Summary: Miss A complained about a council and care agency regarding her placement at supported accommodation. We found fault with the agency for the care it provided which led to risks to Miss A’s mental and physical health. The agency has carried out work to improve its care and will provide a personal remedy to Miss A.

The complaint

1. Miss A has complained about Cambridgeshire County Council (the Council) and Willow Care and Support Limited (the Agency) in relation to care they provided to her under section 117 of the Mental Health Act at supported accommodation from April 2022 to April 2023. Specifically, Miss A complains:

• the Council should not have chosen the Agency as a care provider as it had been given a ‘requiring improvement’ rating by the Care Quality Commission (CQC),
• the Council did not move Miss A quickly despite her placement being a safeguarding risk,
• carers provided by Willow Care were not trained in first aid, did not check on her regularly, provided her with the wrong medication or dosage, slept on the job and did not communicate with her effectively,
• the Agency organised a move to a new property which fell though at the last minute as it had not got the permission of the Council for the move,
• a manager at the Agency shouted at staff in front of Miss A which was upsetting for her to witness,
• the property was not properly locked and secured by the Agency,
• staff did not tell Miss A how to work the heating in the property leading to her being cold in winter,
• an oven broke and was not replaced so Miss A could not prepare meals for months,
• a manager told Miss A she would be liable for unpaid rent as she had not signed a tenancy agreement; and
• a questionnaire with Miss A’s thoughts on her care was never collected by the Agency.

2. Miss A said the neglectful care led to distress and pain and she tried to end her life on several occasions.
3. Miss A would like the Council and the Agency to take ownership of these failings, provide an apology and make improvements to ensure this does not happen to other vulnerable patients.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA). The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended).
5. The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services (Health Service Commissioners Act 1993, section 3(1)).
6. ‘We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
7. If it has, we may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
8. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
9. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

10. During my investigation I have considered evidence from the Council and the Agency in the form of social care records and assessments as well as complaint responses and responses to my enquiries. I also spoke to Miss A and considered her written evidence.
11. I also considered the relevant legislation and guidance.
12. I received comments from the Council, Miss A and the Agency on my first draft decision statement. After considering these comments I offered all parties the opportunity to comment on a second draft decision before I made this final decision.

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What I found

Background

13. Miss A was previously detained under section 3 of the Mental Health Act (1983). When she left hospital she was entitled to section 117 aftercare.
14. Miss A was 18 in 2022 when she moved to supported accommodation run by the Agency. Her care plan was to include support with various daily activities and medication. This care was funded by the Council and the Integrated Care Board under s117.
15. Miss A and her parents raised several concerns with the Council about the accommodation and the Agency and in 2023 she moved to a new placement with a new care agency.

Section 117 of the Mental Health Act

16. Section 117 of the MHA states a person may be eligible for aftercare services, if they are intended to meet a need that arises from or relates to a mental health problem and reduces the risk of the person’s mental health condition getting worse.
17. Anyone who may have a need for community care services is entitled to a social care assessment when they are discharged from hospital to establish what services they might need. Section 117 of the Mental Health Act imposes a duty on health and social services to meet the health/social care needs arising from or related to the person’s mental disorder for patients who have been detained under specific sections of the Mental Health Act (e.g. Section 3). Aftercare services provided in relation to the person’s mental disorder under S117 cannot be charged for. This is known as section 117 aftercare.
18. S117 does not define what aftercare services are. Section 33.3 of The Mental Health Code of Practice 2015 (the MHA Code) explains “after-care services mean services which have the purposes of meeting a need arising from or related to the patient’s mental disorder and reducing the risk of a deterioration of the patient’s mental condition (and, accordingly, reducing the risk of the patient requiring admission to hospital again for treatment for mental disorder)”. Section 33.4 adds aftercare can “encompass healthcare, social care and employment services, supported accommodation and services to meet the person’s wider social, cultural and spiritual needs”.
19. Section 33.7 of the MHA Code states Councils and CCGs (Clinical Commissioning Group, since replaced by ICBs) should “maintain a record of people for whom they provide or commission aftercare and what aftercare services are provided.”
20. The ICB shares a statutory duty with the Council to provide, or arrange, s117 aftercare services for eligible service users in the area.

My approach to this case

21. Miss A has raised several issues with the Agency which I have asked the Agency to comment on. The Agency said all the staff involved in Miss A’s care, and the manager of the Agency, had since left.
22. In addition, the Agency said the records were poorly kept so cannot dispute if the events raised by Miss A took place.
23. Due to a lack of evidence from the Agency, along with a willingness on its part to admit fault in this case, I have not investigated each issue individually. This is not to diminish Miss A’s experience, or the impact these failings have had on her. Instead, it is more proportionate for the Ombudsmen to look at the action the Agency took to prevent this happening again. We have also considered whether we can achieve the outcomes Miss A wants as a result of her complaint.
24. In relation to the Council, I have investigated the issues by looking at its explanations and evidence and deciding whether there has been fault leading to the issues Miss A suffered.

The Council’s choice of the Agency and the delay in moving Miss A

25. Miss A has said she is not happy the Council chose the Agency to care for her when it was rated as ‘requires improvement’ by the CQC. She is also not happy it took the Council an excessive amount of time to find a new provider.
26. The CQC is the independent regulator of health and social care in England. ‘Requires improvement’ means the service is not performing as well as it should and CQC has told the service how it must improve.
27. The Council said it would not generally place people with providers with this rating. The Council said its approach is to work with the CQC and provider to make necessary improvements.
28. It will make an action plan with the provider for the improvements. It said at the time it was working intensively with the Agency to make the required improvements.
29. The Council said it was working towards improving sufficiently to work with Miss A.
30. During the period of this complaint the Council said it held meetings with the family and the Agency to try and resolve and improve matters.

Analysis

31. There is evidence the Council put in an improvement plan with the Agency prior to it providing care to Miss A. In addition, it tried to find alternative providers during this period.
32. There was a lack of alternative providers who could provide the specific care Miss A needed. Therefore, I do not find fault with the Council because it was trying to work with the Agency to meet Miss A’s needs.
33. I accept in hindsight the Agency did not improve and could not adequately meet Miss A’s needs. However, the Council has since terminated its relationship with the Agency, meaning this situation should not arise again for other service users.
34. In July 2022, three months after Miss A entered the accommodation supported by the Agency, the Council said it would end its arrangement with the Agency as soon it found an alternative provider.
35. By this time Miss A had left the accommodation on more than one occasion and staff struggled to find her. The Council and Agency both recognised such incidents placed Miss A’s safety at risk and she could have harmed herself.
36. Section 42 of the Care Act (2014) states where a local authority has reasonable cause to suspect that an adult in its area is experiencing, or is at risk of, abuse or neglect, and as a result of those needs is unable to protect herself against the abuse or neglect or the risk of it.
37. The local authority must make whatever enquiries it thinks necessary to enable it to decide whether any action should be taken in the adult’s case. This can then progress into a formal section 42 adult safeguarding enquiry to decide whether any action is required and by whom.
38. The Council said as Miss A was living in a different area at the time it was not responsible for safeguarding enquiries as it would be the council in the area she was living in which would be responsible for this.
39. However, the Council said 11 safeguarding referrals were made. The responsible council decided not to carry out a section 42 enquiry and the advice from the council responsible for Miss A’s safeguarding was to deal with the situation under complex case management. As the Council was not responsible for safeguarding, I have not found fault with it in this aspect of the complaint.

Attempts to find another provider

40. In July 2022, the Council approached 16 providers.
41. By September 2022 the records show there were queries with some of the providers as to whether they could address mental health needs. The Council paused the process in November as it felt the Agency was improving, only for the Agency to signal their intention to end the provision.
42. In December 2022 the Council drew up a new care plan, sent out new requests to providers and by January 2023 had received no positive responses. In February 2023 the Council identified a suitable candidate and Miss A moved in April 2023.
43. There is evidence in her notes the Council was making efforts to find an alternative provider for Miss A. The time taken was significant, but the Council sought providers in July and December 2022 and received no positive responses.
44. Therefore, there is insufficient evidence to say, even on the balance of probabilities, that the Council was at fault in the delay in finding an alternative provider.
45. The Council has outlined improvements it has made since the complaint and offered Miss A and her parents £500 due to the time and trouble taken during the complaint process. I will leave this up to them if they want to accept the offer.

The Agency

46. The Agency has admitted fault in relation to the care provided to Miss A. These faults led to a deterioration in Miss A’s mental health and a risk to her physical health.
47. In response to this the Agency said that it will be undertaking thorough internal reviews with lessons identified from Miss A’s experience. This will include and develop any areas of concerns that require improvement.
48. The Agency went on to say it has:

• put in place a robust recruitment process and staff training. It said it is recruiting qualified staff through a rigorous hiring process,
• provides ongoing training and professional development to ensure staff competency and keep them updated on the latest industry standards,
• has a monthly medication auditing system in place which allows managers to track any shortage or surplus of medication; and
• uses a new digital feed record system for daily activities which allows Managers to check daily notes and any medication errors.

49. In addition, the Agency has a system in place for checking potential service users’ suitability for services.
50. These changes on the face of it will satisfy us the Agency has taken sufficient action to prevent this happening again.
51. The Agency has also offered Miss A £500 for the time taken making this complaint and it is up to her if she wishes to accept this.
52. However, the Agency needs to provide more detail to Miss A and us and I will include this in my recommendations.

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Recommendations

53. I have found that faults with the Agency which have resulted in increased risk to Miss A and a deterioration in her mental health.
54. Therefore, I recommend the Agency, by 23 September 2024:

• Write to Miss A acknowledging and apologising for the increased risk and mental deterioration caused by the faults in its care,
• provide Miss A with details and results of the reviews carried out as a result of the complaint; and
• provide Miss A with detailed information about the changes it has made to recruitment, medication, service user assessments, training and daily note taking to prevent this situation happening again.

55. The Agency should provide us with evidence it has complied with the above actions.

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Final decision

56. I find fault with the Agency with the care provided. The identified faults caused a risk to Miss A’s physical and mental health, and I have made recommendations to address this which the Agency has agreed to comply with. I do not find fault with the Council.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman