Summary: Mr X complained on behalf of his late mother, Miss F who had complex care needs. He complained Alliance Care Limited (the care provider) missed two of Miss F’s care calls during a day in December 2019. This meant Miss F was left in bed, without food and without her medication. The care provider has accepted fault following a Council’s safeguarding enquiry into the matter. We recommend the care provider apologise and pay Mr X £100 to remedy the distress and time and trouble the matter caused him.

The complaint

1. Mr X complained on behalf of his late mother, Miss F. Mr X complained Alliance Care Limited (the care provider) failed to turn up as agreed to care for Miss F on a day in December 2019. Mr X said Miss F had complex care needs and the matter meant she was left in bed, without food and without her insulin injection. Mr X said the matter caused both him and Miss F significant distress.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
5. If we are satisfied with a care provider’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)
6. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

7. I spoke to Mr X about his complaint.
8. I considered the safeguarding investigation into Mr X’s complaint.
9. I considered the care provider’s response to Mr X’s complaint.
10. Mr X and the care provider had an opportunity to comment on my draft decision. I considered comments before I made a final decision.

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What I found

Domiciliary Care

11. Domiciliary care is defined as the range of services put in place to care and support people in their own homes. Support to people at home might include personal care, medication, access to the community, shopping or household tasks such as cleaning and meal preparation. This help and support can be provided by daily visits from a carer.

Safeguarding

12. Councils play the lead role in co-ordinating work to safeguard adults. Anyone who has concerns for the welfare of a vulnerable adult should raise an alert.
13. The purpose of the safeguarding process is to:
• Find out the facts about what happened; and
• protect the vulnerable adult from the risk of further harm.
14. We will not normally reinvestigate a council’s safeguarding investigation. We can consider whether the council conducted a suitable investigation in line with its safeguarding procedures. If we find fault in how this happened we can look again at the matters covered by the investigation.

What happened

15. Miss F had multiple and complex care needs including diabetes, a heart condition and partial blindness. In 2019 Miss F received home care from Alliance Care Limited (the care provider). Miss F received four visits each day from a carer. This included a 90-minute visit at 7.30am and a 30-minute visit at 12.30pm. Mr X said there was one main carer who visited to care for Miss F.
16. During December 2019 Miss F was expecting her usual 7.30am call however nobody turned up. Miss F had an arrangement with the care provider that she could contact the manager directly with any issues. Miss F sent a text message to the manager at 9am to advise the carer had not turned up. She did not receive a response. Miss F then called her usual carer to ask where they were. The carer told Miss F they were not on the rota to visit her today. The carer said they tried to call the manager, but they also did not receive a response.
17. Miss F eventually spoke to the care provider manager at 10am. The manager told Miss F they were in a meeting and that she should instead call the main office number.
18. At 1pm Miss F called Mr X and told him that the carer had not turned up. Mr X said Miss F at this point was incoherent due to a lack of food and not having her insulin injection.
19. Mr X contacted the care provider and spoke to the manager. The manager said a carer was on their way. The manager told Mr X she had received the text message from Miss F however due to being in meetings did not read it until 10am. Mr X says a carer arrived at 2pm to check on Miss F and to provide her with food but then left. Mr X said he and other family members cared for Miss F until the carer arrived at 6pm for the evening call.
20. Mr X asked the care provider for an explanation about what happened. He said it was unacceptable for a carer not to turn up and leave Miss F in such a vulnerable position.
21. Two days after the incident the care provider gave notice that it was terminating its contract with Miss F because it could not longer meet her needs.
22. Mr X complained to the care provider about why a carer did not turn up to care for Miss F. He asked why nobody at the care provider was aware that the usual carer did not turn up and why it took so long to send a carer to see Miss F. Mr X also complained to the Care Quality Commission (CQC) about the matter. The CQC referred the matter to Sandwell Council (the Council) who began a safeguarding enquiry.
23. The care provider responded to Mr X’s complaint in March 2020. The care provider acknowledged Miss F was left without care for a period of time on a day in December 2019. It said Miss F’s usual carer did not inform it that they were sick. The care provider said it had since dismissed the carer. It said although it had an agreement in place for Miss F to call the manager if she had any issues it did advise her to contact the office which is the normal procedure. It said Miss F failed to contact the office and also had a personal alarm which she did not press.
24. The care provider said the incident was caused by a lack of communication between Miss F, the carer and it. The care provider said it would remind staff of the importance of ringing the office if they were unable to work. It also said it had now implemented a new electronic telephone system to minimise the possibility of this type of incident occurring again. It said it had since ensured all service users were aware of both the office and out of hours telephone numbers. The care provider said it would ensure going forward that clients were aware to call these numbers rather than directly contact staff or managers.
25. The Council closed the safeguarding enquiry case in April 2020. The Council substantiated the safeguarding referral. It said Miss F had multiple care needs and relied on her carers for food, medication, personal care for getting out of bed. The Council found Miss F was left in bed until 2pm after the scheduled carer missed both the morning and afternoon calls. The Council said however it was satisfied the care provider had accepted the fault and had put measures in place to prevent similar incidents occurring in the future.
26. Mr X was unhappy with the care provider’s response to the matter and complained to us. In his complaint to us Mr X said the carers from the care provider regularly did not turn up for Miss F’s calls.

My findings

27. Miss F had significant health issues and the care provider left her without care and support until 2pm on a day in December 2019. That was fault. It caused her significant distress and meant she went without appropriate personal care and medication.
28. The records show the Council carried out a detailed safeguarding investigation into Mr X’s concerns. The Council substantiated Mr X’s concerns and the care provider accepted fault in that it failed to provide care for Miss X when it missed a morning call and arrived late for the afternoon call on a day in December 2019. The Council is satisfied with the measures taken by the care provider to prevent similar incidents occurring in the future. There is nothing further I could add to Council’s investigation which would lead to a different outcome.
29. I have however considered the care provider’s response to Mr X’s complaint and whether it provided a remedy to acknowledge the injustice caused. The care provider accepted fault however it has not offered an appropriate remedy. As Mrs F has since died, we cannot remedy the injustice the matter caused to her. However, the matter caused Mr X distress and time and trouble in raising his complaint to the care provider and the CQC. Therefore, I made recommendations for the care provider to remedy the injustice caused to Mr X.
30. Mr X said in his complaint to us that carers from the care provider regularly missed Miss F’s calls. Had this been the case I would have expected Mr X to have raised it as a complaint with the care provider. It is unlikely further investigation into this would lead to a different outcome. Therefore, I have not investigated this aspect any further.

Recommended action

31. The care provider should, within one month of the final decision apologise to Mr X and pay him £100 to acknowledge the distress and time and trouble caused to him when it missed two of Miss F’s care calls during a day in December 2019.

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Final decision

32. I have completed my investigation. I found fault and have made a recommendation to remedy the injustice caused by the fault.

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Investigator's decision on behalf of the Ombudsman