Summary: Mr B complained about the actions of a Care Provider because he says his late mother’s rings went missing in one of its nursing homes. He also said the Council did not do enough to investigate the matter. We did not find fault by the Council. The Care Provider failed to follow its procedures as it did not ensure a record of belongings form was signed by its staff and Mr B’s mother. This is likely to leave Mr B with uncertainty about the whereabouts of his mother’s rings. The Care Provider has agreed to our recommendations and will apologise to Mr B and improve its procedures to ensure residents belongings are properly recorded, agreed, and signed by the resident or their representative.

The complaint

1. The complainant, who I shall refer as Mr B, complains about the actions of Akari Care Limited (the Care Provider), who own and manage St Marks Court which is the residential nursing home where his late mother, Mrs G, was placed from July 2021. Mr B says the Care Provider did not act to safeguard his mother’s valuables and this resulted in the loss or theft of several items including her treasured engagement and wedding rings which he said had much sentimental value. Mr B complains the Care Provider did not conduct a thorough investigation and he suspected its staff falsified or created documents and statements after the event to mislead the findings of the investigation. He says the Care Provider did not act in accordance with the contract it had in place with Gateshead Metropolitan District Council (the Council) so the Council should have done more to investigate the matter
2. To put things right Mr B wants the Care Provider to apologise for the loss or theft of his mother’s items, make a payment to acknowledge the distress and time and trouble caused to him and his family. He also wants the Care Provider and the Council to learn lessons and improve practice to prevent the same thing happening again.

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The Ombudsmen’s role and powers

3. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA)
4. 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)).
5. 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.
6. 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

7. Evidence used to consider this complaint includes:
• written and verbal information from the complainant;
• documents and enquiry responses from the Council and the Care Provider; and
• the law, guidance and good practice relevant to this complaint.
8. All parties had an opportunity to respond to a draft of this decision.
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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What I found

Guidance and administrative context relevant to this complaint

10. The Council has a residential and nursing care contract in place with the Care Provider. In relation to record keeping and personal possessions this says,
• ‘The provider will maintain procedures for the keeping of records that comply with all relevant statutory requirements. These records will include those required by the Care Standards Act 2000, and any regulations and amendments. It is the responsibility of the provider to comply with all current statutory requirements
• The provider will maintain a true and correct set of records in such form as the Council may from time to time specify pertaining to all activities relating to its performance of this contact and all transactions related thereto, such records to be agreed with the provider.
• The Provider shall ensure all employees recognise that each Service User’s room and their possessions are private and personal and are respected as such. Any item belonging to the Service User can only be disposed of with the permission of the Service User.
• The Provider must make a record of every item of personal property which is brought into the Home which is brought to their attention by the Service User or their representative when a Service User is admitted. This property register should be regularly maintained or updated.
• The Provider shall ensure that the Service User is informed as to what is covered by the Provider’s insurances for loss and/or damage to personal property.’
11. The Care Provider has a ‘Record of Residents Belongings Policy and Procedure’ in place dated May 2021. The policy and procedure document says,

‘Akari Care understands the importance of residents who are admitted to our homes being able to bring in items which are important to them. This policy aims to:

• Ensure residents’ property is properly accounted for
• Ensure there is adequate provision for safekeeping of residents’ property.
• Provide assurance for residents and relatives; and
• Provide safeguards for staff against inappropriate and false accusation...

Any items bought into our homes must be recorded on the resident record of belongings form with a description and photographs should be taken of all furniture, jewellery, and personal items. This must be held in a log at the home. Where [electronic recording system] is in use photographs can be uploaded onto the system. For homes not yet on [electronic recording system], photographs should be saved onto the admin PC.

The record of belongings form should be signed by the resident/family member/appropriate representative as well as by the staff member admitting the resident into the home.’

Background

12. Mrs G became a resident in the Care Provider’s home, St Marks Court, at the end of July 2021. The Care Provider said it completed an inventory of Mrs G’s belongings on its electronic recording system. It confirmed it did not take photographs as it recorded Mrs G was admitted to St Marks Court without jewellery.
13. During her stay Mrs G became unwell and moved rooms in the home from residential care to a room with nursing which was located on a different floor.
14. Mrs G remained in the Care Provider’s home until 26 October when her health deteriorated, and she later passed away.

What happened

15. Mr B said he complained to the Manager of St Marks Court in November about the loss of his mother’s belongings as well as other matters. The missing possessions included his late mother’s diamond engagement ring and her gold wedding ring. He said these had great sentimental value.
16. Mr B also complained to the Council in November. He sent the Council a photograph showing his mother’s hands wearing her engagement and wedding rings. He said this showed her enlarged knuckles which meant her rings would be difficult to remove unless by force.
17. Mr B said St Mark Court’s Manager initially provided him with verbal information about the loss of his mother’s rings but said this conflicted with a later written report he received.
18. The Care Provider initially replied to Mr B’s complaint in writing in February 2022. In summary it said:
• two of its staff completed an inventory when the PA was admitted to the Home and both staff members said Mrs G did not have jewellery on.
• it had interviewed 26 members of staff and received statements, but staff did not recall Mrs G wearing rings when on the residential floor and nursing floor.
• it had checked the photograph Mr B had provided of his mother wearing her rings and if the rings had been removed it was possible his mother would have had injury to her fingers. Its records did not show injury to Mrs G’s fingers.
19. Mr B remained unhappy with the response and replied saying St Mark Court’s Manager had told him a staff member recalled seeing his mother wearing her rings. He said this stamen was later retracted. He also said the Manager initially told the police his mother had lost weight and so her rings could have fallen off. He also referred to incorrect dates in the report.
20. The Care Provider sent Mr B a second response in March 2022. It apologised for the incorrect dates but did not come to a different view to the first letter it had sent.
21. The Council also responded to Mr B’s complaint and said:
• it did not carry out a separate investigation to the Care Provider as the complaint was about its staff.
• it did not further investigate the allegations because the police had investigated and later closed the case.

Findings

22. Mr B has provided evidence to show his late mother wearing the rings which are the subject of this complaint. He said their value was more sentimental than intrinsic. The Care Provider’s contract with Mrs G referred to personal property and said, ‘in the event that individual items of personal property exceed £250 in value, we encourage you to take photographic evidence of these items before bringing these items into the Care Home.’ Mr B is adamant his mother entered St Marks Court with the rings on her finger although it is unknown when he took the photograph showing his mother’s hand wearing her rings.
23. The Care Provider said when Mr B first contacted it to report the loss, he said there was one ring missing but then alleged two rings had gone missing. When Mr B made his complaint to the Ombudsmen he reported two rings missing. The Care Provider escalated the allegation of theft to the police and this was appropriate action to take.
24. The Council’s contract with the Care Provider clearly sets out its expectations around personal possessions. The Councils Contract Monitoring Officers visited the home three times between 2019 and 2021. The Council’s officers also completed quality reviews. This provides evidence the Council monitored
    St Marks Court.
25. The Council did not investigate the allegations made by Mr B and I do not find fault with the way it made this decision. The police and the Care Provider were best placed to investigate the matter.
26. The police did not find fault with the Care Provider or the Council following its investigation and Mr B confirms the police case is now closed.
27. Mr B said the Care Provider did not adhere to the contract it had in place with the Council. The Council expected the Care Provider to have a policy and procedure in place to safeguarding residents’ belongings and personal possessions. The Care Provider provided evidence to show that it adhered to this part of the contract it agreed with the Council.
28. In response to our enquiries the Care Provider said the electronic form ‘did not have the facility for a signature to sign the agreement at that time and this is something we have since implemented’. However, the policy provided by the Care Provider is dated May 2021 and likely would have been in place at the time of Mrs G’s admission to the Care Provider’s home two months later.
29. The policy states, ‘The record of belongings form should be signed by the resident/family member/appropriate representative as well as by the staff member admitting the resident into the home’.
30. The evidence available shows staff completed an electronic record of Mrs G’s belongings and personal possessions at the time. This created an electronic copy which was not signed by the staff member or the resident. This is fault as the Care Provider should have followed its policy and procedure it had in place at the time of Mrs G’s admission.
31. When Mrs G moved to a different room on a different floor the Care Provider’s staff packed her belongings to her new room. The Care Provider does not have a procedure in place which would prompt staff to check the resident’s belongings corresponds with the electronic record of the residents’ belongings. It would be good practice for the Care Provider to ensure it has a procedure in place for internal moves within its homes to ensure residents belongings are safeguarded.
32. The failure of the Care Provider to follow its procedures means we cannot now say whether Mrs G or her representative agreed with the record of her belongings the Care Provider completed. Because of this Mr B is likely to experience uncertainty about what happened to his mother’s rings.
33. Even if the Care Provider had ensured the record of residents’ belongings form was signed by its staff and Mrs G or her representative, we cannot say this would have led to a different outcome. It is likely we may have been able to say whether Mrs G had entered the home with her rings. However, on the evidence available now, we cannot say on balance whether she did or not. We cannot say what happened to Mrs G’s rings.
34. The identified fault by the Care Provider is likely to cause Mr B to experience uncertainty. I cannot say any distress he experienced would have been avoided as his mother’s rings may still have gone missing.

Further evidence considered

35. Mr B disputes the validity of the Care Provider’s electronic record which lists his mother’s belongings when she became a resident in the home. He received information from the manufacturer of the Care Provider’s electronic recording system which he shared with the Ombudsmen.
36. In response we asked the Care Provider to send us a full timeline report of inventory interactions while Mrs G was a resident in the Care Provider’s home. This showed the electronic record of Mrs B’s belongings for the start and end date Mrs G was a resident in the home. It also shows any date entries were made. The document provided only shows an entry on the date Mrs G became a resident.
    Mr B remains concerns whether this is a true and accurate record.
37. I have decided it would not be proportionate to investigate this issue further as I have found fault causing injustice on the evidence available. Further investigation is unlikely to change my findings or achieve a different outcome.

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Agreed recommendations

38. Within six weeks of our final decision the Care Provider has agreed to:
• write to Mr B and apologise for the uncertainty he experiences because of the failure to ensure the record of belongings form was signed.
• review its policy and procedures within its homes to ensure both staff and residents have signed the record of belongings form within each home; and
• tell us what procedures it will put in place to ensure residents belongings and personal possessions are properly accounted for and agreed if a resident has an internal move within one of its homes.

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Final decision

39. I have not found fault with the Council. I have found fault with the Care Provider, and it has agreed to our recommendations. This remedies the injustice caused to Mr B, so I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman