Summary: Ms X complained about the care and support provided to her adult son by Choice Support (the care provider), at the supported living accommodation jointly funded by the Council and a Clinical Commissioning Group. The care provider and Council were at fault. Care plans were insufficient, and Mr Y did not receive the community support he was assessed as needing. There were faults in the care provided to Mr Y and in the Council’s safeguarding process. The Council and care provider have agreed to apologise to Ms X and Mr Y and make a payment to acknowledge the distress and frustration caused by the faults. They have also agreed to review their procedures to prevent such faults recurring in future.

The complaint

1. The complainant, who I shall refer to as Ms X, complains about the care and support provided to her adult son, Mr Y, by Choice Support (the care provider), at the supported living accommodation jointly funded by the Council and a Clinical Commissioning Group. She says faults by the care provider left Mr Y with unmet care needs and this had adverse impact on his wellbeing and caused avoidable distress and frustration. She also complains the Council failed to carry out an adequate safeguarding investigation when she raised concerns about the care provided.

Back to top

The Ombudsmen’s role and powers

2. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
3. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
4. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
5. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

Back to top

How I considered this complaint

6. I have considered the information provided by Ms X in writing and by telephone.
7. I have considered written comments and records from the Council and care provider and the relevant law and guidance.
8. I gave Ms X, the Council and the care provider the opportunity to comment on a draft of this decision. I considered their comments before reaching a final decision.
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

Back to top

What I found

10. Mr Y is a young adult with cerebral palsy and a severe learning disability. He communicates non-verbally and is a wheelchair user. He moved into a supported tenancy in November 2016 with support provided by Choice Support (the care provider), following a best interests’ meeting. The notes record it was a fully adapted environment suitable for someone with complex moving and handling needs and with additional health needs. It acknowledged Mr Y would not be living with age appropriate peers. However, the move was temporary and Mr Y would access college during the day with people his own age.
11. This was an emergency placement, initially for two weeks, after his previous placement broke down. This was jointly funded by the Council and Continuing Health Care (CHC) funding (NHS funding). Mr Y attended college during term time. Mr Y’s moving and handling assessment recorded he needed two staff for transfers and for personal care. Mr Y’s Choice Support care plan set out the support staff should provide before college, after college and in the evening.
12. In late November 2016, the Council visited a potential property for Mr Y but it was not suitable to manoeuvre his wheelchair. In February 2017 it considered a further option which again was not suitable.
13. Mrs X emailed the Council in April 2017 expressing concerns Mr Y was still in inappropriate accommodation with a bathroom too small to use properly. The notes recorded the case would be resubmitted to the Council’s accommodation forum.
14. In May 2017 the Council carried out a needs’ assessment. This identified the placement was ‘less than ideal as other tenants were significantly older’ (the other residents were aged 50+). It noted the en-suite at the property was not quite large enough to meet Mr Y’s needs. However, there were no other options available at that time. The needs’ assessment set out that Mr Y needed two staff members for safe accompaniment in the community and for a small number of leisure hours. Mr Y’s hours were built upon the existing block contract hours for the tenants at the supported placement which included one ‘wake-in’ staff member. The assessment set out Mr Y required:
• one hour in the morning and one hour in the evening Monday to Friday except school holidays when he required two persons for 4.5 hours each day;
• two persons for two hours of evening activity support per week;
• two persons to support for 4.5 hours during the day on Saturday and Sunday;
• support from two staff for transfers, for support with washing and dressing and for trips outdoors: and
• an overnight PEG feed which was already in place (where he was fed through a tube directly into his stomach)
15. The assessment noted ‘the new hours will ensure [Mr Y] can have two to three hours of outdoor activity during his non-college days, with two staff on hand’.
16. Mr Y was due to have spinal surgery in summer 2017. The assessment noted he would need time off college and a temporary increase in support hours. It noted Ms X requested Mr Y’s tenancy hours were flexed so staff could support her at Mr Y’s bedside.

Hospital admission

17. In July 2017 Mr Y went into hospital for the planned surgery. At the time it was anticipated Mr Y would be in hospital for two weeks with ten weeks post-operative recovery. The Council reviewed Mr Y’s care plan. It noted Ms X would be at Mr Y’s bedside as much as possible. It agreed Mr Y required enhanced hours when in hospital so staff could relieve Ms X. It proposed an additional 9 hours per day for 12 weeks.
18. Mr Y stayed in hospital for significantly longer than originally anticipated due to complications related to his surgery. Ms X raised concerns about the lack of support provided by the care provider and inconsistent staff times. She raised concerns it appeared to be the same senior staff member providing the care cover. The Council reviewed Mr Y’s support plan in August 2017. The care provider agreed with the Council and CHC Team that staff from the care provider and Ms X would alternate morning and afternoon support for Mr Y with nursing staff taking over in the night. The Council agreed some of the funding could be used to meet staff travel expenses.
19. In October 2017 Ms X raised safeguarding alerts with the Council that a member of the care staff had not given Mr Y a drink when supporting him in hospital and was abrupt with Mr Y. The investigation found a lack of guidance on when or if Mr Y should be offered drinks and when he should be hydrated via his PEG feed. It found there was no interim care plan in place for the hospital stay. There was no SALT assessment or input since Mr Y had move to the placement. No care logs were completed by the care provider’s staff at the hospital and the manager was covering a lot of shifts as staff were unwilling to support Mr Y in hospital. It recommended that:
• Mr Y’s care plan be reviewed;
• A referral made to the SALT Team and guidelines for his eating and drinking be developed; and
• The care provider should look further at why staff were reluctant to support Mr Y in hospital. (It later identified issues around expenses and travelling to and from the hospital).
20. It noted the care provider was now creating a hospital care pathway plan for clients for the future.
21. A discharge planning meeting at the hospital in October 2019, emphasised that socialisation, getting out and not simply lying in bed, was critical to Mr Y’s recovery and strengthening his muscles.

Post hospital stay - November 2017 onwards

22. Mr Y returned to the tenancy in early November 2017. He was prescribed long term antibiotics. The care provider emailed the Council in December 2017 to request a Speech and Language Therapy (SALT) assessment in relation to Mr Y’s eating and drinking. Mr Y returned to college.
23. Throughout November the Council also explored with Ms X the possibility of Mr Y moving out of its area to live in the same area as her. Due to Mr Y’s health this was put on hold.
24. In December 2017 college staff raised concerns Mr Y was pulling at his PEG feeding equipment. There were concerns that staff at the care provider, although trained in PEG, were not specifically trained in Mr Y’s equipment and had insufficient training to manage this appropriately.
25. Ms X submitted complaints about the support provided to Mr Y by the care provider while he was in hospital. She said, staff in the placement did not appear motivated to take Mr Y into the community as outlined in his care plan.
26. The care provider investigated Ms X’s complaints and found there was confusion about the hours allocated to support Mr Y while in hospital. One senior staff member had covered a significant portion of these. Staff had difficulties getting to the hospital and had concerns about supporting Mr Y for long periods on their own. The care provider had spoken with nursing staff at the hospital who raised no issues about the support provided at the hospital.
27. In relation to supporting Mr Y at the care home, it found there was a lack of a specific plan to demonstrate how Mr Y’s care hours should be used, how many staff should support him and when. The care provider found a lack of planning by it and the Council about how Mr Y was to be supported and the impact this would have on the other service users. There were no plans in place regarding how to support Mr Y. At times staff were scratched, nipped or had their clothes torn by Mr Y but had not completed any accident or incident forms. There was no input from the positive behaviour team or moving and handling trainers. Its recommendations included reviewing Mr Y’s support plan and for staff training on supporting Mr Y.
28. During February and March 2018 an occupational therapist and physiotherapist visited Mr Y to review his positioning when in bed, in a chair and when showering. They noted Mr Y was using a borrowed shower chair and was not well supported in it. They were awaiting conversion of the bathroom hoist. A dietician visited and recommended Mr Y’s meals be blended to a porridge consistency and to use a built-up spoon. The care provider’s behaviour support team carried out some staff training to assist staff in managing Mr Y’s behaviour.
29. Ms X raised concerns with the CCG in March 2018. An officer from the Continuing Health Care Team visited Mr Y in March 2018. They noted there was no specific structure to record Mr Y’s time on bed or activities. They noted Mr Y did not appear to be accessing the community on a regular basis.
30. In March 2018 Ms X raised a safeguarding alert with the Council as she had concerns that on one particular day Mr Y was left in bed for a long time. The Council investigated and held a safeguarding strategy meeting. It found Mr Y’s college transport was cancelled late the previous evening. It says the care provider was unable to find additional staff to provide support at the home so Mr Y was in bed too long. The care provider instructed staff to inform line managers or on call promptly of any deficit in staffing levels which may affect Mr Y’s direct support. This should be documented. It also recommended the transport supplier should also provide advance notice, if possible, of when transport was not available. The care provider should also look to increase its ‘bank’ staff.
31. Ms X raised further concerns which were discussed at the safeguarding strategy meeting. These related to a rash and soreness Mr Y had in his groin area. Ms X said, the GP had visited and prescribed a cream on the Thursday but this was not administered for a few days. The care provider acknowledged it had not obtained the prescription for Mr Y over the weekend or requested a paper prescription from the GP as an alternative so had not received the cream until the Monday. The care provider agreed to update staff training on its medication policy.
32. Ms X also raised concerns she had visited Mr Y and found him in a soiled open pad. She did not believe he had eaten an evening meal. The care provider said the pad was left open on instructions from the pharmacy due to his soreness. Staff had been in at 17:30 at which time he had not opened his bowels. Ms X had attended at 18:45. The care provider agreed to carry out checks every 45 minutes when Mr Y was on bed rest and more frequently if Mr Y vocalised. The care provider agreed to look into whether Mr Y had eaten.
33. The meeting also discussed general concerns around whether staff were reluctant to support Mr Y.
34. Also in late April 2018 Ms X submitted a list of complaints to the care provider. This included that:
• staff were not wanting to support Mr Y in the community. The care provider reviewed its daily diaries. It found a variety of activities were undertaken by Mr Y.
• Mr Y was spending too long in bed. The care provider set out that Mr Y required time in bed as he did not tolerate being in a wheelchair for a long time. However, there were no documented records of how long Mr Y spent in bed. It agreed to record in the daily log the length of time Mr Y was on bed rest.
• Mr Y’s personal care was not up to standard. The care provider advised Mr Y received personal care every morning. He had no bespoke shower chair so could not access the shower. It said this was reported to the OT.
• Mr Y was put to bed too early. The care provider explained Mr Y received his evening medication on the bed followed by his night feed which had previously taken 10 hours. This had since changed and now took 5 hours. It would therefore look to review the care plan when Mr Y returned home.
35. Ms X raised a concern Mr Y had a red mark on his bottom. The care provider noted the GP had visited in April and had prescribed cream for Mr Y’s sore groin and for a red mark on his bottom. It was believed this occurred following Mr Y’s long wait for blood tests at the hospital, which meant a prolonged period sat in his wheelchair.
36. In late April 2018 Mr Y was admitted to hospital due to issues with his PEG site. When Ms X attended the care home she found Mr Y had not received his regular antibiotics for 9 days. The care provider explained it had followed the GP instructions regarding the antibiotics. She also found a bottle of medication labelled for Mr Y but which she was not aware he was prescribed. The care provider confirmed the medication was booked in by staff but not queried with the GP or pharmacy. It confirmed this was not administered.
37. Ms X raised a further concern that Mr Y was fed in bed by a member of staff. The care provider confirmed Mr Y must be sat up for all meals to avoid aspiration. In bed this may be completed using the profiling function at a 45-degree incline.
38. In May 2018 the Council held a second safeguarding strategy meeting to discuss the actions taken following the last meeting in April 2018. It found:
• confusion over what hours were funded for Mr Y. The Council confirmed Mr Y had nine hours 1:1 support on a Saturday and Sunday and some of his hours could be taken to provide two staff members to go out.
• there were concerns Mr Y was repeatedly pulling out his feeding equipment and that he needed 1:1 support. There was confusion over whether or not staff should re-insert it or insert a new one or whether it required nursing input.
• The care provider advised a plan had been put in place a couple of weeks ago setting out Mr Y’s daily activities broken down by 15-minute periods. It had also involved its behavioural support team.
• Mr Y could get a shower at college but could still not receive one at the home. A hoist had been purchased but he did not have a shower chair.
• In relation to whether Mr Y had missed a meal, the care provider confirmed its records showed Mr Y had eaten tea and confirmed who had supported him. It said it was not normal practice for Mr Y to be fed in bed but a staff member on that day had decided to do so. It said Mr Y needed an assessment regarding eating.
• The care provider had interviewed staff regarding supporting Mr Y. Staff found it frustrating as Mr Y grabbed, hit, nipped and pulled at their clothes. It distressed staff when Mr Y pulled at his feeding equipment. Staff felt whatever they did was not good enough for Ms X. Staff had received some training from the positive behaviour support team and there were plans to train staff in breakaway and diffusion techniques. The staff team felt Mr Y would be better supported in a different environment.
39. In June 2018 the Council and CHC representative held a future planning meeting with Ms X to look at where Mr Y should live after his hospital discharge. Mr Y did not return to the supported living accommodation after his hospital stay.
40. The Council wrote to Ms X in December 2018 partially upholding her complaint about the way the safeguarding allegations were investigated. It said it had dealt with the issues raised as one complaint which led to a failure to consider the severity of each allegation. The care provider had a greater opportunity to contribute to the case conference than she did so it agreed to reopen the investigation.
41. The Council held a safeguarding review meeting at the end of March 2019. It wrote to Ms X in May 2019 to advise her of the outcome. It apologised for the delay in arranging the review. This reviewed the safeguarding process. It said it had considered the allegations as a whole rather than as individual quality issues. It found poor practice rather than that abuse had occurred. It acknowledged the practices from Choice Support fell below the standards expected and would be monitored by the Council’s quality team. It acknowledged Mr Y was in the care home too long. Ms X remained unhappy with the safeguarding investigation and complained to the Ombudsman.

Findings

42. Mr Y was admitted to the supported tenancy as an emergency placement, initially for a matter of weeks. The Council recognised issues regarding the suitability of the placement including the bathroom size and age of other residents, however at the time the placement was considered suitable as a temporary move. The Council correctly followed the best interest process in reaching this view and there was no fault in the way it reached the decision to move Mr Y to the placement.
43. The Council considered two alternative placements in late 2016 and early 2017 but neither was suitable. Mr Y was then in hospital for 16 weeks and during this time there were discussions about the possibility of him moving nearer to where Ms X lived. The Council liaised with the other authorities regarding the potential move, exploring the potential costs and available facilities. However, due to Mr Y’s health, the move was placed on hold. Mr Y’s stay at the care home was much longer than anticipated but this was not as a result of fault by the Council.
44. The care plans developed for Mr Y when he first entered the supported placement were insufficient. There were no specific risk assessment and insufficient detail in the care plan to provide staff with clear direction and instructions on how to manage Mr Y’s behaviour and his feeding and fluid regime. There was no clear guidance on whether or not Mr Y could be fed in bed. The care provider did not seek guidance on Mr Y’s feeding regime until November 2017 after Mr Y’s hospital admission. This is fault.
45. The care plan prepared by the social worker in May 2017 included two hours allocated for two staff to support Mr Y with evening activities each week and nine hours on Saturday and Sunday. This was to ensure Mr Y could have two to three hours of outdoor activity during non-college days with two staff on hand plus one evening session a week.
46. Although the daily records show a variety of activities, they lack detail. The records show no activity noted for 17 consecutive days between 4 and 21 February a further 17 days between 21 February and 10 March and then for 28 consecutive days between 18 March and 14 April where he did not receive the amount of support to access outdoor activities that he was supposed to. Mr Y did not attend a regular evening activity. This is fault.
47. Mr Y needed time on his bed to stretch. However, the care plan prepared by the care provider gave no clear indication of how long Mr Y should be in bed for and when and when he should be in his wheelchair. This was fault. It was not until April 2018 that the care provider prepared a detailed plan of how Mr Y’s day should be structured.
48. The delay in completing a detailed plan of how Mr Y’s day should be structured is likely to have limited any preferred activity or choice he wanted. His opportunity to access the community and have more of an independent lifestyle is likely to have been restricted.

Hospital stay

49. Mr Y’s hospital stay was significantly longer than expected and the care provider was not prepared for this. The Council and care provider failed to prepare a suitable support plan for Mr Y’s hospital stay. The care provider failed to ensure sufficient staff were available to support Mr Y in hospital. It failed to provide staff with clear guidance on what support they were expected to provide at the hospital including when Mr Y should be changed and what food/fluid they should provide. This is fault.
50. The failure to plan properly and assess the needs and wishes of Mr Y is likely to have impacted on his wellbeing. Ms X complained about what happened and it is likely she experienced distress because of this fault.

Post hospital stay

51. Ms X raised a number of concerns about the support provided to Mr Y and some of which were upheld. This included that he was left in bed too long one day and a delay in getting medication for a rash. The care provider made recommendations to address this including staff training and improved communication around college transport.
52. Mr Y was unable to access a shower at the care home. Mr Y did receive personal care but this was no substitute for a shower. The Council and care provider took too long to address his need for equipment to facilitate this. This is fault.
53. There were nine days when Mr Y did not receive antibiotics. However, the records show the care provider was following medical instructions and this was not fault.
54. The Council investigated Ms X’s complaint about the safeguarding process and found fault. It accepted the alleged perpetrators were given a greater opportunity to contribute to the case conference and agreed to reopen the investigation. However, it delayed doing so and this is fault. It then did not, as agreed, reopen the investigation to allow further exploration of the issues she raised but reviewed the process itself. This therefore did not address the concerns Ms X had raised and this is fault. The Council’s fault in its safeguarding process is likely to have caused Ms X avoidable distress and frustration.
55. However, Mr Y is now living elsewhere. The purpose of a safeguarding investigation is to prevent harm and to remove the risk of harm. There is nothing to be gained by now reconsidering the safeguarding investigation. There was evidence of fault by the care provider and Council and the care provided to Mr Y fell short of the standards he could reasonably have expected. This is likely to have caused Mr Y distress and frustration and impacted on his independence. This also caused avoidable distress and frustration to Ms X.

Back to top

Agreed actions

56. The Council and care provider have agreed, within one month of the final decision, to apologise to Ms X for the impact the faults caused to her. They have also agreed to each pay her £250 to acknowledge the avoidable distress and frustration she experienced when they provided poor care to Mr Y and the Council then failed to reopen the safeguarding investigation.
57. In addition, the Council and care provider have agreed to apologise to Mr Y for the impact caused by the failure to provide him with care and support meeting the standard he should reasonably have expected. The Council and the care provider have also agreed to each pay Mr Y £1000 to acknowledge the likely impact the faults had on his wellbeing, his opportunity to access the community and to promote his independence.
58. The Council has agreed to reiterate to its staff the importance of making safeguarding personal. Staff should establish with the adult at risk and/or their representative, what their desired outcomes and actions are in relation to the safeguarding issue presented. The adult at risk and/or the representative should be central to the safeguarding process and be given every opportunity to contribute to the investigation. It should do this within two months of the final decision.
59. The care provider has agreed to reflect on the findings of this investigation and tell the Ombudsmen what action it intends to take or has taken to ensure its staff are committed to ensuring service users care plans are personalised, reviewed in a timely manner and risk assessed in order to promote service users’ wellbeing and independence. It should do this within two months of the final decision on the complaint.

Back to top

Final decision

60. I have completed my investigation. I have found fault causing injustice which the Council and care provider have agreed to remedy.

Back to top

Investigator's decision on behalf of the Ombudsman