The Ombudsman's final decision:
Summary: Mrs B complained about actions taken by a Care Provider, including a missed care visit to her husband, Mr B, leaving him in distressing circumstances. We cannot safely conclude that the Care Provider informed Mr and Mrs B that the visit would be late and we find it failed to follow up subsequent calls and messages from Mrs B. We have asked the Care Provider to pay Mr and Mrs B £300.
- missed a visit on one occasion, leaving her husband in a distressed, unhygienic and uncomfortable state;
- did not have or use an emergency procedure;
- repeatedly ignored requests for an earlier visit in the mornings, so Mr B was left in bed for an unacceptable length of time each day; and
- gave notice following a complaint and refused to rescind it.
The Ombudsman’s role and powers
- We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
- If we are satisfied with a Care Provider’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)
How I considered this complaint
- I have considered the complaint and the documents provided by the complainant, made enquiries of the Care Provider and considered the comments and documents from the Care Provider. I have written to Mrs B and the Council with my draft decision and considered their comments.
What I found
Business Continuity Plan
- The Care Provider has plans in place to ensure customers receive safe and effective care in emergency situations. The plan includes severe weather events including snowstorms. The plan requires the Care Provider to:
- monitor weather reports and if required check on the condition of vulnerable customers living in isolated locations;
- assess safety of staff;
- keep a list of all staff with 4WD vehicles;
- advise customers appointments may be late due to conditions;
- borrow 4WD vehicles to reach cut-off customers who need assistance; and
- prioritise services according to risk rating.
- Mr B receives three visits a day from care workers. The final visit at 21:00 involves getting him ready for bed and using the toilet before bed, using a hoist. Mrs B cannot assist with these tasks as she is also disabled. He started using the Care Provider on 30 January 2019.
- On Friday 1 February 2019 there were heavy snowstorms which affected the Care Provider’s ability to get to all its customers on time.
- The Care Provider says that a member of its staff telephoned Mrs B at 21:30 to say the carer due to attend had broken down in the snow. She would come herself but it would take over an hour to get to them. In support of its view it has provided a screen shot from an iPhone showing a call made to Mrs B’s number at 21:30 on 1 February 2019, lasting 13 minutes. It has provided a second screen shot (taken half an hour after the first one) showing two calls made to Mrs B’s number on a Friday in response to one missed call from Mrs B. The Care Provider says Mrs B was angry and aggressive, said 11 pm was too late and hung up.
- Mr and Mrs B are adamant they did not receive the call. Mrs B has provided evidence that she called the emergency number at 21:52, 22:16, 22:31 and 22:32 (all lasting less than 1 minute). She says she left two voicemail messages but was unable to do so on the last two occasions. She also called the office telephone number and left several voicemails, expressing annoyance at not being able to get through on the emergency number.
- Mrs B’s evidence shows that she also called Bristol City Council’s main number at 22:22:00 and 22.22.54 and the emergency social services number at 22:24. Bristol City Council have provided their records of the call and the subsequent referral. This confirms Mrs B rang them at 10.23pm and explained the situation. She said Mr B’s morning and lunchtime visits were amalgamated into one and no-one had turned up for the evening visit. Mr B had not been to the toilet all day. He needed to be hoisted over the toilet and into bed. The duty worker advised Mrs B to call the Care Provider’s out of hours number and call back if she couldn’t speak to anyone.
- She rang back at 22:35 to say the out of hours number was switched off. She rang the landline number and left a message. The duty worker tried to arrange alternative care for Mr B but nothing was available. He rang Mrs B back at 23:33 to say he could not find anything and advised her to ring 111. He then tried the Care Provider’s out of hours number but could not get through and was unable to leave a message. He wrote the following summary and referred the case to Mr B’s social worker to follow up.
This lack of service is effectively an adult safeguarding issue in terms of care provider neglecting their responsibilities, leaving [Mr B] with no help with toileting and getting to bed. There has been no communication from the care agency, neither is there any facility for [Mr and Mrs B] to communicate their needs to the agency. Please can the s/w treat this as such and take safeguarding actions.
- The Care Provider says it did not receive any voicemail messages on that number that night. It says the on-call representative would not normally have been doing visits and taking calls but due to the weather she had to do both, so calls to the emergency number were transferred to the mobile telephone. It suggests this may have affected the receipt of voicemail messages.
- The Care Provider rang Mrs B back on Monday 4 February 2019. Mrs B said she had made several calls to the emergency number but no-one had got back to her. Mr B had not had a visit and sat in his wheelchair all night with wet clothing.
- The Care Provider investigated the complaint and spoke to the member of staff who had been on call on the Friday night. She wrote an account of the call she made to Mrs B and said Mrs B had refused the visit.
- The Care Provider wrote to Mrs B on 7 February 2019 saying it had investigated her complaint. It had not found any problems with the telephones and no voicemails were received on the on-call telephone. The on-call representative had called her at 9.30 pm to inform her she could not visit until about 11 pm, but Mrs B said ‘what is the point?’ before ending the call. The Care Provider assumed from this that Mrs B did not want a visit.
- Mrs B replied on 21 February 2019. She disputed the Care Provider’s version of events and submitted a copy of the outgoing calls from her telephone. The list started at 21:52. She said she had not received a call at 21:30. She also requested that Mr B’s morning visit was earlier as he was staying in bed too long.
- The Care Provider replied on 4 March 2019 repeating its findings and suggesting they agreed to disagree. It said it could arrange earlier visits on an occasional basis but it had no space for a regular slot at present. He was on the waiting list when a space became available.
- On 17 March 2019 the Care Provider said Mrs B was very rude to a member of staff during a telephone call. It also had reports from the carers attending Mr B that Mrs B had been complaining about the service in a rude, angry manner, particularly about staff in the office. As a result of these reports the Care Provider cancelled a meeting due to take place on 21 March 2019 and gave Mrs B notice that it would be terminating the service on 16 April 2019. It said this was due to Mrs B’s aggressive and threatening manner towards its staff.
- Mrs B replied on 22 March 2019. She said she was only concerned about the lateness of the calls and wanting an earlier morning slot. She denied ever being aggressive or threatening and asked if the Care Provider would reconsider.
- The Care Provider declined. Mrs B found another agency, who started on 7 April 2019. Mrs B complained to the Ombudsman.
- I asked the Care Provider to provide details of the telephone records later in the evening, but it said no further records were available. Mrs B says the evidence she provided shows all the calls she made on 1 February 2019.
missed a visit on one occasion, leaving her husband in a distressed, unhygienic and uncomfortable state
- The Care Provider has provided evidence that it made a call to Mrs B at 9.30pm on 1 February 2019 which lasted for 13 minutes. But the second screenshot does not correlate with this call: it was taken half an hour later than the first one and shows a missed call from Mrs B’s number followed by two outgoing calls to her number on a Friday. The first screenshot should show details of the missed incoming call and the two outgoing calls, but it only shows one outgoing call at 9:30pm. The second screenshot could have been earlier in the day or from a different Friday. This calls into question the validity of the first screenshot.
- Mrs B’s evidence supports her view that she telephoned the Care Provider on several occasions that evening but all of them after 9.30 pm. The calls were short, but it is impossible to know whether messages were left. Mrs B has been unable to obtain any further records to show incoming calls to her number that evening.
- The evidence from Bristol City Council supports Mrs B’s version of events and that the duty worker was also unable to get through to the out of hours number that evening.
- Given the discrepancies in the call records provided by the Care Provider and the additional evidence from Bristol City Council I am unable to safely conclude that the Care Provider called Mrs B at 9.30pm to offer a visit.
- Regardless of this Mrs B called the out of hours number four times after this and the duty social worker called once more. I would have expected the Care Provider to have responded to these calls whether or not a message was left. The failure to do so was fault which led to Mr B being left in an unacceptable state for a whole night.
did not have or use an emergency procedure
- The Care Provider has provided a copy of its emergency procedure. It covers bad weather situations and it requires the Care Provider to inform customers that visits may be late due to bad weather. It also requires it to have an out of hours emergency number. Given the failure to answer or respond to messages and calls on the emergency number I have concluded the procedure was not followed.
- I note that given Mrs B’s disability, Mr B’s visit should have been assessed as a priority one. There is no evidence that it was.
repeatedly ignored requests for an earlier visit in the mornings, so Mr B was left in bed for an unacceptable length of time each day
- The Care Provider acknowledged Mrs B’s request for an earlier visit and explained that it was unable to accommodate it. But it had placed Mr B on a waiting list for the first available slot. I cannot find fault with this process.
gave notice following a complaint and refused to rescind it
- The Care Provider has provided evidence from its staff of several occasions when they considered Mrs B was rude and aggressive. The Care Provider decided to give notice due to the impact of this behaviour on its staff. That was a decision for the Care Provider to make and I cannot identify fault in its actions. It explained its reasons, considered Mrs B’s response and gave her adequate time to find a replacement.
- In recognition of the distress caused to Mr and Mr B by the failure to do the care visit, I asked the Care Provider (within one month of the date of my final decision) to pay Mr and Mrs B £300. The Care Provider has not refused to do this
- I consider this is a fair and reasonable way of resolving the complaint and I have completed my investigation on this basis.
Investigator's decision on behalf of the Ombudsman