Summary: There was fault in the way the care agency handled two visits and the Council has upheld Ms B’s complaint. The Council has already remedied the injustice.

The complaint

1. Ms B and her mother, Mrs C, complain about the actions of a care agency which provides care to Mrs C. They say the care worker failed to turn up for a care visit and then attended very late. Later that day the agency tried to send a care worker who had been previously banned from the house to a care visit which required two care workers.

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The Ombudsman’s role and powers

2. 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)
3. 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)
4. 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

5. I have discussed the complaint with Ms B. I have considered the documents that she and the Council have sent and both sides’ comments on the complaint.

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What I found

6. Mrs C lives on her own and receives support from a care agency, paid by the Council. Two care workers attend four times a day. Mrs C also pays privately for extra care which includes a weekly appointment to take her to the hairdresser. Ms B lives abroad part of the time and lives with Mrs C when she is in the UK.
7. Ms B’s father passed away on 18 November 2018 and Ms B returned to the UK. She arrived on 21 November 2018. She says she was exhausted, jet-lagged and grieving for her dad. She had to break the news of her father’s death to Mrs C. She was trying to deal with stressful and difficult circumstances.
8. The carer was due to take Mrs C to the hairdresser at 1:15 pm but failed to arrive.
9. Ms B rang the agency and spoke to agency worker, Ms K. She explained what happened. Ms K rang care worker L who was meant to attend at 1:15pm. Ms L told her she had thought the call was a tea time call. Ms L said she would go to Mrs C’s house immediately.
10. Agency worker K rang Ms B and said Ms L did not know that the call was time specific. Ms B took Mrs C to the hairdresser instead.
11. Care worker L arrived an hour late and was already at the house when Ms B and Mrs C returned. Care worker L tried to explain why she was late, but Ms B said she was not interested in anything she had to say. Ms L was aware of Ms B’s bereavement so she asked Ms B if she was ok and offered her a hug. Ms B became very angry at Ms L and shouted and swore at her. As Ms L saw that her presence was only making the situation worse, she left soon after.
12. Later that day, the agency rang Ms B and said that only one carer, Ms M was available to carry out the evening visit. Ms B said Ms M had been banned from attending Mrs C’s home because of a previous issue. She said Mrs C needed two carers and the agency should provide this. The agency then resolved the situation and sent two different carers later that day.
13. Ms B complained about the issues to the agency on the same day. The manager of the agency replied on 29 November 2018 and said the reason for the late visit was ‘entirely human error.’ She said she had added an exclusion to Ms M visiting Mrs C’s home so the problem should not happen again.
14. Ms B wrote to the agency and said she was not satisfied that the agency blamed human error for the late visit. She said she had spoken to care worker L and the explanation that she did not know the call was time specific was not the truth.
15. Ms B was not satisfied that the second issue had been addressed sufficiently. She said the agency should have known that all visits require two carers and that the carer they were proposing was banned from attending.
16. The agency’s manager provided a formal written response to the complaint on 7 December 2018.
17. She said:
• The missed visit on 21 November 2018 was caused by human error. Care worker L had misread her rota.
• Care worker L attempted to explain the reason for her lateness and offered Ms B a hug. She then left as she did not want to upset Ms B further.
• The decision to try to swap the shift to care worker M was made in mistake. The out of hours team dealt with the matter rather than the local team and they were not aware of the fact that Ms M was not meant to attend Mrs C’s home.
• The matter was resolved and two appropriate carers attended.
• An immediate exclusion was put on the banned carer so this would prevent the issue arising again.
• The manager apologised for the distress caused.
18. Ms B escalated her complaint to the Council on 14 December 2018.
19. The Council carried out a section 42 enquiry into the complaints. The outcome of that enquiry was that the agency should clearly record any care provisions and ensure that all staff, both front line and office staff, are aware when a member of staff has been declined to complete a visit so that the care worker is not sent to that home again.
20. The Council carried out a review of the care services on 7 January 2019. Mrs C said she was happy with the agency. Ms B had some concerns about some of the staff who she said had broken things. She felt the agency did not have a contingency when they were short staffed.
21. They agreed that:
• The social worker would raise the issues with the agency.
• If Ms B was still not satisfied with the agency on her next visit, the Council would organise a meeting between the agency, Mrs C, Ms B and the Council.
• Ms B would leave a note book around the house as reminders for the carers.
22. The Council carried out a further visit to Mrs C on 22 January 2019 to seek her views on the care agency. Mrs C said she was happy with the care service and did not want to change providers.
23. Care worker L explained why she missed the visit. She said: ‘I had not seen this on my rota as I don’t usually do this and I had her for a tea call and I thought that was that.’
24. The Council provided its response on 29 January 2019. The officer said:
• Care worker L misread her rota for the visit on 21 November 2018. She thought the 1.15 pm visit was the teatime visit. The office staff then contacted her and she went straight to Mrs C’s home but was an hour late.
• One of the carers who was meant to attend on the evening was unable to carry out the visit and contacted the out of hours team. The out of hours team was not aware that care worker M had been banned from attending Mrs C’s home. The care coordinator on the day had been new and had not been aware. However, all the care coordinators had now been briefed.
• The Council carried out a review of the service on 7 January 2019 and Mrs C was generally happy with the care provided.
• Ms B had raised concerns that sometimes staff were unfamiliar with Mrs C’s preferences and did not know where things were in the house. The Council would discuss this with the agency.
• Ms B had agreed to leave a notebook to assist communication. If there were still concerns about the service in the future, then a review meeting could be held.
25. Ms B was not satisfied with this response. She said:
• It still did not address her complaint that the office staff’s response was wrong and that she had let the carer take the blame.
• There was no acknowledgment that her father had passed away and that Ms B had to tell Mrs C this news and deal with everything on the day the mistakes happened.
• The agency had not taken responsibility for its poor service so it had not learnt from the mistake and would not improve.
• The Council’s response was late as it should have been provided by 10 January 2019.
26. She wanted to escalate the matter to the next stage.
27. The Council said Ms B could take the matter to stage 2 of the complaints process but did not think this would add much to the outcome Ms B wanted. Alternatively, Ms B could take the matter to the Ombudsman. Ms B decided to proceed to the Ombudsman.

Analysis

28. The agency has already acknowledged that there was fault when care worker L was late for the 1.15pm visit. The agency explained how it happened and says it was human error. The agency apologised for the fault.
29. Ms B says that she accepts care worker L’s explanation for the late visit but wants the Ombudsman to further investigate the fact that agency worker K lied when she said Ms L did not know the call was time specific. She is also not satisfied with the explanation of the fault as human error. She feels the agency’s office staff try to blame the care staff for errors when they occur.
30. There was fault in the way the agency dealt with the visit. I have not found further evidence of fault beyond what the Council and the agency already identified. The error was made by Ms L as she had not read her rota properly. That was, as the agency said, a human error.
31. Ms L only gave Ms K a short explanation of why she missed the call saying she thought the call was a tea-time call. Ms K then said Ms L thought the call was not time specific. I cannot speculate how well Ms K understood Ms L’s brief explanation. From the evidence I have, I cannot say that Ms K deliberately tried to mislead Ms B when she spoke to her.
32. The Council and the agency have already identified why the agency tried to offer a worker Ms B did not want to attend and this was fault. The agency has apologised for the error and has taken action to ensure it does not occur again.
33. The Council has reviewed the care package and Mrs C has said she is happy with the care providers and does not want to change.
34. The Council has suggested a meeting between the agency, the Council, Mrs C and Ms B if there are continuing problems with the agency which is a good way forward.
35. I am therefore of the view that the Council has appropriately remedied the injustice which occurred through the fault.

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Final decision

36. There was fault which the Council has already remedied.

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Investigator's decision on behalf of the Ombudsman