Upheld, recommendations

Summary

Mr C complained that he was unreasonably charged for additional works he had not agreed to, or been advised of, following on from his initial agreement for smaller works to be carried out by the council to his property. Mr C said that the increased charge was unreasonable.

We found that, having decided to charge Mr C for the additional works, the council did not follow their own procedures in how they authorised, inspected and charged for the repair or communicated with Mr C. There was also a delay of six months after completing the works before the council queried the increased invoice from the council's building maintenance division, and invoiced Mr C. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not following the correct process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Consider whether a deduction of the administrative charge is appropriate in light of the failings identified.

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

• Ensure works invoices which have increased substantially are queried within a reasonable timescale.
• Ensure invoices are issued to owner occupiers within a reasonable timescale.

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.

Summary

Mrs C complained to the council about social work involvement in the care her late mother received whilst in a care home. Mrs C considered that the way the council handled her complaint was unreasonable and that the action plan they created as a result of the complaints investigation did not adequately address the failings identified.

We upheld Mrs C's complaint about the handling of her complaint as we found it had not been acknowledged within the appropriate timescales.

We took independent advice in relation to the council's action plan from a social work adviser. We found that whilst the action plan points themselves may have been reasonable, insufficient information had been supplied to Mrs C to allow her to understand how these had been implemented by the council. We also found that the action plan did not cover an area where failings had been identified. We considered this was unreasonable as the council had an adult support and protection role in this connection. We upheld this complaint and made recommendations to address the failings identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the complaints handling failing and for failing to provide Mrs C with information to evidence how the action plan would be implemented. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Issue an amended action plan that shows how the council have learned from Mrs C's complaint and will prevent failings from recurring.

In relation to complaints handling, we recommended:

• Timescales for acknowledging complaints as set out in the complaints handling procedure should be met.

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.

Summary

Mr C complained that the association had responded unreasonably to his complaints of anti-social behaviour and his request to move home in response to this.

We found that the association had not followed procedures as set out in their anti-social behaviour and allocation policies. In relation to the complaints of anti-social behaviour, we found that timescales were not met, there was no evidence that Mr C was supported or a resolution sought and Mr C was not communicated with reasonably. Therefore, we upheld this aspect of Mr C's complaint.

The association failed to respond reasonably to Mr C's request to move home. It was found that Mr C was not informed of the outcome of his request to move, there was no evidence that the request was discussed with the Area Housing Manager or Area Director as was procedure, or that Mr C was notified of the decision to refuse his request. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not following the Anti-Social Behaviour policy and the Management Transfer process, including not informing him of their decision in regard to his management transfer request. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• The association should follow the relevant procedure when responding to reports of anti-social behaviour.
• The association should follow process when responding to requests for a management transfer.

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.

Summary

Mr C complained about the lack of response from his housing association to concerns he raised that second hand smoke from a neighbouring property was entering his home. Mr C was unhappy that the issue had been ongoing for over a year without any action being taken against his neighbour. The association advised that they had attended Mr C's property, met with his neighbour, arranged for the local authority's environmental health services to conduct an inspection and hired a private company to conduct a further inspection. The association advised that none of these actions had been able to provide evidence to support Mr C's complaint about noxious fumes in the property.

We found that the association responded appropriately to Mr C's initial complaint about the fumes. We noted that following this, Mr C had identified that the fumes were strongest during the evening and through the night and, therefore, any daytime inspections are unlikely to find evidence as the odours will have dispersed. We found that it took the association a further seven months before an inspection of the property was arranged and a further five months before the environmental health service attended the property at night. The findings of the night inspection were that no fumes were observed and the matter was considered closed. We accepted that the investigation had been unable to find evidence to support Mr C's complaint of noxious smells. However, we considered that the inspection should have been carried out much sooner. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to inspect his property sooner and for the additional stress this caused him. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

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

• Review existing procedures to determine if more clarity should be included (e.g. in correspondence sent to tenants) to explain how an issue is being treated (i.e. a repair, anti-social behaviour, general enquiry).

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.

Summary

Mr C complained that the association did not respond within a reasonable timescale to his reports of water ingress in his home.

We found that the association's repairs policy states that emergency repairs should be responded to within four hours, urgent repairs within three working days and routine repairs within 20 working days. The association provided no evidence to support how Mr C's reports were categorised, however, it took two months for investigations to be carried out to Mr C's reports of a fault, outwith all timescales. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not responding to his reports of a fault with the roof within a reasonable timescale. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Ensure processes are followed to respond to reports of a fault.
• Ensure repairs are categorised as either emergency, urgent or routine.

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.

Summary

Mr C complained that the advisory disabled parking spaces outside the multi-story flat where he lived, were repeatedly impeded by other cars that were parked inappropriately. Mr C was unhappy as he was unable to get in and out of the spaces freely and he believed that his housing association were not doing enough to ensure that they were making reasonable adjustments for his disability. He also stated that inappropriate parking was a breach of the tenancy agreement.

The association responded by stating that the spaces were only advisory and, therefore, they did not have enforcement powers due to the spaces being on land privately owned by them. They made enquiries to the council about obtaining a traffic regulation order, which would allow them to take appropriate enforcement action. They explained that this would involve a long consultation process and at a significant cost to the association and, therefore, they were still in the process of considering this matter going forward. In the meantime, they advised that residents had been lettered highlighting that the spaces in question were to be kept for blue badge holders and that people should park courteously. They also asked concierge staff to monitor the situation and ask people if they would move.

Mr C felt that the matter was still ongoing and brought his complaint to us. He was concerned that the association were not taking all the action available to them. We acknowledged that the association did not have legal powers to enforce the spaces. However, we noted that the association's litigation team had accepted that people subject to the tenancy agreement were breaching its terms by parking inappropriately, that they could be advised of this breach and that further action may be forthcoming. We found that a reasonable adjustment by the association would be to require people to move their cars and take appropriate follow-up action. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the distress and inconvenience he experienced with regards to parking problems. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• The association should revisit their responsibilities in making reasonable adjustments under the Equalities Act 2010 and take action to ensure disabled parking spaces are free from obstruction from inconsiderate parking.

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.

Summary

Miss C and another member of her family applied for welfare powers for an adult relative. As part of that process, a Mental Health Officer (MHO) interviewed Miss  C over the phone. When Miss C saw the MHO's report, she felt what she said during the interview had not been reflected accurately. Miss C complained that the partnership refused to change the report.

We found that the partnership concentrated on the issue of what was actually said or not said during the phone interview. We were critical of this approach, as it meant the central issue of what was the correct position in relation to Miss C's adult relative was overlooked. We looked at the MHO's handwritten note of the phone interview, which we found supported Miss C's view of the phone interview. The partnership did not consider the handwritten note as being the best available record of the call, which we found to be a failure on their part.

We accepted that the opportunity to review a draft of the report was not possible in the circumstances. However, as a matter of good practice, we expected that an interview would start with an explanation of what would happen with the information provided at the interview, and would end with the interviewer reflecting back to the interviewee their understanding of the points made, and seeking confirmation of that understanding. This is standard interviewing procedure, and one we expect all staff conducting interviews to be aware of. We upheld Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for a failure to properly investigate and respond to her concerns. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of and conduct interviews in line with good interviewing practice.

In relation to complaints handling, we recommended:

• Staff investigating complaints at stage 2 of the complaints process should be sufficiently trained in good investigative practice.

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.

Summary

Mrs C complained about the care her mother (Mrs A) received at St John's Hospital. Mrs C complained about the number of ward moves that Mrs A experienced. Mrs A had dementia and Mrs C said that the number of ward moves caused Mrs A to become disorientated. Mrs C also complained about the personal care that Mrs A received and the communication from nursing staff.

We took independent advice from a nursing adviser. We found that:

• the number of ward moves that Mrs A experienced was unreasonable in view of her reduced cognitive function and delirium (sudden confusion)

• the board had failed to keep adequate records regarding the risk assessment and decision making for Mrs A's ward moves and how Mrs A and her family were informed of the ward moves

• the board failed to adequately assess and document Mrs A's care needs. In particular there was no care plan in place to cover Mrs A's personal hygiene needs

• a “Getting to Know Me” document was not in use during Mrs A's admission to St John's Hospital.

In light of the above we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the number of ward moves that Mrs A experienced, the failure to keep adequate records regarding Mrs A's ward moves, the failure to adequately assess and document Mrs A's care needs and complete a 'Getting to Know Me' document. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• The movement of patients with cognitive impairment between wards should be in line with national standards and guidance.
• The reason for moving patients to another bed, room or ward should be clearly documented and shared with the patient and/or their representative in accordance with Standard 15 of the Care of Older People in Hospital Standards.
• Nursing assessments and care plan documentation should clearly document the care needs and preferences of patients.
• The 'Getting to Know Me' document should be completed and used to inform a person-centred care plan.

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.

Summary

Mr C complained on behalf of his friend (Mrs A) about the care and treatment she received at the Western General Hospital. Mrs A was referred to neurosurgery (the branch of medicine that deals with the anatomy, functions, and disorders of nerves and the nervous system) and was found to have signs of wear and tear to the discs in her cervical spine (the soft cushions of tissue between the vertebra), which was causing compression (squeezing) to her spinal cord. A scan showed that this had caused mature damage in one area of her spinal cord.

Mrs A was referred for surgery to prevent her condition from worsening. Specifically, an anterior cervical discectomy and fusion (where disc material is removed to reduce spinal cord compression). After her surgery, Mrs A experienced weakness and reduced mobility. The board carried out a further scan, which found that Mrs A had mature damage in a second area of her spinal cord. Mr C complained that the surgery went wrong and that Mrs A was never told that surgery could make her condition worse.

We took independent medical advice from a consultant neurosurgeon. We found that Mrs A was appropriately referred for surgery, as she had signs and symptoms of spinal cord compression. However, we found that there was insufficient evidence that the risks of surgery, and of not having surgery, were clearly explained to Mrs A in the consent process. We also found that as Mrs A signed the consent form on the morning of the surgery, she was not given a reasonable timeframe to consider the risks listed on it.

We considered that the surgery might have caused Mrs A's new mature spinal cord damage, given the steps involved. However, we also found there were signs that Mrs A's spinal cord compression had worsened in the months before her surgery. Therefore, we were unable to definitely conclude that the surgery had caused her new mature spinal cord damage. Nevertheless, we found that the possibility of this happening and the other risks involved, should have been appropriately explained to Mrs A and documented. In light of that failing, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failings identified in the surgical consent process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• The consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery, and what is discussed as part of the consent process (including risks and benefits) should be documented.

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.

Summary

Mrs C complained to us about the nursing care and treatment her mother (Mrs A) had received at the Western General Hospital after she had fallen and injured her head. Mrs C, who had power of attorney for Mrs A, was concerned about the nursing care she received. Mrs C had particular concerns about her falls care and monitoring; pain relief; personal care and hygiene; and the communication with Mrs A. Mrs C also had concerns about a lack of response to Mrs A's weight loss and to her swollen leg.

We took independent advice from a nurse. We found that there was a failure to prepare timely and comprehensive care plans in relation to Mrs C's care needs, and to review the ongoing effectiveness of those care plans. We found that this should have been carried out with the appropriate involvement of Mrs C and her powers of attorney but there was no evidence that this had been done. We also found that there were failings in the board's records-keeping, as there were gaps in completing care round checklists which were sometimes not completed fully. We upheld Mrs C's complaint.

We noted that the board did not identify the failings we found in the nursing care provided to Mrs C. In addition, the board did not provide us with all relevant documentation at the appropriate point in our investigation. Therefore, we made recommendations in relation to their complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in the nursing care Mrs A received.

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

• Patients should have comprehensive nursing assessments and clear care plans in place, which are regularly reviewed, to facilitate consistent and person-centred care, with the appropriate involvement of patients and their powers of attorney.
• Care round checklists should be completed consistently and fully.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.
• The board should ensure that clinical evidence demonstrating the treatment and care provided is provided at the appropriate point in an SPSO investigation.

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.