Summary: There was fault on the part of the Council’s commissioned care provider which caused injustice to Mrs X. The Council should recognise the distress caused to Mrs X and her family and offer a suitable payment.

The complaint

1. Mr A (the complainant) complains that the provider’s staff failed to give adequate hygiene care to his elderly mother and instead left her in soiled clothes relying on Mr A to complete personal care. He says as a result Mrs X felt vulnerable and neglected and he took her to his home instead.

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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(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.
5. 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

6. I considered evidence provided by Mr A and the Council as well as relevant law, policy and guidance.
7. Mr A and the Council had an opportunity to comment on my draft decision.

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What I found

8. Mrs X lived in extra care accommodation an hour’s journey from her son and his partner. She had a care package provided by Amplius care provider (commissioned by the Council) at the time of the incident.

What happened

9. On 5 February 2025 Mrs X telephoned Mr A to say she was suffering from diarrhoea but the carer who had attended her that afternoon had just replied ‘oh dear’ and walked away when Mrs X told her she had soiled herself. Mr A and his partner drove to Mrs X’s flat that evening and arrived at about the same time as another carer. Mr A says the carer did not assist them to give personal hygiene care for his mother or change the bed sheets which were also soiled.
10. Mr A says they spent a couple of hours cleaning up Mrs X and her bedding and flat. He says as a result they also became ill with norovirus and his partner had to take time off work and she lost earnings.
11. Mr A contacted the Council’s social work duty team to advise what had happened. His partner called separately to advise that Mrs X had cctv cameras in her flat. The duty team alerted the Council’s safeguarding team. The Council’s records show Mr A told the Council he thought Mrs X required an increase in her care package from the current 4 x 15 minute calls a day. He emailed the Council on 13 February to make the complaint and explain his mother’s increased needs. He asked for an urgent safeguarding review.
12. A social worker contacted Mr A on 16 February about the incident. She also contacted the team leader at the care agency. The team leader contradicted Mr A’s account and said Mrs X had not asked for assistance but instead had telephoned her son to help.
13. The social worker met Mrs X and Mr A on 19 February. They both expressed concern that Mrs X’s needs were not being met and that staff (including management) often failed to treat her with dignity, sometimes entering her flat without prior warning. The social worker noted that the current care calls were insufficient to meet Mrs X’s needs.
14. An increase in funding for Mrs X’s care was agreed by the Council.
15. On 1 March a different care provider was awarded the contract for care services at the Extra Care housing.
16. The social worker viewed the cctv footage. Her notes for 10 March record “Discussion with (team leader) who confirmed she had not seen the CCTV footage of the alleged incident. I explained that I had and there was clear evidence of one member of staff on their mobile phone during a care call and it was also evident that (Mrs X) requested for assistance multiple times and this was not provided. Furthermore (Mr A) clearly told the care staff that he would leave them to provide his mother with assistance which never transpired.”
17. The safeguarding investigation identified risks with Mrs X’s care. The carers involved were removed from Mrs X’s care and other carers were made aware of the concerns.
18. Mr A complained direct to the care provider Amplius. It said it had not initially recognised there was a service failure on its part but after Mr A asked it to review the cctv footage it agreed the service provided fell short of its standards. It said another provider had taken over the contract and it would investigate the complaint further.
19. A note on the social work case recording for 14 March says, “Advised to raise the concern with commissioning due to the lack of support with addressing the issues presented.”
20. The new agency refused to increase the care for Mrs X as advised because of their concerns of some cluttering in her flat. The social worker explained to the team leader there was a duty of care to provide the additional service and asked for the contact details of the new manager, but the team leader was unable to give them.
21. Mr A took Mrs X out of her flat and to his home as she was not receiving sufficient care. He said he had made a complaint to the new provider and been told he was ‘number 48’ on the list. He says they took 10 days to acknowledge his complaint.
22. At a meeting at Mr A’s home it was agreed that Mrs X would remain there. Mrs X said she did not want to return to the Extra Care housing. She said she had lived there for 10 years but had not been happy with the standard of care she had received for some time.
23. Mr A complained to us. He said the carers from Amplius had neglected Mrs X and left her in soiled clothes and bedding until he and his partner cleaned her up. He said the new care provider was refusing to deal with his complaint.
24. The Council says although it was naturally aware of the safeguarding investigation it did not know about the complaint until we contacted it. It says it expects commissioned care providers to respond to complaints in the first instance but people should be able to complain to the Council if not satisfied.
25. The Council says “Unfortunately, it would be fair to say that due to the change in contract and change in care provider during the complaint, may have hindered the conciseness and timeliness of the response”. It goes on, “It is difficult to comment in respect of access to the CCTV at the stage 1 investigation because we cannot find any evidence that CCTV evidence was offered at this point. The provider states they were not aware this was available, and the complainant says they had advised that it was available. Had it been viewed at stage 1, action would have been taken sooner and avoided a stage 2 escalation.”

Analysis

26. The commissioned care provider was at fault in failing to provide a good standard of care to Mrs X, possibly over a period of time and specifically when she was ill. That was fault which caused her and her family injustice and distress.
27. It was an oversight not to view the cctv footage when it was first known to be available. The team leader (whose account of events appeared to be unreliable) was aware as was the social worker, who viewed the footage herself. As the Council acknowledges, viewing this at an early stage might have resolved the complaint sooner.
28. No doubt the change in contract affected the response to the complaint, but I am not satisfied either care provider responded appropriately. Amplius failed to view the cctv footage initially and Atlas first delayed in responding to the complaint and then, Mr A says, would not deal with it as it was the responsibility of the previous provider.
29. In addition there were concerns that Atlas, the second care provider, did not increase Mrs X’s care package as agreed. That led to her leaving the flat.

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Action

30. Within one month of my final decision the Council will apologise to Mrs X and her family on behalf of its commissioned care providers for the failure to provide her with a good standard of care and specifically for the failure to attend to her properly when she was ill.
31. Within one month of my final decision the Council will reimburse to Mrs X the last two months of the contribution she made towards the cost of her care package.
32. The Council will also, within two months of my final decision, offer Mrs X £500 in recognition of the poor care she received, and a further £500 to Mr A and his partner for the trouble they were put to in providing care for Mrs X and the distress they suffered as a result.
33. The Council should provide us with evidence it has complied with the above actions.

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Investigator's decision on behalf of the Ombudsman