Jef Smith looks at a Local Government Ombudsman report on the lessons learned from complaints about care providers.

In the (bad?) old days, when the inspection of residential care services was the responsibility of local councils and health authorities, I remember attending a meeting at which the head of an inspection unit was addressing the managers of the homes in her area. After discussing the processes involved with regulation she concluded her remarks with: “And please let’s have no complaints; they’re so time-consuming.”

She was right, of course, about the drain on resources that a complicated complaint can constitute, but she was quite wrong in trying to suppress all critical comments from residents. These days, far-sighted homes welcome contributions from the still relatively rare service users who are prepared to speak their minds, since they regard complaints, along with praise, as valuable consumer feedback.

The volume of complaints is therefore a difficult indicator to assess; it could be that a home is providing the sort of poor service which deservedly attracts censure, but on the other hand it is possible that staff are sufficiently secure in their practice to welcome, and act on, candid input from the people who really count.

The Commission for Social Care Inspection (CSCI), the Care Quality Commission’s predecessor, was distinctly ambivalent about this issue. In 2007, it suddenly and very controversially announced that it had no statutory powers to formally investigate complaints from service users. Although it claimed that the decision was taken on legal advice, it was difficult not to link the withdrawal from the task, which had been routinely undertaken by previous regulatory bodies, to the CSCI’s known irritation at the amount of staff time involved in handling complaints.

The CSCI, surely correctly, insisted that investigating complaints was the responsibility in the first instance of the management of the service in question, but this ignores the fact that situations can arise in which an independent view is critical both to gaining the complainants’ confidence and to ensuring that matters are thoroughly and dispassionately looked into. The CSCI insisted that it continued to wish to hear about customers’ dissatisfactions as part of its overall quality-monitoring function, but this gave no satisfaction to seriously dissatisfied service users who felt that their criticisms should be examined by someone outside the immediate care environment.

The issue continued to exercise the Department of Health, which moved in 2008 to introduce, under the banner “Making Experience Count”, an integrated complaints system for all health and social care providers. The new streamlined arrangements, it was suggested, would make complaints investigation and resolution simpler and faster. The objective remained to resolve complaints locally wherever possible but, in recognition of the fact that this was not always feasible, recourse to the Local Government Ombudsman (LGO) was made available where necessary.

Initially access applied only to people whose care fees were paid for by an adult social services department, leaving self-funders still unprotected, but this obviously unjust anomaly was later corrected by legislation. Since October 2010, therefore, the LGO’s jurisdiction has included complaints about independent sector providers, whoever is funding the service.

How, two years on, is the new system working? There is a steady stream of published reports on cases on which the LGO had adjudicated but all of these relate to complaints against a local authority. This is because, surprisingly, the legislation does not provide the power to make public reports about independent providers. (The LGO’s office, misleadingly in my view, calls the independent sector “private”, a term which in care circles generally refers only to commercial organisations, excluding not-for-profit bodies.) The lack of power to publish reports on all complaints is a serious omission; the fact that a home has had a complaint against it upheld by the LGO is surely something any prospective resident has a right to know.

The Ombudsman’s report

In an attempt in some measure to fill this gap, the LGO published earlier this year a special report with the title Adult Social Care: LGO — The Single Point of Contact for Complaints. This document pulls together lessons learned from the complaints about care providers that have crossed the LGO’s desk, with the intention, in the words of Dr Jane Martin, LGO’s chair, “to support informed choice and to bring about improvements”.

Adult social care is a growing area for complaints, with numbers increasing from 1820 in 2010/11 to 2256 in 2011/12, a rise of 24%, even though the numbers in all other local government sectors fell. Only 110 of these complaints concerned independent sector residential care, as compared with 162 relating to council homes, despite the fact that the great majority of residential places are now in private or voluntary homes. This, however, doubtless reflects the newness and unfamiliarity of the service rather than a real qualitative difference, and the numbers can surely be expected to grow significantly in future years.

The “Single point of contact” report identifies four key emerging trends in complaints and contains some useful illustrative case material. These major areas in which lessons might be learned are improving the quality of care, making informed choices, protecting the most vulnerable, and resolving complaints locally.

Improving the quality of care

On improving quality, the report lists the most commonly raised issues as the attitudes of care staff, staff skills in handling dementia, the meeting of health needs and prompt access to medical help, and responsiveness to call bells. These are all predictable areas for dissatisfaction, underlining the sorts of improvements many homes still need to make.

The case study selected to illustrate this point concerns a man who suffered anxiety and confusion and was found by a neighbour in a street two hours after going missing, his absence not having been noted by the home’s staff. After initially resisting relatives’ concerns, the manager eventually responded to pressure from the LGO to investigate the incident more thoroughly. In due course remedy payments of £250 each were made to the resident and his relatives. Perhaps more important, after consultation with the residents generally and their families, systems to provide better security were introduced; a happy outcome for all concerned.

Making informed choices

Sensible choices, the report points out, need good information, but some providers are still in breach of the CQC’s Essential Standards, Outcome 3, which requires the provision of a clear statement of both the services to be provided and the amount and method of payment of fees. Care contracts should be absolutely transparent, the document states, listing the specific areas such as the costs of accommodation, separately chargeable services, and notice arrangements that should be included.

It is amazing that such elementary business practices still have to be put in place in some homes, particularly as charging arrangements are often complicated, so more than ever need to be spelled out clearly. A case study in the report illustrates this point with an account of a couple’s difficulty in getting a home to refund money after it had been agreed that the NHS had paid for the nursing element of their care. Only the LGO’s intervention obliged the home to rectify its error.

Protecting the most vulnerable

The number of cases involving safeguarding which are referred to the LGO is “small but significant”, and recent press coverage will surely lead to an increase in future years.

The case study quoted in this section deals with the unusual situation of the failure by a local authority to look after the contents of the house of a man admitted to a residential home, with the result that the house was ransacked, with a probable loss of valuable items and perhaps even cash. The council eventually admitted that the building had been inadequately secured and paid compensation to both the family for their distress and the service user in notional recognition of his loss.

Again, perhaps the most important outcome was that the authority reviewed its procedures for handling such situations in future.

Resolving complaints locally

Finally, the report considers the well-rehearsed issue of good and timely complaint handling, an issue the LGO found so important that a letter was sent to all providers urging them to review their procedures.

The case study reproduced here, however, is of a complaint where the LGO found in the home’s favour. A resident was given notice to leave a private care home after a sustained period of argument with his family about the quality of the care provided. For their part the home’s management said they had repeatedly looked into the family’s claims but thought they were unjustified, particularly as they had followed medical advice that did not support some of the family’s views about how best to manage the resident’s catheter and pain relief. The Ombudsman’s investigation found that the care home did nothing procedurally or legally wrong in terminating the contract for care because of the conflict.

Such cases are always distressing — in this instance, the situation was made sadder by the fact that the resident died shortly after the move — and the LGO’s scrupulous consideration demonstrates just how complex unraveling disputes can sometimes be.

Conclusions

The LGO expresses one major caution about complaints in social care: people who may have suffered are rarely in a position to complain themselves, with the result that “most complaints made to us have come from close relatives, advocates or friends of a service user”. Investigators go to great lengths to establish the bona fides of any such representatives, asking whether they have been duly authorised, whether the service user has the legal capacity to make decisions on their own behalf, whether indeed the complainant is a suitable person to take up the issue.

Such checks pose the question: what happens to residents who have a legitimate cause for complaint but no one to act on their behalf? Advocates are few and far between, and many residents lack concerned relatives or close friends. Homes with residents who are relatively powerless have an even greater responsibility to ensure that they listen out for, and then pay attention to, their residents’ critical comments.

The LGO report concludes with a promise of further work in the social care area, responding particularly to the climate of concern that has arisen from recent publicity about adult abuse, and collaborating with care providers and their membership bodies. Regular newsletters are promised — the first appeared in November and featured several fresh case studies — and the LGO wants more information about its service included in the information given to new clients. “A culture that encourages complaints,” says the report, echoing a point that will be familiar to any home confident of the quality of care it offers, “is positive for all.”

Last reviewed 20 December 2012