Summary: We will not investigate Mrs Y’s complaint about the care provided to her father, Mr X, when he was resident in a care home. This is because we consider it unlikely that our investigation would be able to add to the work that has already been undertaken by the care home and Council in response to Mrs Y’s complaint.

The complaint

1. The complainant, Mrs Y, is complaining about the care provided to her father, Mr X, when he was resident in Portway House Care Home (the Care Home). This placement was part-funded by Sandwell Metropolitan Borough Council (the Council).
2. Mrs Y is complaining about several aspects of the care provided to Mr X. This includes personal care, nutrition, mental health care, hygiene, and the behaviour of staff. Mrs Y also says that the Care Home served Mr X with notice without good reason, meaning he had to move to a different placement.
3. Mrs Y says this level of neglect and lack of care was traumatic for Mr X and his family. Mrs Y says the Care Home’s decision to serve Mr X with notice caused him further distress and affected his health.

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The Ombudsmen’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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).
5. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe it is unlikely we could add to any previous investigation by the bodies concerned.

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How I considered this complaint

6. In making my final decision, I considered information provided by Mrs Y and discussed the complaint with her. I also considered relevant information from the Council and Care Home. I invited comments on my draft decision from Mrs Y and considered her response.

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What I found

Background

7. Mr X has complex physical and mental health needs. He began residing in the Care Home in June 2023.
8. In June 2024, Mrs Y submitted a series of complaints about Mr X’s care. In the meantime, Mrs Y’s sister, Mrs T, submitted a further complaint concerning similar issues.
9. In July, the Care Home provided separate responses to Mrs Y and Mrs T. Mrs Y remained in correspondence with the Care Home until August. During this period, the Care Home served Mr X notice, as it said it was unable to meet his complex needs.
10. In the meantime, the Council began to undertake safeguarding enquiries under section 42 of the Care Act 2014. These are often known as ‘s42 enquiries’. A local authority must make enquiries, or cause others to do so, if it believes a vulnerable adult is experiencing, or is at risk of, abuse of neglect. The enquiries are intended to establish whether any action needs be taken to prevent abuse or neglect and who will take this action.
11. As part of the enquiry process, the Council met with Mr X and his family. The Council reviewed care documentation relating to Mr X and consulted with a Speech and Language Therapist (SALT). Furthermore, the Council directed the Care Home to complete an internal investigation to identify areas of improvement.
12. In early August, the Council concluded its safeguarding enquiries. The Council substantiated the family’s concerns about Mr X’s care. It made specific reference to nutritional and personal care. The Council explained that an urgent referral had been made to the SALT team in July to review Mr X’s care needs. In addition, Mr X’s care plans had been updated to reflect the need for greater standards of personal care.
13. In September, Mr X moved to a different placement.
14. In November, the Council completed a quality assurance visit to monitor the Care Home’s progress against the previously agreed actions. The visit observed that staff training was up to date and that the Care Home had put in place a programme of quality audits. The visiting team also provided feedback for the Care Home staff on their observations.

My analysis

15. The evidence I have seen shows Mrs Y’s concerns have already been subject to considerable scrutiny by the Care Home, Council and Care Quality Commission (CQC). This has led to significant improvements in the standard of care provided by the Care Home.
16. The Care Home currently remains subject to review by the Council’s Quality and Safety Team. This is part of a wider regional quality partnership, including health and social care agencies, that shares information about local services (such as care homes). Furthermore, the Council shares relevant information with the CQC to inform its inspection regime.
17. In light of this, I consider it unlikely that an investigation by the Ombudsmen would be able to add substantively to the work that has already been undertaken to improve services at the Care Home in response to Mrs Y’s complaint.
18. Further, I note the Care Home has been unable to reach a conclusion on some issues. This included key concerns around Mr X’s personal care and oral care. This was due to the absence of comprehensive care records in relation to these aspects of Mr X’s care. This is being addressed as part of the Council’s quality monitoring.
19. However, the lack of records in these areas at the time of the events Mrs Y is complaining about would similarly hamper any investigation by the Ombudsmen. I think it unlikely, on balance of probabilities, that we would be able to draw any more firm conclusions on these issues than the Care Home was able to.
20. It is understandable Mrs Y is concerned about the standard of care Mr X received in the Care Home. Nevertheless, taking the above into account, we will not investigate Mrs Y’s complaint.

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Final decision

21. We will not investigate Mrs Y’s complaint. This is because we would be unlikely to add to the work that has already been done by the Care Home and Council in response to Mrs Y’s complaints to those organisations.
22. We have now closed the case on this basis.

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Investigator's decision on behalf of the Ombudsman