Improving the way we share information with the Care Quality Commission (CQC) can help people who provide adult social care services to put things right when care goes wrong.

We ensure the findings from our investigations are followed up by the CQC in their monitoring and inspections of care homes, domiciliary and other adult social care services.

We think how a provider acts on our findings can be a key test of its willingness and ability to learn from feedback. Ensuring improvements are made helps to avoid the same mistakes being repeated, and others experiencing the same poor care.

We have an Information Sharing Agreement (ISA) and Memorandum of Understanding (MOU) with CQC which enables us to share information from our investigations with the regulator.

If we have found a potential breach of CQC’s fundamental standards, we share the decision immediately with CQC. Feedback from inspectors has included:

“LGO complaint upheld but noted that provider had taken action immediately to apologise for the shortcoming in the service provided and has taken learning action from this. Discussed with Registered Manager and noted for next inspection.”

Both organisations receive numerous calls that are better handled by the other, and so as part of the ISA either organisation can transfer calls if the other is better suited to handle the caller's complaint

As a result of this arrangement, 14 people received closure for their complaints last year. One person received a refund of fees plus £500 in recognition of distress suffered. Additionally, the care provider agreed to staff training about mental capacity. Last year, 3,503 people were signposted to the correct organisation.

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A care provider recently demonstrated the wrong way to approach an Ombudsman investigation.

We were forced to publish an Adverse Findings Notice (AFN) earlier this month about Corden Assist Ltd, trading as Bluebird Care (Wandsworth).

The care provider refused to comply with our recommendations to apologise to a family and pay them £200 to put right failings we found with the homecare it provided to their elderly relative.

Thankfully cases of non-compliance happen rarely, but it does highlight the importance of taking a mature attitude to resolving disputes.

The family asked us to investigate after they said the company charged them for care their relative did not receive for three days in September 2016.

According to the family, the carer was not able to cope with the alleged behaviour of the relative, who has dementia, and asked one of the relatives to help.

The company was not able to show us adequate records that the care it charged for was provided. It also failed to record concerns expressed by the carer about his ability to deal with the relative, and family members’ concerns about the level of care provided.

Following the initial investigation in July, the Ombudsman also asked the company to waive 50% of the fees for the three-day period.

It failed to carry out any of the recommendations, and has instead decided to pursue the family through the courts for unpaid care fees.

In order to hold the provider to account, we issued a press release, which was covered in local media, and also published a public notice in the press. We are also working with the CQC to ensure cases of non-compliance with our recommendations are published on its website in future.

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An assessment of the client’s home environment and any risks this may pose to their care is a key part of a person’s care plan.

The assessment should identify any obvious hazards and put in place a plan to minimise or, where possible, eliminate risk. In a recent case involving a vulnerable woman receiving council-commissioned agency care in her home, we found fault in care planning because there was no identification of the risk caused by placing her on the toilet too close to a hot radiator. This was compounded by carers’ lack of awareness that the woman had no feeling down one side of her body and difficulties expressing herself.

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