Summary: Mr X complained the Council failed to properly consider his complaint about Council commissioned care his mother, Mrs Y received, from Housing 21 and failed to provide an appropriate remedy after upholding the complaint. There was no fault in how the Council considered Mr X’s complaint, and the Care Provider had already provided an appropriate remedy for the injustice caused by fault in its actions relating to Mrs Y’s care.

The complaint

1. Mr X complained the Council failed to properly consider his complaint about Council commissioned care his mother, Mrs Y received, from Housing 21 and failed to provide an appropriate remedy after upholding the complaint. Mr X said this caused him frustration and distress. Mr X wanted the Council to reimburse some of the care fees paid for his mother’s care as recompense for the injustice he was caused.

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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. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide:

• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome, or
• there is no worthwhile outcome achievable by our investigation.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

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 normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. 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

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

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What I found

Relevant legislation and guidance

Care arrangements

9. An ‘extra care scheme’ offers both accommodation and care services for older people that have a care need, as assessed by adult social care. An on-site care team supports people living in a scheme and is available 24 hours per day, 7 days per week. The care provider is commissioned by the Council to deliver care and support services.
10. This Council monitors the service to make sure the service is safe, effective, caring, responsive and well led. The Council states a performance log and annual quality monitoring visits will be used as part of monitoring arrangements.

Complaint procedure

11. Councils should have clear procedures to deal with social care complaints. Regulations and guidance say they should investigate and resolve complaints quickly and efficiently. A single stage procedure should be enough. The council should include in its complaint response:

• how it considered the complaint;
• the conclusions reached about the complaint, including any required remedy; and
• whether it is satisfied all necessary action has been or will be taken by the organisations involved; and
• details of the complainant’s right to complain to the Local Government and Social Care Ombudsman. (Local Authority Social Services and National Health Service Complaints (England) Regulations 2009)

What happened

Background information

12. Mrs Y lived at an extra care scheme that also provided care administered by Housing 21 (the Provider). Mrs Y had lived there for more than 12 months and at the time of events investigated had care visits four times per day which were commissioned by the Council to meet her eligible care needs.
13. Mr X, Mrs Y’s son, complained to the Provider about the quality of care Mrs Y received after he overheard care workers being abusive to Mrs Y while he was on the phone with her in late December 2023. The Provider accepted the complaint and stated it would investigate. The Provided updated Mr X verbally and explained the action it was taking in January 2024. The Council was not informed of the matter at that time.

Events in summer 2024

14. Mrs Y told a care worker in the early morning that she was feeling unwell. The care worker recorded in a handover note in Mrs Y’s room that Mrs Y looked pale and the day-time care workers should call the GP in the morning. The day-time care workers next visited Mrs Y shortly before midday. Mrs Y had died having not received medical attention. A care worker used Mrs Y’s mobile phone to contact Mr X and told him his mother had died.
15. Mr X complained to the Council at the end of August 2024. Mr X complained the Provider informed him via his mother’s phone that she had died which caused him distress, and the care worker did not take appropriate action when Mrs Y became unwell which prevented her receiving medical care or having her family with her. Mr X also complained about the events in December 2023, which he said the Provider did not give an outcome on. Mr X wanted the Council to reimburse the fees for Mrs Y’s care since December 2023 to the summer of 2024. The Council accepted the complaint.
16. The Council held a safeguarding information sharing meeting at the end of September to identify if the Provider needed to take action to improve its service and if any disciplinary action was necessary for the care workers involved.
17. The Council, the Provider and Mr X attended the meeting. During the meeting it was agreed that although Mrs Y’s death may not have been avoidable, the care she received at the time was inadequate. The care worker who attended Mrs Y and was told she was unwell should have contacted medical services or the ambulance service, called Mrs Y’s family and returned to Mrs Y to undertake welfare checks. The care worker minimised the urgency of the situation and did not take the correct action, as the written handovers were not responded to until 11am in the morning. The Provider explained the disciplinary action it had taken against the care worker and said it did not have policies in place for unwell people.
18. The safeguarding information sharing meeting identified an action plan:
• The Council would liaise with the integrated health board about training resources for the Provider’s staff.
• The Provider would consider changes to staff training and documentation and share relevant policies and procedures with the Council.
• The Provider would work with staff to consider the risk of using a person’s own phone to contact family members.
• The Provider would share its new handover form with the Council’s commissioning team for review.
• The minutes of the meeting would be shared with the Care Quality Commission (CQC) for targeted inspections.
19. It was agreed that no further meetings were needed. The Provider expressed its remorse and said it had taken action to make sure the matters did not reoccur. The Provider would report back to the Council on the identified actions within four weeks. The Council’s commissioning officer would consider ongoing monitoring and support for the Provider.
20. Mr X asked the Council in October to consider the minutes of the meeting in its response to his complaint. A week later the Council asked Mr X for an extension to provide its complaint response. Mr X agreed.
21. The Provider sent Mr X a written response to the complaint he had raised in December 2023 about what he had overheard on the phone, setting out the action it had taken as a result of the complaint.
22. The Council contacted Mr X the day its response to his complaint was due and explained it was waiting for the action plan from the Provider following the safeguarding meeting before responding to the complaint. It said it would provide a response within two weeks.
23. The Council provided its complaint response to Mr X by the extended deadline. The Council said:
• The Provider had investigated concerns about the way care workers talked to Mrs Y in December 2023 and took disciplinary action. The Provider had informed Mr X of the end result over the phone but accepted it should have provided a written response which it will do in the future. The Council said the Provider acted appropriately and partially upheld the complaint.
• The Provider did not take the correct action when Mrs Y reported she was unwell in summer 2024 which was “a serious miscommunication and a lack of accountability”. It upheld this element of complaint and said it would monitor the improvements and actions the Provider has/was taking to improve services as set out in the safeguarding meeting.
• It had reviewed Mrs Y’s records over a 12-month period from August 2023 to July 2024, excluding the matter of December 2023 which had already been investigated. It found no evidence Mrs Y’s care was insufficient overall and no concerns were raised. It said in the absence of specific occurrences to consider it did not uphold this element of complaint.
• It apologised for the upheld matters. It did not agree waiving fees on the basis of the partially upheld complaint was appropriate.
24. Mr X was dissatisfied with the Council’s response and called the responding officer. The Council wrote to Mr X the following day and stated it would discuss the matter with a senior officer and would fully respond to his appeal the following week.
25. The Council sent a further complaint response at the end of November 2024. It agreed with its previous response and said appropriate actions had been identified and agreed with the Provider.
26. Dissatisfied with the Council’s response, Mr X complained to us in December 2024. Mr X said he wanted to amend the complaint at stage two, but the Council’s response did not reflect that.

Additional information

27. At the same time Mr X complained to the Provider.
28. In January 2025 the Provider sent Mr X a response. The Provider:
• said a manager would normally contact a person’s family and the care worker should have used a work mobile and apologised;
• apologised for the lack of written response to Mr X’s December 2023 complaint;
• offered Mr X a £2,000 goodwill payment in addition to writing off £750 arrears to recognise the distress for the lost opportunity for Mr X to be with Mrs Y before she died;
• Offered £250 for the upset and distress of receiving news of Mrs Y’s death on Mrs Y’s mobile phone; and
• Offered £250 for the lack of a written outcome to the December 2023 complaint.
29. The Council has provided evidence the actions identified during the safeguarding information sharing meeting have been considered and completed as appropriate, and it had monitored the improvements.

My findings

30. Mr X complained to the Council about matters in late August 2024. At that time the Council was also holding a safeguarding information sharing meeting. The Council kept Mr X informed about delays in the complaint handling process and the reason for the delays. When Mr X raised concerns about the response over the phone, the Council considered the matter and provided a further response. The Council explained why it would not provide a refund of care fees. There was no fault in how the Council considered Mr X’s complaint.
31. The Council and Provider both accepted there was fault in the Provider’s actions in the care it provided in December 2023, and the care it provided following Mrs Y reporting that she felt unwell, and in it contacting Mr X using Mrs Y’s phone after she had died, which caused Mr X distress.
32. The Provider and Council identified and carried out appropriate actions to improve its service. The Council had apologised for the upheld complaints and the Provider had paid Mr X £2,500 and written off a further £750 in outstanding fees to remedy the injustice caused to Mr X. This is beyond what the Ombudsman would recommend in these circumstances.
33. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions and service of the Provider. The Provider has already remedied the injustice caused by the identified fault. Further investigation would not lead to a different outcome.

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Decision

I find fault causing injustice which the Council and Care Provider have already remedied.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman