Summary: There was fault by the Council as there were delays once a social worker was allocated. The Council was at fault in its investigation of a safeguarding complaint about Mrs X’s inadequate care and it then failed to carry out the independent investigators recommendations. Mrs X says the Council delays and poor handling of her complaint caused her great distress. Carrying out the recommendations now, with an apology and payment to Mrs X’s daughter remedies the injustice.

The complaint

1. The complainant, who I shall call Ms B, complains for her late mother Mrs X.

2. Ms B complains there was a delay in assigning a social worker when she complained about her mother’s inadequate care and that interim advice given to her by duty social workers was unhelpful. She also complains the social worker allocated was on sick leave and she was not told the Council had assigned the case until 8 weeks after her first complaint.
3. Ms B also complains that social workers had formed a negative opinion of her before they had met her and did not treat her with respect. She says this caused her great distress, as she was very worried about her mother at the time.
4. Ms B also complains the social workers investigation of her complaints about the care given to her mother was inadequate and they did not challenge Roxton Nursing Home’s decision to evict her mother.

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The Ombudsman’s role and powers

5. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
6. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
7. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
8. 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, section 30(1B) and 34H(i), as amended)
9. We may investigate matters coming to our attention during an investigation, if we consider that a member of the public who has not complained may have suffered an injustice as a result. (Local Government Act 1974, section 26D and 34E, as amended)

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How I considered this complaint

10. I read the papers put in by Ms B and discussed the complaint with her.
11. I considered the Council’s comments about the complaint and any supporting documents it provided.
12. Roxton Nursing Home, Ms B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
13. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Key facts

14. Mrs X moved to Roxton Nursing Home in December 2017.
15. Ms B became increasingly concerned about her mother’s care in 2018. She complained to the Council about the standard of care on 18 May 2018.
16. The notes of the initial call said that Ms B phoned to request her mother move to another nursing home as she was not happy with the care. Ms B said the care home used her mother’s bathroom as a store room for wheelchairs and slings which were nothing to do with her mother. Ms B said volatile and disruptive residents disturbed her mother when she was watching television. Ms B was told her message would go to the area team. A social worker returned the call on 21 May and left a message the case would be allocated. Ms B called back on 22 May.
17. Ms B rang Mrs X’s previous social worker, Officer A, on 22 May. He told her the case was awaiting allocation but advised her to see if the home could address her concerns before ‘jumping’ to a new placement.
18. Ms B rang again on 31 May to chase the allocation of a social worker. A duty social worker rang Ms B back the same day and said the case was still awaiting allocation. The social worker sent a message to the area team asking for allocation of the complaint.
19. Ms B spoke to the duty social worker on 1 June. She said she was going on holiday on 2 June for two weeks and wanted to speak to an allocated social worker before he/she spoke to the care home. Ms B continued to call the Council to chase a response over the next few weeks.
20. The Council assigned Mrs X a social worker (Officer S) on 20 June. Officer S rang Ms B on 26 July and agreed to meet at Ms B’s house on 7 August. Again Ms B asked the social worker not to contact the care home until after they had met.
21. Ms B says that when she visited her mother at 5pm on 28 July, her mother was sat in her room, distressed in soiled clothing. Ms B says her mother’s personal care chart said care staff had not attended to her since 8am and her breakfast plates were still there. Ms B said that she got help and 3 carers came up and said it must have just happened. Ms B said the manager did not visit her mother as they had had a garden fete that day.
22. Ms B phoned Officer S on 30 July 2018. She said that she had visited her mother on Saturday and her mother was covered in faeces so she had asked the care staff to help her mum. Ms B said the care home owner had phoned her to say he was going to evict Mrs X. Ms B again said she wanted to meet the social worker before Officer S spoke to the care home and they arranged to meet on 2 August.
23. Officer S, her supervisor (Officer M) and Ms B met on 2 August 2018. Officer S also spoke to the care home owner and manager. The care home staff explained they felt they had to end the contract because of the upsetting and disruptive influence Ms B had on the staff and other visitors.
24. Officer S started finding a new care home the next day. Ms B told Officer S on 6 August had found a place at a new care home and Mrs X moved into the new home on 14 August.

My analysis

Complaint about delay in social worker allocation

25. The Council has an assessment and support planning allocation protocol. This says that no case will wait for more than 4 months to be allocated. It also says that allocation to a named social worker must be in line with the prioritisation framework for the risk level of the case. And, that allocation must ensure the worker has enough time to contact before the 4 months ends. It also says the contact from allocation to an individual should be within 5 days to arrange the assessment or re-assessment.
26. The priority levels range from level four (low) to level one (high). The Council says it classed Mrs X’s case as level three. This includes adults whose social circumstances and/or health are moderately affected because of their disability. The Council’s procedure says that it will prioritise allocation to start assessment within 4 weeks.
27. The Council assigned a social worker to Ms B after 4 weeks and 5 days, so within the Council’s ideal timescale of 4 weeks. She received an initial call from the assigned social worker 5 weeks after the date of allocation. The Council’s procedure says that contact should be made within 5 days after allocation, so there was a delay of about 4 weeks at this time.
28. The Council’s procedure specifies the date in weeks, not days so it is not clear whether allocation should be by 4 weeks or in the 4th week. From the information I have, I cannot say there was delay in allocating a social worker as the case was allocated in the 4th week. Ms B clearly wanted more urgency, but the Council is entitled to prioritise its work and I can see from the information recorded from the telephone calls there was no reason for the Council to consider it urgent or high risk.
29. The allocated social worker did not contact Ms B within 5 days of the complaint being allocated. This was fault, even if unavoidable as the officers was on sick leave.
30. I do not consider the delay after allocation of 4 weeks caused significant injustice to Ms B, other than understandable frustration that things were not happening quickly enough. The Council contacted Ms B within 4 months, the longest the Council said that a case should wait before allocation. Ms B was contacted and a meeting arranged before the incident on 28 July 2018 so there is no certainty that earlier contact with the social worker would have prevented this incident or the events that followed. So, I consider an apology remedies the injustice from this point.

Complaint about attitude of the social worker

31. Ms B complains about Officer M’s attitude. She says the social worker had never met her but referred to her as ‘this woman’ and told another social worker not to read her emails. Ms B says that while the Council has apologised for the social worker putting the remarks in writing, she has not had an apology for the social worker thinking or saying those things.
32. In response Officer M has said that Ms B’s complaints and concerns were taken seriously at the meeting on 2 August 2018. In response to the complaint both Officer M and Officer S said that they deny acting in an unprofessional manner and were not dismissive. The Council apologised for any undue upset caused by the interaction between Ms B and Council officers.
33. Ms B made a data access request. In response to this she received copies of emails from the Council. In one email Officer M said ‘don’t bother reading the latest missive from the daughter’. In another email Officer M said ‘This woman will have to be fairly, but firmly dealt with’.
34. Ms B complained to the Council about these emails, and several other issues in the way Officer M wrote about her in the files. All Ms B’s complaints were upheld by the Council and so I do not intend to reinvestigate. I consider the inappropriate comments made by Officer M in the files were fault. In response to Ms B’s official complaint the team manager at the Council apologised for the unfortunate use of language. I consider the apology a satisfactory remedy to Ms B’s complaint, although I appreciate it may not meet Ms B’s expectations.
35. It is not possible for me to find out exactly what the thoughts or attitude of the social workers were towards Ms B at the time and so I do not consider it right to ask the people involved to apologise directly for Ms B’s interpretations of their words, which may not have been the same as theirs. I consider the apology already given a satisfactory remedy to Ms B’s complaint, although I appreciate it may not meet Ms B’s expectations.

Council’s investigation of Mrs X’s care and eviction

36. In response to Ms B’s concerns about the incident on 28 July, Officer S brought forward the meeting with Ms B and the care home owner.
37. The Council partially upheld Ms B’s complaint on this matter. The investigating officer found there was no investigation at the time into the evidence provided by Ms B that her mother had been sat in soiled clothing and there was equipment in the shared bathroom. The investigation found Officer M should have raised the photographs showing soiled pads left on floors, bins and the side of the bath as an environmental safeguarding issue.
38. The investigating officer also found the carers and nurses failed to document what they had done or what food Mrs X had eaten on 28 July 2018. The care home reprimanded one carer and gave a written warning because of her failing to record changing Mrs X’s incontinence pad or the food she had eaten. The investigating officer found there was no recording on the file to suggest that care staff had attended to Mrs X after 8am that day.
39. The investigating officer also got a view from an independent witness and looked at 9 witness statements on the care homes files. The statements said the manager was polite when Ms B said the care home had neglected her mother.
40. The investigating officer recommended:
• The Council sends a letter of apology to Ms B for failing to look into the environmental safeguarding issues she raised in August 2018.
• The Council raises the issues with the care home of poor file recording and poor level of care provided to its residents as identified by Ms B with the Commissioning Team.
• The Council responds to the findings of the independent investigation to Ms B, identifying any learning from the complaint and how it intends to action any failing by the care home.
41. It is clear there was fault by the Council. Officers failed to investigate Ms B concerns about the events of 28 July and the Council’s independent investigation has shown that her concerns were justified. There were failures by the care home, in the care of her mother, that social workers should have addressed at the time.
42. There is some evidence the Council officers who commissioned the care started to look into Ms B’s concerns and had some contact with the Care Quality Commission. However, the result of this has become muddled with Ms B’s official complaint. The Council then commissioned an independent investigation into Ms B’s complaint, which was thorough and so did ensure the Council looked at all her concerns.
43. Of great concern is that the Council has confirmed the independent investigators recommendations have not been carried out. Ms B has received no apology and it has supplied no evidence that it has raised the issues with the care home. The Council has also said that it does not consider any of the complaints to be serious enough to raise with the Care Quality Commission.
44. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
45. The concerns, identified by the independent investigator, relate to safeguarding and inadequate care and could affect other residents in the care home. It appears there may have been a breach of the fundamental standards around safe care and treatment, meeting nutritional and hydration needs and premises and equipment. Coupled with complaints about delay and not investigating the complaint at the time, the failure to carry out the independent investigators recommendations is evidence of serious fault by the Council. It has compounded Ms B’s distress, when her mother was seriously ill.
46. It is difficult to remedy the injustice caused to Ms B and the late Mrs X. The fault by the Council has put Ms B to time and trouble in pursing her complaint. She had to continue to complain about the distress caused to her mother and relieve the events of that day. So, I consider a financial remedy and apology is fitting to recognise the injustice caused.
47. Ms B feels that if these matters had been investigated at the time, the Council would have been better able to challenge the care home owner’s eviction of her mother. While I understand her view, it is clear to me the relationship between Ms B and the care home had already broken down, and I cannot see that officers could have changed the care owner’s decision. Ultimately, the care home made its own decision that it could no longer continue and given that Ms B had already told the Council she wanted to move her mother (albeit with concerns about whether this was the best thing to do) I cannot say that a better investigation would have meant that her mother would not have had to move.

Agreed action

48. The Council apologises for the delay in contact after the social worker was allocated within one month of the date of the decision on the complaint.
49. The Council pays Ms B £500 towards her time and trouble, and distress in dealing with her complaint within one month of the date of the decision on the complaint.
50. The Council carries out independent investigators recommendations (and provides evidence of this) within two months of the date of the decision on the complaint.
51. The Council audits any upheld ASC complaints concluded over the previous 12 months which have not been escalated to the LGSCO, to ensure any recommendations have been properly implemented within two months of the date of the decision on the complaint.
52. The Council puts in procedures to ensure that recommendations resulting from its own investigations are implemented fully and in a timely way within two months of the date of the decision on the complaint.

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Final decision

53. I have completed my investigation of this complaint. This complaint is upheld and I consider the actions recommended above remedy the injustice caused. I have also notified the CQC of the decision as I consider there may have been a breach of the fundamental standards of care.

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Investigator's decision on behalf of the Ombudsman