Summary: There was fault in the agency’s decision to refuse to give Ms C the spare key to the house she lives in and to double lock the door. The Ombudsman recommends that the agency apologises in writing to Ms C and her daughter Ms B.

The complaint

1. Ms C complains about Home Instead Senior Care agency in Reading. Ms C complains about an incident when she was locked into the house and the agency refused to give her the key. Her daughter, Ms B, represents her in the complaint. Ms C also complains about the agency’s communication with her and Ms B.

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The Ombudsman’s role and powers

2. 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)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

4. I have considered the documents Ms B and the agency have sent in and Ms B’s comments on the draft decision.
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

6. Ms C lives with her son Mr D and her grandson. The agency started to provide support to Ms C on 16 April 2019. The plan said Ms C was able to move safely around the house, but did so slowly. She had a heart condition which she managed with medication. The agency provided some limited support once a week.
7. Mr D was going to be away on 14 and 15 May 2019. His son was also on holiday but was returning on the evening of 14 May 2019. Mr D asked the agency to attend twice that week, on 14 and 15 May 2019 so that Ms C had support on the days when she was on her own.
8. Mr D says he left the key to the house at the house and told Ms C where the key was. He also put a spare key in the key safe outside the house. Ms C says Mr D did not tell her where the keys were.
9. Mr D had been burgled the previous year so he always double locked the front door, on the advice of the police.
10. Ms C was on her own in the house on 14 May 2019. She says a delivery person came to her door, but she could not open the door to them because it was locked.
11. Ms C called Ms B and explained what had happened. She said she looked for the keys in the house but could not find them. Ms B says Ms C sounded distressed. Ms C told Ms B that she had pain down her neck and arm. Ms B was worried that, if Ms C needed a doctor, she would not be able to let them in. As the carer was coming over at 11 am, Ms B suggested that Ms C should obtain the spare key from the carer.
12. The agency staff and Ms C differ on exactly what happened after that so I will set out both sides’ recollections of events.

What Ms C said

13. The carer attended and let herself in with the spare key. Ms C says she told the carer that she had pain down her neck and arm. She explained the situation about the key to the carer and asked the carer to leave the key so she could open the door when the carer was gone. The carer rang the office and was told not to give Ms C the key and to double-lock the front door.
14. Ms C rang Ms B while the carer was at the home and told her the carer would not give her the key. Ms B told her to ring the police as she felt it was not safe for Ms C to be locked in the house in case there was a fire or an emergency.
15. The carer left and double-locked the front door and put the key back in the key safe.
16. Ms C rang Ms B and told her what happened. Ms B advised her to ring the agency and ask them for the key safe number and then arrangements would be made to unlock the door. (I presume the plan was for Ms B to drive over and unlock the door.)
17. Ms C rang the agency and asked for the key safe number, but the agency refused to give her the number. She rang Ms B back to let her know.
18. Ms B rang the police. The police told her that they could not make the agency take action. Ms B said that if the agency could not give the key safe number to the police, then the police should ask the agency to meet Ms B at the property to unlock the door.
19. The police rang the agency and then rang Ms B back. The police said that the agency had told them Ms C was fine. Ms B disagreed and rang the agency directly. She says the manager told her that Ms C had rung the agency but she had not asked for the key safe code. The manager then agreed to go to the house and unlock the door.
20. Ms B then went to collect Ms C and Ms C went to stay with Ms B.
21. Ms C rang the agency on 15 May 2019 to cancel the visit. She told the manager she was staying with Ms B because she had been locked into the house. Ms C says the manager interrupted her and said: ‘You were not locked in, I let you out.’ Ms C says the manager then asked her a lot of questions. Ms C says the manager’s tone and manner was aggressive.

What the agency said

22. The carer’s record of the visit is brief. The only reference to Ms C’s health is that Ms C was out of breath. The note mentions that the carer called the office regarding the key.
23. The carer gave a more detailed statement as part of the agency’s investigation into the incident. In the statement the carer said Ms C was sitting on the bottom step when the carer first arrived as Ms C was out of breath.
24. The carer said: ‘I rang the office to ask if she could keep the key from the key safe but I was informed that I was to lock up and put the key back and her grandson was back that afternoon from his holiday. [Ms C] wasn’t happy about this but I explained I had to follow what I had been told to do and she said it wasn’t my fault.’
25. The carer said Ms C was on the phone to Ms B and she could hear Ms B saying that if the carer would not give the key, then Ms C should ‘call the police or me back and I will come and get you.’
26. The carer said she checked Ms C was ok as she was breathing fast. Ms C said she was fine, just a little out of breath. The carer left and double-locked the front door and put the key in the key safe.
27. The report says the manager of the agency then received a call from Ms B. Ms B told her Ms C was locked in the house and that Ms C had called the agency and had asked for the key safe number. The manager said Ms C had called but had not mentioned the key safe.
28. The police called after this call and said Ms B had contacted them. The manager told them the grandson would be back from holiday this afternoon.
29. Ms B then called the agency back and said that the agency would not give the key safe number to Ms C or the police. The manager said neither Ms C nor the police had asked for the key safe number and she could not give the number to Ms B as it was not her house.
30. The manager then rang the police to check they were happy for the agency to go to the property and unlock the door. The police officer agreed that was the only course of action and the manager went and unlocked the door.
31. In the investigation report the manager says Ms C rang around 4 pm on 14 May 2019 to cancel the visit for the next day. She rang again on 15 May 2019. There is only one record of a call by Ms C which is dated 15 May 2019 at 9:30 am.
32. It is my understanding the agency also rang Mr D and left him a message to explain what had happened. He rang back and explained that the reason why he wanted the house double locked was because of the burglary and said he had told Ms C where the keys were.

The complaint

33. Ms B complained to the agency on 21 May 2019 and the agency replied on 24 May 2019. I have summarised the complaint and the responses.
34. Ms B said:
• The agency had locked Ms C in the property and refused to give her the key, despite the fact that she had expressly asked for this. The agency knew that she had pain down her neck and arm when it refused to give her the key.
• The agency only agreed to unlock the door after Ms B and the police became involved.
• The agency denied that Ms C asked for the key safe code when she rang the agency.
• The agency told the police Ms C was fine when she was not.
• The agency worker spoke to Ms C in an aggressive manner on 15 May 2019.
35. The agency said:
• Ms C was never locked in the house as the key was in the house and Mr D had told Ms C where the key was. Removing the key from the key safe would add to ‘potential risk to her overall wellbeing’.
• Mr D said it was his understanding that Ms B said Ms C had heart pains and the agency did not take any action. He said Ms C had been saying this for about a week before his trip and had been medicating this with aspirin. The carer noted that Ms C suffered discomfort although Ms C did not say she had pain down her neck and back.
• In response to the complaint that the agency refused to give Ms C the key safe code when she rang the agency, the agency said the manager offered an alternative compromise. The agency said it followed the wishes of Mr D who installed the key safe and that the code was a matter of privacy.
• In the next paragraph, the agency denied that Ms C had asked for the key safe code.
• In response to the allegation about the way the manager spoke to Ms C, the agency said the manager informed Ms C she would be charged for the cancelled visit which was standard practice.
36. The agency referred the matter to the local authority’s safeguarding team and the Care Quality Commission and says they were satisfied with the agency’s actions.
37. I questioned the agency’s report as there were some contradictions, particularly in relation to the telephone call Ms C made on 14 May 2019. In the report the manager states that Ms C ‘had called but did not mention the key safe.’
38. The report also responded to the complaint of Ms C being refused the key safe code when she rang the office, but then later said she did not ask for the key safe code which was a further contradiction.
39. The agency told me that Ms C did not ring the agency on 14 May 2019. It said the reference related to a conversation between the manager and Ms C when the manager went to unlock the door.

Analysis

40. My first observation is that it is not clear why neither Ms C, nor Ms B, nor any of the agency staff rang Mr D to ask him where he left the key. This would have been the obvious solution to the problem. Alternatively, the agency carer could have helped Ms C in looking for the key.
41. Nevertheless, I can only investigate the facts as they happened. I accept that Ms C could not find the key.
42. The agency knew Mr D wanted the door to be double locked because of the risk of burglary and it knew that Mr D’s son was going to return later in the evening on 14 May 2019. Therefore the agency took a decision which it felt was in Ms B’s best interest.
43. However, Ms C had the mental capacity to make decisions, she signed the contract with the agency and paid the bills. She was the agency’s client. She expressly asked the carer to give her the key or not to double lock the door. The agency’s refusal to comply with either of those wishes was fault. The agency says Ms C was never locked in the house as there was a key. That is not correct. As Ms C could not find the key, the agency had, in effect, locked Ms C in the house against her will. The agency should have followed Ms C’s wishes.
44. In terms of the injustice, the injustice was limited as as the agency went to unlock the door later in the day. Ms B says this happened about 3 and half hours after Ms C first raised the issue. I accept this would have been stressful to Ms B and Ms C as they felt Ms C was at risk.
45. Ms C says she mentioned the pain in her arm and neck to the carer, but the carer says this was not the case. It is difficult for me to comment as there is no detailed record of the visit at the time. It may be that the carer did not hear the comment or could not remember what Ms C said when she gave her statement after the events. The carer mentioned Ms C’s breathlessness in the record of the visit and was concerned about this, but, as far as the carer was concerned, there was nothing in Ms C’s presentation that suggested that Ms C needed urgent medical care.
46. I have also considered Ms B’s complaint that the agency denied that Ms C asked for the key safe code when she rang them. Unfortunately, the records of the calls on that day are limited. However, I agree that the communications of the agency about this issue could be better. The agency contradicted itself within the report and is now saying the conversation happened when the manager went to unlock the door.
47. There are limited records of the telephone calls between the police and the agency. They do not mention Ms C’s health at all. Therefore, in the absence of any other evidence, I cannot say what, if anything, the agency told the police about Ms C’s health or that there was any fault.
48. There are no recordings of the telephone call on 15 May 2019 when Ms C called the agency to cancel the visit. Therefore, in the absence of any other evidence, I cannot say there was fault in the way the manager spoke to Ms C.

Agreed action

49. The agency has not commented on the draft decision or the recommended remedy.
50. The Ombudsman recommends that the agency apologises in writing to Ms B and Ms C within one month of the final decision.

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Final decision

51. I have completed my investigation and found fault by the agency.

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Investigator's decision on behalf of the Ombudsman