken to visit her;
• Miss C also missed the opportunity to make a more informed choice on whether, in the ongoing absence of a care home placement within the Borough, another placement outside the Borough but closer to Miss C and / or Mrs D’s home may have been more suitable;
• Miss C was put to unnecessary time and trouble in making unnecessary enquiries of care homes in the area that would not meet Mrs D’s needs at this time.

The complaint about care home standards

61. My starting point in considering complaints about the quality of care in a residential care setting is to consider the ‘fundamental standards’ for care expected by the CQC. These are set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations). The CQC issued guidance in March 2015 on meeting the regulations.
62. I consider the following Regulations relevant to this complaint.

• Regulation 9 – this requires care providers to deliver person-centred care, which includes recognising personal preferences wherever possible.
• Regulation 10 – this requires care providers to treat people using their services with dignity and respect. This includes making sure people have privacy when it is needed.
• Regulation 12 – this aims to ensure that people using care services do not receive unsafe care and treatment. It requires providers to prevent avoidable risk of harm.
• Regulation 14 – covers nutritional and hydration needs. This says providers must ensure people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. This is to reduce risks of malnutrition and dehydration.

63. I find there is evidence to suggest that on occasion, and especially when Mrs D first moved into the care home, her care may have fallen short of the standards expected. In particular, the case notes suggest that Miss C’s complaints about Mrs D’s personal care (showering and hair care) and being put to bed early or being left to sit in her underwear, were supported by the Council. This suggests there were occasions therefore when Mrs D did not receive care that was person centred and/or was not treated with dignity and respect.
64. On balance, I also consider it likely the Care Provider has sometimes failed to meet Mrs D’s dietary needs. Miss C has relied on Mrs D’s first-hand accounts of what she has eaten when raising this with the Council and Care Provider. While there is evidence in the notes that Mrs D may not always recall events accurately, I think it unlikely she has been mistaken every time she has reported eating food outside her diet plan. In particular, it is not clear that when offering snacks (which will not appear as menu choices) that staff have adhered to offering low fat choices.
65. That said, I think it likely that matters have improved over time and there is no fault in the care planning documents the Care Provider has for Mrs D at this time. I also find there is no evidence to support the failure of the Care Provider to answer call bells. I also consider there is no evidence that would enable to me to reach a finding that staff have spoken to Mrs D inappropriately. I noted Mrs D’s care plan appeared to offer good advice on this point to care workers. And Miss C made a sensible suggestion when asking the Care Provider to help Miss C understand how her call alarm works.
66. On balance, I consider any failings here unlikely to have had a significant negative impact on Mrs D’s care. Evidence for this can be found in the decision taken by the neighbouring London authority not to take any significant action further to the safeguarding alert which was raised in August 2021. Also, in the best interest decision making reports drawn up to approve Mrs D’s continuing placement in the care home. While I accept failings in keeping to Mrs D’s diet plan could also result in health complications there is also no evidence to demonstrate her admission to hospital resulted directly from this. And overall, I find the Council has taken seriously all of Miss C’s concerns expressed about Mrs D’s care and sought to intervene at times to ensure she received better care.
67. Yet despite all this there will have been some avoidable distress caused to Mrs D and by consequence, Miss C, for those occasions when the quality of care has fallen below standard.

The Council’s complaint handling

68. Finally, I consider it appropriate to comment on two aspects of the Council’s complaint handling where there has been fault. First, there was a delay of around three months in responding to Miss C’s complaint when she asked for a review of its reply to her initial complaint (which forms part of the Council’s complaint procedure). It is also apparent Miss C had to chase the Council for a response and it did not keep in touch with her. Both the delay and failure to keep in touch were unacceptable.
69. Second, I have commented above that I consider the Council should have been more open about the reasons why it could not secure a residential care home bed for Mrs D, when replying to Miss C’s complaint. But I also note the Council made a statement that it may be able to help Miss C with visiting Mrs D. That statement was vague, and it is not clear what the Council had in mind. And when pressed, it has not told us what it meant by this statement although it apologised for not following this up and indicated a willingness to do so. When offering to take action further to a complaint the Council should ensure it is specific about the action it will take. It should for example, explain who will be taking the action, what it will consist of and by when.
70. These faults also added to Miss C’s injustice in the form of her frustration, time and trouble. It is noted also this was at a time of exceptional pressure for Miss C coping with her own illness and bereavement, as well as trying to support her mother.

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Agreed action

71. The Council accepts the findings set out above. In order to remedy the injustice I have identified above, it has agreed that within 20 working days of this decision it will:
1. apologise to Miss C, accepting the findings of this investigation;
2. pay Miss C £500 in recognition of her distress, time and trouble and that of Mrs D;
3. put forward its proposals for supporting Miss C in visiting Mrs D initially referred to in its complaint response to Miss C;
4. complete a reassessment of Mrs D’s needs (to complete within the following 20 working days) to see if she may now qualify for nursing care and if so, look for a nursing home bed in its area without delay (it has told us it has already begun this). In the event Mrs D is still assessed as needing a residential placement, then the Council should give information to Miss C as to her position on the waiting list; how that has been prioritised and how quickly it anticipates being able to offer a placement in one of the residential homes upon the building works being ‘signed off’.
72. In addition, the Council has agreed to try and learn some wider lessons from this complaint. Within 40 working days of this decision it will:
1. ensure our concern about the shortage of residential care beds in the Borough, caused by the ongoing building works affecting the three residential care homes is shared with the senior officer and elected Member with responsibility in this area. They will write to us with an update to explain the cause of any ongoing shortage, how long it is expected to last and any further action being taken to keep any ongoing shortage of beds to a minimum;
2. give a reminder to relevant social work staff and those who work with complaints about our expectations around openness and transparency; that in communications with users of services and their relatives who are in the same position as the complainant, the Council should be clear about the reasons for the shortage of residential care beds and how long it expects this to last;
3. issue a reminder to staff who deal with complaints of the need to be specific about the action to be taken (and by when and by whom) when agreeing to take action to remedy a complaint.
73. The Council should provide us with evidence it has complied with the above actions.

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Final decision

74. For reasons set out above I upheld this complaint finding fault by the Council causing injustice to Miss C and Mrs D. The Council accepted these findings and agreed actions that I considered would remedy that injustice. Consequently, I completed this investigation satisfied with its response.

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Investigator's decision on behalf of the Ombudsman