Summary: Mr B complained on behalf of his partner, Mr C, that they experienced persistent problems with the Council’s contractor undertaking minor adaptations needed by Mr C. We upheld the complaint, finding poor customer service by the contractor and faults by the Council in its practice. We considered these caused avoidable distress, which was an injustice to both Mr B and Mr C. The Council accepted these findings and at the end of this statement we set out the action it has agreed to remedy that injustice and improve its service.

The complaint

1. Mr B complained on behalf of his partner, Mr C, that there were persistent problems in the service provided by NRS Healthcare (‘the contractor’), when Mr C needed minor adaptations to their home. In particular, Mr B complained the contractor:

• failed to arrive for a first appointment;
• could not complete an adaptation at a second appointment because of a partition wall;
• gave inadequate notice of a third and fourth appointment;
• had incorrect details of the adaptation needed;
• arrived too early for a later joint appointment with the Council.

2. In addition, Mr B complained the Council Occupational Therapist arrived with the wrong equipment at that joint appointment.
3. Mr B said as a result, he and Mr C experienced inconvenience and frustration through multiple contacts with the contractor and the Council. He said attempts made by the contractor and the Council to remedy his complaint were inadequate. He also had concern, the complaint revealed systemic problems with the contractor. And that this had implications for vulnerable adults, who did not have people to advocate for them in the way that he had done for Mr C.

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The Ombudsman’s role and powers

4. 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).
5. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
6. We must 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)
7. 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)

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How I considered this complaint

8. I considered evidence provided by Mr B and the Council, as well as relevant law, policy and guidance.
9. I gave Mr B, the Council and the contractor opportunity to comment on a draft version of this decision statement. I took account of any comments they made, or further evidence they provided, before finalising the statement.

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What I found

The key facts

10. Mr C is in his seventies and is the partner of Mr B. Mr C has chronic physical and mental health conditions, which mean he needs care and support.
11. In early June 2024 an occupational therapy assistant, working for the Council, assessed Mr C’s need for minor adaptations in the home. They found Mr C needed grab rails fitted in the shower to support him when washing. They also found Mr C needed a bed lever to support his movement in bed and transfers from the bed. This was after Mr B and Mr C reported concern that Mr C had fallen out of bed when transferring, and considered he was at risk of further falls.
12. The Council placed an order with its contractor for grab rails for the shower. It ordered twelve-inch (or 300mm) grab rails. This is also what it recorded in its assessment. Mr B told me he understood the Council agreed to provide 450mm grab rails.
13. It recorded in its notes that Mr B and Mr C would “decide and confirm” what bed lever Mr C wanted. It said that it took this to mean, they did not want to pursue an order for a bed lever at that time. So, after the Council placed its order for the grab rails it closed its referral. It did not write to Mr B or Mr C to explain this, nor confirm the action it had taken.
14. Meanwhile, Mr B told me that his understanding was the Council would revert and provide more detail on the bed lever it proposed fitting.
15. The contractor arranged to fit the shower grab rails eight working days after receiving the referral. The contractor failed to arrive.
16. Mr B re-arranged for the contractor to fit the shower grab rails a week later. This time the contractor arrived but said they could not fit the rails. They had a concern the shower was on a partition wall and they did not have the right equipment to fit the rails in those circumstances. I saw nothing in the June 2024 assessment, nor with the order placed with the contractor, that advised the shower was on a partition wall.
17. Mr B contacted the Council to let it know about the problems he and Mr C had experienced. The Council raised the matter with the contractor. It told Mr C that following that contact, it expected the contractor to complete the work “as a matter of urgency”.
18. Mr B re-arranged for the contractor to visit a third time. It told him that it would provide a day and specific time slot. However, when the contractor arranged a third visit, it only let Mr B know the day before. Mr B said he had to cancel the visit because of the short notice and that Mr C had appointments elsewhere. He asked the contractor to provide more notice and give a timeslot.
19. Mr B raised the matter with the Council. It arranged for the contractor to make a fourth appointment. It did this in mid-August. When it did so it did not send a text message with the appointment until the night before, at 9:00pm. The time it proposed visiting clashed with an appointment Mr B had.
20. Mr B therefore made a complaint, which the Council forwarded to the contractor, with the expectation it reply. It also commissioned a different contractor to fit the shower grab rails. Mr B reported no problems with the second contractor, who attended before the end of the month and fitted the grab rails without incident.
21. During his contact with the Council in mid-August, Mr B also raised a query about Mr C’s need for a bed lever, following its assessment in June. The Council agreed to carry out a joint visit with its contractor in early September to supply and fit a bed lever.
22. The contractor initially arrived for that appointment a few hours too early. They later returned at the correct time, when the Council’s occupational therapist was also present. The occupational therapist brought a bed lever to the appointment, but it was the wrong one.
23. The Council therefore arranged a second joint appointment to fit the bed lever a few days later. The contractor completed the fitting, without incident.

Mr B’s complaint

24. As noted at paragraph 20, Mr B made a complaint in mid-August 2024, which the Council forwarded to the contractor to reply. Separately, in September 2024, Mr B also complained to the Council about its use of the contractor, following Mr C’s experience of the service. He was also unhappy the contractor had failed to respond to his complaint.
25. The Council replied in October 2024. Its response said the Council had identified some concerns about the contractor’s service. It told Mr B that it had meetings every two weeks with the contractor and made unannounced spot checks to help drive improvement of its service. It said that it saw evidence of a “steady, albeit slow” improvement in the contractor’s service. It said that when Mr B had first complained about the contractor in mid-August, it had passed the complaint to the contractor for it to reply.
26. Around the same time, Mr B received a reply to his complaint from the contractor. In that response, the contractor recognised fault for not attending the first visit. It gave reasons why its technician had not fitted the grab rails on the second visit and said it had tried to reschedule a third visit sooner. It said that when Mr B contacted it to express unhappiness at not having a time slot for the third visit, it had tried to arrange for that. But that Mr B, unhappy with its service, had chosen to cancel the order. It said that in mid-August the Council had told it to supply two 12-inch grab rails.
27. The contractor said because of Mr B’s complaint it had delivered a ‘toolbox talk’ to its managers. This was to “ensure they are answering and informing customer services in the escalation group”. The contractor also promised a gesture of goodwill to Mr B and Mr C, which consisted of it sending a small bowl of fruit. Mr B said it arrived later than promised, was of poor quality and contained fruits which Mr C cannot eat.
28. Mr B escalated his complaint to the Council, unhappy with the contractor’s reply. In its final reply, sent in November 2024, the Council noted the contractor had recognised missing an appointment, having scheduling issues and delay. It said the contractor had made changes to its internal procedures to provide better communications to users of its service. It said it was at the contractor’s discretion if it chose to make a gesture of goodwill in reply to a complaint.
29. Between the two replies from the Council in response to his complaint, Mr B received correspondence via a local Councillor with whom he had also raised his concerns. In that correspondence, the Council recognised the poor customer service Mr C received. It explained the contractor had replied to Mr B’s complaint and the Council had replied to Mr B’s concern about how it held the contractor to account. It set out in general terms how it sought to hold contractors accountable for their service.

My investigation

30. My investigation first sought to establish details about the Council’s contract for minor adaptations. The Council told me it was one of 22 London authorities who are members of the London Community Equipment Consortium (LCEC). The LCEC awarded a contract to the contractor in April 2023 to provide minor adaptations.
31. Under the contract, the contractor was to provide users of the service with minor adaptations within five working days of order. The contractor would make clear to users when it would deliver their equipment and that it would be “right the first time”. It would let them know if it was running late with a delivery.
32. I asked the Council how LCEC oversaw the contractor’s service and what it did if there were concerns. The Council said the LCEC held three different meetings at manager, commissioner and director level, where it might discuss such concerns. It said if the contractor failed to meet ‘key performance indicators’ then it could issue warnings and potentially end the contract.
33. The Council recognised, as it had in its correspondence to Mr B, that it had some concerns about the contractor’s performance and that it continued to meet with it every two weeks. It said it also carried out regular audits covering matters such as the contractor’s stock, their storage facilities and to inspect policies, certifications and records. The contractor told us that it was now delivering minor adaptations quicker than at any point since it began delivering services in 2023.
34. I established that what the contractor meant by a ‘toolbox talk’, was a short briefing it gave to managers. It said that following Mr B’s complaint, it had held one of these talks to remind managers how to alert customer services when a technician had “issues with delivery or installation”. It said that following this procedure would lead to contact the user of the service within 24 hours. It said this was its “escalation process”. It also said that following our investigation it would keep a central record of all these toolbox talks for future reference.
35. The contractor also told us that to improve its customer service it had given communication training to its customer service staff and their managers. It also undertook monitoring of calls with customers.
36. The contract with the LCEC, also required the contractor to have a complaint procedure. This said the contractor aimed to reply to complaints within 20 working days.
37. The Council also has its own complaint procedure. This says that if it receives a complaint about a contractor’s service it will (with the complainant’s permission), refer it to the contractor. The complainant can also ask for the Council to receive a copy of the reply. If, once the contractor has replied, the complainant remains dissatisfied then they can escalate their complaint to the Council. The Council says it will then consider the complaint under its adult social care procedure.
38. This procedure has two stages in turn. On its website, the Council says it will first try to resolve the complaint quickly, if it can. But if it cannot do that it will move to the ‘investigation stage’ and aim to respond in 20 working days. After that, the Council will signpost complainants to this office.
39. During my investigation, after I had issued my draft decision statement, the contractor was the subject of a winding-up order. Consequently, it is now in liquidation, with the Official Receiver maintaining business operations to secure the transition of its contracts to third parties.

My findings

40. As explained in paragraph 3, where a contractor delivers a service for a council, then we treat any complaint about the contractor’s service as one made against the Council. In this case, Mr B highlighted several examples of poor customer service by the contractor. There was no dispute that after the Council ordered shower grab rails for Mr C, the contractor:

• missed an appointment;
• could not complete the installation at the second appointment because of the partition wall;
• failed to give enough notice, or a time window, for its third appointment;
• failed to give enough notice of its fourth appointment.

41. Later, its technician arrived at the wrong time for a joint appointment with the Council to fit the bed lever.
42. This sequence of events resulted in me making finding of fault. While taken individually, none of these failings caused significant injustice. However, I took account of their cumulative effect over a short time. I considered Mr B and Mr C experienced distress, because of the unnecessary frustration and delay caused by the fault.
43. I recognised both the Council and contractor apologised for some fault during the investigation. I also recognised the contractor made a well-meaning, but ill-judged goodwill gesture when it sent Mr B and Mr C a bowl of fruit. But I did not consider these actions went far enough to recognise the injustice caused. So, I recommended the Council take further action to remedy this, which it agreed to. I recommended the Council take this action, as it was responsible for its contractor’s service.
44. In addition, I did not consider the Council could escape all criticism for its service in this case. I could not come to any finding on whether the Council was at fault for the size of grab rails ordered for Mr C. There was no fault by the contractor here as it clearly received an order for 300mm grab rails. But Mr B and Mr C understood the Council had originally promised something different.
45. However, as the contemporaneous record did not say this, I could not say the Council got this wrong.
46. But I had a further concern about the Council’s approach to Mr C’s need for a bed lever. It closed the referral made in June 2024, having arranged for supply of the grab rails only.
47. The Council notes suggested it understood Mr B and Mr C would revert to it following the assessment and tell it what bed lever they preferred. It said this followed its understanding they did not want to proceed with a lever straight away. But this was not what Mr B and Mr C understood.
48. I noted the Council did not confirm its advice in writing, nor tell Mr B and Mr C it had closed the referral. I considered this a fault. Even if the Council acted in good faith, when it believed Mr B and Mr C did not want to proceed with a bed lever, it should have confirmed its actions. This would have avoided any of the later confusion. It had also closed its referral despite knowing Mr C had an unmet need for this adaptation. If Mr B had not raised the matter again in mid-August 2024, Mr C’s need would have remained unmet.
49. I recognised that after mid-August the Council did act quickly to meet this need. But it was further fault that its Occupational Therapist arrived at Mr B and Mr C’s home with the wrong bed lever. Given they quickly rearranged the appointment, I found limited harm arose from that error. However, by that time, nearly three months had elapsed since the Council identified Mr C’s need for the bed lever. During that time, he experienced and remained at risk of falling from his bed. That was his injustice.
50. I considered next any wider lessons arising from this complaint. I found the contractor had tried to learn from the first missed appointment when it gave its “toolbox talk”. I considered this a proportionate response. There will be times when technicians miss appointments for reasons beyond their control. The point of the contractor’s ‘escalation process’ as I understood it, was to make sure it contacted quickly the user of the service and quickly rebooked any appointment. That was good practice.
51. But I found neither the Council nor contractor had sought to learn lessons from the second missed appointment. I considered its technicians would encounter a common variety of working environments when attending to fix adaptations, and partition walls must form part of that. I was surprised therefore that this could result in the need to rebook an appointment. I recommended that both the Council and contractor should consider what happened here and see if they could prevent this matter causing future failed appointments. Both agreed to this. However, following the collapse of the contractor’s business, it will no longer be possible for the Council to pursue this.
52. Another concern I had, was that I had no clear picture of how the contractor sought to give both proper notice of its appointments, and its policy towards providing time slots. Again, I recommended action to address this. While the Council and contractor agreed, it is again no longer possible to pursue it with the contractor’s business having collapsed.
53. Following my analysis at paragraph 48, I also wanted the Council to consider how it could avoid closing cases before ensuring vulnerable people had the adaptations it assessed they needed. It agreed to a recommendation here, detailed below.
54. I also considered whether the complaint suggested any wider systemic failings in the contractor’s service. Clearly Mr B and Mr C’s experience was poor. But I had to be careful of inferring too much from one poor experience. It was for the Council, and other members of the LCEC, to ensure they gathered data about the contractor’s performance. The Council would then have the breadth of knowledge to ascertain if the contractor routinely delivered such poor service. I found the Council unclear about the data it collected. But given the contractor’s business collapse, I did not pursue this further.
55. I noted there was evidence which showed the Council had not taken a ‘hands off’ approach to monitoring the contractor’s performance. For at least 12 months it held fortnightly meetings with the contractor. It also explained its programme of audits. And the contractor explained steps it took to improve customer service, which I assumed were not coincidental. I did not consider it proportionate to recommend any action to address any wider customer service issues, which would in any event, now be moot. This was also because the Council was only one of 22 authorities which form the LCEC, each of which should also have been providing oversight.
56. But, I had made one final recommendation which concerned complaint handling. In its reply to Mr B’s complaint, the contractor did not offer any signposting on what he should do, if unhappy with the reply. The contractor did copy the reply to the Council, but I did not consider this was enough. It should also have told Mr B that he could now access the Council’s complaint procedure or signposted him to this office.
57. In this case it was fortunate that Mr C had an effective advocate in Mr B, who knew how to escalate his complaint. So, any fault in the contractor’s complaint handling, did not cause either an injustice. But this would not have been the case with everyone. And while the Council had some oversight here, because Mr B let it know of his concerns, this would not apply to everyone unhappy with its contractor’s service. As some may have made a complaint only to the contractor, without contacting the Council. I therefore made another recommended further action here to ensure better monitoring by the Council of the contractor’s responses. However, this too cannot be pursued following the contractor’s business collapse.

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Agreed Action

58. The Council has agreed that within 20 working days of this decision it will:
1. apologise to Mr B and Mr C, accepting the findings of this investigation and taking account of the comments at paragraph 59 below;
2. make a symbolic payment to Mr B and Mr C of £250. Half of this is to recognise the injustice set out in paragraph 42 of this statement arising from the fault of the contractor. The other half is for that set out in paragraph 49 arising from the fault of the Council.
59. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council will consider this guidance when making the apology agreed.
60. Within two months of this decision, the Council has also agreed that it will:

• brief all its occupational therapists and occupational therapy assistants on the importance of aiming to avoid closing referrals where a need for adaptations remains outstanding and in communicating any decision to the user of the service. Closure should only happen in exceptional circumstances; for example, where the Council has a clear record of the user not wanting the suggested adaptation. Or, if Council cannot complete adaptations without waiting for the customer to revert to it, it should introduce a policy to give at least one reminder before closing the referral and / or tell the user it has closed the referral if it has not heard from them.

61. The Council will provide us with evidence it has complied with the above actions.

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Decision

62. For reasons set out above I upheld this complaint finding fault by the Council causing injustice to Mr B and Mr C. The Council has accepted these findings and agreed action that I consider will remedy that injustice and make a service improvement to help prevent a repeat. Consequently, I have completed my investigation satisfied with its response.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman