London Borough of Hammersmith & Fulham (18 007 262)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 15 Feb 2019

The Ombudsman's final decision:

Summary: Ms X complains about the quality of domiciliary care provided to her late mother. The Council did not ensure the care agency addressed Ms X’s concerns properly. Consequently, the problems continued which meant that Mrs Y did not receive the service to which she was entitled.

The complaint

  1. Ms X complains about the quality of domiciliary care provided to her late mother, Mrs Y. She complains about:
  • missed visits
  • carers not keeping to allotted times
  • carers not staying for the allotted time but recording that they have
  • over 50 different carers visiting
  • one carer arriving instead of two
  • occasions when two carers did not arrive at the same time, in some instances there was a 30-minute delay before a second carer arrived
  • concerns about a care coordinator at the care agency
  • having three different Council social workers
  • bullying behavior from a Council social worker
  • the Council failing to properly investigate her complaints

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The Ombudsman’s role and powers

  1. 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).
  2. 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, section 25(7), as amended)
  1. 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)

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How I considered this complaint

  1. I have:
  • considered the complaint and discussed it with Ms X;
  • considered the correspondence between Ms X and the Council, including the Council’s response to the complaint;
  • made enquiries of the Council and considered the responses;
  • taken account of relevant legislation;
  • offered Ms X and the Council the opportunity to comment of a draft of this statement.

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What I found

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 applies to care providers. The Care Quality Commission (CQC) monitors, inspects and regulates adult care services providers to ensure they meet fundamental standards of quality and safety.
  2. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014).

The Council’s complaints policy

  1. Where a complaint cannot be resolved quickly the Council screens complaints to determine the potential risk to the service user and the organisation. It grades the risk as low, medium and high.
  2. The policy says “Where the complaint covers services arranged by the Health Service or Care Agency as well as Adult Social Care, the Customer Care and Complaints Manager will ensure that early discussions take place between the relevant staff (health or care agency) and the Council, to agree who should take the lead role. This would generally be assigned to the organisation which covers a greater part of the complainants concerns. The two organisations will cooperate fully, usually to support an integrated response unless it is agreed with the complainant that the elements are best dealt with separately”.

What happened

  1. Mrs Y received care commissioned by the Council from MiHomecare Limited (the Agency) She was 89 years old. She had cognitive impairment and needed support with all daily living tasks.
  2. In July 2017, following a hospital stay, Mrs Y was discharged home with 4 daily care visits from two carers. At this point she was bed bound and needed a hoist for all transfers.
  3. Ms X became concerned about the quality of care shortly after Mrs Y went home from hospital. She first complained to the Council on 31July 2017. She complained about late visits, carers on occasions when one carer visited when there should have been two.
  4. Mrs X made numerous complaints, some verbal, some written, to the Agency, and the Council. I have seen copies of all correspondence exchanged, which show Ms X’s concern and increasing level of frustration. On each occasion Ms X complained to the Council it passed her complaints back to the Agency.
  5. After repeated complaints by Ms X the Council met with Ms X, other family members, and the Agency on 10 August 2017. The Agency acknowledged its failings and all parties agreed an action plan. The Council says, “a number of actions were agreed (including choosing 4 preferred carers)”.
  6. On 25 August 2017 Ms X complained to the Council again that carers other than the nominated few were visiting, and that carers were turning up late/alone. The Council passed the complaint to the Agency.
  7. Ms X contacted the Council again on 31 August 2017 to reduce the care visits from four to two because of problems with the Agency, she said Mrs Y could not cope with the number of different carers visiting. She said 55 carers had visited Mrs Y in a short space of time. Ms X said she and her brother would undertake some of the care to reduce visits from carers. The Council passed the complaint back to the Agency.
  8. The Agency responded to Mrs X’s complaint in writing on 31 August 2017. It accepted its failings and apologised. It said it would address the issues raised with the care coordinator, and would monitor the care provided to Mrs Y.
  9. Despite the Agency’s assurances the same problems continued.
  10. A council officer contacted Mrs Y’s family on 4 September 2017 and was told the situation was not resolved. The Council arranged to review Mrs Y’s care.
  11. The Council completed the review on 31 October 2017. I have seen a copy of the review document. This records all the issues recorded in paragraph 1 above. The reviewing officer advised Ms X to consider direct payments and “to contact social services in the event of a breakdown in the service”. The Council took no further action.
  12. On 1 November 2017, a district nurse expressed concern about the reduction in care visits, from four a day to two. She made a safeguarding referral to the Council on the 1 November 2017.The Council says that following a discussion with a senior district nurse the referral was not progressed. The Council says there was no indication of abuse or neglect and Ms X did not ask the Council to deal with her complaints under safeguarding.
  13. The Council says on 5 December 207 it allocated an officer to arrange a meeting with all parties.
  14. Ms X says a social worker telephoned her in December 2017. She says the social worker questioned her about how she and her brother were managing to coordinate Mrs Y’s care. The social worker told her she had not read Mrs Y’s notes. Ms X told the social worker she was upset by her manner at least twice during the conversation. The social worker arranged to meet with Ms X on 19 December 2017. Ms X later sent the social worker an email to say she was upset and cancelled the meeting. Ms X later received an email from the social worker saying she would rearrange the meeting.
  15. Mrs Y was admitted to hospital in early January 2018 and sadly passed away.
  16. On 8 January 2018 Ms X received a letter from the Agency. The Agency acknowledged its failings and apologised for the distress and inconvenience caused to Mrs Y and Ms X.
  17. Ms X complained to the Council about the bullying behaviour of a social worker on 16 February 2018. She said this happened on 8 December 2017. The Council says the complaint was passed to the social worker’s manager. The Council has no records to show how this was dealt with. In response to my investigation the Council says, both the manager and the social worker have left the Council and it is unable to comment further.
  18. Following Ms X’s complaint to the Council in February 2018 she received an undated letter from the Agency in March 2018. The author acknowledged Mrs Y had received poor care and explained this was due to wider issues relating to poor management. The author went on to say said The Agency had been working with the Care Quality Commission (CQC) to develop an improvement plan. The author said, “I would like to unreservedly apologise that you feel your mother suffered because of our failings and understand how your feelings towards how the care was being managed at the end of her life”.
  19. The council says it had been aware of concerns about the Agency since May 2016. It says concerns similar to those that affected Mrs Y had been raised by CQC and by officers at contract monitoring meetings.
  20. It says it worked closely with the care provider and CQC, to develop an improvement plan, which focused on addressing the following:
  • Medicine Management – the consistency and accuracy of documentation
  • Risk Assessments – overall quality of assessments and recording of sign off by all relevant parties
  • Care Plans – overall quality of care plans and recording of sign off by all relevant parties
  • Communication Issues – responsiveness of the branch office to resident’s queries and complaints. 
  • Consistency of care – improving practice and consistently following procedures around key issues such as No Replies.
  • Notifying CQC – provider did not always send notifications of serious incidents and safeguarding concerns to the CQC. 
  1. The action plan was completed at the end of February 2018, and since then council officers have attended regular contract monitoring visits. It has also updated and reviewed its performance.


  1. The Council had a duty under section 8 of the Care Act 2014 to meet Mrs Y’s eligible needs. It did so by an arrangement with the care agency. Any failings in the care agency’s service to Mrs Y were fault by the Council because the care agency provided services on the Council’s behalf under section 8.
  2. Councils should ensure Agencies have a robust system in place to proactively record and monitor the delivery of care. In this case it failed to do so.
  3. The Council did not respond directly to any of the complaints Ms X made. It should have done so. Despite being aware of historical problems with the Agency it passed all the complaints back to it. It is difficult to understand why.
  4. Despite the agency’s assurances to Ms X, and the Council, it did not resolve recurring problems. The persistence of the complaints about the same issues, and the concerns reported by the CQC should have led the Council to intervene proactively. It did not do so. This is fault. Because of this fault Mrs Y’s needs were not properly met. Consequently, Ms X and her brother, had to undertake some of the care, and had to constantly check up on the care provided by the Agency. They should not have had to do so. This caused unnecessary stress and put Ms X and her brother to significant time and trouble, in both caring for Mrs Y, and pursing the complaints.
  5. The records show Mrs Y had visits from over 50 carers between August and October 2017. This is unacceptable and poor practice.
  6. Continuity of carers helps to promote the delivery of person-centred care. At the very least a person should know in advance who will be visiting them. This is particularly important where a person has cognitive impairment. Mrs Y never knew which carer would arrive. This caused uncertainty and anxiety for her and her family. This is fault.
  7. The Council completed a review of Mrs Y’s care in October 2017. All the reoccurring problems were documented. The reviewing officer’s response was to advise Ms X to think about direct payments, and to ask her to inform the Council if the service broke down. This was an unacceptable response. The advice was of little assistance to a family struggling to oversee the care of an elderly vulnerable adult.
  8. The Council has no records to show how it investigated Ms X’s complaint about the behaviour of a social worker. It says the officer and the manager did not keep records and have now left the Council. The fact that officers have either not made, or kept, relevant complaint-handling records is fault. This denied Ms X a response to her complaint.
  9. It is no longer possible to remedy the injustice to Mrs Y, as she has died. However, the Council’s failure to ensure she received adequate quality of care and its failure to address Ms X’s concerns properly caused Ms X distress and she was no longer able to trust the Council to deliver care. This resulted in her undertaking some of the care and constantly checking up on the carers because the Council failed to do this effectively. This put her to significant trouble in pursing her concerns

Agreed action

  1. The Council will:
  • write to Ms X to apologise for the poor care Mrs Y received, and for its failure to respond to her complaints about this.
  • pay Ms X £500 to remedy the distress she has been caused and the trouble she has been put to in pursuing these concerns.
  • monitor the care agency’s performance including records, care plans and call time adherence as part of its regular contract monitoring and take appropriate action to address any concerns in service. The Council should send me full records of the next quarterly monitoring it completes for the care agency, including details of any improvements required;
  • under the terms of our Memorandum of Understanding and Information Sharing Protocol, I will send CQC a copy of the final decision statement.

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Final decision

  1. The Council did not ensure the care agency addressed Ms X’s concerns about poor care properly. Consequently, the problems continued which meant that Mrs Y did not receive the service to which she was entitled.
  2. The Council failed to deal with Ms X’s complaints about a social worker.
  3. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman

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