Summary: Mrs X complained the Council failed to act to resolve issues with a care package and wrongly allowed the care provider to ask Miss Y to attend some visits. The Council delayed arranging a review when issues with the care package became clear and the care provider contacted Miss Y without Mrs X’s permission. That caused Mrs X and Miss Y distress. An apology and guidance to officers is satisfactory remedy.

The complaint

1. The complainant, Mrs X, is represented by her daughter, Miss Y. Mrs X complained:
• the Council failed to act to resolve issues with the care package; and
• the care provider, acting on the Council’s behalf, contacted Miss Y to ask her to take part in some visits in 2024 without Mrs X’s permission.
2. Mrs X says the Council’s actions caused her and Miss Y 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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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 our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

7. As part of the investigation, I have:
• considered the complaint and Miss Y's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
8. Miss Y and the organisation 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

The Care Act and statutory guidance

9. The Care Act 2014 and the Care and Support Statutory Guidance 2014 set out the council's duties towards adults who require care and support. The Council also has its own policies.

Assessment of needs

10. The Council has a duty to assess adults who have a need for care and support. If the needs assessment identifies eligible needs, the Council will provide a support plan which outlines what services are required to meet the needs.

Care Quality Commission

11. The CQC is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings.
12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards. This says that:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. (regulation 12).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).

What happened

13. Mrs X has a need for care and support and the Council arranged carer agencies to provide that support to her. Mrs X has had difficulties with previous care providers before a new care provider took over in June 2024. At that point Mrs X received four care calls per day at 7am, 12pm, 4pm and 7:45pm totalling three hours 30 minutes per day.
14. Shortly after the care provider took over the package Mrs X raised concerns about carers not arriving on time and contacting Miss Y without consent. The care provider also contacted the Council to tell it the call times took significantly longer than agreed.
15. A Council social worker visited Mrs X to discuss her concerns on 14 June.
16. Mrs X contacted the Council on 18 June to say she wanted to switch care providers. Mrs X raised concerns about certain carers not meeting her expectations and two incidences which she asked the Council not to report back to the care provider. Mrs X acknowledged the care provider was new and understood the importance of trying to work through the initial issues.
17. On 18 June the care provider reported some issues between Mrs X and a carer over the weekend. The Council asked for a copy of the communication logs.
18. The Council wrote to Miss Y on 25 June about the care provider expecting her to take part in the assessment visit. The Council told Mrs X the care provider had apologised and said it would only contact Miss Y in an emergency in future. The Council said it had agreed an increase to the hours as the care calls were taking longer than previously agreed. The Council said it had provided clarity to the care provider around the tasks carers should and should not carry out.
19. On 1 July the care provider told the Council about an incident over the weekend where it said Mrs X had physically and verbally attacked a carer. The care provider asked the Council for a joint visit with a social worker. The care provider said it would have to pull out of the package if it continued.
20. The Council contacted the care provider on 15 July for an update. The care provider told the Council things had not improved and raised concerns about Mrs X’s behaviour towards carers. The Council said it would discuss the option of an unscheduled review.
21. The care provider reported further issues on 17 July which had resulted in Mrs X refusing care. The care provider contacted the Council again on 28 July to report further issues. The care provider asked the Council to allow more time for the care visits as they were running over the allotted time.
22. The Council contacted Mrs X on 29 August to discuss the issues and left her a message. The Council contacted the care provider on the same day to discuss the concerns raised. The care provider raised concerns about Mrs X asking carers to complete tasks which were not in the care plan. The care provider also raised concerns about its ability to provide carers to cover the evening and weekend calls as Mrs X had refused care from all but two of its carers.
23. The care provider contacted the Council again on 9 September to report Mrs X had turned away carers. The care provider alleged Mrs X was rude to them. The Council agreed to speak to Mrs X. The Council tried to speak to Mrs X on 10 September but could not get a reply.
24. The Council completed a review of the care package in October 2025. At that review Mrs X made allegations about treatment she had experienced from some of the carers. The care provider also raised concerns about how Mrs X had dealt with its carers and said the relationship had broken down and it could no longer provide Mrs X with care. The Council agreed to look for a new care provider.
25. The care provider says as part of the learning from this complaint it has:
• provided additional staff training on managing difficult behaviour;
• improved its protocols for escalating to social services when a client continually refuses care;
• encouraged its team to document more thoroughly every instance of client refusal or abuse.

Analysis

26. Mrs X says the Council failed to act to resolve issues she raised about some of the carers allocated to her by the care provider. Some aspects of Mrs X’s complaint are difficult to investigate as they relate to how carers spoke to her. That is not recorded in the documentary records and therefore it is not possible for me to reach a safe conclusion about how carers dealt with Mrs X.
27. Having considered the documentary evidence I note Mrs X raised some initial concerns with how the care provider managed the package in June 2024. I am satisfied the Council acted on those concerns by speaking to Mrs X and the care provider and then visiting Mrs X. I am satisfied the Council made clear the issues were because the package was new and Mrs X needed to allow time for the package to settle. I therefore have no grounds to criticise the Council for how it dealt with the issues in July 2024.
28. I have seen no evidence Mrs X or Miss Y raised concerns about specific carers or raised further concerns with the Council after the initial problems. I cannot criticise the Council for not acting on concerns it did not know about. It is also clear some of the carers employed by the care agency have raised counter allegations about how Mrs X dealt with them. Without any evidence to show how carers treated Mrs X or any evidence in the documentary records to show carers refusing to provide Mrs X with care and as she did not raise those concerns with the Council at the time I have no grounds on which I could criticise it.
29. However, I am satisfied the care provider continually raised concerns with the Council about issues with the care package. In particular, the care provider raised concerns with the Council about Mrs X refusing to allow most of its carers to attend to provide her care after experiencing issues. The care provider raised concerns about Mrs X’s behaviour towards some of the carers. The care provider also raised concerns about the length of time some visits were taking and Mrs X asking carers to complete tasks not included in her care plan.
30. As the care provider had raised concerns about the package potentially breaking down I would have expected the Council to follow up on that. I have seen no evidence the Council considered arranging a meeting with Mrs X and the care provider to discuss the issues or whether to hold a review until October 2025. Given the issues the care provider was raising I consider that fault.
31. It is clear from the October 2025 review paperwork the outcome of the review was that the care provider could no longer provide care to Mrs X. That is because the relationship between Mrs X and the care provider had broken down. Had the Council held an earlier review it is possible that could have resolved the situation. I appreciate though it may also still have meant the Council needed to find a new care provider given Mrs X had experienced similar issues with previous care providers. Delay holding a review considering the early problems with the care package is fault.
32. Mrs X says despite telling various carers she would not accept care from them the care provider continued to send those carers out. It is clear from the documentary records Mrs X refused care on each of those occasions. I understand Mrs X’s concern if she had care related concerns about the carers who had attended her. However, I am also aware carers have made allegations about Mrs X’s treatment of them. Added to that, the care provider made clear it had a limited amount of carers and Mrs X refused many of those carers. That meant early in the package, the care provider only had two carers it could provide and neither of those carers worked weekends. The documentary records also show the care provider tried to provide different carers and only used the carers Mrs X had denied entry to on those occasions when nobody else was available. I am satisfied the care provider had raised those concerns with the Council and its failure to investigate that further is fault.
33. I make no comment on the actions of the carers Mrs X has raised concerns about. It is not my role to comment on personnel matters. The documentary evidence also does not provide any clarity for most of the issues Mrs X has raised. There is also conflicting information in the documentary records about Mrs X’s attitude to the carers. In those circumstances I cannot reach a safe conclusion about whether Mrs X missed out on care because of fault by the care provider acting on behalf of the Council. That is because it is clear the occasions on which Mrs X did not receive care were those where she refused entry to the carer sent.
34. It is possible though the issues could have been resolved earlier if the Council had arranged a meeting or an early review. That would also have allowed the Council to consider the issues around the care provider continuing to send carers to Mrs X that she had previously refused access to. I therefore consider Mrs X and Miss Y are left with some uncertainty about whether matters could have been resolved if the Council had acted as it should have done.
35. As remedy for that I recommended the Council apologise to Mrs X and Miss Y. As a review has now taken place and the Council intends to identify a new care provider I do not make any further recommendations to address the relationship between the care provider and Mrs X. However, I recommended the Council provide guidance to officers in adult social care about the circumstances when they should arrange an early review or officer intervention when issues with a care package are identified. The Council has agreed to my recommendations.
36. Mrs X says the care provider sent carers to complete her care when it suited them, rather than sticking to the hours agreed. The evidence I have seen satisfies me Mrs X’s care plan states she will receive care at 7am, 12pm, 4pm and 7:45pm. I would not expect any care provider to stick rigidly to the exact times. The care provider has pointed out it would normally expect carers to arrive within 30 minutes of the allotted time. I therefore do not consider it would warrant a finding of fault if carers arrived within 30 minutes of the allocated time. I would expect the Council to have made clear to Mrs X though that carers may not be able to attend at the exact time and that they have a leeway of around 30 minutes either side of the time specified. I have seen no evidence to suggest the Council told Mrs X that and that is fault.
37. Having considered a record of the times carers arrived though, there are a significant number of occasions when carers arrived either more than 30 minutes before the time the visit was due or more than 30 minutes after. For some of the late calls there was more than an hour difference between the allotted time and the time carers arrived. In some cases that was before the allotted time and in others it was after the allotted time. I am particularly concerned about the late calls for the morning call and the early calls for the bedtime call. In some cases Mrs X’s bedtime call was taking place before 7pm, with some of the morning calls taking place after 9am. That is a significant difference from the allotted time and is fault. It is unsurprising in those circumstances Mrs X believed carers turned up when it suited them.
38. I appreciate sometimes carers can be held up in traffic or previous care visits can overrun, as they have done in Mrs X’s case sometimes. However, if carers expect to attend more than 30 minutes after the start time I would have expected them to let Mrs X know. Otherwise there would be no way for Mrs X to know whether the call was going to be missed. Failure to tell Mrs X in those circumstances is fault. As remedy for this part of the complaint I recommended the Council apologise to Mrs X. As I understand the relationship has now broken down between Mrs X and the care provider I will not recommend the Council monitor the times the care provider is attending, as I would otherwise have done. The Council has agreed to my recommendation.
39. Mrs X says she has asked the Council to extend the time for the care visits but it has not taken any action. Mrs X says she needed extended times because the carers do not have time to carry out some of the actions she wants them to take, such as painting her nails. Mrs X also says she asked the Council to move the final care call to a later time as it was too close to the teatime call.
40. The first point to make here is that the carers are only expected to carry out the tasks set out in the care plan. Painting Mrs X’s nails is not included in the tasks in the care plan and I therefore cannot criticise carers for failing to undertake that task. I do not have any evidence though to show Mrs X contacted the Council to ask for longer visit times. Nor do I have any evidence Mrs X asked the Council to move the final care call to a later time. As I said earlier though, given the issues that arose with this care package at an early stage I would have expected the Council to have carried out a review earlier. That could have addressed any concerns Mrs X had about the length of care visits or visit times.

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Action

41. Within one month of my decision the Council should:
• apologise to Mrs X and Miss Y for the distress they experienced due to the faults identified in this decision. The Council may want to refer to the Ombudsman’s updated guidance on remedies, which sets out the standards we expect apologies to meet; and
• provide guidance to officers in adult social care about the action they should take when service users and/or care providers report issues with a care package.
42. The Council should provide us with evidence it has complied with the above actions.

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Final decision

43. I find fault causing injustice. The Council has agreed action to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman