Summary: Mr X complained the Council failed to contact him when carers from Comfort Care Services failed to gain access to his mother’s property to deliver care services on three subsequent days. The care provider failed to follow its no reply procedure and Mr X’s mother was found by paramedics in a distressing state which required hospital admission. A remedy to acknowledge the distress and improve services to prevent similar situations is proposed.

The complaint

1. Mr X complains the Council failed to contact him, as agreed, when carers from Comfort Care Services failed to gain access to his mother’s property to deliver care services on three subsequent days.
2. Mr X say his mother was found by ambulance paramedics and taken to hospital.

Back to top

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)

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).

4. 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)
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

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

Back to top

What I found

No reply policy and procedure

8. The care provider has a written policy setting out what its workers should do when a service user does not appear to be at home or does not respond to requests for entry. It states that under no circumstances will the attempt to establish the service user’s safety be discontinued until the exact circumstances are known, or the matter has been placed in the hands of emergency services.
9. The policy sets out the steps the care worker should take which includes notifying a manager. It says the manager should attempt to contact the service user and their representative or emergency contact and the service user’s social worker. It says if the care provider is unable to satisfy itself the service user is safe, the manager should contact the police.
10. In situations where a service user with capacity is known to leave home, the policy states that a process must be agreed with the service user and any commissioners of what should happen if the care worker fails to gain access.

Key facts

11. This section sets out the key events in this case and is not intended to be a detailed chronology.

12. Mr X’s mother, Mrs Y, lives alone in Hillingdon. Mr X lives with his family in Ireland but spent several weeks with his mother in December 2024 to February 2025 due to a decline in her health.
13. On 6 January 2025, a social worker carried out a home visit to assess Mrs Y’s needs. Mr X reported concerns about his mother’s cognitive decline and in particular risks associated with poor nutrition and unsafe door locks. Notes suggest Mrs Y was unwilling to accept support. The notes show Mr X felt his mother should be moved to residential care as a community based package of care would not work for his mother. The Council said it was unable to complete a mental capacity assessment because of Mrs Y’s lack of engagement.
14. By 30 January, Mr X sent an email to the Council confirming his mother had agreed to have carers at home. The social worker recommended three calls per day from carers. Mr X said his mother would not accept this and so one call a day was agreed with a start date of 6 February.
15. On 6 February Mrs Y opened the door to the carer but advised she did not need any support and the carer left. The following day the carer arrived but Mrs Y did not answer the door. The carer telephoned her office and was advised by the manager to move on.
16. When the carer arrived on 8 February, again Mrs Y did not answer the door. After 10 minutes the office attempted to call Mrs Y but she did not answer and so the carer was advised to move on.
17. Mr X says that he had been unable to speak with his mother for a few days and so he telephoned a neighbour who had a key and asked them to check on her. Mr X says the neighbour found his mother on the bed, disorientated and cyanosed. The neighbour called an ambulance and paramedics took her to hospital. While waiting for the ambulance, the carer made the daily visit.
18. The neighbour contacted Mr X who flew back the same day to be with his mother. Mr X says that when he arrived at his mother’s house it was desperately cold and that the heating must have been off for days as the olive oil in the kitchen had solidified. He also says there was evidence his mother had fallen in the kitchen. Mr X said that at no time had the social worker contacted him to report that the carers had been unable to gain access.
19. Mr X contacted the care provider about the situation. The care provider acknowledged the distressing circumstances around Mrs Y’s hospital admission and said that protocol was followed each day when difficulty accessing the property was reported to the office. It apologised for not notifying the difficulties in gaining access to Mr X in real time.
20. Mr X also contacted the Council and it treated his letter as a formal complaint. It responded on 4 June saying it was evident the care provider failed to follow the non-entry procedure as it had not reported to adult social care and next of kin. It said its Quality Assurance Team was working with care providers to improve care delivery to service users.
21. Dissatisfied with this response Mr X complained to the Ombudsman.

Analysis

22. The Council commissioned the care provider to visit Mrs Y once a day from 6 February. This was in response to a care assessment which noted Mrs Y had cognitive decline and was displaying behaviours that indicated she may be at risk of self neglect and harm. However, the extent of her needs was unclear and Mrs Y was reluctant to accept help. It was therefore decided to commission a short term service which could assess the level of need.
23. I am aware that Mr X felt his mother required a residential placement. However, the Council felt this was not the least restrictive option and Mrs Y’s exact needs were hard to establish as she did not engage with the care assessment. I am satisfied the Council used its professional judgment to commission a community based package of care in order to further assess need and so do not find fault on this point.
24. It was known that Mrs Y was fiercely independent and reluctant to accept help. While there was no history of significant incidents of harm or evidence of falls, it was known there was cognitive decline and a need to fully assess Mrs Y’s needs. It is also noted the Council had been unable to establish if Mrs Y had mental capacity to make decisions about care needs.
25. Therefore, once the package of care started, I consider the no reply policy should have been followed. The information provided indicates the carers followed the procedure by contacting the office but there is no evidence of any further action by the office in accordance with the procedure. The care provider left the situation on two days running not knowing Mrs Y’s circumstances and whether she was safe. No contact was made by the care provider with either the social worker or Mr X.
26. We do not know how long Mrs Y was in need of help. It is also unclear how long the care provider would have continued to instruct its carers to move on without establishing Mrs Y’s circumstances. While there may not have been previous evidence of high risk incidents or behaviour, the failure to follow the no reply procedure amounts to fault.
27. I cannot see that any specific instructions were given to the care provider by the Council about how to manage the situation if Mrs Y did not respond to the calls. It seems to me that this was something that could have been anticipated based on the information held before the care package started. While it may not have been a situation that warranted police intervention, other escalation actions may have resulted in a different outcome for Mrs Y and caused less distress for her and Mr X.

Back to top

Action

28. To remedy the injustice as a result of the fault identified above, the Council will, within one month of my final decision, take the following action:
• Apologise to Mr X and Mrs Y for the fault identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended;
• Make a payment of £500 to recognise the distress caused to Mr X and Mrs Y; and
• Provide details of the actions taken by the Quality Assurance Team to specifically address the issues that are highlighted by this case and to prevent similar situations. If actions have not yet been taken, provide details of an action plan setting out how it will do this.
29. The Council should provide us with evidence it has complied with the above actions.

Back to top

Final decision

30. I have completed my investigation with a finding of fault for the reasons explained in this statement. The Council has agreed to implement the actions I have recommended. These appropriately remedy any injustice caused by fault.

Back to top

Investigator's decision on behalf of the Ombudsman