Decision Report 202301048

Summary

C complained about the health and social care partnership’s (HSCP) investigation of a medicine protocol breach identified at their relatives (A) care home in the week before A's death. A social worker investigated the breach in response to an Adult Support and Protection (ASP) notice raised by the care home, and determined that no further action was required. Separately, the Care Inspectorate had investigated other concerns raised by C about the care and treatment provided to A, including the medicine protocol breach. The Care Inspectorate’s investigation identified failings and made recommendations for improvement. In light of this, C contested the partnership’s position, indicating their view that the investigation was faulty, particularly noting the outcome of the Care Inspectorate’s investigation of the same matter.

C received a stage two complaint response letter from the partnership. We considered the response had not fully considered C’s concerns, therefore, we asked the partnership to provide a further response to C’s complaint. C remained dissatisfied with the partnership’s second response.

We took independent advice from a social work adviser. We found that the partnership had a duty to investigate the concerns raised in keeping with ASP legislation. We noted that this matter had been investigated by a single social worker. However, we found that the Care Inspectorate were better placed to investigate the matter in keeping with the Health and Social Care Standards, with the partnership’s role being to liaise with the Care Inspectorate and the care home regarding the outcome and recommendations. While the social worker’s report was in itself reasonable for an inquiry, we found that it was better suited to be used in collaboration with the other relevant agencies. We upheld the complaint.

We also upheld a complaint about complaint handling, noting that C had not been made aware that their concerns were being managed in line with the complaint handling procedure, that the matters to be investigated had not been confirmed at the start of the process and that the complaint responses did not fully address C’s concerns.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The partnership should reflect on this decision, particularly taking into account the professional judgement and the decision-making process applied in this case, in reference to the guidance and how this is interpreted in practice.

In relation to complaints handling, we recommended:

• The partnership should ensure complaints are correctly identified and processed in accordance with their complaints handling procedure. Responses to complaints should be clear and answer the points of concern raised.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.