Privacy settings

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

Royal Borough of Windsor and Maidenhead Council (19 014 898)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 04 Mar 2021

The Ombudsman's final decision:

Summary: We have found fault in the way the Council carried out a safeguarding investigation into the care that the Agency provided, fault in the way the Council decided the care plan and fault in the care the Agency provided. The Council has agreed to apologise to the family and pay them £1,000 for the distress they suffered in addition to the £1,000 reduction in the fees the Council has already offered.

The complaint

  1. Ms B, who is Mr C’s ex-wife complains on behalf of Mr C, who has sadly passed away.
  2. She says the care provided by the Agency did not meet Mr C’s needs, the Council failed to carry out a proper safeguarding investigation into the Agency’s care and there was fault in the Council’s care plan when Mr C was discharged from hospital.

Back to top

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)
  3. 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)

Back to top

How I considered this complaint

  1. I have discussed the complaint with Ms B. I have considered the information that she and the Council have sent, the relevant law, guidance and policies and both sides’ comments on the draft decision.

Back to top

What I found

Law, guidance and policies

  1. The Care Act 2014 and the Care and Support Statutory Guidance 2014 (updated 2017) set out the Council’s duties towards adults who require care and support.

Duty to meet eligible needs

  1. The Council has a duty to assess adults who have a need for care and support. If the needs assessment identifies eligible needs, the Council will provide a support plan which outlines what services are required to meet the needs.

Safeguarding duty

  1. Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:
    • has needs for care and support
    • is experiencing, or at risk of, abuse or neglect and
    • as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
  2. If the section 42 threshold is met, then the Council must make enquiries or cause others to do so. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by whom.

Council’s safeguarding policy

  1. The council has its own adult safeguarding procedures which describe the investigation process.
    • Stage 1: Safeguarding referral to the Council. This is the duty of any agency involved with a vulnerable adult who they suspect is at risk.
    • Stage 2: The enquiry. The Council carries out the enquiry or asks another agency to carry it out on the Council’s behalf. Once an enquiry is finished, a report should be completed, overseen by the Safeguarding Manager. The Council retains responsibility for the enquiry, even if it is carried out by another agency.
    • Stage 3: The safeguarding plan and review. The plan sets out the steps to take to ensure the future safety of the person at risk.
    • Stage 4: Closing the enquiry.

Pressure Ulcer Pathway Policy

  1. The Council also has a Pressure Ulcer Pathway policy which assists in explaining when professionals such as a care workers should make a safeguarding referral. The policy says the person should be referred to Safeguarding if there is:
    • Significant damage i.e. category 3 or 4, unstageable ulceration or multiple category 2, and
    • There are reasonable grounds to suspect it was preventable, or
    • Inadequate measures were taken to prevent development of pressure ulcer, or
    • Inadequate evidence to demonstrate the above.
  2. It says this protocol should be applied to pressure ulcers reported by anyone including carers, relatives and patients, as any tissue damage, no matter who reports it, should be investigated.

What happened

  1. Mr C was an elderly man who was bedbound and was unable to move the lower part of his body. He was entirely reliant on care workers for all his needs. The Council funded a package of care which consisted of two care workers from the Agency attending four times a day.
  2. Mr C owned a large house and he lived in an upstairs bedroom of the house. There was a ground floor flat in the house which Mr C had previously rented out. However, Ms B was temporarily living in the flat in the months before Mr C died.
  3. Ms B said that, in the two years before his death, Mr C had several hospital admissions because of pressure sores. The pressure sores would heal when Mr C was in hospital, but would deteriorate again when he was at home.
  4. On 25 July 2018, the district nursing team sent a safeguarding referral to the Council and said:
    • Mr C’s pressure areas had deteriorated.
    • The Agency’s staff, who changed the dressings, had not informed the district nurses of the deterioration.
    • There were occasions when the Agency’s staff did not complete personal care. The district nurse challenged a staff member about this and the staff member said that they did not change Mr C at lunch time. When they were challenged again, they gave a different answer.
    • Mr C appeared unkempt.
  5. Mr C was taken to hospital on 30 July 2018. The ambulance service made a safeguarding referral which said:
    • Mr C had said that he did not have enough food in the house.
    • Mr C was at the top of the house and there was no working stair lift.
  6. The hospital team made a safeguarding referral on 31 July 2018 which said:
    • Mr C had multiple pressure sores on arrival at the hospital, ranging from grade 2 to 4 and necrosis (death of body tissue).
    • Mr C said he did not have enough food.
  7. The Council decided the referrals met the threshold for a safeguarding enquiry on 1 August 2018. The social worker visited Mr C on 7 August 2018 and he gave his consent to the enquiry.
  8. The Council held a safeguarding meeting on 25 September 2018. Mr C was unable to attend the meeting (there was no space for his bed), but the social worker obtained his views. Mr C said some of the Agency’s care workers did not know what to do in terms of care and sometimes he was left in an unchanged pad. He had a special mattress which would sometimes sound an alarm, but some of the care workers did not know what to do. Sometimes care workers did not turn up or only one care worker turned up. He also had difficulty ringing the Agency at the weekend as nobody would answer the phone or ring back if he left a message.
  9. The meeting heard that the main safeguarding concerns were pressure sores, malnutrition and dehydration.
  10. In terms of the pressure sores, the meeting heard that Mr C did not like being turned, but did not refuse care in the hospital. The pressure sores were made worse if he was left in wet incontinence pads.
  11. It was agreed that, to address the concerns about malnutrition, the care workers would need to note food intakes from now on.
  12. The meeting heard that Mr C had been medically ready for discharge since 20 September 2018, but the discharge was delayed until the safeguarding concerns were resolved.
  13. There was a list of actions which would follow from the meeting, although oddly, this did not include carrying out the safeguarding enquiry or writing the safeguarding report. However, in the narrative, there was a suggestion that this would be done by the Agency.
  14. The occupational therapist and the tissue viability nurse assessed Mr C in hospital.
  15. The hospital discharge team spoke to Mr C and he agreed to have a ToTo bed. A ToTo was a hospital type bed for patients who were at the highest risk of pressure ulcers. The bed turned patients automatically at regular intervals day and night.
  16. In October 2018 the social worker spoke to Mr C and the family (separately) about Mr C’s care package.
    • Mr C said he did not want to change the care agency. He liked the care workers who provided his two first care sessions (morning and lunch) and wanted them to carry out his later two sessions. He said he wanted to go home.
    • The family felt that the care package of four calls a day was not sufficient and that only a care home would meet his needs. The social worker said Mr C had mental capacity to decide where he wanted to live and he had said he wanted to go back home. The family also said that Mr C did not have enough money for food, to pay the bills and the care package. The social worker said that Mr C would be financially assessed as his financial circumstances had changed.
  17. The Council held a meeting with the family on 18 October 2020 to discuss the discharge plan. Mr C did not attend the meeting as there was no space for him.
  18. The council’s proposed care plan was:
    • The Agency would continue to provide the morning and lunch call and the Council would find a different agency to provide the tea and evening call.
    • The social worker would make a referral to the community occupational therapist to review Mr C once he was at home.
    • The district nurses would visit Mr C three times a week.
    • Mr C and the family had agreed to arrange a meal delivery service.
    • The family would buy a heater to ensure Mr C’s room was warm.
    • The discharge coordinator would chase the district nurses regarding the new mattress. This had to be in place before the discharge.
    • The ToTo bed was being arranged.
    • The social worker explained the financial assessment process to the family so they could submit the paperwork for a review.
    • The Council would increase the care package from four calls to six calls a day.
    • The six calls included night care calls. The tissue viability nurse had reported that Mr C was doubly incontinent and often did not realise he had soiled himself. Lying in a soiled pad led to infections and skin breakdown and therefore the night-time care was essential to minimise the risk of further pressure sores.
  19. The social worker completed the care plan after this meeting. The care plan dated 2 November 2018 said:
    • Mr C would receive four calls a day with one additional night call to support with the change of pads.
    • The carers should attend at 06:00, 11:30, 15:00, 18:30 and 22:30.
    • The 6:00 call was for 45 minutes as carers had to provide full personal care and toileting as well as provide breakfast. The other calls were for 30 minutes. Care workers were required to change Mr C’s incontinence pad at each call, except at 11:30 when the change was ‘as required’.
    • Mr C was at high risk of pressure sores. He had been reassessed and the package of care had been increased by one night call to mitigate the risks. It said that Mr C needed frequent repositioning. The ToTo bed and the mattress would help with this but the carers should reposition him at the night care call. Mr C also had diabetes so it was important that the care workers attended on time so that he could eat at regular intervals.
  20. The Council tried, but was unable to find another care provider for Mr C. Mr C then agreed to remain with the Agency on the understanding that the care workers doing the later calls would be different.
  21. The Council’s funding panel approved the funding for the increased package of care on 2 November 2018. The weekly cost of the package increased from £502 to £691. Mr C’s contribution to the cost (£165) remained the same.
  22. Mr C was discharged from hospital on 8 November 2018. The transfer summary said a ToTo bed, an air mattress and a pendant alarm had been arranged.
  23. The Agency contacted the Council on 12 November 2018 and told them that Mr C had declined the 22:30 calls. Mr C told the care worker he had never had these visits and would not pay for them. The care worker tried to explain to Mr C that the calls were needed to change the pad and to minimise the risk from pressure sores but Mr C said that was not needed now that he had a bed that moved. The Agency also said Mr C was refusing personal care at the bed visit although he allowed this very reluctantly with encouragement.
  24. The social worker visited Mr C on 14 November 2018 to discuss the safeguarding enquiries. Mr C said he was not happy with the many care calls because he was spending a lot of money. He wanted to reduce the calls and he wanted a financial assessment. One of the care workers said that she had called the district nurses to attend immediately (it is not clear which time this call relates to) due to a pressure sore on Mr C’s bottom, a rash on his legs and swollen legs.
  25. Mr C said the safeguarding enquiry could be closed as the care workers were doing a good job and he was happy with the service.
  26. A Council finance officer spoke to Mr C on 22 November 2018 and said the previous financial assessment did not show evidence of a rental income. Mr C said people had lived with him in the past, but they had never paid rent. Mr C said he did not want a financial review as his financial circumstances had not changed.
  27. The social worker spoke to the Agency on 19 December 2018. The Agency worker said Mr C had cancelled the fifth call because he complained of the finances. The Agency said the package was going well.
  28. The Council received a safeguarding referral on 21 December 2018 from the team leader of the district nursing team. He said the district nurses noted the following during their visit:
    • Mr C told the district nurse that the carers told him that he had ‘marks’ on his back and he said it felt sore.
    • The district nurse checked Mr C’s back and found a grade 4 pressure wound and said there was a strong odour present.
    • Mr C’s sacrum (bone at the bottom of the spine) was covered in a small amount of faeces.
  29. The social worker spoke to the district nurse on 24 December 2018. The district nurse said Mr C was seen on 22 December 2018. The pressure sores were still at grade 4. The problem was that Mr C was incontinent of faeces and the faeces then spread over the wounds which severely reduced the healing process. The district nurse team had made a referral to the tissue viability nurse on 20 December 2018, but the tissue viability nurse team was short staffed. The social worker said she would hold a multi-disciplinary meeting to discuss the matter but would wait until the tissue viability nurse had been to see Mr C. The social worker said she would incorporate this safeguarding referral with the other existing referrals.
  30. The social worker spoke to the Agency on the same day. The manager said the care workers were going in but had not submitted any adverse reports.
  31. The tissue viability nursing (TVN) team made a safeguarding referral on 31 December 2018. The TVN said the care workers were leaving as she arrived. The TVN said:
    • Mr C’s sacrum was in a wet soiled pad. The soiling had not been recent as faeces adhered to the skin.
    • He was laying on three other pads negating the use of the pressure relieving equipment.
    • There was thick build up of filth in the groin and Mr C said it felt sore.
    • Two rough towels were inserted between Mr C’s legs.
    • Sheets were rucked up causing marks on his skin.
    • Large hard crumbs of bread were in the bed causing indentations on Mr C’s skin.
    • Mr C said the carers did not visit for long and did not clean his groin very often.
  32. The TVN explained to the social worker that she visited immediately after the carers so it was clear that the carers had not changed his pad at lunchtime. She was also aware that the carers only stayed for 15 minutes which was not enough time to provide care.
  33. The social worker rang the Agency to say that no pad care was provided today. The Agency said it would look into it but Mr C could be difficult and sometimes declined care.
  34. The social worker visited Mr C on 3 January 2019. Ms B said the care over the Christmas period had not been great and said he had been left for a period of 15 hours as one of the carers did not turn up. There had been many occasions when the lunch time carers had not shown up for their call. There were times when he had soiled his pad and the carers had not turned up so he was sitting in a soiled pad until the next call.
  35. The Council organised a safeguarding strategy meeting for 11 January 2019.
  36. Ms B said she came home in the evening of 12 January 2019. She checked the care note for that day and noticed she had arrived 12 minutes after the care workers left. The note said Mr C was ‘fine’.
  37. Ms B said she found Mr C ‘breathless, shivering, desperately unwell, dark brown urine in catheter, feeling sick’. Ms B called an ambulance. She said that Mr C was in such a poor condition that it took the ambulance team one and a half hours just to stabilise him so he could be taken to hospital.
  38. The ambulance service made a safeguarding referral as they were so concerned about the condition they found Mr C in. The concerns were:
    • Mr C was in bed with faeces leaking out of his pad and soiled bed sheets.
    • The dressing on the pressure sores was soiled and old.
    • Mr C was vulnerable and did not seem to be receiving appropriate care.
    • Mr C said that carers came in very late in the mornings, spent little time in the house (4 minutes) and did not leave him with basics such as water.
  39. Sadly, Mr C passed away on 16 January 2019 from sepsis.
  40. The Council held a safeguarding meeting on 4 March 2019 which Mr C’s social worker, Ms B, the Agency’s quality officers and the district nurse attended.
  41. Ms B gave the background history. She said Mr C’s decline in just nine weeks had been significant. She said the care in the last weeks of Mr C’s life had been ‘appalling’, there were times the care workers stayed for less than five minutes.
  42. She said that Mr C sometimes refused a change of pad because it was so painful. He would cry out as it was so sore. She understood why he would refuse, but felt that the care workers should not just have left it.
  43. The district nurse said:
    • ‘It looked as though Mr C was being moved up and down in a poor manner. He had lost the weight he had gained whilst in hospital and looked skeletal. Moving him would have sheared his skin.’
    • The nurse who raised the safeguarding said ‘the conditions were squalid and there was ingrained dirt on his skin. When [Mr C] had a heel wound, the carers were asked not to put pillows under his feet. The carers had to be asked several times before this stopped. This was an ongoing problem. The carers would also use two pads to collect extra faeces or urine but this does not work. [The nurse] was concerned about his care and raised the safeguarding.’
    • ‘… there is a process when the skin has shear marking. It was significant enough to break down [Mr C’s] skin. This showed consistent poor handling.’
  44. The social worker said she had requested an investigation report from the Agency but this had not been received. The social worker noted that there had been two safeguarding reports that had not been received and said the Agency should provide the investigation report by 15 March 2019.
  45. The social worker chased the Agency on 2 April 2019 for the report as it had still not been received.
  46. The only Agency records that were received, as far as I can see, were the care records for 30 and 31 December 2018. These records were difficult to read and did not contain much detail. The notes said Mr C was ‘fine’ but refused pad changes on several occasions. The last call on 30 December 2018 was at 18:00 and the first call on 31 December 2018 was at 08:32 which meant that Mr C was without any care for 14 and a half hours. The care worker was two and a half hours late for the morning call and then only stayed for 30 minutes, instead of 45 minutes.
  47. On one occasion, the care worker stayed for only 10 minutes, on another for 15 minutes. Some care workers provided detail on what food and drink they offered to Mr C although there was no record of quantities. Some care workers gave no detail and just said: ‘gave dinner’.

Ms B’s complaint

  1. Ms B complained to the Council in in September 2019. Her complaint related to the care provided by the Agency, the Council’s safeguarding investigation and its care planning.

The Agency’s inadequate care

  1. Ms B said:
    • The carers did not stay for their allocated times and were often late. She witnessed times when the care workers stayed less than five minutes. Their daily records were poor. There were four times when they forgot to give Mr C his medication. They did not provide proper care in terms of changing the continence pads or moving Mr C.
    • The Agency staff had not alerted the ambulance on the day Mr C went to hospital even though he was clearly very unwell.
  2. The Council said:
    • It had asked the Agency for the relevant records, but the Agency had not been able to supply them. Therefore, the Council could not make a decision on Ms B’s complaint, but it offered to reduce Mr C’s outstanding invoice by £1,000.

Council’s safeguarding investigation and care planning

  1. Ms B said:
    • The Council failed to take the appropriate safeguarding action in July 2018 after receiving several safeguarding referrals when Mr C was admitted to hospital. It asked the Agency to provide a report but never followed this up.
    • The Council continued to allow the Agency to provide care to Mr C despite the safeguarding concerns about the Agency which were never properly investigated.
    • There was a cycle of Mr C going into hospital and getting better and then deteriorating at home to the point where he had to be admitted to hospital.
    • The care plan of home care did not meet Mr C’s needs and the Council did not sufficiently explore a plan of a move to a nursing home when Mr C was discharged from hospital. Mr C was not present at the meeting to decide his care plan.
  2. The Council said:
    • Mr C had capacity to make decisions about his care plan. The social worker recommended a nursing placement, but Mr C refused.
    • Concerns were raised that Mr C was neglecting himself and this was investigated through the safeguarding process.
    • Mr C cancelled his care in the evening, and he was refusing access to his property. This was difficult for agencies to manage.
    • The concerns about the Agency were investigated through the safeguarding process. The Agency needed to improve its communication and its record keeping and the Agency was being monitored by the Council.
  3. As part of its response to the Ombudsman’s enquiries, the Council provided me with a lot of documents regarding the Agency. These showed that there were other concerns about the Agency and the Council was addressing these as part of its safeguarding and quality assurance monitoring.
  4. The Council said the Agency had been taken over by a different company since the time of the complaint and the new company was unable to access the old records.
  5. The Council made further comments in its response to the Ombudsman and said:
    • ‘It was hard to say that the care contributed to [Mr C’s] decline as there was a lot of reference to difficulties with care as a result of [Mr C’s] requests not to be changed.’ The Council was only notified of concerns about the care at Christmas 2018.
    • There was no attempt to ascertain the actual extent of missed calls or poor care by the Agency in the first safeguarding enquiry. No conclusions were made after the safeguarding meeting and another meeting was meant to be held but was then cancelled as the social worker spoke to Mr C.
    • ‘We appear to have tried to make [Mr C] remaining at home work as he has capacity, but we do not appear to have actively tried to explain the risks to him, undertaken a risk assessment or talked to other agencies about the risk...’
    • ‘The package which … was planned for 6 calls a day, reduced to 4 a day at [Mr C’s] request which feels to me to be unsafe, but no-one acted on it.’
  6. The Council says: ‘The Ombudsman’s request has led to a review of the initial complaint response to this case and has highlighted a number of practice issues that were not immediately obvious. A comprehensive revaluation of events is being undertaken and further improvements in process and practice will follow.’
  7. The Council says it has taken the following steps to improve the service:
    • The Quality Assurance process has been strengthened.
    • The Council had made the Panel process (which approves care packages) more robust and a large package like Mr C had would now require an exploration of all support options based on risk before it was approved.
    • It had introduced a Vulnerable Adults Multi-Agency framework which provided a structure for managing people with complex needs including people who refused care.


  1. I will consider the complaints against the Council and the Agency separately.


  1. The Agency had a responsibility to provide care, but it also had a safeguarding duty. I will consider both aspects.
  2. The Council said it could not make a decision on Ms B’s complaint about the inadequate care by the Agency as it did not have the Agency’s care records.
  3. I have considered the evidence that is available. In total, the Council received six safeguarding referrals from agencies involved with Mr C, namely, the district nurses, the tissue viability nurse, the ambulance service and the hospital. The district nurse also provided verbal evidence at meetings.
  4. The agencies’ evidence raised concerns in July 2018 about the severity of Mr C’s pressure sores which were grade four. The district nurses and the hospital questioned why these sores developed and why intervention was not sought earlier. The district nurse said Mr C looked ‘skeletal’ in December 2018 and that his skin showed signs of consistent poor handling.
  5. The tissue viability nurse painted an even bleaker picture with Mr C left in a wet soiled pad with faeces adhered to his skin, a thick build up of filth in his groin, rough towels between his legs and so on.
  6. Similarly, when the ambulance service collected Mr C in January 2019, they noticed faeces leaking out of his bed, soiled bed sheets and said the dressing on the pressure sores was old and soiled.
  7. Ms B and Mr C also provided verbal evidence. They both complained of missed visits, late visits, visits cut short and care workers not providing the care they should have done.
  8. The limited records I saw were poor and this was fault in itself. They did not provide detail of Mr C’s food intake even though this had been raised as a requirement at the safeguarding meeting in September 2018. The records showed several occasions where the care workers only stayed for a very short time and one occasion when they were very late. Mr C was left without care for 14.5 hours which would have greatly increased the risk of the pressure sores deteriorating.
  9. I have considered all of this evidence and I am of the view that the different agencies, Mr C and Ms B were telling the truth. I can make a decision on the balance of probabilities and I conclude that there was fault in the Agency’s care of Mr C as described in the evidence.
  10. I have also considered the Council’s argument that the problem lay with Mr C as he sometimes refused care. I accept that may have been the case, but I do not think that this absolves the Agency of responsibility for the fault. This links in to the second fault I have found in the Agency’s actions, which is its failure, on several occasions, to make its own safeguarding referrals about what was happening.
  11. If Mr C was refusing care and if this was affecting his pressure sores or his health, then the Agency had a duty to make a safeguarding referral to the Council.
  12. Clearly Mr C’s bedsores had deteriorated badly by December 2018 and the care workers knew about it. Mr C told the district nurses on 21 December 2018 that the care workers had told him he had ‘marks’ on his back, which turned out to be a grade four pressure sore.
  13. The social worker spoke to the Agency about this on 19 December 2018 and the Agency said ‘the package was going well’. The social worker spoke to the Agency on 24 December 2018 and noted: ‘The care workers are going in but they have not submitted adverse reports.’
  14. It is striking that every other agency that became involved with Mr C, raised an immediate safeguarding referral. Yet, the Agency whose care workers saw Mr C every day and who were in an ideal position to see when new pressure sore were developing, never made a safeguarding referral. This was fault.
  15. I also find fault with the care workers’ failure to raise the alarm on 12 January 2019. Ms B described Mr C’s presentation and the fact that he was rushed to hospital. Yet, the care workers saw Mr C only 12 minutes earlier and did not call an ambulance or even raise any concerns about Mr C’s presentation.
  16. There was also fault as the Agency failed to carry out an investigation into the safeguarding concerns or provide the safeguarding reports in July 2018 and in March 2019.


