Summary: Mr X complained about the quality of care provided to his daughter Miss Y at a Council commissioned supported living placement. There was some fault in the care provider’s record keeping, in its support with completing an activities planner and in its failure to share the care plan with Miss Y. The Council has agreed to apologise to Miss Y and Mr X and make a symbolic payment to Miss Y to acknowledge the frustration and uncertainty caused.

The complaint

1. Mr X complained on behalf of his adult daughter, Miss Y, about the quality of care provided to Miss Y at the Council commissioned supported accommodation, Warwick Manor run by Glenholme Healthcare. In particular Mr X complained the care provider:
1. Delayed producing a care plan and failed to involve Miss Y in its creation or provide her with a copy. He says the care was too long to be an effective working document for staff.
2. Failed to arrange suitable, varied activities for Miss Y and failed to carry out those activities detailed in the care plan, such as supporting Miss Y to cook twice weekly, supporting her to use a bus and supporting her interest in gardening.
3. Stopped providing transport for Miss Y, which it had initially provided, which limited her ability to access activities.
4. Failed to support Miss Y effectively when she was hearing voices. In particular it failed to use the thoughts and voices charts which were detailed in the care plan which would enable staff to both communicate with Miss Y about the voices and monitor her well-being through their completion.
2. As a result of the failings Mr X said Miss Y had to leave the placement and her family now provides her support. He said Miss Y lost an opportunity to gain some independence and this has had an emotional and financial impact on her and the family.

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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 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)
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. 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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How I considered this complaint

8. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance. I have considered records from the supported living placement, including a sample of the daily care records it completed and Miss Y’s care plan.
9. I gave Mr X and the Council the opportunity to comment on a draft of this decision. I considered the comments I received before making a final decision.

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What I found

The relevant law and guidance

10. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
11. 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. The standards include:
• Providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences (regulation 9).
• Providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).

What happened

12. Miss Y has a long-term mental health condition. As part of this Miss Y can hear voices. The Council reviewed Miss Y’s needs assessment in May 2022. Mr and Mrs X and Miss Y participated in the review. Miss Y had been living in a supported living placement but had returned to live with Mr and Mrs X due to issues with the support provided.
13. In October 2022 Miss Y moved into a new supported living placement, Warwick Manor. She continued to go home to her parents two to three days a week. At the placement she received one to one support between 8am and 10pm with a share of waking night support. Miss Y received one to one support in the community. When Miss Y moved in, Mrs X provided the care provider with a comprehensive manual regarding Miss Y’s care and support.
14. The care provider completed an initial needs assessment and care plan. The records say Miss Y ‘was offered to participate in this, however [she] declined and will read through once complete.’ It said Miss Y found completing forms and care plans overwhelming so the plan was created around information from Miss Y’s parents, professionals and observations from staff whilst supporting Miss Y. Miss Y says the plan was never discussed with her and she was not given the opportunity to read it.
15. The plan set out the support Miss Y should receive and how it was to be delivered. This included support with a weekly planner to promote and support her to complete daily living skills and community activities. The care plan could be accessed by staff using a mobile handset. The software enabled interactions to be scheduled and allocated. Carers could access specific sections of the plan as required and record their notes and observations.
16. In November 2022 Miss Y’s care coordinator noted she had settled well at the new placement. In late January 2023 the care provider visited Mr and Mrs X to discuss how Miss Y was adapting to living at the placement. Mrs X referred to a recent café visit where Miss Y felt uncomfortable but when asked by staff if she was okay she had just said yes. The care provider noted it would pass on to staff that Miss Y could hide how she was feeling. It noted Miss Y was going shopping with support from different staff members and was letting staff into her flat more often. It noted Miss Y was attending music lessons.
17. In February 2023 the care coordinator noted Miss Y said she liked the placement and the carers were very supportive.
18. Miss Y’s care coordinator visited her at the placement in March 2023. They noted Miss Y said staff were not taking her to activities of her choice. She had asked to go to the gym and staff had not taken her and had not taken her to a place of worship. She had attended a voluntary job but had been stopped going without notice. The care coordinator raised Miss Y’s concerns with the care provider.
19. The care provider arranged a review meeting with Mr and Mrs X following this. This noted staff would ask Miss Y directly about the voices she was hearing. Miss Y had settled well and was slowly opening up to staff members although it was recognised she was still developing trust with people. It noted Miss Y had an activity planner but this would be more specific going forward. It noted Miss Y visited her parents every week usually for three days and they spoke highly of the support Miss Y received at the supported living placement. It noted the family and staff at the supported placement appeared to be working well together in supporting Miss Y. It noted Miss Y would like staff to drive her to places twice a week. The manager advised very few staff drive or have business insurance. The manager advised staff would need to be reimbursed for mileage which Mr X supported. The notes record the manager said they were wary of any opinion which suggested Miss Y should be doing more, and given her diagnosis and the impact this had on her everyday life.
20. In April 2023 Miss Y joined a gym. She attended an induction with staff support but cancelled this later that month. Mr X bought her an exercise bike to use.
21. The care provider updated the care plan following a meeting with Miss Y’s parents in April 2023. It noted staff would be present when Miss Y completed the planner and would suggest activities. It stated ‘staff are to encourage [Miss Y] to cook two meals per week and write this on the planner’. It said ‘please do not just put on the planner “[Miss Y] to go for a walk”. Please ensure you write on the planner to where’. It said Miss Y was getting an exercise bike which needed adding to the planner, along with trips to local places of worship and craft activities Miss Y enjoyed. It said to encourage and support Miss Y to find new clubs and activities to attend and broaden her social interactions.
22. It said Miss Y now had a new thoughts and voices chart to be placed in the activity planner for Miss Y to score her thoughts and voices twice a day.
23. The plan noted Miss Y had not accessed public transport. It said support for this would be included on the daily planner with Miss Y’s input.
24. The plan noted that all interactions should be recorded on the care provider’s electronic system.
25. Between April and June 2023, Miss Y cooked with staff around once a week. On other days Miss Y often ate ready meals.
26. I have examined the care provider’s records for January to June 2023 which show staff asked Miss Y about the voices she was hearing every day. Some staff asked her to rate the voices on a scale of one to ten. During August 2023 the care staff also completed a chart. They asked Miss Y about the voices she was hearing at least once and sometimes twice a day and recorded her comments on the handwritten chart.
27. In August 2023 the Council reviewed Miss Y’s care plan. It noted she had made a remarkable improvement since moving into supported living. She was participating in outdoor activities, her sleep and appetite were reasonable and she was engaging with staff who took her out on fresh air walks. She enjoyed activities of her choice. It noted she received support with cooking each week.
28. I have examined Miss Y’s activity plans from July 2023 to September 2023. They showed brief details of activities such as music practice, attending music lessons, watching a film, craft activities, ‘walk’ or ‘go for walk’, housework activities, and on one occasion go shopping to buy ingredients for a meal. On some days the plan also included brief comments on the activity such as ‘enjoyed her walk’. The electronic case records for the same time period show staff asked Miss Y to complete the activities planner and showed Miss Y undertook activities including shopping and cooking for a friend who visited, housework, practicing her music, clothes shopping, attending a place of worship and going to the park to feed the ducks. On occasions Miss Y was asked to go for a walk or cook but did not want to. Staff also called Miss Y when she was at home at the weekends. They noted the activities Miss Y undertook at home which included attending a place of worship, a regular weekly club, gardening and baking.
29. In September a carer noted Miss Y asked about the garden at the placement. The care advised they would look to have a tenants meeting to discuss what everyone wants from the garden. They noted Miss Y said Mr X was not happy with the planners and that staff did not sit and talk with Miss Y about her day. The carer said there was a place in Miss Y’s planner for that and staff would be spoken to, to ensure it happened. They suggested staff sat with Miss X every evening to ask about the voices but that Miss Y would need to work with the staff for this to happen. Later that month a carer noted they updated Miss Y about the garden and she would be in charge of the flowers.
30. In September 2023 the care coordinator visited Miss Y. They noted Miss Y’s parents would like staff to write on her daily report discussions they had with Miss Y about the voices and her mood and behaviour. They noted Miss X would like to start cooking with staff on a weekly basis.
31. Mr X says in September 2023 staff stopped transporting Miss Y in their cars. In November Mr X met with the manager of the supported placement to discuss the transport issue. Mr X said the decision to stop the agreement to provide transport for Miss Y left the placement far less viable. He raised a number of other issues around the support provided to Miss Y, activities and support for Miss Y’s voices.
32. The manager responded and explained the company’s policy was that staff would not take the people they supported in their own cars but could support Miss Y in her own car or public transport. They could also support Miss Y to apply for additional benefits. They said Miss Y had a weekly planner and chose what activities to do. In response to my enquiries the care provider said there was not a blanket policy for staff not to use their own cars. This may be considered if there were specific requirements factored into the care contract.
33. Mr X responded. He said Miss Y needed a plan with aims, methods and regular reviews. He said the manager had said there was a care plan but this could not be shared without Miss Y’s consent which he had discussed with Miss Y who said she had never seen the plan. He asked the manager to review the plan with Miss Y’s help to ensure all carers were familiar with and could support Miss Y with her thoughts, delusions and voices and that carers discuss the voices with her. Mr X said the sheets he suggested were ignored and then discontinued without further discussion. Mr X suggested the plan set out how Miss Y would be supported to go forwards with her life at the supported placement. Mr X said essentially he was requesting more effective use of Miss Y’s care hours.
34. In November 2023 Miss Y’s care coordinator spoke with the care provider after Mis Y and her parents raised issues about the support she received at the placement. The care provider said Miss Y made a weekly plan but would not engage and would ask staff to leave her alone. The care provider said they had agreed a new plan whereby Miss Y could bring her car to the placement which could be used to transport her. The care coordinator agreed to arrange a meeting with Mr X to address the issues raised and find a way forward.
35. In late November 2023, following a home visit, Miss Y did not return to the supported living placement. In December 2023 Miss Y and Mr and Mrs X met with the care provider, her care coordinator and Miss Y’s social worker to talk about the issues raised by Miss Y and her parents. Miss Y read out her concerns and reasons why she did not want to return to the placement. These included that she was told she could have transport to music lessons, apply for a mobility car and transform the garden and none of this had happened. She raised issues around the manager at the placement and that she felt unsupported. Mr X questioned whether all the carers were able to work with someone with Miss Y’s mental health condition. The care provider said it would take her comments on board.
36. In January 2024 Mr X collected Miss Y’s remaining belongings. Following this the care provider emailed Mr X requesting confirmation that Miss Y would not be returning.
37. In early February 2024 Mr X submitted a formal complaint to the care provider covering a range of issues. It responded later that month. In summary, its response included:
• Individual staff members need appropriate insurance to transport people to activities and appointments. It is not a contractual obligation to use personal cars for this purpose. There were three employees with relevant insurance who were available to support Miss Y but on several occasions Miss Y refused to go in their cars. Other options were offered including supporting Miss Y to get a blue badge, to use public transport and to obtain a bus pass.
• Miss Y contributed to designing the garden at the placement. Miss Y was supported with voluntary work at another of the provider’s properties. This was cancelled at short notice on occasion due to a person there being unsettled.
• Staff supported Miss Y out shopping. When Miss Y overspent they advised her not to and informed Mrs X when this happened.
• Staff used distraction techniques to support Miss Y when she heard voices and had completed relevant training.
• A review of Miss Y’s care plan did not progress as she did not return to the placement.
38. It noted there were some concerns around communication which led to misunderstandings. It apologised for any misunderstanding and frustration caused.
39. Mr X responded that:
• they had a verbal agreement to provide transport. If Miss Y refused to get in a carer’s car this should have been recorded in the daily notes and there was no evidence of this. He said Miss Y was not supported to obtain a blue badge and had a fear of using buses and had not used one for many years so public transport would not be appropriate.
• Mr X considered the failure to produce a care plan at the start of the placement contributed to the placement failing. Mr X said he only received a copy of the plan following a subject access request.
• There was little done to foster Miss Y’s interest in gardening. He said Miss Y stopped attending the voluntary work as she felt underappreciated and staff failed to control Miss Y’s overspending.
• He said some staff were effective and some not in managing Miss Y’s voices. Forms were created to encourage dialogue with Mis Y about voices but were not completed. He considered Miss Y did not receive planned care but maintenance care at best.
40. Mr X remained unhappy and provided his detailed comments in late March 2024.
41. In Spring 2024, as a result of Mr X’s concerns, the Council carried out a quality assurance visit to the supported living placement. It found no significant concerns and was satisfied the care and support delivered by the provider was of a good quality.
42. The care provider responded to Mr X’s further concerns in early October 2024. It did not uphold Mr X’s concerns. It said it had completed a care plan which was available for all staff to follow. The care plan provided staff with guidance on dealing with Miss Y’s illness and was available on electronic handsets at the point of care delivery as part of its live care management system.
43. Mr X remained unhappy and complained to us.

Findings

The care plan

44. The Council completed a needs assessment and carried out a review with Miss Y and her family in Augst 2023. The records show the care provider created a comprehensive care and support plan based on information from the family, including a folder produced by Mrs X, and input from the Council’s needs assessment. The plan was also updated in April 2023. The care staff had on-line access to this through the electronic system. Mr X says Miss Y would have wanted to be involved in the care plan’s production, yet the care plan stated Miss Y did not want to be involved. However, the plan also stated Miss Y would be given the opportunity to read it through. I have seen no evidence this happened or that Miss Y was provided with a copy. The plan is comprehensive however the failure to share it with Miss Y was fault and meant Miss Y was unclear of what exactly was in plan and had no opportunity to comment on it.
45. Mr X considers the plan is too large to be effective. That in itself is not fault. The plan covers a wide range of areas and staff were able to access relevant sections through their electronic handsets.

Miss Y’s activities

46. The records show staff sat down with Miss Y to plan her weekly activities and that Miss Y undertook activities each day. When the care plan was reviewed in April 2023, staff were asked to not put ‘go for a walk’ in the care records but to specify where to. This did not happen. The care records frequently continued to say ‘walk or ‘go for a walk’. It lacked detail and care staff did not do as they were requested to do in the care plan. This was fault.
47. The care plan said Miss Y should be encouraged to cook with staff twice a week. The records show Miss Y cooked with staff on a weekly basis but this reduced over time. The records include occasional comments form staff saying to Miss Y she had not cooked for a while, however this was generally in the evening and not when she was completing the planner. The care provider did not comply with the care plan, which was fault.
48. From the case notes I have seen, there is no evidence the care staff encouraged Miss Y to identify new clubs or suggested new activities, in line with the care plan. The care plan also suggested Miss Y should be supported with cooking twice weekly. The records show this happened on a weekly basis and then later became far more infrequent. The records show there were occasion when staff commented Miss Y had not cooked for a while but this should have been raised and discussed on a weekly basis when Miss Y completed the care plan. This was fault.
49. The records I have considered show Miss Y was supported to undertake activities every day. These included shopping for food and clothes, attending coffee shops, going to the park or ‘round the block’. However, on balance, the care provider was not as proactive as it could have been in encouraging or suggesting alternative activities for Miss Y and failed to ensure the activities planner was sufficiently detailed. This was also fault.
50. Miss Y was able to make her own decisions and there were occasions when Miss Y declined to cook or to undertake the planned activity. That was her choice. The electronic records also show when this happened staff would on occasion go back and ask again later. However, the lack of detail in the records leaves Mr X with a sense of uncertainty over whether more could have been done to support Miss Y to undertake a wider range of activities.

Miss Y’s transport

51. Miss Y’s needs assessment completed by the Council did not specifically include a requirement of the care provider to provide transport. The records show that during her stay staff occasionally drove Miss Y to music lessons and to the shops. Mr X first raised the issue of transport in March 2023 and the care provider failed to clarify exactly what could and would be provided. Mr X says this was stopped in September 2023. The care provider’s response to Mr X’s complaint and to me fails to clearly explain what happened. It suggests transport was still available but was limited to those staff who had insurance were on shift and Miss Y was willing to be transported by. It also said staff transporting residents may be considered if there were specific requirements factored into the care contract. This lack of clarity was fault. This meant Mr X was not clear over whether staff could ever continue to transport Miss Y and on what basis and when this might happen.
52. Miss Y was able to walk to the shops and the park and to undertake other local activities. So, the lack of staff transport did not prevent Miss Y accessing the community although it limited her options. However, in the records I have seen there is no evidence Miss Y suggested other activities which required transport or that she missed out at that time.
53. The care provider said alternative methods of transport were suggested, including public transport, a blue badge and Miss Y using her own car. Miss Y was not able to use public transport without help. In April 2023, the care plan said staff would encourage her to use public transport and I have seen no evidence this happened or that staff suggested this to her. This was fault and leaves uncertainty over what might have happened if staff had sought to progress this sooner. The care provider also suggested it would offer support to Miss Y with obtaining a blue badge or bringing her own transport to the placement. These options were not suggested until late 2023 and did not progress as Miss Y did not return to the placement. The relationship between Mr X, Miss Y and the care provider broke down in late 2023 before this matter was fully resolved.

Failed to support Miss Y effectively when she was hearing voices.

54. The care provider agreed to complete a ‘voices’ chart. This was only completed for a short number of weeks in August 2023. The failure to complete this, as agreed with Mr X was fault which caused Mr X frustration. However, the records show staff regularly asked Miss Y about the voices and also asked her to score how they were affecting her. Mr X said Miss Y was not always honest with staff but that is not something I can hold staff accountable for.

Action taken by the care provider

55. The Council shared a draft of this decision with the care provider. In response, it provided details of the action it is taking to prevent a recurrence of the faults in future. This included:
• Reviewing the accessibility of its electronic care plans with individuals and evidencing on its system more clearly where a care plan is shared and agreed by an individual.
• Increased guidance and support to operational teams regarding the oversight and completion of support plans and interactions via ‘mindful and meaningful documentation’ workshops.
• Redesigning the support plan and risk assessments, to be personalised and outcome focused and in line with relevant standards, with full implementation due by the end of the financial year.
• Within the new support plan template, transport requirements are clearly stated.
56. I am satisfied the action the care provider is taking is appropriate to prevent a recurrence of the faults identified and so have not made any further recommendations for service improvements.

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Agreed Action

57. Within one month or the final decision the Council has agreed to:
1. Apologise to Mr X for the uncertainty and frustration caused by the care provider’s faults.
2. Apologise to Miss Y and pay her a symbolic payment of £200 to acknowledge the uncertainty and frustration caused by the care provider’s faults. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology.
58. The Council should provide us with evidence it has complied with the above actions.

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Decision

59. I found fault causing injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman