Summary: The Council’s contracted care agency, Hallam24 Healthcare, failed to provide adequate home care to Mrs C. The Council also delayed carrying out a care review and informing her daughter, Miss B of the outcome of its safeguarding investigations. The Council was at fault for its delays and lack of communication, and for the poor standard of care given to Mrs C. Because of the fault, Mrs C suffered a lack of care, and it caused uncertainty, stress and worry to Miss B. The Council has agreed to apologise to Miss B, make a symbolic payment, issue staff briefings and provide staff training.

The complaint

1. Miss B complains the Council failed to protect her late, vulnerable mother, Mrs C, despite raising concerns with it about the home care provision she was receiving.
2. Miss B says her wellbeing has been impacted, she has been signed off work due to stress, and she has ongoing mental health issues. She says the poor standard of care also put her mother at risk.
3. Miss B would like the Council to make improvements to its service for other service users, including improvements in its communication and timeliness.

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The Ombudsman’s role and powers

4. 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)
5. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:
• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

6. Part 3 and Part 3A of the Local Government Act 1974 gives us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
7. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
8. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council/care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
9. 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

10. I have investigated matters in this case from early April 2023 to late August 2024.
11. I have investigated matters from April 2023 when the complaint issues began. Although some of these issues date over 12 months from when Miss B brought her complaint to us, Mrs C died in the interim. I consider this to be a good reason to exercise discretion and investigate Miss B’s complaint from this time onwards.

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How I considered this complaint

12. I read Miss B’s complaint and spoke to her about it on the phone.
13. I considered information provided by Miss B and the Council.
14. Miss B and the Council have had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

15. 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.

Reviews

16. 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.

Safeguarding

17. 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. (Care Act 2014, section 42)

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What happened

18. This is a summary of events, outlining key facts and it does not cover everything that has occurred in this case.
19. Mrs C had a care plan of four care visits daily by Hallam24 Healthcare, on behalf of the Council.
20. In mid-April 2023, the Council visited Mrs C at her home. During the visit, Miss B told the Council about her concerns about the standard of home care Mrs C had been receiving from Hallam24 Healthcare. She raised concerns about finding untaken pills in Mrs C’s bed and carers forgetting to give her breakfast.
21. In May 2023, Miss B moved into Mrs C’s home. Miss B told me Mrs C was unable to move and communicate independently and due to the degree of Mrs C’s vulnerability, she had concerns about Hallam24 Healthcare not completing all care tasks during care visits.
22. In early July 2023, Miss B contacted the Council to request a short-term review of Mrs C’s care. She also sent it a copy of the issues she had about the standard of care.
23. In mid-August 2023, the Council visited Mrs C at her home to carry out a review of her care needs. It discussed Mrs C’s care plan with Miss B and arranged for Miss B to meet with the care managers from Hallam24 Healthcare to discuss her concerns.
24. A few days later, Miss B reported to the Council carers had been arriving late to care visits and had not been giving Mrs C her breakfast.
25. In early September 2023, the care managers at Hallam24 Healthcare met with Miss B to discuss her concerns.
26. A few days later, Miss B contacted the Council to report Mrs C had had a missed care visit. The Council made safeguarding enquiries with Hallam24 Healthcare about the incident. In response, Hallam24 Healthcare told the Council:
• The carer had transport issues, so it had arranged for replacement carers to complete the care visit. The replacement carers said they did not complete the visit as it was not on their rota.
• It had had one-to-one discussions with the carers, and it would be closely monitoring them.
27. In late October 2023, Miss B reported further concerns about Mrs C’s care to the Council. The concerns included issues with the carers not changing Mrs C’s incontinence pads, and carers leaving her in unsafe lying positions in her bed.
28. In mid-November 2023, the Council made further safeguarding enquiries with Hallam24 Healthcare about the concerns Miss B had raised with it about Mrs C’s care.
29. In late November 2023, Hallam24 Healthcare told Miss B it had arranged a meeting with the carers in question about the issues with Mrs C’s positioning in bed, the length of care visits, and incontinence pad changes. It said it had clarified the care tasks detailed in Mrs C’s care plan and it would closely monitor the carers.
30. In early January 2024, Miss B raised a complaint with the Council about the poor standard of care Mrs C had received and the handling of the matters.
31. A few days later, Miss B reported concerns to Hallam24 Healthcare about how the carers had been giving Mrs C her medication. It said it would discuss this with the carers.
32. On 11 March 2024, the Council sent Miss B its final response to her complaint and acknowledged there had been delays. It told her it had been unable to update her about the concerns she had raised and the safeguarding investigations because it had been waiting on information to do this.
33. Mrs C died in early May 2024.
34. In early June 2024, the Council received information from Hallam24 Healthcare in response to the safeguarding enquiry it made in November 2023. Hallam24 Healthcare told the Council:
• Carers had said Mrs C was difficult to position in bed on occasion. It said it was unable to ask for further information about why she was left in a poor lying position as the carers in question had since left Hallam24 Healthcare. However, at the time of the incident it said the carers were spot checked at Mrs C’s property to ensure there was not a reoccurrence, although Miss B said in response to my draft decision the carers observed at the spot check were not the carers who had left Mrs C in a poor lying position.
• Mrs C refused to take medication on occasion.
35. In late June 2024, Miss B brought her complaint to the Ombudsman.
36. In late August 2024, the Council informed Miss B of the outcomes of its safeguarding investigations and apologised for the delay in giving her this information.

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Analysis

37. The tasks Mrs C’s carers needed to complete at each visit were clearly detailed in her care plan, but there is evidence which shows these care tasks were not always completed by the carers. I have seen evidence of occasions where:
• Mrs C had not had her medication;
• there were over 12 hours between a night-time care visit and the following day’s morning care visit;
• Mrs C was left in an unsafe lying position in her bed;
• Mrs C had unchanged incontinence pads; and
• there had been missed care visits altogether.
38. The care services given to Mrs C by Hallam24 Healthcare on the Council’s behalf fell below an acceptable standard. This was fault. This fault meant Mrs C experienced a lack of care on several occasions. This fault also caused avoidable worry and stress to Miss B and meant at times she had to provide care to Mrs C herself. It also meant she continued to contact the Council to ensure the care plan accurately reflected Mrs C’s needs, and she moved in with Mrs C as she was uncertain Mrs C’s care would improve and she would be safe.
39. In response to my draft decision, the Council told me it worked with Miss B to explore the option of changing the care provider, but it says Miss B did not wish to do this which it understands. The Council instead worked with Hallam24 Healthcare to reduce the care concerns.
40. The Council took appropriate action at the times Miss B reported concerns to it about Mrs C’s care, and responded to her communications to let her know what it would be doing. It updated the care tasks in Mrs C’s care plan for extra clarity; arranged a visit for Miss B to discuss her concerns with Hallam24 Healthcare; and carried out safeguarding investigations. The Council made appropriate safeguarding enquiries with Hallam24 Healthcare, and they both took suitable actions as a result. They:
• closely monitored and held one-to-one discussions with carers;
• gave reminders to carers about completing all care tasks in Mrs C’s care plan – specifically positioning her correctly and changing her incontinence pads; and
• the Council told Hallam24 Healthcare it should ensure all staff are provided with moving and handling training, and it should ensure all care plans are regularly reviewed.
41. In response to my enquiries, the Council told me it has no formal safeguarding meeting notes. In response to my draft decision, the Council said its procedures do not require safeguarding meetings to be held for all situations, and it is for staff to consider how best to collate further information required for the safeguarding enquiry. As outlined in paragraph 40, the Council made appropriate safeguarding enquiries and took suitable action as a result.
42. The Council has accepted there was delay in it reviewing Mrs C’s care needs. This was fault. The Council also delayed informing Miss B of the outcome of its safeguarding investigations. It said this was due to waiting for information it needed to complete its enquiries. The safeguarding process began in September 2023, and it shared the outcomes with Miss B in August 2024, after Mrs C had died. This was fault, which caused uncertainty to Miss B.
43. Miss B says the Council also carried out a financial abuse investigation about her as it had concerns about her managing Mrs C’s finances, but the Council did not send her the outcome. I asked the Council about this, and it told me the outcome was that:
• Miss B had provided evidence to appropriately justify the expenditures from Mrs C’s accounts; and
• appropriate formal financial oversight was put in place by Miss B becoming an appointee for Mrs C.
44. The Council accepts it did not share the outcome of this investigation with Miss B, and it told me it has discussed the matter with relevant staff members to avoid this happening in future.
45. Sometimes we will recommend a financial payment to the person who brought their complaint to us. This might be to reimburse a person who has suffered a quantifiable loss, or it might be more of a symbolic payment which serves as an acknowledgement of the distress or difficulties they have been put through. But our remedies are not intended to be punitive and we do not award compensation in the way a court might. Nor do we calculate a financial remedy based on what the cost of the service would have been to the provider.
46. The Ombudsman has published guidance to explain how we calculate remedies for people who have suffered injustice because of fault by a Council. Our primary aim is to put people back in the position they would have been in if the fault by the Council had not occurred.
47. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment.
48. However, if we consider the person who has complained to us has been adversely affected by the impact of that poor care on their relative, we may make a recommendation to remedy their own distress.
49. In response to my enquiries, the Council said it has offered a symbolic payment of £200 to Miss B in recognition of the time she has taken in relation to her complaint. I am not satisfied however, that in the circumstances of this complaint, £200 is an appropriate symbolic remedy for Miss B. Given the prolonged period the issues with Mrs C’s care were ongoing, how many times Miss B reported problems, and the delays, this amount does not fully acknowledge the impact of the injustice caused to Miss B. The Council has agreed to take the action below to reflect this.

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Agreed action

50. To remedy the outstanding injustice caused to Miss B by the fault I have identified, the Council will take the following actions within four weeks of my final decision:
• Apologise to Miss B for the standard of care given to Mrs C, the delays and lack of communication. This apology should be in accordance with the Ombudsman’s guidance Making an effective apology.
• Pay Miss B a symbolic payment of £500 to acknowledge the uncertainty, stress and worry caused by the fault I have identified.
51. Within three months, the Council will issue a staff briefing to remind Council and Hallam24 Healthcare staff, where relevant, of the importance of:
• reassessing and completing reviews of care plans in a timely manner;
• following care plans; and
• raising concerns about care plan tasks when necessary to avoid tasks being uncompleted.
52. Within three months, the Council will also provide staff training about good communication when making and communicating decisions to service users.

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Final decision

53. I have completed my investigation and uphold Miss B’s complaint. There was fault by the Council which caused injustice to Miss B and Mrs C. The action it has agreed to take is sufficient to remedy that injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman