Summary: Ms A complains about the care and treatment her aunt, Mrs B, received at Lavender Court, run by Somerset Care. We will not investigate this complaint because Somerset Care has already admitted it made mistakes and acted to ensure they do not happen again. We have seen evidence of these actions and further investigation is unlikely to achieve anything more.

The complaint

1. Ms A complains about the care and treatment her aunt, Mrs B, received at Lavender Court, run by Somerset Care. Her care was part self-funded, part NHS funded.
2. Specifically, Ms A complains;
• Neither her family or solicitor, who held Lasting Power of Attorney (LPA) for Health & Welfare, were informed of important clinical decisions about Mrs B’s end of life care.
• A member of staff shared details about another patient over the phone.
• The first complaint response raised more concerns than it answered, forcing Ms A to raise another complaint, during which Somerset Care then admitted mistakes and apologised.
• Ms A worries Somerset Care put blame on individual staff members rather than looking at the lack of support they were receiving which led to the mistakes.
3. The events caused distress to the entire family and led to them not being able to say goodbye properly. Ms A has lost faith Somerset Care will make the changes it has promised and other residents could suffer the same.
4. Ms A would like external oversight to ensure the changes Somerset Care promised have been put into place.

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The Ombudsmen’s role and powers

5. We have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting for both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
7. The Ombudsmen provide a free service but must use public money carefully. They may decide not to start or continue with an investigation if they believe:
• it is unlikely they could add to any previous investigation by the bodies.

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How I considered this complaint

8. I considered all the information provided to us by Ms A.
9. I considered the Ombudsman’s Assessment Code.
10. I have considered the actions taken by Somerset Care and Lavender Court after its local complaint investigation. I asked the organisation to provide evidence it had completed the actions it said it would.

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What I found

11. Ms A made a formal complaint to Somerset Care in May 2024.
12. Somerset Care investigated Ms A’s complaint and sent a first response in June 2024. In this letter, it admitted fault. It said:
• Mrs B’s family should have been contacted and it had made a mistake leaving a voicemail for Ms A, even though she had told them she was on holiday and her brother should be contacted instead.
• It admitted a nurse had given information about another resident.
• It also admitted while it was not standard procedure to contact a solicitor, it was in their notes they held LPA and it should have contacted them.
13. Somerset Care apologised to Ms A. It said it had “identified learnings from your experience which will be acted upon, namely the need for extra training in good communication and documentation.”
14. Ms A was not happy with the response and raised further concerns with Somerset Care.
15. It provided a second response in July 2024. In this letter, it added further information to its previous response, and admitted further fault. It said:
• It should have contacted the family sooner when the doctor had decided Mrs B was to go to end of life care.
• The telephone system was reinstalled wrongly, which meant they could not get through when they called.
• Miscommunication led Mrs B’s sister to believe she was improving, this was a mistake.
• It did not provide clear answers when family asked who senior staff were.
• It did not record the correct communication preferences which led to not telling family and solicitor important decisions.
16. Somerset Care apologised again to Ms A. It said after further review, it had identified several concerns and it needed to act to improve its service. These were:
• “We need to review the process for end of life care. The resident should be at the centre of this process, supported by their families and chosen representatives. We need to make more effort to plan in advance and gather important information, such as funeral directors and special wishes, to ensure all information is collated and these conversations aren’t rushed or held at inappropriate times.”
• “We need to re-educate and reiterate the importance of Powers of Attorneys and the legal authority these appointments hold.”
• “The technological systems within the home need to support the team to do their job effectively and this includes the telephone system. This needs to be reviewed and amended as a matter of priority.”
17. Ms A brought her complaint to the Ombudsmen because she had lost faith in Somerset Care. She did not believe it would complete the improvements it said it would.
18. While assessing Ms A’s complaint, I contacted Somerset Care and asked for evidence it had completed the actions it had listed in its two complaint response letters.
19. Somerset Care provided evidence which I am satisfied shows it has completed the actions it said it would. It has actively taken steps to improve its service to ensure the faults it identified would not happen again.
20. Ms A wanted reassurance from the Ombudsmen Somerset Care has acted because of her complaint and done what it said it would do. We have seen evidence this is the case. Further investigation by the Ombudsmen would not achieve anything more. The organisation has admitted fault, apologised, and taken action to improve its service to make sure the identified faults do not happen again.

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Final decision

21. We will not investigate this complaint because it is unlikely we could achieve anything more.

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Investigator's decision on behalf of the Ombudsman