Summary: There was fault in the late Mr Y’s care, which was not delivered in line with his care and support plan as care calls were much shorter than they should have been. The Council has already identified fault and taken some action by apologising to the family and ending its contract with the Care Provider. The Council will make a payment to reflect the avoidable distress described in this statement.

The complaint

1. Ms X complained Thames Homecare’s (the Care Provider’s) care to her late relative Mr Y was not in line with his care and support plan. London Borough of Southwark (the Council) commissioned and funded Mr Y’s care. Ms X said this caused or contributed to Mr Y’s death and caused his family avoidable distress.
2. Ms X also complained about the manner in which they learned of Mr Y’s death and about repairs to Mr Y’s property not being done.

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What I have investigated

3. I investigated the complaints in paragraph one. My reasons for not investigating the complaints at paragraph two are at the end of this statement.

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The Ombudsman’s role and powers

4. 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)
5. The Council commissioned the Care Provider for Mr Y’s home care under powers and duties in the Care Act 2014 which I set out in detail in the next section of this statement. We can investigate the Care Provider’s actions.
6. 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)
7. We provide a free service, but we must use public money carefully. We do not start or may decide not to continue with an investigation if we decide we could not add to any previous investigation by the organisation. (Local Government Act 1974, section 24A(6))
8. We cannot investigate complaints about the provision or management of social housing by a council acting as a registered social housing provider. (Local Government Act 1974, paragraph 5A schedule 5, as amended)
9. If we are satisfied with an organisation’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

10. I considered Ms X’s complaint to us, the Council’s responses and documents described later in this statement. I discussed the complaint with Ms X
11. Ms X, the Council and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

12. Intermediate care is temporary care to help a person maintain or regain the ability to live independently. Reablement is a type of intermediate care which has a focus on helping the person regain skills and reducing their needs through providing services in the home. (Care and Support Statutory Guidance Paragraphs 2.9 and 2.10)
13. Councils arrange care and support for adults who have eligible needs. They must carry out an assessment of need, determine eligible needs and provide the person with a care and support plan which sets out the care needs and agreed funding. (Care Act 2014, sections 9, 24 and 25)
14. Councils have the power to meet a person’s care needs in an urgent situation, without having carried out an assessment of need (Care Act 2014, section 19(3))
15. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. We consider the 2014 Regulations when determining complaints about poor standards of care.
16. Regulation 10 of the 2014 Regulations says people using care services should be treated with dignity and respect.
17. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences.

What happened

18. Mr Y had dementia and lived with his wife Mrs Y in a council flat. Mrs Y was Mr Y’s main carer and she went into hospital in December 2021. Mr Y also went into hospital for a few days because he could not manage on his own and had not been eating or drinking. Mr Y’s daughter, who lives several hours away from her parents, was said to be shocked at the conditions in the home. There was no care package in place for either Mr or Mrs Y before the hospital admission. Case notes suggest Mrs Y may have previously expressed concerns about the cost of care.
19. The Council put in place urgent reablement care for Mr Y as Mrs Y was going to be in hospital for a while. The reablement care plan was for three calls a day for one hour on each call to support Mr Y with washing and dressing, toileting, continence care, preparation of food and drink, ensuring he ate and drank and took his tablets, with housework and with walking safely using his frame.
20. Mr Y’s case was allocated to a social worker to complete a needs assessment as he was going to need long-term care. The reablement care plan increased to four calls a day from the end of January 2022.
21. The Care Provider’s electronic call time logs for January and February show one regular care worker provided most care for Mr Y. Most calls were well under an hour. In some cases, they were less than half an hour.
22. The social worker completed an assessment of Mr Y’s mental capacity to decide about his care. (Mental capacity is the ability to make decisions.) Because of his failing cognitive abilities, the social worker decided Mr Y could not make decisions about his long-term care, because he could not retain relevant information.
23. The Council’s case records indicate social workers, occupational therapists and social care staff liaised with relatives and with staff from the housing department about practical arrangements such as ordering equipment like a hospital bed, bedding, falls alarm and movement sensors. Council officers also liaised to organise other matters like repairs, a weekly shopping delivery, getting a microwave and deep clean of the property which was said to be in a poor condition.
24. In February, the social worker arranged a virtual meeting with the Care Provider, housing officer and Mr Y’s relative. Unfortunately, the relative could not attend because of work commitments. The view of professionals at the meeting was Mr Y was going to need more support than could be provided at home and he may need a care home placement or at least supported living. Mrs Y remained unwell and in hospital and therefore was not able to care for Mr Y.
25. The social worker completed a needs assessment following a visit to Mr Y in the second week of February. The outcome was Mr Y was eligible for long-term care from the Council.
26. A couple of days later, Mr Y was found on the floor by an occupational therapist (OT), having fallen. He was medically checked. The OT considered he was at high risk of falls and was forgetting to walk with his frame. The Council installed a falls monitor which unfortunately Mr Y kept unplugging because of his memory problems. So it wasn’t a useful device for him.
27. A couple of days before Mr Y died, the Council installed movement sensors in the main rooms. The sensors did not detect falls, but they detected when Mr Y was moving about in the property and the intention was to use them as feedback to establish his movement patterns at night.
28. A care worker found Mr Y unresponsive on the morning of 18 March. the same care worker had visited Mr Y the previous day.
29. The social worker spoke to the police. The records indicate the social worker thought the local police were going to inform the next of kin who lived in a different area.
30. Mr Y’s family did not find out about his death until 21 March when an OT emailed a family member about collecting equipment from the flat. The records show the OT believed relatives had been told of Mr Y’s death.
31. The post-mortem report said Mr Y died from heart failure due to severe disease in the artery to the heart. The pathologist noted Mr Y was a normal body weight for his height and he had food and fluid in his stomach. The coroner’s office confirmed there was nothing to suggest Mr Y was malnourished. There was no inquest and a death certificate was issued which said the cause of death was heart disease. (Inquests are usually only held where there is reasonable cause to suspect a death was due to anything other than natural causes)
32. The Council arranged a meeting at the start of April to consider Mr Y’s case. A team manager, OT and staff from the Care Provider (Mr Y’s care worker and their manager) attended the meeting. The purpose was to consider the complaint the family made. I have summarised the discussion below:
• The movement sensors were installed to establish Mr Y’s movement patterns. He had been switching off his telecare falls monitoring system. The movement sensors picked up movements into and out of rooms because they were on skirting boards. They didn’t pick up movement in the bed
• The care worker said she went into the property at 14:00 on 17 March. But the sensors were not triggered at that time. There was a care call completed at 13:00.
• At the evening call on 17 March, the care worker said she went into the property and saw from outside the bedroom that Mr Y was asleep. She cleaned the kitchen and took bins out. The movement sensor report confirmed activity in the kitchen and at the front door for 7 minutes. The care worker said she had been there for 15 minutes
33. The agreed actions following the meeting were to visit the property to check the location of the bedroom sensor and when it became triggered, for the Care Provider to give the Council two weeks of care records so patterns could be analysed and for the Council to provide a report for the purposes of feedback.
34. The team manager and OT visited Mr Y’s home and checked the location of the bedroom sensor. They established it would trigger if a person took a single step into the bedroom.
35. The Council’s response to the complaint at the end of April said:
• There were inconsistencies in care which would be raised with the Care Provider through the commissioning team
• The records showed there was a call in the evening of 17 March at 18.33, but the movement sensors did not show the care worker going into Mr Y’s bedroom. The care worker’s note of the call said they saw Mr Y sleeping from the open door and so did not go in. She said she went back in at the end of the visit to ask if he wanted food or a drink and he said he was ok.
• The movement sensor records showed the last movement around the bedroom was 13.20 on 17 March. There was no further movement until Mr Y was found unresponsive at the morning call the following day.
• The movement sensor was on the skirting board by the bedroom door. The sensor would go off if a person took one step into the room. One could conclude safely that the care worker did not go into the bedroom on the evening of 17 March. Care to Mr Y was inadequate on the evening of 17 March as the care worker stayed only a few minutes and did not check Mr Y by going into his room or provide him with any food or drink. This would be discussed with the Care Provider at monitoring meetings.
• The movement sensor could not detect movement within the bed only movement around the room. So, it was not possible to say anything more exact about the time of death.
• Mr Y’s care and support plan was a temporary reablement plan. It said he needed four visits each day and an hour a week of housework. The care logbooks from the agency showed this was not provided in a two-week period. Mr Y was supposed to get 71 hours of care over two weeks and the logbooks show he only received 36 hours.
• On 16 and 17 March, tea-time and evening calls lasted under 10 minutes. The care and support plans said Mr Y needed support with getting to and from the bathroom, using the toilet, changing his pad, providing food and fluid and ensuring he drank at least 250 ml and with administering medication. Mr Y’s needs could not have been met on those occasions.
• Mr Y had a long-term care needs assessment in February. This did not include information from the carers’ logs which would have provided earlier recognition that carers were not staying for long enough.
• The case notes indicated there was a blitz clean in February and an urgent meeting of professionals about what action was needed to support Mr and Mrs Y. Family were not available to attend this meeting, but details of an agreed action plan were shared with the family. Professionals were of the view that supported living or residential care may be needed long-term because Mr Y was not able to live independently. It was recognised that a further blitz clean would be needed once essential maintenance and repairs had been completed
• The poor condition of the property and the level of home care he needed raised the question of whether Mr Y should have been moved to a care home or supported living sooner. The professionals’ meeting did not analyse the risk of remaining in the property. To minimise the chance of the same thing happening in other cases, the Council would be introducing a complex case pathway with clearer guidance to staff where there are concerns about living conditions and their engagement with care services. This would ensure better decision-making
• The Council apologised for the failings identified.
36. The Council told me it stopped commissioning the Care Provider for its homecare in August for reasons unconnected to Mr Y’s case. The Council went on to say it had reported to all relevant managers on the outcome of this complaint so they could feed back to staff.

Was there fault and if so did this cause injustice requiring a remedy?

37. The Council commissioned Mr Y’s care with Thames Homecare under its power to provide urgent care and support in Section 19(3) of the Care Act 2014. 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. Any fault by the Care Provider is therefore fault by the Council.
38. There was fault by the Care Provider which acted for the Council. The Care Provider’s call time records indicate Mr Y’s care calls were far less than the commissioned time. On a balance of probability this meant Mr Y’s care needs were not met in line with the reablement care plan. If tasks were completed, they were likely done so in a way which did not respect Mr Y’s dignity because the care worker would have had to rush Mr Y to get everything done. Care was therefore not in line with Regulations 9 and 10 of the 2014 Regulations. This was fault.
39. The Council has already acknowledged failings in Mr Y’s care in the complaint response and apologised to the family. This is a partial remedy to reflect the avoidable distress at learning their loved one did not receive care in line with the commissioned care and support plan. There are no grounds to say the failings contributed to or caused Mr Y’s death which was from heart disease.

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Agreed action

40. The Council will, within one month of this statement, make a payment of £250 to Mr Y’s family (to Ms X) which the family intends to donate to a charity. This is an appropriate remedy to reflect their avoidable distress in addition to the apology the Council has already made.
41. The Council has ended its contract with the Care Provider and so it is not appropriate to recommend further monitoring of the Care Provider or other action to avoid recurrence.

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Final decision

42. There was fault in the late Mr Y’s care, which was not delivered in line with his care and support plan as care calls were much shorter than they should have been. The Council has already identified fault and taken some action by apologising to the family and ending its contract with the Care Provider. The Council will make a payment to reflect the avoidable distress described in this statement.
43. I have completed the investigation.

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Parts of the complaint that I did not investigate

44. Mr Y’s family did not find out he had died until they received an email from the telecare service asking to collect equipment from Mr Y’s house. This was several days after he died. Ms X complained about the Council’s failure to or delay in telling the family about Mr Y’s death and about the way they were notified by email. The Council accepted it was at fault in its complaint response. The Council explained staff did not act in line with policy which was to contact the most appropriate family member to offer condolences. The Council apologised and said it would remind staff about the policy.
45. Ms X provided me with an email from the police officer who attended the scene. The police officer did not say they would contact the family, whereas the case records indicate the social worker believed the police would. Investigation of this point is not proportionate as the Council has already accepted fault, has reminded relevant staff about the correct way to inform relatives of the death of a client and the apology is an appropriate remedy. I could not achieve anything further by investigating this complaint.
46. I did not investigate a complaint about maintenance work to Mr Y’s home. This is a complaint about the Council’s management of social housing and so it is not within our remit. It is a matter for the housing ombudsman.

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Investigator's decision on behalf of the Ombudsman