Summary: Mr X complained that the Council failed to properly investigate when he raised concerns that a care provider it commissioned was not providing appropriate care to his nephew. We found there were issues with the care his nephew received, and the Council had not addressed these robustly or promptly when they were raised. The Council agreed to make a payment to Mr X to recognise the stress and difficulty the matter caused the family. We considered the proposed payment was appropriate and in accordance with our guidance for remedying complaints.

The complaint

1. Mr X’s nephew, Y, receives care which is commissioned by the Council. Mr X raised concerns with Y’s social worker about the care being provided. He subsequently complained that:

• Y’s social worker had failed in her duty of care by not resolving the various issues he raised about the Care Provider’s actions/Y’s care. The issues were detailed in the complaint.
• When he escalated his concern about the social worker, senior managers at the Council did not address the social worker’s actions. The social worker revisited the care placement but no actions were taken to improve Y’s care.

2. An independent investigation was later carried out by the Council at Stage One of its complaint process. Mr X complains this was carried out without agreeing the scope with him first. He further complained:

• the investigation, while detailed, excluded key welfare issues; such as the importance of adhering to routines that help maintain Y’s health and wellbeing;
• Some of the information in the investigation report was not accurate;
• the outcome of the investigation was a detailed improvement plan which Mr X considered to be impractical and required too much scrutiny. This led to the care provider serving notice on Y’s placement; and;
• that his concerns about the Independent Investigation were not resolved at Stage Two of the Council’s complaints process.

3. Mr X told us that because the care provider did not adequately meet Y’s needs, this caused distress to Y. Mr X was also frequently required to visit to help resolve behavioural issues and to provide care for Y at times, when the care provider should have been meeting Y’s needs. The situation was time consuming and stressful as a result.

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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. 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(1), as amended)
6. 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

7. We have looked at events between June 2023 and July 2024 when the Council responded to the complaint.
8. Where an independent investigation has already taken place, we do not generally re-investigate all elements of the complaint. In this case I have noted the outcome of the independent investigation, while also considering Mr X’s concerns that elements of the investigation were unsatisfactory.

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How I considered this complaint

9. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
10. Mr X and the Council had an opportunity to comment on my draft decision. I considered the comments I received before making a final decision.

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What I found

Care and Support Statutory Guidance

11. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says reviews should take place at least every 12 months. It states the first planned review should be an initial ‘light-touch’ review, six to eight weeks after agreeing and signing off the plan and personal budget. This is to provide assurance to all parties that the plan is working as intended and to help identify any teething problems. All reviews should be carried out as quickly as is reasonably practicable, proportionate to the needs to be met.

The Compliant Handling Code

12. Our advice to bodies in our jurisdiction around complaint handling encourages complaint handlers to speak to complainants after reading their complaint. This helps to check understanding and sometimes to manage expectations of the process. In terms of defining complaints, it encourages complaint handlers to produce their own summary of a complaint and share this with the complainant. If a complainant disagrees with the summary, a complaint handler should consider any feedback and ensure they have established what is at the heart of the complaint, but we would not expect them to spend time pursuing changes to gain agreement. We note that complainants would have the opportunity to raise concerns about how the complaint was interpreted through later stages of the process or with the Ombudsman.

What Happened

13. What follows sets out key facts for the purposes of explaining our decision on this complaint. It is not intended to be a full chronology of all events in relation to the complaints raised.
14. Y moved into supported accommodation with Care Provider A in September 2023. He required a consistent key worker, a secure property and help with maintaining his personal care and continence. He also needed help to maintain engagement with in-house and community activities and to regular access to his family.
15. The Council provided a copy of Y’s care and support plan as at 2024. I understand this was substantially the same in 2023. It documented Y’s eligible needs in a reasonable amount of detail. I have not repeated the content in this statement. However, I note that it recorded that Y needed both shared and 1:1 support from staff. It also noted he liked being challenged and needed meaningful activities and structured support in various areas of need.
16. Mr X says soon after Y moved in he raised concern that Care Provider A was not providing the care needed. He stated Y’s accommodation was not secure and he absconded days after moving in, and twice more before Christmas. Care Provider A was not providing any of the 1:1 support agreed and Y did not have a consistent key worker. He noted Care Provider A was not following the actions it should have to maintain Y’s routine. The lack of routine affected his continence and personal care.
17. Mr X says the family reported finding Y’s room in poor condition with Y in soiled clothes on a number of occasions. He stated the lack of adherence to Y’s plan led to him becoming entrenched in poor routines leading to high anxiety and negative patterns of behaviour. He says the social worker did not take suitable action to address these concerns when they were presented.
18. Mr X made a formal complaint in May 2024. Mr X complained about the issues he had raised. When raising his complaint Mr X stated:

• Y’s social worker had not taken any action when the issues were raised with her. This meant the family were left to tackle issues with Care Provider A directly, which had been stressful.
• When Y’s social worker assessed Y’s capacity and asked if he was happy at the placement, she did not do this appropriately and Y’s view could not be relied on as representative of his feelings.
• After Y had been at Care Provider A for around six weeks, a Quality Assessment was carried out and improvement plan put in place. He stated this was not adhered to by Care Provider A.
• The way the matter was investigated was inadequate. Mr X stated Care Provider A had admitted a failure to provide the agreed care but this was later dismissed.

19. The Council arranged for this to be independently investigated. The investigation looked at events between June 2023 and May 2024 when it was received. The Investigation report set out detailed findings in each area of Mr X’s complaint.
20. Overall, the investigation found that:
• There was no evidence that the SW acted in a negligent manner that led to significant harm to Y. She put in place a reasonable care plan at the outset.
• The SW had also carried out placement review meetings and there was some evidence that Care Provider A acted in response to concerns raised, particularly around security. However, it found these meetings were not well documented. I note Mr X later told the Council he had to give the SW a summary of what had occurred.
• The SW met Care Provider A and extensive correspondence was generated about Y’s case. The investigation noted the situation was challenging for a SW with limited capacity as a result. But, the SW should have taken more timely, assertive and proactive steps to address the issues. While the SW escalated the concerns four months after the placement began, the issues should have been tackled far sooner.
• The concerns raised about the quality of care were inappropriately framed as ‘family concerns’ rather than issues with the quality of care that needed to be addressed. The Council should have undertaken a proper quality assurance assessment of Y’s care at the time key points were raised. This had been delayed. Although these were failings, they did not find evidence of negligence or neglect and no significant harm to Y.
• It concluded because the issues were not tackled early on, Mr X was the driving force that led to the issues being addressed. In addition to security, the key issue was that Y needed a structured routine around activity and continence to avoid the related behavioural issues when Y became stressed about these issues.
• The Investigation concluded that 1:1 support had been provided for Y to the level set out in his support plan. It found that Care Provider A had provided a key worker, although there were differing views between Mr X and the Council/Care Provider A as to the expectations of that role. The investigation found that the expectations around consistent support and the key worker role should have been defined in writing ahead of the start of the placement. Prior to the placement the impact of agency staff Care Provider A would be using should also have clarified. It proposed these issues were clarified in writing to confirm the situation.
• The Investigation found evidence that Care Provider A was taking measures to fulfil Y’s continence plan, and staff did prompt him appropriately, but some staff struggled to encourage Y to get up and on occasions he would refuse to engage. There was evidence of laundry management but records were inconsistent.
• At a placement review in October 2023 strategies were agreed to prevent Y becoming stuck in front of a screen, where there were risks of knock-on issues. It noted that by December 2023 Laundry management was a clear requirement for staff supporting Y. As Mr X has highlighted, Y’s need for structure and consistent engagement are key to avoiding continence and behavioural issues. The Investigation looked in detail at behavioural logs and use of support planning tools. It found some shortcomings. It noted support planning tools had not been utilised consistently and a short transition into the placement had meant staff were not au-fait with elements of Y’s support plan. A greater management presence may have helped in the early stages of Y’s placement to support staff to adhere to Y’s support planner, reward chart and routines. Y’s social worker should have sought a formal response to how Care Provider A would deal with these concerns at the review meeting held in October.
• The issue of support planning, the need for engagement and its knock on impact to continence and Y’s behaviour was central to Y’s well-being. The investigation made a number of recommendations for monitoring and regular updates to record and report on progress with these issues. It also proposed Care Provider A developed strategies to help in this area, working with Mr X.
• In terms of security the investigation found that Mr X had made known the risks that Y may abscond ahead of the placement and Care Provider A should have acted on that information. It proposed an apology and action to consider alternative approaches to security. The investigation also considered issues about how Deprivation of Liberty Safeguards (DOLs) issues were considered.
21. In addition to considering the issues at Care Provider A, the investigation considered whether the social worker and the managers at the Council had failed in their duty of care towards Y.
22. The investigation noted that the social worker had been too passive initially, which led to Mr X and his family having to take the lead. There were other points of learning which the investigation highlighted in its findings. Some were issues that should have been better addressed before the placement started and others related to communication and action once concerns were raised. They did not find the social worker had breached a duty of care.
23. The Investigators noted that in response to the escalation to managers, they had two meetings with the family. In response they drafted a letter to Care Provider A but they initially presented the problems with Y’s care as the family’s concerns rather than actual problems with care provision that needed addressing. This was amended. There was evidence of Care Provider A struggling to manage Y’s needs and relying on Mr X. The investigation noted that some issues were addressed in meetings but there was no evidence wider concerns had been addressed by the managers involved.
24. The investigation found that managers did not take robust action to address the concerns early enough. It found the council should have carried out a robust quality assurance assessment to assess the validity of the concerns and deal with them. They recommended the Council acknowledge that the issues of concern were not dealt with in a timely way by the social worker and that the Council should apologise for the wider failure to address them once escalated. They also recommended an improvement plan and consideration about how Y’s care would be overseen and resourced going forward.

Events following the Investigation

25. The Council wrote to Mr X following the investigation accepting the recommendations and findings and setting out action it would take. The Council accepted all of the fault the investigation found and accepted it had caused distress to Y and led to some ongoing issues which had an impact on his wellbeing. It also noted distress was caused to the family. It offered a sincere apology to Mr X for this and offered to pay Mr X £2,000 in recognition of the impact of its actions.
26. Unfortunately, in August 2024, following the outcome of the complaint, Care Provider A gave notice on Y’s placement. This led to a new care provider being sought. Mr X raised fresh issues that relate to the actions taken from this point and about a new placement that Y moved to. Our investigation only considers the complaint Mr X made about Care Provider A and the way the Council dealt with his concerns about the issues he raised while Y was there.
27. Mr X was unhappy with elements of the independent investigation. He stated:

• he had a lengthy initial meeting with the Investigators, but he was unhappy that the investigation scope content was not later agreed with him.
• his complaint was predominantly about the Council’s approach to managing the situation rather than the care provider’s actions.
• the investigation omitted welfare issues affecting Y (the impact of Care Provider A’s lack of adherence to routines and the impact this had on Y’s wellbeing).
• the improvement plan that came from the investigation was too onerous and detailed, and this had caused Care Provider A to serve notice on Y.

Was there fault by the Council

Provision of Care and the initial handling of concerns by the council

28. The investigation found that the care plan put in place for Y was reasonable. It recorded Y’s key needs. It referred to the need for 1:1 care and recorded that Y liked to have structured and meaningful activities in his life and that continence issues needed to be handled sensitively. It referred to the issues that may occur should incontinence occur, and under risks, it noted that lack of stimulation could cause Y to become anxious and challenging and affect his mental health. It referred to a separate behaviour management plan. It noted weekly planners should be used.
29. While all these needs were documented, and there was no fault in the care plan itself, it seems to me that the implications of a lack of structured routine and how this would affect engagement, behaviour and continence issues, were not fully understood, or were underestimated.
30. It has to be accepted that even if a carer was following all required care plan actions, it is possible, at times, that Y may not engage, and issues with behaviour and continence may occur. However, in terms of care provision, the investigation noted evidence that there were examples of Care Provider A not doing all they could to avoid this. They did not routinely use planners and tools to encourage Y to keep to a structured routine and care staff had not had the chance to properly understand his care plan before working with him. Care Provider A was also using agency staff which is likely to have led to less consistency in the approach to Y’s care. The failures identified were fault by the care provider.
31. If Y becomes ‘stuck’ it was known he may lose focus and stop engaging. The knock-on implications of this ultimately affect Y’s wellbeing, because it seems, in those circumstances, he is unable to make positive choices and effectively refuses care or prompts. The investigation found no neglect or negligence by staff. But, the failure to properly understand the implications of not routinely engaging Y and failures in care provision did cause injustice to Y. It was known that Y was at risk of skin breakdown and related issues and these issues did occur. There were also other failings, for example, not properly managing Y’s laundry. Security concerns are also not resolved in a timely way. This also caused Y anxiety.
32. It is acknowledged as part of the investigation that the SW did not act robustly or escalate the issues to get support to do so if required. As a result, the issues were not tacked and resolved at an early stage. So, there was also fault in the way the SW responded.
33. We would have expected the social worker to raise safeguarding alerts given there was concern about Y’s welfare while at Care Provider A. The failure to do so was fault. While the social worker did not raise alerts, the Council told us a safeguarding concern was investigated by the local council where Y lived in April 2024. It regarded the issues as care management, rather than safeguarding concerns. Therefore, it is unlikely that the lack of an earlier report caused any injustice.
34. We have not investigated how safeguarding alerts that were made during this period were dealt with, as this is not within the scope of this complaint.

Council actions when the matter was escalated

35. There was fault in the Council’s response when managers were involved after the referral from the SW. The investigation noted that they did not take robust action to resolve the issues and did not ascertain promptly the issues with Care Provider A’s care provision for Y. This prolonged Mr X’s detailed involvement and the stress and frustration caused and did not improve matters for Y.

Complaint Handling

36. Mr X told us the independent person who investigated his complaint discussed his complaint with him for a round two hours to discuss the issues he was raising. An early conversation is good practice.
37. However, he says that they then began the investigation without sharing the complaint summary to describe what the scope of the investigation would be. We would encourage sharing a complaint summary with the complainant and for the investigator to take account of comments that they may receive about it. I have recommended the Council encourages sharing of complaint summaries in future investigations.
38. However, I do not consider the scope of the complaint was inappropriate. The crux of the complaint was that Y had not received appropriate care at Care Provider A and that the Council had not taken adequate actions when he raised this with the SW and later, managers at the Council. The investigation sought to establish what happened at Care Provider A in order to establish whether care had been appropriate. This is necessary in order to understand whether the Council’s actions were appropriate, in the context of what was happening at the care placement. It follows that I do not consider there was any injustice caused when the complaint summary was not shared with Mr X.
39. I found that the Investigation did consider the importance of adhering to routines and how this affected continence issues.
40. I recognise that in response to the investigation report Mr X highlighted areas that he disagreed with and areas that he thought the investigation had not covered in sufficient detail. However, the report was clearly thorough and it was clear that their findings had been evidenced via references throughout the report to correspondence and Care Provider A’s records. The focus was on care provided and, where things had not been done correctly, how this should be addressed. This was a reasonable approach for the investigators to take. In our own investigations, we do not seek to answer every question that someone raises as part of their complaint. We investigate proportionately focussing on what we consider the key issues to be. So, it follows that I do not consider there was fault by the investigator in not considering all issues Mr X may have wished them to.
41. It was unfortunate that in August, after the investigation, Care Provider A decided to give notice on Y’s placement. The outcome of the investigation included a detailed improvement plan which Mr X considered to be impractical and required too much scrutiny. He felt this was the cause of the care provider serving notice on Y’s placement. I do not consider the detail in the improvement plan was unreasonable.
42. I found the faults that the investigation identified caused distress to Mr X and to Y. Where we decide it is appropriate, we will normally recommend a remedy payment for distress of up to £500. We can recommend higher payments to remedy distress where we decide it was especially severe and/or prolonged or to take account of personal vulnerability of those affected. In this case the Council offered to make a payment to Mr X of £2000. I consider that £1000 paid to Mr X would be a suitable payment to reflect that Mr X was put to significant inconvenience, caused frustration and stress. A payment of £1000 to reflect that Y was negatively affected by the issues with his care would also be appropriate. As a result, I concluded that the £2000 offered by the Council, to the family, to reflect the impact of the fault identified, would be a suitable remedy for the complaint.

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Action

43. Within four weeks of our final decision:
44. The Council should provide evidence that it has paid Mr X £2000. This is to recognise his own distress and to reflect the impact on Y of the failings in the care he received at Care Provider A.
45. The Council should review and ensure that its guidance or instructions for Independent Investigators it commissions takes account of the Complaint Handling Code and our guidance for Complaint Handlers. This can be found on our website.
46. The Council should provide us with evidence it has complied with the above actions.

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Decision

47. I find fault causing injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman