Summary: Mrs X complains the Council: failed to deal properly with safeguarding concerns involving her daughter; a care worker failed to support her daughter properly on 15 February 2022; and both the care provider and the Council failed to deal properly with her complaints about this. The Council accepts it took too long to deal with the safeguarding concerns. The care provider failed to deal properly with Mrs X’s complaint about the events on 15 February. Mrs X has been caused avoidable distress and put to the time and trouble of pursuing the complaint. The Council needs to apologise and pay financial redress.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council:
• failed to deal properly with safeguarding concerns involving her daughter;
• a care worker failed to support her daughter properly on 15 February 2022; and
• both the care provider and the Council failed to deal properly with her complaints about this.

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The Ombudsman’s role and powers

2. 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)
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, sections 30(1B) and 34H(i), as amended)
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)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• invited comments on a draft of this statement from Mrs X and the Council, for me to consider before making my final decision.

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What I found

What happened

6. Mrs X’s daughter, Ms Y, has a learning disability, autism and mental health problems. Every four to six weeks she has episodes of anxiety which last 7 to 10 days, or longer. She lives in her own home with 24-hour support from a care provider. The Council last updated her care and support plan in May 2020. It commissions all her care from the Cambridge Care Company (CCC).
7. CCC’s care plan said Ms Y used incontinence pads at night (when not anxious) and needed prompting to go to the toilet during the day.

Safeguarding concerns

8. On 29 April 2021 Ms Y took almost a week’s medication when it was delivered through the door in a dosette box. A support worker found she had taken all but two tablets after noticing her taking them through a window. The support worker called Mrs X who said to call 999. As no ambulance was available, the support worker drove them to hospital but Ms Y became unresponsive on the way. They had to wait for the emergency services.
9. On 30 April the Council received a safeguarding referral from the hospital.
10. Ms Y was in intensive care for eight days, at times on a ventilator, and remained in hospital until 14 May.
11. After Ms Y returned home the arrangements for delivering her medication were changed, to avoid a repetition.
12. The Council’s records of its safeguarding enquiries show there were delays in receiving information from CCC. There was also no action between 3 November 2021 and 5 January 2022. Mrs X frequently chased progress.
13. The Council sent Mrs X a draft copy of its safeguarding investigation on 17 March 2022. She provided comments on the draft and the Council made further enquiries of CCC.
14. When the Council replied to Mrs X’s complaint in April, it said:
• it apologised for the time taken to deal with the safeguarding concerns;
• this was because of delays in receiving information from CCC and a Council officer leaving the team in November 2021;
• it was now waiting for CCC to respond to Mrs X’s comments on its draft safeguarding investigation;
• in response to Mrs X’s concerns about missed medication, the NHS had shared copies of Ms Y’s positive behaviour support plan and PRN protocol (for medication to be taken when needed) with CCC and its staff had started attending training sessions with the Intensive Support Team;
• CCC’s staff were required to keep the property clean (vacuum and wipe down surfaces) but did not have to do this when Ms Y was out of the property; and
• it would review Ms Y’s needs, as this was long overdue, and identify alternative care and support options.
15. The Council completed its safeguarding enquiries in July and shared the outcome with Mrs X. It found the arrangements for delivering medication had changed because of COVID-19. The pharmacist’s driver would knock on the door, place the medication on the doorstep and wait for the support worker to open the door and collect the medication. Sometimes the driver would post the medication through the door with the support worker acknowledging receipt. On 29 April the driver had posted the medication and left, assuming the support worker would pick it up. Ms Y had already been safeguarded by the action taken in 2021. The Council referred the problems with the delivery to the General Pharmaceutical Council, which addressed them with the pharmacy. Mrs X believes CCC was at fault for failing to take action when the pharmacist’s driver first posted the medication through the door.
16. When I spoke to Mrs X in July, she said the Council had postponed a review of Ms Y’s needs until early August. Mrs X has identified an alternative care provider for her daughter. Mrs X tells me the review has still not happened but the Council is going to address the question of whether it is in Ms Y’s best interests to move to an alternative care provider.

15 February 2022

17. CCC’s records for 15 February say:
• when the care worker arrived at 09.00 Ms Y was in her bedroom doing puzzles;
• she remained in her room until around 11.00, when she pulled out the puzzle drawers in the dining room;
• she did not want to put them away at first but eventually did;
• at 12.15 she wet her underwear, so the care worker changed her clothes and put an incontinence pad on. Ms Y did not want to put her socks back on so the care worker “left her without”;
• at 12.30 she had lunch but didn’t eat well and was more interested in the care worker writing the care notes “trying to take pen, grab hand etc”; and
• after lunch she switched between rooms and did not settle.
18. Mrs X complained that when she visited her daughter at 13.30:
• she was sitting in the dining room with a puzzle, with the remnants of lunch on the table;
• the care worker was sat in the lounge looking at her phone;
• the care worker said she was giving Ms Y space when challenged about using her phone;
• there was a basket of laundry (previous night’s bedding) which had been waiting to be hung up since 10.00 and another load of soiled laundry in the washing machine;
• the care worker said she was about to hang it up;
• when asked why the puzzle drawer was locked, the care worker said Ms Y had emptied it earlier so was restricting her to one puzzle at a time;
• when Ms Y took a magazine from the kitchen, the care worker spoke sharply saying “Don’t eat the paper”;
• the Care Worker had put Ms Y in an incontinence pad, despite needing prompting to go to the toilet during the day;
• Ms Y’s bedding was wet, so her trousers were wet after lying on the bed until midday;
• when Mrs X pointed out the wet trousers the care worker said “Oh not again”;
• after taking her daughter out for a short ride, she asked the care worker to leave and stayed with her until 15.30, when another care worker arrived.
19. CCC did not uphold Mrs X’s complaint. It said:
• the care worker had been sat down when Mrs X arrived as she was experiencing some pain;
• Ms Y had everything she needed;
• care workers used their mobile phones to access CCC’s care planning system;
• the care worker apologised for missing the wet bed. It put this down to her being a new member of staff who was not yet used to Ms Y’s routine;
• it was for care workers to manage their tasks;
• the care worker had locked the puzzle drawer as Ms Y had emptied it;
• it did not accept the suggestion that the care worker lacked empathy;
• the care worker had a good understanding of Ms Y’s care plan, spoke “fondly” of her role and was fully trained;
• it would remind care workers to explain why they are on the phone when accessing care plans; and
• Mrs X should report concerns to CCC’s office to avoid any misunderstandings with care workers.
20. Mrs X is not happy with CCC’s response. She says:
• care workers have 30 minutes overlap to handover and update the online care planning system;
• CCC failed to address her concern that Ms Y did not need an incontinence pad during the day but needed prompting to go to the toilet;
• given that Ms Y remained in bed until midday, the night staff had prepared lunch and washed the overnight bedding, the care worker had done very little;
• under a deprivation of liberty safeguard, the puzzle drawer should only be locked when Ms Y is especially anxious, which was not the case on 15 February;
• the care worker had not attended training arranged by the Intensive Support Team on managing Ms Y’s anxieties and had not observed her during a period of raised anxiety; and
• she had contacted CCC’s office on 15 February.

Is there evidence of fault by the Council which caused injustice?

21. It took 15 months to complete the safeguarding enquiries. There is no dispute over the fact it took too long. Both the Council and CCC share responsibility for that fault. The delay did not affect the outcome of the enquiries, so I cannot question it. Nor did it cause injustice to Ms Y, as there was no risk of the same problem happening again after she returned home in May 2021. The Council needs to review Ms Y’s needs and update her care and support plan.
22. CCC did not address all the issues Mrs X raised about the events on 15 February. It did not address the issue of the care worker putting Ms Y in an incontinence pad. CCC’s records for 15 February suggest a lack of person-centred care. This is because they largely describe Ms Y in terms of the problems she caused for the care worker. It appears the care worker put her in an incontinence pad to make things easier for herself. But this was not in line with her care and support plan. While CCC was right to say it is for the care workers to manage their tasks, it is difficult to understand why someone would leave wet washing in a basket when they had time to themselves before Ms Y came into the dining room.
23. It seems likely the problems Mrs X witnessed on 15 February can be put down to the care worker’s relative lack of experience with Ms Y and the pain she was experiencing that day. Nevertheless, the support Ms Y received on that day and CCC’s response to Mrs X’s complaint amount to fault, for which the Council is accountable (see paragraph 4 above).

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Agreed action

24. 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 actions of the care provider, I have made recommendations to the Council.
25. I recommended the Council within four weeks:
• writes to Mrs X acknowledging the faults I have identified and apologises for them and the distress she has been caused;
• pays Mrs X £200 for the time and trouble she has been put to in pursuing the complaint and the distress she has been caused; and
• provides evidence it has reviewed Ms Y’s needs and updated her care and support plan.

The Council has agreed to do this.

26. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of my final decision statement.

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Final decision

27. I have completed my investigation on the basis there has been fault causing injustice which requires a remedy.

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Investigator's decision on behalf of the Ombudsman