Summary: There was no fault by the Council when it decided not to progress with a safeguarding enquiry when Mrs B fell. There was fault, however, when the Council took too long to review Mrs B’s care needs as intended, and took too long to deal with the complaint made on her behalf about this. The Council’s shortcomings caused both Mrs B and her family distress, frustration and uncertainty. It has agreed to take action to remedy this.

The complaint

1. Mrs B complains that the Council failed to respond to safeguarding concerns her family raised about her in December 2023, and took too long to reassess her care needs.
2. Her grandchild, Mx K, raising the complaint on her behalf, says the Council’s shortcomings have caused them anxiety about the dangers she has been placed in since they found her collapsed on the floor at home. Mx K is worried that Mrs B cannot cope and is still at risk.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
4. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
5. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)

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How I considered this complaint

6. I considered the information provided by Mrs B and discussed the issues with her. I considered the information provided by the Council including its file documents. I also considered the law and guidance set out below. Both parties had the opportunity to comment on a draft of this statement. I have considered all comments received before issuing this final decision statement.

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What I found

The law and guidance

7. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)
8. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
9. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.
10. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.
11. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.

What happened

12. Mrs B lives with a family member. Mrs B receives social care at home of three care calls daily because she is frail and has difficulty with her mobility and balance. An occupational therapist assessed Mrs B’s needs in January 2023 because Mrs B had recently been discharged from hospital and had been receiving more intensive reablement care. The occupational therapist noted that Mrs B used her disability aids and adaptations around the house and these were meeting her mobility needs. Their assessment also said that Mrs B had responded well to the reablement care and they had no further recommendations.
13. The Council assessed Mrs B’s needs under the Care Act in February 2023. The assessment confirmed that Mrs B’s needs had returned to the level of those before her recent hospital stay, and she should continue to have three care calls each day. The carers would help with personal care, and meal preparation. The assessment also noted that Mrs B was at high risk of falls and had a consistent falls history, but had been supported to use her walking aids in her home.
14. In December 2023, the Council received a safeguarding referral because Mrs B had fallen in her home. Mx K said that he had been saying for some time, that his mother needed more care and a review of the best accommodation to meet her needs, as she has fallen several times in her home. The Council noted concerns that Mrs B may be at risk of further falls and there is a lack of a fire evacuation plan. The Council decided that the situation did not meet the criteria for a safeguarding investigation and it would address the concerns by reviewing Mrs B’ care needs.
15. The Council spoke to Mrs B’s son as her next of kin to explain that the Council would not progress a safeguarding investigation. The Council intended to pass the case to its social care team to complete a review of Mrs B’s care needs. However, this did not happen.
16. In March 2024, the care provider contacted the Council. It said that Mrs B’s mobility had declined and her family had explained they could not provide more care as they were out at work. The care provider mentioned significant concern for Mrs B and particularly mentions that the flat is cluttered which makes it less safe.
17. The Council contacted the care provider that day and having checked with it what was needed, the Council agreed to fund a short-term increase of an extra two hours in the first week, and then an extra hour in the following three weeks. The aim was to declutter and clear the flat to make it safer.
18. On 21 March, Mx K complained to the Council that it had not acted on safeguarding concerns and had not reassessed her care needs. The complaint says that Mrs B cannot live alone. They said the Council had put Mrs B at risk. The Council did not respond and the family chased the Council about this twice more.
19. In April 2024, Mx K contacted the Council’s Occupational Therapy service. They said Mrs B needs a new assessment as the care she was receiving was not sufficient. They particularly mentioned that the flat was in a bad state, cluttered and unsafe. The Council said it could not find Mrs B’s case and asked for more details.
20. On 13 June, the Council responded to Mx K’s complaint. The Council said that it had explained at the time why it was not progressing a safeguarding investigation, but that it had intended to review Mrs B’s care needs. It apologised that it had not done this. It would contact Mrs B by the next day to arrange a review of her care needs.
21. The Council reviewed Mrs B’s care needs on 24 June 2024. The assessment noted that Mrs B’s flat was cluttered and that the extra support had not been enough to maintain it. The Council spoke to the family member Mrs B lives with about how they could support Mrs B to declutter and so make the flat safer, given her history of falls. On the basis of the assessment, the Council decided to increase the home care for Mrs B. She would now receive an extra visit each day, making four care visits per day.

Was there fault by the Council causing injustice to Mrs B or her family?

22. I appreciate that this has been a very worrying time for Mrs B and her family. They felt strongly that Mrs B needed more care and were very worried about her falls.
23. There was no fault when the Council decided not to take safeguarding action. It considered the information it had and decided on the best course of action. It was open to the Council to decide that it did not need a safeguarding investigation, but that it did need to review whether Mrs B’s care needs were being met.
24. However, it was fault when the Council failed to carry out a review of Mrs B’s care needs and how these were being met. We would expect the Council to have checked whether the care plan was working when it reduced the care visits to three daily following Mrs B’s reablement package and the Council’s assessment. Based on the information, I have to date, the Council did not do that.
25. It was fault when the Council failed to refer Mrs B for a review following its decision not to take safeguarding action in December 2023. And in any case, it was fault when the Council failed to review Mrs B’s care needs and her care package around February 2024, 12 months after the preceding assessment.
26. The Council has told me that there was nothing to indicate that it should give Mrs B’s review priority. However, I cannot see that it considered the priority or that it explained this to Mrs B or her family.
27. There is no fault in how it assessed Mrs B’s care needs in June 2024. I appreciate that Mx K believes Mrs B needs 24-hour care, but the Council’s assessment was based on its observations and information from the care provider.
28. The Council also took too long to respond to Mx K’s complaint about the service Mrs B had received. Mx K made a formal complaint in March and the Council took 12 weeks to respond to the complaint. Its policy says it will aim to respond within four weeks. There is no indication that the Council told Mx K that its response would be late, or explained why this was.
29. I have considered how the fault I have found affected Mrs B and her family. Mrs B’s care needs review was due in February 2024, but the Council did not do this until June 2024. The Council increased Mrs B’s care as a result of this review. I have considered whether, if the Council had done the review on time, it would have provided more care for Mrs B sooner. However, I cannot say whether it is more likely or not that the Council would have increased Mrs B’s care sooner.
30. This is because when the care provider raised concerns in March 2024, it was satisfied with an additional hour each week to help clear the flat. It had substantial concerns, but did not pursue a reassessment or ask for more time to give personal care.
31. However, the Council’s delay and lack of explanation caused Mrs B uncertainty as to whether she would have a review and receive more care. If the Council had communicated better or reviewed Mrs B’s needs sooner, then she may have been less worried that she was being left at an increased risk of falling.
32. The Council only realised that it had not referred Mrs B for a review as it intended to do when it dealt with Mx K’s complaint. The delay in the complaint handling meant that Mrs B’s review was delayed and it caused Mx K distress, frustration and uncertainty.

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Agreed action

33. The Council will within one month of the date of today’s decision:
• Apologise to Mrs B and separately to Mx K. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• Pay to Mrs B £500 in recognition of the uncertainty and worry it caused her when it took too long to review her care needs.
• Pay to Mx K £250 in recognition of the distress, frustration and uncertainty it caused them when it took too long to review Mrs B’s care needs, and to respond to their complaint.
• Share this decision with relevant Adult Social Care staff and complaint handling staff and remind them of the importance of dealing with care need reviews, and complaints in good time, and the importance of good communication.
34. The Council should provide us with evidence it has complied with the above actions.

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Final decision

35. I have completed my investigation. There was fault by the Council causing injustice to Mrs B and Mx K.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman