Summary: Mrs D complained the Council commissioned care provider (Crowthorne Care Surrey Ltd. t/a Esto Care) in her supported living placement, is failing to provide her with care and support. We found that support was provided in line with Mrs D’s care and support plan and there was no fault in the Council’s safeguarding process. However there had been medication errors and delay in complaint handling. The Council has agreed to apologise to Mrs D to remedy the distress caused.

The complaint

1. Mrs D complains the Council commissioned care provider (Crowthorne Care Surrey Ltd. t/a Esto Care) in her supported living placement, is failing to provide her with care and support, there have been medication errors and the staff are unprofessional. This is causing her to feel anxious and unsafe.

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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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. 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. 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, sections 24A(1)(A) and 25(7), as amended).
5. 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)

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What I have and have not investigated

6. I have investigated care and support in the period from July 2023 to February 2024, when Mrs D brought her complaint to the Ombudsman. I have taken into account the outcome of the safeguarding enquiries which were completed in April and December 2024.
7. I have not investigated Mrs D’s concerns about her council housing application. This relates to a different local authority. Nor have I investigated her move into supported living accommodation. We considered this in a separate case and issued a decision in April 2024.

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How I considered this complaint

8. I spoke to Mrs D about her complaint and considered the information she sent, the Council’s response to my enquiries and relevant law and guidance.
9. Mrs D and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

Care and support

10. The Care Act 2014 requires local authorities to carry out an assessment for any adult with an appearance of need for care and support. The assessment determines what the person's needs are and whether the person has any needs which are eligible for support from the council.
11. Where councils have determined that a person has any eligible needs, they must meet those needs. The person's needs and how they will be met must be set out in a care and support plan.
12. Section 117 of the Mental Health Act 1983 imposes a duty on councils and NHS bodies to provide free aftercare services to patients who have been detained under certain sections of the Act. These free aftercare services are limited to those arising from or related to the mental disorder, to reduce the risk of their mental condition worsening, and the need for another hospital admission again for their mental disorder.

Supported living

13. Supported living is when the person has their own home and support is provided by a care provider. The council has a duty to assess whether someone in supported living accommodation has eligible social care needs. Care and support may be provided by live in carers or support workers who do not live with the person.
14. When a person moves into supported living accommodation, they usually sign a tenancy agreement for their own accommodation, paid for by housing benefit if eligibility is met. Some supported living homes are shared between several people.

Safeguarding

15. 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. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (Care Act 2014, section 42)

Complaint procedure

16. Councils should have clear procedures for dealing with social care complaints. Regulations and guidance say they should investigate a complaint in a way which will resolve it speedily and efficiently. A single stage procedure should be enough. (Local Authority Social Services and National Health Service Complaints (England) Regulations 2009)
17. The Council’s policy is that complaints about care commissioned by the Council should be dealt with by the care providers under their own complaints procedure.
18. Regulations do not say how long a complaint investigation should take but expect this to be determined at the start of the procedure, usually in discussion with the complainant. During the investigation, the council must keep the complainant informed of progress ‘as far as reasonably practicable’. If the responsible body has not provided a response after six months (or, after any previously agreed longer period), it must write to the complainant to explain why. (Regs 13 and 14, Local Authority Social Services and National Health Service Complaints (England) Regulations 2009)

What happened

19. I have set out the key events; this is not meant to detail everything that happened.
20. Mrs D has mental health needs and is receiving free aftercare services under section 117 of the Mental Health Act 1983. This includes medication under mental health services. Mrs D had been living in her own council property but on discharge from hospital in 2022 she moved into supported living accommodation.
21. In June 2023, Mrs D moved into her current supported living accommodation with support provided by Esto Care (“the care provider”), commissioned by the Council. The property is shared with other residents.
22. The Council’s care and support plan of July 2023 says Mrs D required welfare checks, including overnight, and social and emotional support, including support to have social contact and with medication. She did not require support with personal care or meals. Mrs D had previously received one-to-one support but was not assessed as needing this in July 2023.
23. The Council reviewed Mrs D’s support needs in September 2023. The review noted that Mrs D now regretted giving up her council tenancy and found the accommodation unsuitable.
24. Two safeguarding alerts were raised in January 2024. One was because Mrs D had been able to access medication from the medication cupboard which should be kept locked at all times. The second was because staff had left Mrs D unattended with the wrong medication. In both instances, Mrs D had locked herself in her room with the medication and police had been called due to concerns about her welfare. The Council started safeguarding enquiries. Mrs D decided to start collecting and administering her own medication.
25. Mrs D complained to the Council on 22 January about her move into supported living. She said there was no support and the accommodation was unsuitable. There was antisocial behaviour by other residents, including drug use, causing her distress and to stay in her room most of the time. To feel safe, she had to keep her door locked to prevent staff from entering.
26. Mrs D complained to the care provider on 29 January about medication errors, lack of support and unprofessional behaviour by the manager and staff which had a detrimental effect on her mental health. The care provider said it would investigate. Mrs D also complained to the landlord about disrepair and maintenance and that it was having a detrimental effect on her mental health.
27. In February, Mrs D alerted the CQC after the medication cupboard keys were left unattended. A safeguarding alert was raised and included in the ongoing investigation.
28. The Council replied to Mrs D on 14 February. It said the care provider would respond to her complaint about the support provided.
29. Mrs D approached the Ombudsman, but we were unable to investigate as she had not yet received a complaint response from the care provider.
30. Mrs D told us she has been sexually harassed by another resident and emotionally abused by staff which causes her significant distress. She wishes to move to a new property.
31. The safeguarding enquiry concluded in April as substantiated. The care provider would take a number of actions to reduce risk, including:
• All staff to undertake advanced medication training and to be observed administering medication.
• A risk assessment of the medication cupboard.
• Audits of the medicine cupboard to be done at handovers.
• Clear procedures on administering medication to be implemented.
• Changes to the way keys were managed.
32. The Council sent further complaint responses to Mrs D on 4 July and 18 July. It said it was supporting Mrs D with her application for council housing and had offered a move to different accommodation, but it was not suitable.
33. The care provider responded to Mrs D’s complaint on 11 September. It said the manager had left and all staff had been retrained on medication.
34. Mrs D met the Council and care provider on 26 September; this included a review of her care and support needs. Mrs D raised concerns about bullying and emotional abuse by staff. A safeguarding inquiry concluded in December. It had found no evidence of bullying but noted that a member of the landlord’s staff had now left. The care provider agreed that communication with Mrs D should be through a manager.

My findings

35. I have reviewed the care provider’s records of the support it provided to Mrs D from July 2023 to February 2024, including its medication records. This shows it made welfare checks during the day and night, and administered medication, which is in line with her care and support plan.
36. The care provider’s errors in managing the medication in January and February 2024 were fault and caused distress to Mrs D and put her at risk of harm, which is a significant injustice.
37. When the Council received the safeguarding alerts, it ensured there was an investigation by the care provider and considered the findings and what action to take to remove the risks. This is in line with its safeguarding procedures and the statutory guidance. As I have found no fault in the way the Council managed the safeguarding enquiries, I cannot challenge the findings.
38. It took the care provider over seven months to respond to Mrs D’s complaint. This is fault as it is not in line with the complaint regulations and causes distress to Mrs D.
39. Mrs D is distressed by her current living arrangements and says the staff are mentally abusing her. I have seen no evidence of that but the Council should support Mrs D in her wish to move to new accommodation, including different supported living accommodation, if that is her preference.

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Action

40. When a council commissions or arranges for another organisation to provide services, we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of the care provider and make the following recommendations to the Council.
41. Within a month of my final decision, the Council has agreed to apologise to Mrs D for the medication management errors and delay in responding to her complaint.

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Decision

42. There was fault by the Council. The actions the Council has agreed to take remedy the injustice caused. I have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman