Summary: Mrs X complains the Council’s care provider, Eden Futures, has failed to meet her son’s needs and despite the Council upholding many of her complaints about this in December 2022, her son continues to lack support, leaving him at risk of harm. The Council has taken action to ensure Eden Futures improves its working practices and can evidence providing Mr Y with the support he has been assessed as needing. Nevertheless, the Council needs to make a symbolic payment to Mr Y to reflect the lack of support he experienced and any harm he was caused. It also needs to send Mrs X an effective apology.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council’s care provider, Eden Futures, has failed to meet her son’s needs and despite the Council upholding many of her complaints about this in December 2022, her son continues to lack support, leaving him at risk of harm.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

Back to top

How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries;
• considered the Ombudsman’s Guidance on remedies; and
• invited comments on a draft of this statement from Mrs X and the Council, for me to consider before making my final decision.

Back to top

What I found

What happened

6. Mrs X’s son, Mr Y, has a learning disability. He lives in supported living accommodation where he receives support from Eden Futures.
7. Mr Y’s care and support plan says he needs help with:
• Managing and maintaining nutrition (one to one)
• Maintaining personal hygiene (two to one)
• Managing toilet needs (two to one)
• Being appropriately clothed (one to one)
• Maintaining a habitable home environment (one to one)
• Making use of the home safely (one to one and two to one)
• Developing and maintaining family or other personal relationships (one to one and two to one in the community)
• Making use of necessary facilities or services in the local community, including public transport and recreational facilities (two to one)
8. In 2022 Mrs Y complained to the Council about the failure to support her son properly. When the Council replied to her complaint in December, it said:
• The procedures in place for managing the use of Mr Y’s mobility car had not been used effectively. It had been difficult to audit use of the car as neither Mrs X nor Eden Futures had always filled in the required paperwork.
• Mrs X and Eden Futures had agreed a suitable management approach going forward.
• Eden Futures had put safeguards in place to reduce the risk of abuse;
• Eden Futures had not implemented a user-friendly approach to meal planning and cooking, which was not acceptable.
• Eden Futures did not identify or measure how healthy lifestyles were being implemented and supported. It had not provided a meal planning guide or a shopping list to support a healthy lifestyle.
• Despite recent improvements, it was clear they had not been embedded in the entire staff team.
• Eden Futures had failed to devise pictorial prompts for Mr Y’s dietary needs/preferences.
• Eden Futures had failed to provide a continence support plan for Mr Y, infection control procedures or a risk assessment for continence and cleaning support (Mrs X said staff had sometimes left a wet mattress protector on his bed, despite changing other bedding).
• Eden Futures had failed to provide evidence of dealing properly with Mrs X’s complaints. It had reminded Eden Futures of the need for keep proper records.
• The Care Quality Commission (CQC) had identified the need for Eden Futures to respond to complaints in a timely fashion, identify lessons learned and record communication with complainants over feedback.
• Eden Futures failed to provide rotas and staffing information, so could not evidence of providing one to one support for Mr Y (Mrs X’s concerns related to a lack of two to one support, but she is satisfied this has now been resolved).
• Eden Futures had failed to produce a copy of its finance policy. The Council advised Eden Futures it needed to ensure it tailored support to need.
• Mrs X had selected a limited number of care workers to drive her son’s mobility car, which could make it difficult to meet all Mr Y’s needs when using the car.
9. The Council upheld four of Mrs X’s complaints and partially upheld the other two. It apologised if she “felt that the level of contract support has not met your expectations”. It said it was continuing to work closely with Eden Futures and would monitor its performance.
10. Mrs X says the failure to encourage healthy eating habits resulted in her son gaining weight, which has had an irreversible impact on his mobility.
11. The Council says that since Mrs X first raised her concerns the following actions have been taken:
• In October Eden Futures produced a detailed plan for supporting Mr Y with his diet which it sent to Mrs X who had no comments.
• In December the Council updated Mr Y’s care and support plan. This identifies Mr Y’s preference for nutritious and fresh meals, which are beneficial because he has a fatty liver.
• After Mrs X raised concerns in January 2023 about not giving Mr Y a snack between breakfast and lunch, Eden Futures produced a meal planner which it has updated twice following further comments from her. Care workers follow the meal planner, unless Mr Y expresses a preference for alternative food, and record what they have given him to eat. The Council says the preferences for alternative food are sufficiently rare as not to impact Mr Y’s need for a healthy diet.
• The Council has held several meetings with Eden Futures to discuss the importance of eating healthily for Mr Y. It has made unannounced visits, checked Mr Y’s food charts and spoken to the staff supporting him.
• Mrs X has identified the need for a healthy and balanced diet, including the need to avoid too many carbohydrates.
• Eden Futures has produced a booklet, which contains pictures of food Mr Y has enjoyed, to facilitate meal planning.
• Eden Futures is working with Mr Y to increase his independence skills by prompting him to feed himself.
• Eden Futures has installed a communication board to improve communication between care workers about Mr Y’s mood, appointments, food chosen, activities and upcoming events.
• In April they discussed Mr Y’s menu plans and food charts with Mrs X, who suggested changes including the need for more variety. Mrs X also identified the need to record morning and afternoon snacks.
12. The Council says it is satisfied that Eden Futures has made sustainable improvements in terms of keeping good quality records and audits.

Is there evidence of fault by the Council which caused injustice?

13. The Council accepts Eden Futures was not meeting Mr Y’s needs properly. This was because it did not have the right plans and tools in place to do that. This had a significant impact on Mr Y, most notably in the failure to help him maintain a healthy diet and reduced the risk of him developing further health conditions linked to having a fatty liver. That is an injustice which warrants a financial remedy. The Council apologised to Mrs X, but its apology did not meet the standards of an effective apology. In line with our published Guidance, an effective apology should take ownership and avoid passive language or language that is ambiguous or dismissive, including suggesting faults may be linked to someone’s feelings or expectations.
14. The evidence shows that as a result of Mrs X’s complaint, the Council has worked with Eden Futures to make sure it improves its working practices and can evidence providing Mr Y with the support it has assessed him as needing.

Back to top

Agreed action

15. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Eden Futures and the Council, I have only made recommendations to the Council.
16. I recommended the Council within four weeks:
• writes to Mrs X apologising for the lack of support her son received and the time and trouble she has been put to in pursuing her concerns, taking account of our published Guidance; and
• pays Mr Y £300 to reflect the injustice he has been caused.
17. The Council has agreed to do this. It should provide us with evidence it has complied with the above actions.
18. In line with our Memorandum of Understanding and information sharing agreement with CQC, I will send it a copy of my final decision statement.

Back to top

Final decision

19. I have completed my investigation on the basis there has been fault causing injustice which requires a remedy.

Back to top

Investigator's decision on behalf of the Ombudsman