Summary: Mrs B complained about the failure to properly consider her brother, Mr C’s needs before placing him in a care placement, failed to ensure the placement acted appropriately when transferring him to hospital, failed to ensure the care provider put in place support for him, failed to communicate properly with her and delayed responding to her complaint. Mrs B says the failures caused her significant distress. There is no evidence of fault in how the Council considered care placements for Mr C before he moved in to a placement. The Council failed to identify a new placement when Mr C needed to move from that placement and delayed dealing with the complaint. The care provider acting on behalf of the Council failed to include Mr C in the assessment, failed to follow the transition plan and failed to follow the care plan. An apology, payment to Mrs B, a review and reminder to officers is satisfactory remedy.

The complaint

1. The complainant, Mrs B, complained about the care provided to her brother, Mr C. Mrs B complained:
• the Council moved Mr C to a new care placement without consultation;
• the Council refused to consider an alternative care placement which was more suitable for him;
• the Council moved Mr C to the care placement without a proper assessment;
• the Council failed to consider evidence of serious issues with the care placement before Mr C moved in;
• the Council failed to tell the community learning disability service Mr C had moved into its area;
• when telephoning the police following an incident, the care placement failed to tell the police about Mr C’s learning disabilities;
• the care placement failed to send anybody with Mr C to the hospital following that incident;
• the care placement the Council chose left Mr C alone for more than four hours before he was found dead with various injuries;
• the Council refused to provide her with records or communicate with her; and
• the Council delayed responding to her complaint.
2. Mrs B says the Council’s failures have caused her family significant distress and left Mr C without adequate support.

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The Ombudsman’s role and powers

3. 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)
4. 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)
5. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
6. 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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

8. I have not investigated Mrs B’s concerns about the decision to move Mr C to the care placement in August 2022. That is because I am satisfied the decision to place Mr C in that placement was made by the Court of Protection. The Ombudsman does not have jurisdiction over the Court of Protection.

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How I considered this complaint

9. As part of the investigation, I have:
• considered the complaint and Mrs B's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
10. Mrs B and the organisation 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

Care Act 2014

11. A Council must carry out an assessment for any adult with an appearance of need for care and support. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must also involve the individual and where appropriate their carer or any other person they might want involved. (Care Act 2014, section 9)

Angel Support’s admission and discharge policy and procedure

12. This says admission to, and discharge from, hospital can be a difficult and stressful time for service users. It says service users can expect a high standard of support both on admission to hospital and on discharge.
13. It says Angel Support will cooperate fully with others involved in the support of the service user and will respond effectively to emergency situations and will share information in a confidential manner with all relevant services, teams or agencies so the support needs of the service user are met.
14. It says the care coordinator will record immediately that they have followed the service user’s preferred process for notifying the first point of contact in an emergency.
15. It says staff may be required to support service users to attend hospital visits or be a chaperone when they are due to be admitted to hospital.

What happened

16. Mr C has autism and was living in a care home which was due to close. The Council therefore needed to identify a new care placement for him.
17. The Council consulted various care providers but could only identify one provider with a placement available. That was Angel Support Living (UK) Ltd (Angel Support) The Council then shared the relevant assessments and care plans with Angel Support.
18. The Council met with Mrs B and another family member on 27 April 2022, along with staff at Angel Support. The family said they were happy for their brother to live there and that it was close to where one of his brothers lived. The plan from that meeting was for Angel Support to visit and meet Mr C and familiarise themselves with him. The Court of Protection subsequently approved the placement.
19. Angel Support visited Mr C on 6 and 14 July. Mr C also visited Angel Support on 12 July.
20. On 3 August Mr C moved into the accommodation provided by Angel Support.
21. On 12 August 2022 an incident took place at the Angel Support accommodation where Mr C allegedly assaulted staff. The police took Mr C to hospital. Mr C returned back to the Angel Support accommodation on 15 August.
22. A professionals meeting took place to discuss what had happened on 12 August. That meeting noted apparent deficiencies in the care provided by Angel Support. The meeting agreed the Council would look for a new placement. Action points included for the home to be put on the risk of admission list, a positive behaviour support (PBS) plan for Mr C until the Council identified a new placement, for the social worker to provide expectations to the home around incidents and protocols, referral to CQC and for commissioning to set up meetings with the home. The Council also made a safeguarding referral to the local authority where the home was located. That local authority decided not to pursue the matter further.
23. The Council began consulting alternative care placements. That included the care provider Mrs B wanted Mr C to have a placement with. That care provider told the Council on 19 August it would be able to provide Mr C with the placement three months after any support plan was agreed. The Council asked the care provider to assess Mr C and it provided the Council with an assessment and care plan in September 2022. The Council asked the care provider for some clarification around training for staff. While the care provider gave the Council some information about that the Council accepts it concentrated on arranging a day service placement with the care provider for Mr C.
24. A Council social worker visited Mr C on 9 September to carry out a mental capacity assessment about where he wanted to live. Mr C would not come out of his room.
25. The social worker visited again on 15 September and carried out the mental capacity assessment. Mr C said he wanted to stay in the accommodation.
26. The Council continued to look for an alternative placement for Mr C but could not find one that could meet his needs.
27. On 13 November Mr C sadly died.

Analysis

28. Mrs B says the Council moved Mr C into the placement at Angel Support without consulting the family. Mrs B says Angel Support was not suitable to meet Mr C’s needs and the Council presented it to her as a done deal.
29. The evidence I have seen satisfies me Mr C moved into accommodation at Angel Support following a decision by the Court of Protection. As the Ombudsman does not have jurisdiction over the Court of Protection I cannot comment on the decision to place Mr C in the accommodation at Angel Support. Nor can I comment on any concerns Mrs B has about the suitability of Angel Support or the information the Council provided to the Court of Protection about the suitability of the care provider.
30. I am satisfied though the best interests decision the Council completed, and the information it provided to the Court of Protection referred to the family’s views about the proposed accommodation. As well as that I am satisfied Mrs B provided her own witness statement to the Court of Protection which set out her concerns about the accommodation proposed and her wish for Mr C to move to a a more culturally appropriate care provider. Given all of that, I could not say the Council failed to consult the family.
31. Mrs B also says the Council accepted the placement at Angel Support and placed Mr C there before its staff had met him. As I said, as the Court of Protection approved the placement I cannot comment on any concerns Mrs B has about the suitability of the placement. That includes any concerns about whether Angel Support had properly considered whether it was a suitable placement for Mr C without meeting him.
32. I am satisfied though as part of the transition arrangements for Mr C moving into the new placement the service manager and service development manager both visited Mr C. I am satisfied Mr C then visited Angel Support and its staff made a further visit to him as part of the transition arrangements. I am therefore satisfied the Council did not place Mr C with Angel Support without first ensuring he had met some of the staff.
33. However, I note the transition plan said there would be ‘many trips’ by Angel Support to visit Mr C and only two took place. I am therefore not satisfied Angel Support carried out the number of trips it had told the Council it would do. That is fault and is likely to have undermined Mrs B’s confidence in the care Angel Support would provide Mr C with.
34. Mrs B says the Council refused to consider an alternative and more culturally appropriate care provider for Mr C. I am satisfied the Council considered that care provider because the social worker’s witness statement for the Court of Protection referred to the possibility of a placement with that care provider. The social worker set out in his statement why the Council did not consider that provider appropriate, referring to the fact the provider had not given the Council information about any potential placement. The social worker therefore recorded his view that the option was not appropriate as there was no provision available that could provide the support Mr C needed.
35. I appreciate that may well be a view with which Mrs B strongly disagrees. However, as I said in paragraph 4, it is not my role to comment on the merits of a decision reached without fault. As the social worker set out his reasons why the placement with the alternative provider was not appropriate I have no grounds to criticise the Council.
36. Mrs B says the alternative care provider she identified arranged to visit to assess Mr C and were told he had gone out when they arrived. Mrs B says that is not credible because Mr C was always in. I have to rely on the documentary evidence. I do not have any documentary evidence showing any attempt by the alternative care provider to visit Mr C. I also do not have any evidence of the Council frustrating any visit. I therefore have no grounds to criticise the Council.
37. Mrs B says the Council moved Mr C to the Angel Support without it carrying out a proper assessment. Mrs B says all Angel Support did was read Mr C’s notes. Having considered the documentary evidence it is clear when Angel Support produced the care and support plan it did not involve Mr C in drawing that up. Instead, the care and support plan was based on the information from the previous care provider and the experience of staff members that had worked with Mr C.
38. I would have expected Angel Support to include Mr C in the assessment. I also recognise from the documentary records though that Mr C was not always willing to engage with staff. I do not know whether that was the issue here. In those circumstances though I would have expected Angel Support to involve family members who had experience of Mr C to ensure a rounded assessment. Failure to do that is fault.
39. Mrs B says the Council failed to consider evidence of serious issues with Angel Support before it moved Mr C there. I have not found any evidence to suggest the Council knew about any issues with Angel Support before Mr C moved in. Angel Support had provided the Council with detailed information about its experience in managing those with challenging behaviour. I have seen no evidence to suggest the Council had any reason to query that before the incident in August 2022. I therefore have no grounds to criticise the Council.
40. I am satisfied though following the incident in August 2022 the Council agreed to look for an alternative placement for Mr C. It is clear despite consulting other care providers, including the one Mrs B had chosen, the Council had not identified another placement for Mr C to move to before his death in November 2022. However, as the Council agreed to move Mr C to an alternative placement as it had concerns about the ability of the placement to meet his needs the failure to identify one before November 2022 is a service failure. I consider that is likely to have left Mrs B with some uncertainty about whether the situation would have been different had Mr C been moved to an alternative placement.
41. Mrs B says the Council failed to tell the community learning disability service Mr C had moved areas. Mrs B says this means Mr C missed out on neurology, epilepsy and other services which put his life in danger. The evidence I have seen satisfies me as part of the transition plan the psychiatrist agreed to hand over care through a handover meeting with the learning disability service. That transition plan also recorded the new GP would arrange access to the local epilepsy nurse. That is what I would expect to happen given these were health related issues. I would not expect the Council to make those arrangements. As I am satisfied it was covered as part of the transition plan I have no grounds to criticise the Council.
42. Mrs B says Angel Support failed to tell the police Mr C had learning disabilities and epilepsy when it telephoned the police on 12 August 2022. Mrs B also says Angel Support did not send any of its carers to the hospital with the police and none of its staff provided information to the hospital about Mr C.
43. There is no evidence Angel Support provided the police or hospital with any information about Mr C on the day of the incident on 12 August 2022. Nor is there any evidence a member of Angel Support staff accompanied Mr C when he went to hospital. That is not in accordance with the plan Angel Support agreed or its policy. Mr C’s plan said staff would accompany him to any medical and healthcare appointments. Failure to do that or to provide information to the police and hospital about Mr C’s diagnoses is fault. Angel Support should also have contacted family members to tell them about the transfer to hospital and there is no evidence it did that. That is also fault.
44. Mrs B says Angel Support left Mr C alone for more than four hours. Mrs B says at the end of that four-hour period staff members found Mr C dead in his room. Mrs B says that should never have happened as Mr C required 1:1 support.
45. The evidence I have seen satisfies me the care plan for Mr C said he required 1:1 support. For the day Mr C died there is evidence of a staff member attempting to provide him with a drink and some medication at 3pm and the next time that member of staff saw Mr C was when he was found dead in his room at 8pm. I understand Mrs B’s concern in that situation.
46. The documentary evidence also shows Mr C was unsettled and aggressive towards staff members which is why they withdrew to give him time to calm down. That is in accordance with the behaviour plan Angel Support had in place. I have also seen a record of events on the day in question which records the staff member went back to Mr C’s room and stood outside on a number of occasions between 3pm and 7pm. On each of those occasions the staff member could hear Mr C inside.
47. However, there is no clear recording about the times at which the staff member visited Mr C and stood outside his room, other than the visit at 5:45pm and 7:50pm. Nor am I satisfied the record the staff member kept is contemporaneous. There is also no clear recording about why staff did not make any attempt to see Mr C in person to ensure he was safe. I would have expected staff to do that given Mr C could be heard potentially harming himself and as he had epilepsy. I therefore cannot be satisfied Angel Support properly followed its care plan on the day Mr C died. I cannot say whether that contributed to his death as only a coroner could make that link. I consider though Mrs B is left with some uncertainty about whether the situation would have been different had Angel Support followed the care plan.
48. Mrs B also says she regularly visited the care home and found Mr C covered in bruises. Mrs B says that never happened in the previous care home. The evidence I have seen though satisfies me the previous care provider noted difficulties with Mr C’s behaviour. That included violent outbursts and self harming. It therefore seems to me likely, on the balance of probability, Mr C’s presentation with Angel Support was similar.
49. Mrs B says the Council refused to provide her with copies of its records and failed to involve her in meetings. Mrs B also says the Council regularly arranged meetings at a time it knew she could not attend and on one occasion cancelled a meeting without notice.
50. I have found nothing in the documentary records to suggest the Council refused to provide Mrs B with copies of its records. Nor have I found any evidence of the Council failing to involve Mrs B in meetings or arranging meetings at a time it knew she could not attend. There is some evidence though of meetings being arranged or changed at short notice. The Council accepts irrespective of the reason for that short notice it expects advocates and family members to be present at meetings. As part of the remedy for the complaint I recommend the Council remind officers of the need to ensure family members are given sufficient notice, where possible, when meetings are arranged or rearranged.
51. Mrs B says the Council delayed responding to her complaint. The evidence I have seen satisfies me Mrs B put in her complaint on 14 March 2024. However, there is no evidence the Council responded to that complaint until 15 November 2024. That is a significant delay and is fault. That is unlikely to have left Mrs B feeling the Council took her concerns seriously.
52. I have set out in this statement various areas where I have found fault. I now have to consider an appropriate remedy to reflect the injustice caused by the faults I have identified. I cannot remedy any injustice to Mr C as he has sadly died. However, I consider Mrs B has suffered a separate injustice as she is left with significant distress and uncertainty about whether the situation would have turned out differently had the faults not occurred. As remedy for Mrs B’s injustice I recommended the Council apologise to her and pay her £500. The Council has agreed to my recommendation.
53. I also recommended the Council review what happened in this case in terms of identifying a new care provider following the incident in August 2022 to identify any procedural issues that can be addressed to ensure the same situation does not occur for other service users in future. The Council should also remind officers dealing with complaints about the need to ensure the Council complies with the published complaint timescales. The Council should also ensure officers are aware of the need to keep those that have complained up to date when delays occur.
54. Although the Council arranged for Angel Support to provide a placement for Mr C it is not located in the Council’s area. I therefore cannot make any recommendations around the Council addressing any procedural issues with Angel Support. I will send a copy of my final decision to CQC though for its information.

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Action

55. Within one month of my decision the Council should:
• apologise to Mrs B for the distress and uncertainty she experienced due to the faults identified in this decision. The Council may want to refer to the Ombudsman’s updated guidance on remedies, which sets out the standards we expect apologies to meet;
• pay Mrs B £500;
• review what happened in this case in terms of identifying a new care provider following the incident in August 2022 to identify any procedural issues that can be addressed to ensure the same situation does not occur for other service users in future;
• remind officers working in adult social care of the need to provide advocates and family members with sufficient notice of meetings, where possible;
• remind officers dealing with complaints about:
1. the need to ensure the Council complies with the published complaint timescales;
2. the need to keep those that have complained up to date when delays occur.
56. The Council should provide us with evidence it has complied with the above actions.

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Final decision

57. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman