Summary: Ms X complained the Council failed to arrange suitable care for Mr Y so his identified care needs were not met and he was at risk of harm and financial abuse. The Council was not at fault for the inconsistency in staffing to support Mr Y. There was fault when a carer left Mr Y unattended. This caused Ms X frustration and worry. It has agreed to apologise to her for this. The Council properly investigated this through its safeguarding procedures. The Council failed to ensure all staff communicated consistently with Mr Y. It has agreed to make a payment to Mr Y to acknowledge the impact of this.

The complaint

1. Ms X complained the Council failed to arrange suitable care for her son, Mr Y, so his identified care needs were not met and he was at risk of harm and financial abuse. This affected his behaviour and caused Ms X distress and frustration.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with a council’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)

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How I considered this complaint

4. I have considered the information provided by Ms X on the telephone and in writing. I have considered the information provided by the Council in response to our initial enquiries.
5. I gave the Council and Ms X the opportunity to comment on a draft of this decision and considered any comments received before reaching a final decision.

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What I found

6. Mr Y is a young adult with severe learning difficulties. Mr Y can display challenging behaviours which mean he is best supported by male carers.
7. In March 2018 Mr Y moved into a supported living two-bedroom bungalow with 24/7 staffing provided by company A, following a tendering exercise by the Council. Company A was the only company to apply for the tender. The initial proposal was to move another person into the bungalow at a later date. This never happened. Two staff members supported Mr Y for three days each. Ms X supported Mr Y one day a week.
8. In early 2019 company A decided to cease providing support in the Council area. It advised service users of this in March 2019. Ms X met with company A and the social worker in March 2019. The notes record Mr Y had settled well in his 12 months at the property. The social worker said the possibility of transferring Mr Y to another provider was being explored. They noted Mr Y ’needs consistency and it would be best if his two key staff members could tupe [where employees transfer from one employee to another when a business changes owner] to a new service’.
9. The Council decided its in-house provision, company B, would take over Mr Y’s support package. The initial expectation was that the two care staff from company A who supported Mr Y would transfer over to company B. Only one of Mr Y’s two staff members, transferred over to work for company B. The other staff member resigned prior to transfer.
10. In early May 2019 the social worker contacted company B raising Ms X’s concerns about the regular member of staff not transferring over and they asked about the plans to introduce new staff members to Mr Y. They told company B they had been given a likely start date of mid-June for company B to take over the care package. The social worker also spoke to company A who said they had provided the Council with details of their current vacancies which needed filling.
11. Later in May the social worker emailed a senior manager. They said they were aware one of Mr Y’s key staff members was not transferring and this was likely to have a significant effect on Mr Y. They said it was important staff working with Mr Y understood how to communicate with him. The senior manager responded that they were having to recruit a lot of new staff to fill company A’s vacant posts and would have to use agency workers in the interim as recruitment would be ongoing. They would look to see if there were some experienced staff, or staff who had worked with him previously, who could support Mr Y. They fed this back to Ms X at a meeting in early June 2019 which company A also attended. In mid-June company B took over supporting Mr Y.
12. In August 2019, Ms X raised concerns with the social worker about poor communication with agency staff, poor recording of finances and general concerns about the impact on Mr Y of inconsistent staffing. The social worker spoke to Company B who acknowledged there were communication issues with agency staff which it was addressing. It was struggling to recruit and the short time scale for transfer had not helped. It planned to move one of its existing staff to support Mr Y in September and to advertise again.
13. In August 2019, a carer took Mr Y out to a fast food restaurant and then a pub, leaving him unsupervised. The carer sent Ms X a video of Mr Y in the pub with a group of women. The carer had also overspent Mr Y’s budget. Mr Y’s regular carer agreed to go and find him and brought him home. Ms X raised a safeguarding alert. The Council investigated and upheld the safeguarding, that Mr Y was put at physical and financial risk, as substantiated. Company B agreed to address the actions of the carer. The Council’s safeguarding enquiry also recommended the Council recruit a full team to support Mr Y, ensure carers make good use of choice and information boards in Mr Y’s property and support him to attend scheduled activities.
14. Ms X met with the social worker and Company B in mid-August for a review meeting. Company B agreed it would be beneficial to put a better routine in place for Mr Y but this was difficult when they were so reliant on agency staff. It said managers were meeting every new member of agency staff before they worked with Mr Y and talked them through the policies, procedures and Mr Y’s support needs.
15. Ms X spoke to the social worker in early September. She said there were lots of signs Mr Y was unhappy including incidents of him damaging property. She also raised concerns in early October that some agency staff were unable to drive so Mr Y could not attend activities and that agency staff were not leaving receipts for expenditure. When they took Mr Y out they were not always recording the purpose or an explanation of the activities they took Mr Y to. Staff were also failing to check the fridge contents, leaving out of date food in there. The social worker agreed to refer Mr Y to the NHS Learning Disability Nursing Team.
16. The social worker contacted company B expressing concern about the impact inconsistent staffing was having on Mr Y. Company B responded that they had been unsuccessful in the recent recruitment drive. The member of staff they had identified to work with Mr Y had resigned. In late October 2019, the social worker met with Ms X, company B and a new social worker who was due to take over the case. Ms X raised concerns that some of the agency staff spoke little English and struggled to communicate with Mr Y, they were not always leaving receipts and were using some of Mr Y’s money for their own food. Staff did not have the skills to communicate effectively with Mr Y and were not treating him with dignity and respect. Company B agreed to continue to address issues with agency staff. It agreed to discuss again with the agency having three or four regular staff for consistency and to tighten up the guidance on managing Mr Y’s money.
17. The new social worker met with Ms X in November 2019. They discussed the option of retendering Mr Y’s support contract but felt other companies may also struggle to recruit staff in the area. They discussed exploring an alternative placement for Mr Y. Ms X agreed the Council should explore alternative accommodation options. She said a self-contained flat service model may be more appropriate.
18. There was an incident at the property in November 2019 where Mr Y threw objects and damaged property. Company B completed a risk assessment and removed glass aftershave bottles and photo frames from the property. The other actions included reducing the amount of cutlery and crockery in the property and advising staff to buy plastic drinks bottles rather than cans. In a further incident later in the month Mr Y smashed his television. The social worker agreed to explore alternative options. In early December the social worker identified two potential options for self-contained supported living flats.
19. In December 2019, the NHS Learning Disability (LD) Nurse and Speech and Language Therapist visited Mr Y. They reported that Mr Y’s current provider did not have accurate information about his communication/sensory needs. Some incidents of Mr Y’s behaviour were a result of miscommunication. The lack of visual routine and reliance on verbal choice making/demands may be contributing to his variable presentation in engaging in activities. The combination of no structure with variable staff was likely to be contributing to his behaviours that challenge. They made some initial recommendations for action. However, the Learning Disability Team found it hard to promote positive behaviour support for Mr Y due to a lack of a consistent core staff team.
20. The social worker arranged a multi-disciplinary meeting in January 2020 with company B, the speech and language therapist (SALT) and Ms X. The SALT said some strategies to support Mr Y had not transferred from company A to company B. Company B said consistency of approach was difficult due to not having a stable staff team. The SALT advised Mr Y had a communication passport for staff to read. Company B agreed to ensure agency staff read this when they were on shift. The SALT also suggested staff used task analysis laminated documents. The social worker said they were further exploring the option of a move to a self-contained flat. Another company had also offered to support Mr Y in his current home.
21. The social worker sought approval to further explore the self-contained flat. The Council’s decision makers requested more reassurance that agency staff would not be used and there would be enough staff to enable a ‘change of face’ if needed. It also requested risk assessments and input from the health service. Following this, in February 2020 the Council agreed to fund the proposed move.
22. The social worker continued to work with Company B to try to ensure a more stable staff team. Mr Y attended a psychiatrist appointment with the LD Nurse. They updated the social worker that Mr Y had no current mental health issues but needed a behavioural support plan implemented with consistency and more stability regarding staff and daily routines.
23. In February 2020 family members visited the proposed flat with the LD Nurse. They considered it a positive option and that a move would be in Mr Y’s best interests. Mr Y also visited the property.
24. In March 2020 the Council reassessed Mr Y’s needs. The assessment noted Mr Y’s social worker acknowledged at a multi-disciplinary team meeting in October 2019 that Mr Y’s service ‘due to staffing/recruitment ongoing issues was not safe and sustainable and as a result agency staff were used in the main which appeared to have a significant impact on [Mr Y’s] unsettled behaviours and presentation.
25. They noted company B had undergone four recruitment drives but was unable to find permanent staff to support Mr Y. It believed the location of the property may have impeded staff recruitment.
26. They noted the current staffing issues could not be resolved and an alternative self-contained flat was identified with a view to ensuring Mr Y received a consistent, safe and sustainable service.
27. At the end of March 2020 Mr Y moved to a new supported living placement. Ms X says Mr Y is more settled with consistent staffing.

Findings

28. Company A’s decision to end its support provision was outside the Council’s control and left the Council with limited time to identify suitable alternative provision to meet Mr Y’s needs. The Council agreed to use its in house provision, company B, to support Mr Y. The Council sought to transfer staff over to company B but was only successful in doing so with one staff member.
29. Company B had to provide staff to cover Mr Y’s support package. Between May and October 2019, it tried on four occasions to recruit staff to support Mr X but was unsuccessful. It therefore used agency staff to ensure Mr Y received sufficient support. It worked with the agency to try and ensure regular agency staff were used and tried transferring staff from elsewhere in the Council to support Mr Y. Mr Y did not have a regular support team and the lack of consistency and changes in support is likely to have impacted Mr Y’s behaviour. However, that is not because of fault by the Council.
30. From late May 2019 the social worker made it clear to company B how important it was for staff to understand how to communicate with Mr Y. When company B took over supporting Mr Y no positive behaviour support plan was in place. Managers met with agency workers before they started to support Mr Y but there was a lack of consistency in how staff communicated with Mr Y.
31. The social worker recognised the impact inconsistent staffing was having on Mr Y. Following liaison with the LD nurse and SALT they found Company B did not have accurate information about Mr Y’s communication and sensory needs. This is fault, as this lack of information impacted on Company B’s ability to meet his needs. The Council was responsible for ensuring Mr Y’s needs were met and when arranging the change of provider, should have ensured company B had the required information to do this. The SALT Team were also unable to effectively promote positive behaviour support due to inconsistencies in staffing. At the multi-disciplinary team meeting in January 2020 the SALT advised Mr Y had a communication passport for staff to read. While the amount of staff changes was outside company B’s control there is no evidence the Council ensured staff used consistent techniques to communicate with Mr Y. This is fault. This is likely to have had some impact on Mr Y’s behaviour but it is difficult to separate this out from the impact the inconsistency in staffing had on Mr Y.
32. There was fault when a member of staff left Mr Y unsupervised in the community. Although Mr Y did not suffer harm, this caused Ms X frustration and worry. The Council responded appropriately and conducted a safeguarding investigation and made recommendations to remove Mr Y from any future risk of harm, including that the carer no longer support him This was appropriate.
33. Company B was not able to provide the consistent staffing Mr Y needed so there was no fault in the Council’s decision to seek an alternative placement for Mr Y. The Council’s decision makers sought assurances about the proposed new support to ensure it could meet his long term needs. It was not at fault for doing so.
34. Company B carried out risk assessments in response to concerns about Mr Y’s behaviour, which included the removal of glass objects from Mr Y’s room. The deterioration in Mr Y’s behaviour may have resulted from the situation. However, it was not fault to take action to reduce risks of harm to both staff and Mr Y.

Agreed action

35. Within one month of the final decision on this complaint the Council has agreed to pay Mr Y £200 to acknowledge the impact the inconsistency in communication had on him. It has also agreed to apologise to Ms X for the frustration and worry caused by the actions of the staff member who left Mr Y unsupervised in the community.
36. Within two months of the final decision the Council has agreed to remind staff to ensure that when there is a change of care provider, the new provider is made fully aware of the person’s needs, including any previous input from health services such as SALT.

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Final decision

37. I have completed my investigation. There was fault leading to injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman