Sheffield City Council (20 013 706)

Category : Adult care services > COVID-19

Decision : Upheld

Decision date : 17 Feb 2022

The Ombudsman's final decision:

Summary: Mr X complained the Council failed to ensure it had effective monitoring processes in place in relation to his daughter, Miss D’s, supported living placement and also delayed in responding to his complaint. The Council has already accepted there was a need to improve monitoring and has taken appropriate steps to address this. The Council took too long to respond to Mr X’s complaint. It has already apologised for this which is suitable to remedy the frustration this caused Mr X. It has also agreed to provide evidence that the outstanding work to the communal room has been completed and it has raised the issue of unacceptable delays with the Landlord.

The complaint

  1. Mr X complained:
    • the Council failed to ensure it had effective monitoring processes in place in relation to his daughter, Miss D’s, supported living placement; and
    • delayed in responding to his complaint.
  2. He also complained that Miss D found the staff on site unapproachable and said she had not been protected adequately from being intimidated by other residents.
  3. As a result, Mr X says Miss D has no trust in the support provided in the placement, is distressed by the state of disrepair and no longer wants to live there.

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The Ombudsman’s role and powers

  1. 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 has done. (Local Government Act 1974, sections 26B and 34D, as amended)
  2. I have decided to exercise my discretion and investigate matters from August 2019. This is when the incident in the communal room (detailed below) took place resulting in Mr X complaining to the Council.
  3. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. Part 3A covers complaints about care bought directly from a care provider by the person who needs it or by a representative, and includes care funded privately or with direct payments under a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
  4. In this case, the Council arranged and paid for Miss D’s care. Therefore, we will treat the actions of the care provider as if they were the actions of the Council.
  5. 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)
  6. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide there is not enough evidence of fault to justify investigating or further investigation would not lead to a different outcome. (Local Government Act 1974, section 24A(6))
  7. If we are satisfied with a council’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)
  8. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

  1. I spoke to Mr X and considered his view of his complaint.
  2. I made enquiries of the Council and considered the information it provided. This included correspondence with Mr X, Miss D’s support plan and her daily notes and quality monitoring reports.
  3. I wrote to Mr X and the Council with my draft decision and considered their comments before I made my final decision.

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What I found


  1. Mr X’s daughter, Miss D, lives in a supported living placement. She has her own flat and there are also communal facilities for all the tenants who live there.
  2. The Council awarded the supported living contract to a provider (the Company) several years ago. Most of Miss D’s daytime support is carried out by another provider and she has no complaints about this. A Company staff member sleeps on the premises to provide support at night if needed. It will also provide emergency support when required.
  3. The Company leases the building from a private organisation (the Landlord). The Company has a contract with the Landlord which states the Landlord is responsible for the maintenance and repairs of the building. The Company is responsible for reporting maintenance and site issues to the Landlord such as damage to communal rooms, furniture and carpets. The Company has a form on which it enters the details of repairs reported to the Landlord which I viewed during my investigation. The form outlines the repair, who reported it and when it was completed.
  4. The Council has the following arrangements in place:
    • its Operational Commissioning Team (OCT) commissions the support provided by the Company; and
    • its Quality and Performance Team (QPT) monitors the provision.
  5. The QPT monitors provision in two ways:
    • by carrying out an annual monitoring visit to the Company’s offices to audit documentation such as staffing, training, safeguarding, support planning and medication administration and control; and
    • by an annual visit to the supported living placement to talk to tenants and to check issues such as the state of the placement, staffing, activities, health and wellbeing and social inclusion.
  6. The Council has a traffic light-based scoring system by which it scores various aspects of the placement, including communication, staffing, activities, environment and support plans. The system works as follows:
    • Green – standard met or one or more issues that are in progress or easily resolved;
    • Amber – one or more issues which could affect service delivery but can be resolved with more significant input from the provider;
    • Red – one or more issues that will need substantial provider input and/or of a more urgent nature with an impact on service delivery.

What happened

  1. In June 2019, the QPT carried out a visit to the Company’s office. It awarded the Company a green rating.
  2. In August, Mr X raised issues about the state of the communal room following an incident involving another tenant. He said the room was unusable with a damaged sofa, blood on the carpet and broken kitchen units.
  3. In December, Mr X spoke to the manager of the placement about the communal room and other issues with the building. They met later that month.
  4. Prior to that meeting, the Council carried out a site visit to the placement and awarded the placement a green rating for ‘environment’. In response to my enquiries about why the placement was given a green rating in light of the state of the communal room, the Council said this was because the Company had recognised the problem and had taken appropriate action by raising the matter with the Landlord.
  5. In March 2020, the country went into lockdown because of COVID-19 and Miss D returned home.
  6. In November 2020, Mr X complained to the Council. Mr X said his principal concern was that the Council was failing to adequately monitor the placement and the Company; specifically, the Council had failed to:
    • monitor the quality of social support and care provided by the Company in any meaningful way;
    • ensure any quality monitoring of the placement;
    • involve tenants’ views in monitoring the placement;
    • make clear to the Company what was expected of it in managing the placement;
    • ensure the placement was consistently and efficiently managed by the Company; and
    • respond effectively to any concerns expressed.
  7. As a result, Mr X said there were constant disrepairs to the property which were either never resolved or took too long to resolve. As a result, Miss D had become anxious that staff were not listening to her when she reported issues and she now lacked trust in them and did not want to return. Mr X and Miss D provided the Council with examples to illustrate the issues they were complaining about.
  8. The Council responded in April 2021. It apologised for the length of time it took responding to Mr X’s complaints and partially upheld aspects of them. In relation to the communal room, it said the remedial works had been delayed and then put on hold due to COVID-19. The Council said it understood the work had only recently been completed and as a result the room had been out of action for a considerable time. It apologised for the poor state of the communal room and the delays which it said were unacceptable.
  9. The Council said would it carry out the following actions:
    • improve the consistency of recording within the quality monitoring reports;
    • implement new quality checks planned prior to the pandemic as part of the monitoring process;
    • establish clearer communication processes between the two Council teams (OCT and QPT) to ensure that relevant issues are recorded and communicated clearly to providers with the requirement for providers to formally respond within a set timescale;
    • if the issues raised by Mr X had not been resolved, the QPT would initiate a joint meeting involving OCT, the Company and QPT, to develop an improvement plan where required to resolve the issues raised by Mr X; and
    • the OCT would offer Mr X and Miss D a mediation meeting to discuss ways to strengthen their relationship with the Company, including the possibility of advocacy.
  10. Mr X remained unhappy and complained to the Ombudsman. He provided examples of repair issues he had raised. Mr X said these examples were to put his complaint into context and he did not want the Ombudsman to investigate the issues themselves.
  11. The Council provided me with an update on the recommendations in its complaint response. It said:
    • since June 2021, where possible due to COVID-19, the QPT had reintroduced site visits;
    • monthly meetings between the officers carrying out the routine monitoring visits and their supervisors now included spot checks on the quality of the monitoring reports;
    • the QPT and OCT had met following feedback from a tenant consultation which included support from an independent advocacy service. The two teams were satisfied the Company was taking the actions from this meeting forward around “person-centred approaches, staff training, communications and activities”;
    • the QPT and OCT met monthly to exchange information about supported living providers. These started in June 2021;
    • the OCT was in regular contact with the Landlord to discuss tenancy and accommodation issues and a housing assessment visit had been prioritised dependent on COVID-19 restrictions; and
    • a new staff post would shortly be advertised. The role would be to carry out a consultation to hear tenants’ views during the on-site quality monitoring visits; and
    • Miss D was due to have a care review and the mediation meeting would be held then with the relevant staff.
  12. In addition, the Council said it was in the process of ensuring more robust monitoring was put in place with clear evidence of actions taken with responsibility given to a specific person to ensure repairs were made or in progress within a reasonable timeframe.
  13. The Council also provided the daily records from August 2019 held by the Company as well as records from 2021 from Miss D’s care provider.
  14. The notes recorded where Company staff interacted with Miss D on an ad hoc basis and where it had helped with medications when Miss D’s care provider had arrived late. In relation to incidents Mr X had raised to me relating to police incidents in 2019, the Council provided records to demonstrate what had occurred, an evaluation of events and proposed actions to help prevent a reoccurrence.
  15. I issued a previous draft decision which Mr X responded to, challenging some of the Council’s responses to my draft decision. He said the Council was incorrect when it said all the work had been completed because the sofa had not been replaced. He also said the flooring had not been replaced at the point in time, although this had now been completed. He said this demonstrated the Council’s poor monitoring of the placement.
  16. The Council told me in response that the furniture for the communal room had been on order since November 2021. It had escalated this with the Landlord and it accepted the timescales were not acceptable.
  17. It said some of the other works had taken too long to complete and following a recent housing assessment it was addressing these, and other issues, with the Landlord.
  18. Mr X also said the Council had not yet completed Miss D’s care review and mediation meeting. The Council responded and said it was waiting for feedback from Miss D’s advocate following information regarding Miss D’s plans at the placement. It said the review would take place in January 2022.

My findings

Quality monitoring

  1. In its response to Mr X, the Council partially upheld some of Mr X’s complaints and explained how it would change the way it worked with the Company to improve quality monitoring. The Council has provided information on how it has met these recommendations. This shows all but one has been met. In relation to the outstanding recommendation to hold a mediation meeting, the Council says it plans to hold this at the same time as Miss D’s review which is due to take place. The Council has also said it will improve the way it records and monitors repairs at the placement.
  2. The main example Mr X gave of the Council’s failure to properly oversee the placement concerned delays in repairing the communal room. In its complaint response the Council said that notwithstanding the effect of COVID-19, the repairs had taken too long and it apologised to Mr X for this. The Council also said it was addressing these issues with the Landlord and accepted the work had taken too long.
  3. The Council has admitted it acted with fault. It should provide evidence to the Ombudsman that the work has been finished.

Support for Miss D

  1. Most of Miss D’s care was provided by another provider. The Company was responsible for night-time care when required and emergency care when Miss D’s own provider was not there. The case notes recorded day to day interactions with Miss D which demonstrate nothing of significance. The records detailing the events in August and September 2019 demonstrate the Company and Council took appropriate action.
  2. I will not investigate this matter further. This is because it is unlikely I would find fault and further investigation, particularly into issues prior to Miss D’s return home in March 2020 for lockdown, would achieve nothing meaningful at this stage.

Complaint response

  1. The Council took around five months to respond to Mr X’s complaint. Although it is acknowledged that the pandemic affected councils’ abilities to respond, the Council should have either kept Mr X updated or provided him with a realistic indication of when it would be able to provide a response. Its failure to do so is fault. The Council has already apologised which is satisfactory to remedy the frustration this caused Mr X.

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Agreed actions

  1. Within three months of the date of the final decision, the Council has agreed to provide the Ombudsman with evidence that:
    • the sofa has been replaced in the communal room; and
    • it has raised the delays in carrying out works at the placement with the Landlord.

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Final decision

  1. There was fault in the Council’s actions. The Council has agreed to my recommendations. Therefore, I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman

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