The Ombudsman's final decision:
Summary: the complainant complained the Council’s commissioned Care Provider, Comfort Call (Durham) failed to provide services it had commissioned leading to his mother not receiving all the care she needed, putting her at risk of harm and causing distress to the family. The Council says Comfort Call accepted fault and committed to improvements but that any further remedy was unnecessary. We find the Council at fault for the poor care service and it has agreed to apologise, pay £500 to the complainant, and monitor the contractor’s future performance.
- The complainant, whom I shall refer to as Mr X, complains Comfort Call (Durham) (a part of City & County Healthcare Group Ltd) the Care Provider commissioned by the Council failed to provide the care set out in the care plan. Mr X says it provided care that was unsafe or of a poor standard.
- Mr X says this resulted in his mother, Mrs Y, not receiving some care visits and medication or receiving shorter visits or at different times than set out in the Care Plan. Mr X says the Council failed to properly supervise the delivery of the care or deal with complaints in a timely way.
- Mr X says the Council failed to alert him or his family about missed visits which is a safeguarding issue, or when Comfort Call staff found Mrs Y unwell and, he says, leaving her at risk of significant harm.
- Mr X wants the Council to waive any unpaid care contributions in recognition of the failings and to improve its supervision of care providers.
What I have investigated
- 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)
- 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)
- If 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)
How I considered this complaint
- In considering this complaint I have:
- Contacted Mr X and read the information presented with his complaint;
- Put enquiries to the Council and Care Provider and reviewed their responses;
- Researched the relevant law, guidance, and policy;
What I found
- Mrs Y has dementia and other conditions. In July 2019, the Council commissioned a package of care consisting of four care calls per day from Comfort Call, which agreed it could meet Mrs Y’s care needs. Responsibility for providing and supervising the quality of care for Mrs X between 15 July and 19 September 2019 lay with the Council.
- Following concerns raised about the quality of care provided the Council reviewed Mrs Y’s needs and commissioned a different care provider to deliver her care from 10 October 2019. Mrs Y has sadly since passed away.
- The Care Plan for Mrs Y said she needed a breakfast, lunch, tea-time, and evening call. The Care Plan scheduled the calls for 9.00am, 1.30pm, 5.00pm and 8.00pm. The Care Plan scheduled each call except lunchtime to last 30 minutes. The Care Plan said the lunchtime call to provide support with a small snack and drink need last only 15 minutes. The Care Plan said carers would provide personal care and ensure Mrs Y wore suitable clothing and took her medication. Under the Care Plan the family organised keeping the home clean and tidy.
- The Council checked Comfort Call had received the Care Plan and asked Comfort Call to consider making earlier calls if the staff became available.
- Mr X says Care Call agreed the visits would be at 8.00am, 12.00 noon, 4.00pm and 8.00pm. The Council said flexibility of 30 minutes either side of these times would be acceptable. Mr X says over half of the visits received by Mrs Y fell outside these limits. In one instance the care worker attending for the afternoon or tea-time call left at 4.20pm. The evening call care worker then arrived ten minutes later at 4.30. That resulted in cares preparing Mrs Y for bed too early and without a later call. Mr X says visits occurred between the following times:
- Morning – 6.55am and 9.15am
- Tea-time – 3.00pm and 5.25pm
- Evening – 4.30pm and 9.15pm
- Medication not given on some visits, medication given at the wrong time of day and sometimes left on the bedside table for Mrs Y to take without supervision;
- A failure to visit resulting in Mrs Y receiving no food or drink or medication;
- Cancellation of an evening visit with only three hours’ notice and no substitute carer offered;
- Notes left in the contacts book in Mrs Y’s home but no direct call to the family to alert them when Mrs Y became ill, had a fall or when her telephone stopped working;
- Visits not made at the set times or for the set duration.
- In response to the concerns the Council raised a safeguarding alert. The Council contacted an alternative care provider, but they could not offer a service. The Council told the family it could not find an alternative provider so the family said it would like to change to a direct payments’ arrangement, and source the care provider themselves.
- The Council’s social worker spoke with Mr X on 19 September 2019 and he told the social worker to give two weeks’ notice to Comfort Call in line with the contract. The social worker said that if the direct payment arrangement had not been set up by the end of the notice period the family would need to provide the care calls. The social worker called Comfort Call and gave notice. On 20 September 2019 Mr X telephoned the Council to say he had cancelled all care calls and the family would now support Mrs Y until a new care provider could be found.
- The Council conducted a review of the Care Provided which it completed on 24 September 2019. The social worker considered Comfort Call’s response to the concerns raised about the service provided over the weekend of 13 September 2019. The safeguarding referral led to no further action because Comfort Call’s service had ended on 20 September 2019 and so Mrs Y had been removed from any risk of significant harm. The Council’s investigation noted Comfort Call had not reported to the Council any missed medication or appointments or that staff had found Mrs Y unwell.
- In line with arrangements the Council had with Comfort Call it redirected the complaint to Comfort Call and told Mr X on 27 September 2019, it had done so. The Council told Mr X if he remained dissatisfied on receipt of Comfort Call’s response, he could raise the matter again with the Council. He did on 18 November 2019. In March 2020 following consideration of Comfort Call’s investigation and after consideration by the Commissioning Service the Council told Mr X it would not waive the outstanding fees of £975.39. The Council did not examine Comfort Call’s records or notes. It believed the action taken by Comfort Call in response to the complaint addressed Mr X’s concerns and the fault identified did not warrant a remedy equivalent to nearly £1,000.
Comfort Call’s investigation
- In its response to the complaint in November 2019, Comfort Call upheld complaints that Mrs Y’s medication had not been administered properly. That some visits had not taken place; staff had not given notice of cancellation of a visit, and staff had not adhered to the agreed visit times. Comfort Call partially upheld the complaint staff had not reported Mrs Y’s falls to the family. Comfort Call said in failing to tell the family of Mrs Y’s fall its staff had failed to follow proper reporting procedures. Comfort Call said staff reported Mrs Y as saying she did not want her family told she felt unwell, but had she continued to feel unwell Comfort Call would have contacted the family.
- Comfort Call did not uphold the complaint that it had not told the family when Mrs Y’s telephone stopped working. The notes in the records about the telephone reflected problems Comfort Call experienced in getting its electronic recording system to recognise Mrs Y’s telephone number. Comfort Call believe the family misunderstood the notes as meaning the telephone did not work for calls to and from the number.
- Comfort Call said it had taken the concerns raised and the upheld complaints seriously and it would be using the complaint to train staff and improve standards. It decided the complaint had been partially upheld (because one complaint had been not upheld and another only partially upheld.) In its letter Comfort Call says: “We accept your mother’s package of care should have been managed more effectively…”
Analysis – was there fault leading to injustice?
- 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, where I find fault with the actions of Care Call, I will recommend action to the Council to address the impact of those faults.
- My role is to decide if the Council’s commissioned service has been provided without fault. Where there is fault, I must decide what impact that has had and what the Council should do to address it.
- Comfort Call accept Mrs Y did not receive all the agreed care visits, or her full medication. This placed Mrs Y at risk and caused the family anxiety as well as inconvenience. Missed care visits had to be covered by the family but those not reported to the family placed Mrs Y at risk because nobody would know she had not received care at the appropriate time. The failure to report Mrs Y’s fall to the family is contrary to the family’s reasonable expectations and the duty to tell them of any significant incident affecting Mrs Y. The service provided meant Mrs Y sometimes had visits close together making them of less value to her. Expecting her to retire for the night at 4.30pm instead of the set evening visit of 8.00pm does little to enhance Mrs Y’s dignity and left her for too long before the morning visit. The large variation in times went beyond the usual 30 - minute accepted variation either side of an appointment time.
- The Council responded to the family’s concerns promptly. The Council correctly referred concerns for a safeguarding evaluation which resulted in no action needing to be taken. However, I have concerns about how the Council evaluated Comfort Call’s complaint investigation. I find it at fault for not examining the notes and records before accepting Comfort Call’s findings or considering whether it should offer a further remedy to simply upholding the complaints, and whether this sufficiently addressed the concerns raised and upheld. The Council did not address whether it should have offered at least an apology for the faults upheld.
- The Council has not shown that it considered the impact on either Mrs Y or the family of the faults identified and upheld. The lack of visits, the missed medication and failure to report a fall or illness are significant matters and placed Mrs Y at risk of harm. The missed calls meant Mrs Y went without food and personal care impacting on her dignity and wellbeing. That caused avoidable distress and inconvenience for the family. That is not what they expected from a service commissioned by the Council and which has oversight of that service.
- Therefore, I find the Council’s commissioned care service did not provide the level of care Mrs Y and her family had the right to expect. I also find the Council failed to fully investigate and consider the impact of the failings on Mrs Y and the family and whether a remedy should be given. Sadly, Mrs Y has passed away. However, her family have experienced avoidable distress and avoidable time and inconvenience dealing with the complaint and sourcing a new care agency for which I believe the Council should provide redress.
- In response to my sharing my draft decision with the Council, it has assured us it will monitor performance of domiciliary care services which have been under unprecedented pressure during the Covid-19 pandemic. The Council accepts this does not excuse any poor-quality services delivered on its behalf.
- In recognition of the injustice to Mr X and his family caused by the faults identified in this investigation, I recommend, and the Council agrees to within four weeks of my final decision:
- Provide a written apology to Mr X;
- Pay Mr X £500 in recognition of the avoidable distress and inconvenience caused by the faults including the impact on Mrs Y’s dignity.
In completing my investigation, I find the Council at fault causing injustice.
Investigator's decision on behalf of the Ombudsman