  1. The Council had a dual role as it was responsible for the safeguarding enquiry under Section 42, but also responsible for providing a care plan that met Mr C’s needs.
  2. In my view, there were some failures in both duties.

Safeguarding enquiry

  1. There was fault in the way the Council carried out the two safeguarding enquiries.
  2. In July 2018 the Council had heard from the district nurses that the Agency’s poor care contributed to the deterioration of the pressure sores. The Council knew there was a history of Mr C deteriorating at home and improving in hospital which indicated that he complied with treatment. The Council had a duty to find out what the cause of the problem was and whether it was the care plan or the care provided (or a combination of both) that was the underlying problem.
  3. The Council started a safeguarding enquiry into the care the Agency provided and whether this met a satisfactory standard. However, I have not seen evidence that this investigation was carried out and this was fault.
  4. The safeguarding meeting on 25 September 2018 was meant to set out the plan for the safeguarding enquiry. The meeting heard that a safeguarding investigation would be carried out and a further meeting would be held once the investigation was completed. The minutes were not clear but it was implied that the Agency would carry out the investigation and write the report.
  5. The Agency never provided a report or any care records and the Council’s safeguarding enquiry was allowed to drift.
  6. It appears the Council focussed on Mr C’s care plan without formally addressing the safeguarding allegations against the Agency and this was a mistake which had later serious consequences.
  7. The social worker then abandoned the enquiry on 14 November 2018 after speaking to Mr C.
  8. There was also fault in the Council’s second safeguarding enquiry in January 2019. The Council asked the Agency to carry out the enquiry and provide the report, but this did not happen. The last communication about the enquiry was in April and the matter was allowed to drift again without any conclusion. This was fault.

Care planning

  1. There was also fault in the way the Council decided the discharge care plan. I note good practice as the Council involved the relevant professionals such as the occupational therapist and the tissue viability nurse and organised a family meeting.
  2. However, there were a number of problems. Firstly, the Council’s failure to carry out the safeguarding enquiry meant it never really established what the root causes were of the deterioration that Mr C experienced every time he went home.
  3. From the discussions, it appears the Council accepted that there was a problem with the care provided by the Agency as it said it would commission a different agency for the afternoon calls.
  4. The Council then held a meeting on 18 October 2018 to discuss the care plan. I agree with the Council that there was fault in the way the meeting was held. The Council failed to invite the relevant expert professionals to the meeting as neither the district nurses nor the tissue viability nurse were invited. The district nurse later said that she had great concerns with a plan of discharge to the home and would have said so at the meeting.
  5. Secondly, there was insufficient consideration of any alternative plan apart from a return home. The family felt that a return home was unsafe and that only a care home could meet the 24/7 needs of Mr C. It appears the Council agreed, but was of the view that, as Mr C had capacity and wanted to go home, there was nothing it could do. I agree the Council had no power to force Mr C to do something he did not want. But it did have a duty to explain the different options and the greater risks associated with these options. There was insufficient consideration or discussion of the other options.
  6. I also agree with Ms B that Mr C should have been at this meeting. I accept the social worker obtained his views but the meeting would have been the perfect setting to discuss the different options and decide the best plan.
  7. There were then further problems as the plan that was agreed at the meeting in October 2018 was not the plan that was implemented when Mr C went back home.
  8. The Council’s proposed care plan tried to address two of the main risk factors in Mr C’s pressure sores. These were:
    • Mr C was immobile so he had to be turned frequently.
    • Mr C was incontinent and sitting in a soiled pad increased the risk of sores and stopped the healing.
  9. The care plan that the Council proposed to the family on 18 October 2018 included an increase from four calls to six calls a day which was meant to address both causes of the deterioration of the pressure sores. The Council also proposed to change the care agency for the afternoon calls and this would address the concerns about the poor care.
  10. However, the Council then changed the care plan to five calls a day and this was the plan that was taken to its funding panel and approved. There is no explanation of why the plan was changed and how the Council assessed that this was safe. This was fault.
  11. The Council also changed the plan as it allowed the Agency to continue to provide the care as it could not find an alternative agency.
  12. There was further fault as the Council was then informed that Mr C had reduced the five calls to four calls, soon after his return home. Therefore, the Council knew that Mr C’s plan was back to four calls a day by the Agency, which was more or less the care the plan he had before the latest hospital admission. The TVN and the district nurses had advised the Council that four calls a day was not sufficient to meet Mr C’s needs and was unsafe, but the Council failed to take action.
  13. As a side issue, it appears to me that one of the reasons why Mr C refused the extra calls was that he thought his financial contribution had increased as a result of the extra calls. It appears nobody explained to him that his contribution had not increased as he was already contributing the maximum amount for his income. However, I appreciate that this was not the social worker’s role.

Complaint response

  1. There was some fault in the Council’s initial complaint response which did not fully investigate the matter. The Council appeared to dismiss a lot of the complaints as it said Mr C had capacity to decide where he wanted to live and whether he wanted to accept care or not. That may be true but did not provide the entire picture of what had gone wrong and what the Council and the Agency could have done differently.
  2. I do appreciate that the Council’s response to the Ombudsman acknowledged some of the fault that I have identified and I also note the service improvements the Council made which should address some of the underlying problems.
  3. The Council also sent me evidence that it was addressing the wider concerns about the Agency’s practice through its safeguarding and quality assurance monitoring. Therefore, although it was concerning that the Council did not address the Agency’s failures in Mr C’s case, it has shown that it was taking action to ensure that the Agency improved.


  1. To summarise, the fault I have found is that the Agency failed to provide proper care to Mr C on occasion, failed to raise safeguarding alerts about the pressure sores and failed to provide the safeguarding reports.
  2. The Council then failed to carry out the proper safeguarding investigation into the concerns raised. This meant it was never clear what the causes were of Mr C’s deterioration every time he went home. The Council devised a care plan without fully involving the relevant people, the family and Mr C at the crucial meeting. The Council did not fully explore all the options in the care plan. The care plan was then largely abandoned when Mr C returned home and the Council failed to take appropriate action despite being aware of this.


  1. Sadly, Mr C, who suffered the main injustice from the Council’s fault has passed away and therefore any injustice to him cannot be remedied.
  2. However, I do not underestimate the injustice the family has suffered by witnessing what was happening to Mr C. The family will always wonder what would have happened if things had not gone wrong.
  3. I also note that, although the Council said it could not make a decision on the care provided by the Agency, the Council reduced the invoice for the care by £1,000.
  4. I cannot remedy Mr C’s injustice but I can try to remedy the distress the family has suffered. Such injustice cannot generally be remedied by a payment, so we seek a symbolic amount to acknowledge the impact of the fault. The Ombudsman usually pays between £100 and £300 for distress, but can exceptionally go higher. I am of the view that, in light of the seriousness of what happened and the severity of the distress, a sum of £1,000 would be appropriate in this case.

Agreed action

  1. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the service of the Agency, I have made recommendations to the Council.
  2. As the Council has already implemented a number of service improvements as a result of the complaint, I do not recommend any other service improvements.
  3. The Council has agreed to take the following actions within one month of the final decision. It will:
    • Apologise to Mr C’s family and acknowledge the fault.
    • Pay the family £1,000 for the distress they have suffered as a result of the fault. (This is in addition to the £1,000 reduction in the charges).

Back to top

Final decision

  1. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page