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Ms A complained to me about the treatment and care provided to her mother, Mrs X, whilst she was a resident at “Blue House Care Home”. The Care Home had been contracted by Aneurin Bevan Local Health Board (“the LHB”) to provide Mrs X’s care on its behalf.

Ms A also complained about CSSIW’s actions following the investigation of her complaint. In particular its failure to undertake any enforcement action against the Care Home, and its reference to Ms A’s complaint as “resolved” in its annual inspection report, a comment Ms A felt was misleading.

Having reviewed all of the information available I found that Mrs X, a patient of the LHB, expected to be provided with a package of NHS care that met all of her needs in a manner that would promote wellbeing, independence, autonomy and self-worth. However the evidence available to me suggested that the care provided by the Care Home on behalf of the LHB failed to meet that expectation.

The LHB contracted with the Care Home that it would undertake a form of contract monitoring, which resulted in a reported annual inspection. In my view the monitoring undertaken at the Care Home was ineffective, and the provisions within the contract relating to complaints handling failed to meet the requirements of the NHS Guide to Handling Complaints in Wales 2003. Ms A’s complaint about the LHB was upheld.

With respect to Ms A’s complaints about CSSIW, I found that the investigation process had been so narrow that serious failings had not been identified. I also found that the CSSIW compliance process was not robust enough in this case to ensure that service user’s basic needs were being adequately met. Furthermore, despite CSSIW recognising that at the time of the investigation and publication of the investigation report, Ms A had not been satisfied with the findings and intended to pursue the matter further, it used the term “resolved” when describing her complaint, this was disingenuous. I partly upheld this part of the Complaint.

The Ombudsman recommended that the LHB and CSSIW pay Ms A £500 and £250 respectively as an acknowledgement of the service failure identified in this report. He also made a number of systemic recommendations including a review of policies and procedures for contracted out care.

A copy of the full report downloaded below.