Summary: Mr X complains about repeated failures by the Council’s care providers (Horizon Care & Welfare Association, Immaculate Healthcare Services Limited Croydon, Supreme Care Services Ltd and Abletrust Care) to support his grandmother, Mrs Y, between June 2023 and February 2024. There was fault in the care provided by Horizon Care & Welfare Association, Immaculate Healthcare Services Limited Croydon and Supreme Care Services Ltd which either caused harm to Mrs Y or put her at risk of harm. The Council also failed to involve Mrs Y in reviews of her needs. The Council needs to apologise to Mrs Y and make a symbolic payment to her for the distress caused. It also needs to take action to improve working practices.

The complaint

1. The complainant, Mr X, complains about repeated failures by the Council’s care providers (Horizon Care & Welfare Association, Immaculate Healthcare Services Limited Croydon, Supreme Care Services Ltd and Abletrust Care) to support his grandmother, Mrs Y, between June 2023 and February 2024.

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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 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)
3. 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)
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, sections 24A(1)(A) and 25(7), as amended)

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How I considered this complaint

5. I have considered evidence provided by Mr X and the Council, as well as relevant law, policy and guidance.
6. Mr X, the Council and the care providers had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

What happened

7. The Council reviewed Mrs Y’s needs in June 2023, after Horizon Care & Welfare Association gave notice following difficulties with delivering her care. The Council identified the need, following a stroke, for support with:
• Managing personal hygiene
• Being appropriately clothed
• Managing toilet needs
8. The review did not identify a need for support with accessing the community, as Mrs Y was “housebound”, could “only go out for a walk in her wheelchair” and liked to stay at home and watch TV. The review said family supported with shopping, cooking and house cleaning. The Council said the care workers were only there to do personal care and tidy up, and were not there to do “deep cleaning tasks, such as vacuuming, which had been requested.
9. The Council agreed to continue providing two care workers to visit four times a day:
• 45 minutes in the morning
• 30 minutes at lunchtime
• 30 minutes at teatime
• 30 minutes in the evening
10. Following the review, during which Mrs Y expressed regret for the problems Horizon Care & Welfare Associate had experienced in supporting her and said she wanted it to continue to support her, the care provider agreed to continue supporting Mrs Y. Horizon Care & Welfare Association’s care plan for Mrs Y said her family met all her needs for support with food, drink and medication.
11. In August, following concerns raised about one of its care workers treating Mrs Y roughly, Horizon Care & Welfare Association agreed to remove the care worker from her rota.
12. However, on 4 October Horizon Care & Welfare Association gave the Council seven days’ notice to find another care provider. It said this was because it no longer had enough care workers to support Mrs Y, following the complaint of rough handling. On 6 October it agreed to extend the notice period to 17 October.
13. The Council reviewed Mrs Y’s needs on 6 October but made no changes to her assessment or care and support plan. It did the review over the telephone
14. On 11 October Horizon Care & Welfare Association told the Council the decision to give notice was not because of the complaint of rough handling, but because it did not have enough staff to cover her calls.
15. Immaculate Healthcare Services agreed to take over Mrs Y’s package of care from 18 October. On 18 October it produced a care plan for Mrs Y. This identified all the tasks which needed to be completed to meet Mrs Y’s needs. It included medication prompts and supporting with meals and drinks.
16. On 16 November Immaculate Healthcare Services agreed to look into concerns about poor timekeeping, the lack of a care folder, an incident on 24 October (severe bruising, not using personal protective equipment (PPE), poor communication by care workers, and not tidying up after a visit. It apologised for the lack of contact before starting the care package and put this down to the late delivery of information (from the Council).
17. On 30 November Immaculate Healthcare Services reviewed Mrs Y’s care package. It identified log sheets which had not been completed properly, and alerted care workers to the need do so. They also discussed the timing (lateness) of visits, care workers not washing their hands and the need for changes to the information in Mrs Y’s care folder.
18. On 1 December Immaculate Healthcare Services told the Council its care workers had been “put under immense pressure”, resulting in care workers not wanting to visit Mrs Y. It said this meant it no longer had the capacity to support her and would end its visits on 7 December.
19. The Council reviewed Mrs Y’s needs as a “paper exercise” before changing the care provider. The review did not involve Mrs Y and confirmed the needs previously agreed.
20. Supreme Care Services agreed to take over Mrs Y’s care package from 8 December. The Council asked it to contact Mrs Y before taking over her care package and to try to adhere to call times and let Mrs Y know if care workers were running late.
21. Supreme Care Services did not contact Mrs Y and did not visit her until 11.30 on 8 December. Mrs Y received support from Mr X until the care workers arrived. The Council noted it needed to decide whether to make safeguarding enquiries into the incident on 24 October which left Mrs Y with broken skin. Care workers also failed to attend for the afternoon call, but Mr X remained with her.
22. Supreme Care Services missed further calls on 9, 10 and 11 December. At the request of Mrs Y’s family, the Council reluctantly agreed to find another care provider. The Council noted Supreme Care Services had not been given a chance to succeed.
23. The Council reviewed Mrs Y’s needs again on 11 December. As before, this was a paper exercise which did not involve Mrs Y. The Council noted the need to review Mrs Y in person, as she could not communicate over the telephone.
24. Abeltrust Care agreed to take over Mrs Y’s package of care from 13 December.
25. Mr X complained to the Council in March about the failure to meet Mrs Y’s needs.
26. The Council replied to Mr X’s complaint in May 2024. In response to his more general concerns, it said:
• All care workers should wear ID, which should be visible to clients and families, and should comply if asked to show ID.
• Many care providers used electronic recording systems, accessed via an application on the care workers’ phones, or via a mobile device provide by the care provider. Care workers should not make personal calls, but may need to take urgent calls from their care provider.
• Care workers were required to speak good English and should not speak another language unless it was needed to communicate with the clients.
• Care providers had to do recruitment checks and train care workers. The Care Quality Commission oversaw compliance, as did the Council when doing quality visits.
• Care workers had to complete infection control training, which included the correct use of PPE.
• Care packages included preferred call times and care workers had to attend as close to the preferred times as possible. But emergencies could cause delays, in which case the care provider should let clients know. Care calls should not be missed without communication. The Council checked to make sure care providers only charged for calls delivered.
• Care worker had access to clients’ files and were expected to familiarise themselves with the contents and understand the client’s needs and preferences before delivering care.
• It was concerned to hear that care worker left at 20.30 and did not return until 14.45 the next day, leaving Mrs Y soiled. This should have been raised as a safeguarding concern. The Council was investigating what happened and would provide an update when it had done this.
27. In response to Mr X’s specific concerns about the individual care providers, the Council said:
• Horizon Care & Welfare Association agreed to remove a care worker from Mrs Y’s package of care, following the complaint of rough handling. It gave notice on 4 October 2023, as using a care co-ordinator and a supervisor to meet Mrs Y’s needs was not sustainable. Horizon Care & Welfare Association had not been aware of the allegation that the care worker had washed their feet in Mrs Y’s sink until Mr X complained to the Council, but had investigated the matter. The Council could not share the result with Mr X as it related to a named individual.
• Immaculate Healthcare Services used electronic call logs and had given Mrs Y’s daughter access to this. It had also provided a paper logbook, as asked. The care workers had reported a severe bruise on Mrs Y’s leg and a GP had attended. They did not know Mrs Y was taking medication for an infection, as they did not manage her medication. After Mrs Y’s daughter raised concerns about care delivery, a supervisor had made an unannounced spot check, but was turned away and made an appointment instead. Immaculate Healthcare Services accepted several care calls were late and apologised. It put this down to waiting with other clients when an ambulance had been called. Following a breakdown in the relationship between Mrs Y’s daughter and the care workers, Immaculate Healthcare Services had agreed to provide refresher training for care workers and asked her to allow them to work without interference. It had provided PPE to be kept in Mrs Y’s home, although that was contrary to its usual procedure. At a meeting in November 2023, it had agreed to repair a door allegedly damaged by care workers using a transfer aid. When the daughter raised concerns about late morning calls, Immaculate Healthcare Services had monitored them until the care package ended. The Council had taken steps to ensure lessons had been learned
• Supreme Care Services agreed it should not have accepted Mrs Y’s care package, as it did not have enough care workers in her area, and apologised for its mistake. The Council had started safeguarding enquiries under section 42 of the Care Act 2014, and would contact Mrs Y and her family about the incident.
• Abeltrust Care confirmed all care workers had to wear ID and suggested it may not have been visible as they were wearing coats in the cold weather. However, they should always make it visible when arriving at someone’s home.
28. The Council visited Mrs Y in July 2024 to review her needs and updated its assessment. It identified the need for support with:
• Being appropriately clothed, for which she received support from care workers
• Managing and maintaining nutrition, for which she received support from family
• Managing toilet needs, for which she received support from care workers
• Maintaining a habitable home environment, for which she received support from family
• Maintaining personal hygiene, for which she received support from care workers and her family
• Eating and drinking, for which she received support from her daughter
29. They discussed problems with the standard of care delivered by some care workers, including a lack of compassion and communication issues when delivering personal care. These were described as historical complaints, which Abeltrust Care had addressed by unannounced visits (agreed in advance with the family).

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

30. The evidence shows there were problems with the care Mrs Y received from Horizon Care & Welfare Association, Immaculate Healthcare Services and Supreme Care Services which amounted to fault, for which the Council is accountable. It appears there have been incidents which have either caused harm to Mrs Y (e.g. missed calls) or put her at risk of harm (poor hygiene). The Council was quick to blame Mrs Y’s family for problems with Supreme Care Services, but it did not have enough care workers to meet her needs.
31. The evidence also shows that there have been safeguarding issues which were not reported to the Council by Immaculate Healthcare Services or Supreme Care Services when they occurred. This also amount to fault for which the Council is accountable.
32. The Council has reviewed Mrs Y’s needs on several occasions without involving her in the process. There is nothing in its records to suggest Mrs Y has lacked the capacity to make decisions about her care. The Council’s failure to involve her in the process does not therefore comply with the requirements of the Care & Support Statutory Guidance. While the Guidance provides for a light touch approach and makes it clear that reviews need to be proportionate, it also says they need to be person-centred. That cannot be achieved without involving the person themselves, and anyone else they want to support them. A review after a care arrangement has broken down provides an opportunity to ensure future arrangements are more sustainable.

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Action

33. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of care providers and make the following recommendations to the Council.
34. I recommended the Council:
• Within four weeks writes to Mrs Y apologising for the problems she experienced with the care delivered by Horizon Care & Welfare Association, Immaculate Healthcare Services and Supreme Care Services, and pays her £300 for the distress caused.
• Within eight weeks:
1. Works with Immaculate Healthcare Services and Supreme Care Services to ensure they understand their responsibilities to report safeguarding incidents when they occur;
2. Takes action to ensure officers involve people in reviews of their care needs.
35. The Council has agreed to do this. It should provide us with evidence it has complied with the above actions.
36. Under the terms of our Memorandum of Understanding with the Care Quality Commission and information sharing protocol, I will send it a copy of my final decision statement.

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Decision

37. I find fault causing injustice. The Council has agreed to take action to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman