Summary: Mr X complains on behalf of his mother, Mrs Y. He says the care provider on behalf of the Council failed to communicate with the family and did not have any understanding of his mother’s needs. He also says it had unsafe practices. Mr X says the Council failed to respond to him when he raised a complaint. Mr X says this caused him and his family distress. We have found fault in the actions of the Council for failing to ensure the care provider could access Mrs Y’s property leading to missed medication and for failing to respond to Mr X’s complaint. The Council has agreed to issue an apology, pay a financial payment to Mr X and complete service improvements.

The complaint

1. Mr X complains on behalf of his mother, Mrs Y. He says the care provider on behalf of the Council failed to communicate with the family and did not have any understanding of his mother’s needs. He also says it had unsafe practices. Mr X says the Council failed to respond to him when he raised a complaint.
2. Mr X says this caused him and his family distress.

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The Ombudsman’s role and powers

3. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
5. 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)
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.

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How I considered this complaint

7. I have considered the information provided by Mr X and the Council.
8. Both Mr X and the Council were invited to comment on my draft decision. Any comments provided have been considered before a final decision was issued.

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What I found

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
10. Regulation 10 says people using care services should be treated with dignity and respect.
11. Regulation 12 says medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe.
12. Regulation 17 says care providers should keep an accurate and complete record of the care they give to a person.

The Councils complaint procedure

13. The Councils complaint procedure says it will respond to complaints in a timely and appropriate manner.

What happened

14. Mrs Y was admitted to hospital in January 2024.
15. The hospital discharged Mrs Y in late January 2024. Mrs Y’s re-enablement plan stated a best interest meeting had taken place with Mr X. The best interest meeting decided Mrs Y should return home to her assisted living property. Mrs Y would receive four care calls a day to include help with personal care, meals, medications and general welfare.
16. Mr X contacted the Council the same day as the hospital discharged Mrs Y to report the carers had missed Mrs Y’s bedtime call as they could not gain access to the property. Mrs Y’s care notes record that Mr X said this was because the correct information had not been passed to the carers about the key safe code. The missed call meant Mrs Y missed her medication.
17. The Council spoke to the care provider who confirmed the call was missed but the carer spoke to Mrs Y through the intercom. The care provider also told the Council the carers now had the key safe code to allow them access to Mrs Y’s property.
18. Mr X contacted the Council two days later to say he had attended Mrs Y’s property and found her fully dressed in a soiled bed with faeces on her. Mr X asked for the current carers to be stopped immediately.
19. The Council contacted the care provider who reported it attended Mrs Y’s property at 8:50 and Mrs Y was already dressed sat in the living room. The care provider said it provided Mrs Y with breakfast and made her bed.
20. The Council spoke to Mr X about what the care provider had said, and Mr X told it he had arrived at 9:35. Mr X said it would be impossible for Mrs Y to have undressed, soiled the bed and redressed in the time between the care provider leaving and him arriving.
21. The Council raised a safeguarding referral in early February 2024
22. Mr X raised a complaint in early February 2024 and said the care provider acting on behalf of the Council had failed to have the information it needed on Mrs Y’s needs. He also said the care provider had failed to give Mrs Y her medication and had left her in a soiled bed.
23. Mr X also said the care provider had given wrong information about what had happened when it completed Mrs Y’s morning visit.
24. The Council acknowledged the complaint the same day.
25. The Council started a safeguarding investigation in mid-February 2024.
26. The Council spoke to Mr X in late February 2024 and told him his complaint was being followed up by ICE and the safeguarding hub.
27. The council contacted Mr X again in March to say it was still gathering information to investigate his complaint.
28. The Council completed its safeguarding screening investigation in late March 2024 and found the provider had taken appropriate actions to mitigate the risk of further incident and therefore no further action was needed.
29. Mr X chased for a reply to his complaint in June 2024.
30. The Council issued a response to Mr X’s complaint in August 2024. It apologised and told Mr X it had investigated his concerns. The Council said it had found the care provider had implemented a sufficient protection plan to mitigate the risk of further incident. The Council also confirmed it no longer worked with the care provider.

Analysis

31. The care provider has confirmed it did not gain access to Mrs Y’s property on the first night the hospital discharged her. This meant Mrs Y missed her medication. This is fault and a potential breach of regulation 12.
32. The care provider could not access Mrs Y’s property because the carer did not have the key safe code. This is fault and a potential breach of regulation 17.
33. Mr X says he found Mrs Y in a soiled bed with faeces on her. The care provider says it made Mrs Y’s bed when the carers attended. The Council investigated this and was satisfied the care provider had put measures in place to safeguard Mrs Y going forward. However, at that point Mr X had already cancelled the care provider’s attendances with Mrs Y and instructed a different care provider.
34. I am satisfied with how the Council investigated the safeguarding issues raised and completed enquiries with the care provider. The Council reached the decision no further action needed to be taken in relation to the safeguarding investigation. The Council later stopped working with the care provider.
35. The Council failed to tell Mr X about the outcome of the safeguarding investigation and failed to respond to his complaint raised in February 2024 until August 2024. The Councils complaint procedure says it will respond to complaints in a timely and appropriate manner. However, it did not do so here, and this is fault.
36. The faults identified about the care provided to Mrs Y would have caused distress to Mr X but was limited to a short period. Mr X cancelled the care provider within a few days and instructed a new provider which he was happy with.
37. I understand Mrs Y suffered no side effects having missed her medication.
38. The faults identified in relation to the Council failing to respond to Mr X’s complaint again would have caused him distress. There is a significant period between when Mr X raised his complaint and the Council’s response. Mr X chased the Council for a response but failed to receive one for around six months.

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Agreed action

39. Within one month of a final decision the Council should:

• Write to Mr X and apologise for the faults identified.
• Pay Mr X £250 to recognise the distress caused to him.
• Remind staff in writing of the importance of responding to complaints in a timely manner.

40. The Council should provide us with evidence it has complied with the above actions.

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Final decision

41. I have found fault in the Councils actions for failing to ensure the care provider could access Mrs Y’s property leading to missed medication and for failing to respond to Mr X’s complaint.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman