Summary: Mr X complained about the quality of care provided by a Council commissioned care provider, Safe Hands Care and Support Service. Mr X also complained about Safe Hands Care and Support Service’s handling of his complaint and accusations that he was racist. We found fault with the Council for failing to ensure the care provider completed a suitable investigation into Mr X’s complaint. The Council agreed to our recommendation to apologise to Mr X and ask the care provider to complete a suitable investigation in line with its policy.

The complaint

1. Mr X complained about the quality of care provided by a Council commissioned care provider, Safe Hands Care and Support Service (Safe Hands).
2. Mr X complained about the lack of responses to his complaints by Safe Hands and the accusation by Safe Hands that Mr X was racist following his complaints.

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What I have and have not investigated

3. I have not investigated Mr X concerns about the exact quality of the care provided. The reason for this is the Council has completed a suitable safeguarding investigation which has found inconclusive evidence of neglect or abuse by the care provider.
4. Mr X is not complaining about the actions of the Council, or its safeguarding investigation. Further investigation by the Ombudsman into the Council about this matter would not provide any meaningful outcome.

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The Ombudsman’s role and powers

5. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
6. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.
7. 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

8. I have considered all the information Mr X provided. I have also asked the Council questions and requested information, and in turn have considered the Council’s response.
9. Mr X and the Council had opportunity to comment on my draft decision before I made my final decision.

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What I found

Safe Hands complaint procedures

10. Safe Hands details six steps it should take when a person complains to it.
11. The first step is to try to resolve the complaint immediately.
12. Safe Hands will apologise to the person for the need to make a complaint at step 2 and explain its complaints process.
13. At step 3 Safe Hands will report the complaint to the most senior member of staff on duty who will log the complaint.
14. Safe Hands should send an acknowledgement of the complaint at step 4, which it should send within 3 working days of receipt of the complaint.
15. Step 5 of Safe Hands process is to complete a full investigation into the complaint and provide a written response. This written response should include a summary of the issues, details of the evidence relied on and a presentation of the findings. The written response should also include an explanation and conclusion with an apology, if applicable, and signposting to the Local Government and Social Care Ombudsman.
16. At step 6 Safe Hands will close the complaint if a satisfactory outcome has been reached.

Council responsibility

17. As commissioners of the care, it is the Council’s responsibility to ensure the care provider completed a formal robust investigation.
18. If a person raises concerns with the Council about the quality of care provided by a commissioned care provider, the Council should complete a separate adult safeguarding investigation.

What happened

19. Mr X received care from a Council commissioned care provider, Safe Hands, until 30 June 2021. Mr X started to receive care from a new care provider from 1 July 2021.
20. Mrs Z, acting for Mr X, complained to the Local Government and Social Care Ombudsman, the Ombudsman, about Safe Hands who directed Mr X to the Council as the commissioner of the care provider.
21. Mrs Z complained to the Council on 29 October 2021 about Safe Hands. The Council spoke with Mrs Z over the telephone before meeting with both Mr X and Mrs Z. The Council completed a full safeguarding investigation into Mr X’s concerns.
22. On 17 December 2021, the Council wrote to Mrs Z to provide the outcome of its investigation. The Council said its safeguarding investigation was inconclusive. The Council said this did not discount Mr X’s concerns but that there is not enough evidence on balance to decide exactly what occurred. Therefore, the Council could not decide whether there was abuse or neglect. The Council agreed to the following actions:
• For Safe Hands to provide copies of Mr X’s care records.
• For Mr X to make a complaint directly to Safe Hands.
23. On 24 January 2022, Mr X made a direct complaint to Safe Hands about the level of care he received and detrimental comments made about him. Mr X asked Safe Hands to complete an investigation into his concerns and that he receive an apology for the claims that he is difficult and racist. Safe Hands signed for this letter on 31 January 2022.
24. Mr X wrote to Safe Hands again to chase up a response to his complaint letter of 24 January 2022. Safe Hands failed to respond to Mr X’s contacts.
25. Mrs Z complained to the Ombudsman on 4 May 2022. The Ombudsman liaised with the Council who confirmed it had provided a response to Mr X's complaint through a safeguarding investigation. The Council contacted Safe Hands who said it had not received a complaint from Mr X.
26. On 17 May 2022, the Council told Safe Hands to provide a complaint response to Mr X. Safe Hands said it would investigate the complaint and provide a response by 21 June 2022.
27. On 24 June 2022, Safe Hands called Mr X to discuss his complaint before sending a written complaint response the same day. Safe Hands said it apologised for:
• The incident when Mr X was allegedly called a racist.
• The incident when a carer allegedly jumped on his bed.
• Delays in providing Mr X with his daily logs.
28. Safe Hands also provided the Council with a copy of its complaint response.
29. Mr X brought his complaint back to the Ombudsman on 2 July 2022 because of his dissatisfaction with Safe Hands complaint response.

Analysis

30. The Council has a responsibility to ensure a commissioned care provider has a suitable complaints procedure and that it completes a suitable investigation of complaints made to it in line with this complaints procedure.
31. Safe Hands has a suitable complaints procedure but failed to follow this complaints procedure for Mr X’s complaint. Safe Hands failed to acknowledge or respond to Mr X’s first two complaint contacts. Safe Hands then failed to acknowledge the third complaint contact with Mr X, as passed over by the Council, or provide a response within the timescale promised. This was poor complaint handling and is fault.
32. Safe Hands also failed to complete a full investigation into Mr X’s complaint. The Council has confirmed this within its response to the Ombudsman’s enquiries. Safe Hands has not completed a suitable investigation and only apologised for “alleged” fault by its staff. Safe Hands failed to reach a satisfactory outcome to Mr X’s complaint. This was fault.
33. The Council had sight of Safe Hands’ complaint response to Mr X’s complaint and has accepted the response was inadequate. The Council should have followed this matter up with Safe Hands to ensure it provided a suitable complaint response but it failed to do so; this was fault. The Council should ensure that Safe Hands provides a suitable complaint response to Mr X to address his concerns in line with its policy.
34. The Council has already taken suitable action to improve its own service in response to Mr X’s complaint. The Council has confirmed it will introduce a system that requires commissioned care providers to tell it or any complaints they have received in the previous quarter. This system will enable the Council to monitor complaints about commissioned care providers and the actions of its commissioned care providers. I consider this a suitable resolution to the underlying issues presented in Mr X’s complaint.

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Agreed action

35. Within one month of the Ombudsman’s final decision the Council should:
• Apologise to Mr X for failing to ensure Safe Hands Care and Support Service provided a suitable complaint response in line with its policy.
• Instruct Safe Hands Care and Support Service to complete a full investigation into Mr X’s complaint, in line with its policy, and provide a suitable written response to Mr X’s complaint. This written response should include a summary of the issues, details of the evidence relied on, a presentation of Safe Hands’ findings including an explanation and conclusion.
36. The Council should provide us with evidence it has complied with the above actions.

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Final decision

37. There was fault by the Council as the Council has agreed to my recommendations, I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman