Summary: Ms C complained about the way the Council responded to concerns she raised about her care, and the lack of support she received in finding a Personal Assistant. We have found no fault in the way the Council acted.

The complaint

1. The complainant, whom I shall call Ms C, complains the Council has failed to:
• Provide adequate support with recruiting a suitable personal assistant (PA) or care agencies for her.
• Carry out safeguarding enquiries into the concerns she raised about care workers.
• Take all her care needs into account when determining the support she needs.
• Ensure she receives enough funds to arrange adequate support to meet the needs it has identified.

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What I have investigated

2. I have investigated the complaints about the support the Council provided to find a PA, and the way in which it responded to concerns she raised, until early 2020.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this report, we 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. We 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)
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 (in this case the Broker), we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
5. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)

Relevant Legislation and Guidance

6. Direct payments are made to individuals to meet some or all their eligible care and support needs and enable people to commission their own care and support to meet their eligible needs. This might involve the person using a care agency to provide support or employing a personal assistant (PA). If someone receives direct payments the Council should support them to use and manage the payment properly.
7. The Council has an agreement with a company (‘the Broker’), to provide direct payment support and a brokerage service. The service specification includes:
• advice and support in liaising with registered care providers;
• assistance in the development of contingency plans in case of a breakdown in the care and support arrangements;
• assisting the service user to mediate and resolve problems (as directed by the service user) and involve advocacy if required;
• supporting the service user to recruit personal assistants;
• signposting to appropriate recruitment sources;
• ongoing support liaising with care agencies as necessary; and
• ongoing support with making amendments to the support plan.
8. The Care Act guidance says that:
• The Council has a safeguarding duty, when an adult
1. is experiencing, or at risk of, abuse or neglect, and
2. is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
• A council must make enquiries, or cause others to do so, if they reasonably suspect an adult is experiencing, or is at risk of experiencing, abuse or neglect. An enquiry could range from a conversation with someone, right through to a much more formal multi-agency plan or course of action. It should establish whether the any action needs to be taken to prevent or stop abuse or neglect and if so, by who.
• The aim of adult safeguarding is to prevent harm and reduce the risk of abuse or neglect to adults with care and support needs and stop abuse or neglect wherever possible.
• One of the six key principles that underpin all adult safeguarding work, is that “It is better to take action before harm occurs.”
9. The Council’s Safeguarding Decision-Making Tool describes when a referral should be made to the Safeguarding Team. It says that:
• Possible Safeguarding: Recurring missed medication or administration errors in relation to one service user that cause no harm.
• Referral must be made: Missed medication where harm does occur.

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How I considered this complaint

10. I considered the information I received from Ms C and the Council. I also interviewed two Council officers. I shared a copy of my draft decision statement with Ms C and the Council and considered any comments I received, before I made my final decision.

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What I found

11. Ms C has been receiving a Direct Payment (DP) from the Council to enable her to recruit a PA to provide the support she needs. The Council has a contract with the Broker to provide support to clients such as Ms C to find suitable PAs.
12. Ms C has a direct payment and prefers to have all her care delivered by PAs. Ms C had two PAs working for her. When one PA left, and she had difficulties recruiting a replacement PA, she tried to use part of her DP to recruit a care agency. This would mean that Ms C would have support from her remaining PA from Monday to Friday and have support from a care agency at the weekend. She would receive support with personal care, medication, mobility and provisions of meals and drinks.
13. The Broker subsequently provided a list of care agencies to Ms C who she could consider employing. Ms C had a DP which meant:
• It would be up to her to decide, following a discussion with the care agency, whether she believed the agency could meet her needs and if she would like to hire them.
• The contract would be between Ms C and the care agency.
• If Ms C was unhappy about the care or the care workers, she should first of all discuss this with the help of the Broker with the care agency to try and resolve. Alternatively, she could decide to find another care agency if she was unhappy with the support.
• However, if Ms C would raise a significant concern with the Council that she felt would put her at immediate risk of abuse, the Council would have a duty to carry out a safeguarding enquiry if it believed the concern met its threshold for this.
14. One of the tasks of the Broker is to advertise the vacancy for Ms C’s PA and, through that, obtain CVs from people who are interested in becoming her PA. Ms C had previously made a complaint to the Ombudsman about the Broker. The Ombudsman concluded in June 2019 that the Broker had passed CVs to Ms C from candidates who were clearly unsuitable to be her PA. As of June 2019, Ms C had not been able to recruit the new PA she needed.
15. Ms C says the Broker has continued to fail to support her with recruiting suitable PAs. She says it has not been able to provide her with enough suitable CVs from candidates from which she could select a suitable PA.
16. Ms C’s weekend support from care agency A started early May 2019. However, as the agency was more expensive than usual, this would only be until another agency could be found.
17. The Council said the Broker carried out several actions to get CVs from people who were interested and qualified to become Ms C’s PA:
• The Broker placed Ms C’s advert on its own website. It also placed an advert on the Bolton and Manchester Metropolitan University sites, a few days later.
• The Broker also contacted 7 people on its own PA register who matched her requirements.
18. The Broker suggested to the Council at the end of May 2019, that it could put Ms C’s advert on websites such as Gumtree and Monster. However, it needed the Council’s permission to use Ms C’s DP to pay for the costs of around £100-200 per month to do this. The Council said it would discuss this internally.
19. Ms C complained to the Council in June 2019 that the Broker was not giving her enough CVs of suitable candidates. Ms C said the support she received from her allocated Independent Living Advisor (ILA) from the Broker was good, but the strategy the Broker was using to find suitable candidates was not working. The Council contacted the Broker to obtain its response. The Broker said:
• It had received 16 CVs and had only forwarded the six CVs that were suitable.
• Four candidates did not turn up for the interview, despite confirming they would.
• It provided a list of local care agencies to Ms C, which she could use in the interim.
20. The Council also told Ms C that it had reviewed how well the Broker supports its clients in general, and found that:
• Service users felt supported and were very happy overall with the service they received.
• The Agency use all forms of free advertising, as service users do not have a budget to advertise any PA vacancies. The ILAs have good local knowledge on where adverts can be placed for free. However, there were further opportunities that could be explored, such as local job fayres.
21. Ms C changed to care agency B in mid July 2019.
22. At the end of July 2019, Ms C told the Council the Broker had supported her with interviewing two applicants. Both were suitable, and she appointed the person with the most experience. The PA would support her during the evening on weekdays, with the care agency supporting her at the weekend.
23. Ms C had a complex medication regime with several different types of medication. Ms C knows all what medications she has to take and when she is prescribed to take them. There are times Ms C takes medication at a time when care workers are not present. Some of the medication had to be taken on an ‘if and when needed’ basis.
24. Ms C told the Council at the end of August 2019, that:
• The PA she recruited stopped because she could no longer work on weekdays.
• The care agency had continued at the weekend. However, this was not going too well with issues regarding medication management and items being left out. The Council’s record does not indicate that Ms C was very concerned about this. However, Ms C decided that, based on her experience, she wanted to change to another care agency, which would address any issues.
25. The Broker says the PA who recently stopped, had offered to work at the weekends, but Ms C said she wanted to keep the care agency at the weekend instead. This could have addressed any care issues she had with care agency B.
26. According to the records, Ms C did not mention any concerns when she communicated with her social worker during the first half of October 2019. Her long-term PA was supporting her during the week and the care agency at the weekend.
27. Ms C told the Council in October 2019 that she had not received any more CVs for a while and asked if anything could be done. As such, the Council agreed the Broker could use funds in Ms C’s DP account to advertise her PA vacancy. It was proposed to first try a site who could advertise with Indeed, LinkedIn, Twitter and Facebook. The Broker placed an advert that same month.
28. A senior manager investigated Ms C’s concern about the Broker. Ms C had a meeting in mid-October 2019 with the Head of Service and an officer from the Quality Assurance Team to discuss it. The Council said:
• As of 15 October 2019, the agency had received CVs from 36 candidates, 16 of these CVs were sent to Ms C. It also contacted 8 people on its own PA register.
• 9 interviews took place, 7 of which were attended and supported by the Broker.
• All adverts placed by the Broker were still active.
• The advert was also put on the Council’s new PA Web, which is a matching tool to link people looking for PAs with people who would like to be a PA. Staff were also attending Bolton College, Job Centre Plus and other community groups to encourage more interest in people becoming PAs and promoting PA Web. The Council would also put leaflets about this in coffee shops, supermarkets, leisure centres and in the local press.
• It was unfortunately a very difficult employing environment.
• Ms C confirmed at her meeting with the manager that her needs where being met by her current long-standing PA and agency B, but she would prefer a second PA to an agency.
• Since June 2019, the Broker has been screening applications by checking CVs and speaking to the respective applicants to ger more information.
29. At this meeting, Ms C also complained about care agency B. She said: care workers were not checking if she had taken her medication, watching that she was taking it, or completing the Medication Administration sheet (MARS). The Council explained to Ms C that part of the problem was related to Ms C self-medicating at a time care-workers are not present. This meant the care workers could not make a record of this on the MAR sheet. Ms C confirmed however she was happy with agency B overall and did not want to change them. The Council said it would tell the Broker to arrange a meeting with agency B to discuss and solve her concerns.
30. On 29 October 2019, the Broker met with Ms C and the manager of the care agency later that same day. The Broker reported they discussed all of Ms C’s concerns and agreed actions to resolve them. Ms C said her current regular carers were fabulous and much better than the once from previous providers. The care agency said it would draw up a detailed support plan for Ms C and introduce new protocols and medication training for all staff. The Broker had only received one recent PA application that looked to be suitable.
31. The Broker emailed Ms C’s social worker on 29 October 2019. It said: “there have been more issues with medication being missed at the weekend, which has caused her to be in significant pain and discomfort”. Ms C also said she had asked the agency to provide specific training to the staff supporting her with her specific medication needs. However, this had still not happened. This showed that Ms C had not received the medication she needed, and she was not (always) able to avoid that. Furthermore, despite having asked if her care workers could be trained in better managing Ms C’s medication, this had not happened yet.
32. Despite the care agency’s promises, the Broker reported again to the social worker on 11 November 2019 that “the carer missed her meds again last weekend, which resulted in her being very unwell for the next few days”.
33. Ms C called her social worker again on 18 November 2019. She complained about several issues, including the issues she had already raised about medication, which she felt were safeguarding issues. The social worker felt the issues around medication management were not safeguarding issues but said she would ask her ILA to support her at an upcoming meeting she would have with the agency to discuss these issues. Ms C’s ILA reported back to the social worker the next day and said the care agency said it would do a full investigation and provide Ms C with new care workers. However, Ms C said she wanted to change agency and a new agency (agency C) started several days later.
34. The Broker told the Council on 2 December 2019 that Ms C had complained about agency C saying it had missed medication and there were no MAR sheets in her care file. There were other issues as well. As such, Ms C wanted the Broker to arrange a meeting with agency C. Ms C also said she wanted to change agency again. In response, the social worker called Ms C the next day and said that carers should record any medication they give to Ms C and see her take.
35. Ms C contacted the Council again on 5 December 2019. The record states she provided an overview about negative experiences she had with care providers over the last two months. However, she had since changed care provider. Ms C wanted the Council to investigate these as safeguarding concerns. However, the safeguarding team decided this should be dealt with as a complaint, because Ms C changed care agency which meant she would no longer be at risk.
36. The records state that the Integrated Service Manager would discuss and assess with Ms C what level of medication support she needs. Level 1 of medicines administration is when the person self-medicates with general support, and level 2 is when care workers administer the medication. Ms C’s case was somewhere in between as she would self-administer some of her medication (when care workers were not present). Following the telephone call, the Council suggested that Ms C be assessed as requiring level 2 medication administration and thus any carer support with medication will need to be recorded on a MARS sheet. She would continue to take some tablets independently and care workers would not record this on the MARS. The Council said that: As Ms C was a Direct Payment recipient, she was responsible for organising her care as the employer. Therefore, it was up to her to direct the care agency about the care she needed, including how she wanted support around her medication.
37. Ms C interviewed a PA early December 2019 and decided to employ her for six days a week.
38. Ms C’s new care agency (agency D) started mid-December 2019. However, after a few days, Ms C told the Broker she wanted to change care agency.
39. The Council received an email from the Care Quality Commission. It included concerns that a care worker failed to give Ms C’s medication as prescribed, which resulted in an A&E attendance due to Ms C becoming ill. The Council says that this alert met its criteria for a Section 42 Safeguarding enquiry, and it started an investigation.
40. Ms C said her new PA was brilliant and was learning everything really quickly.
41. In the meantime, another new care agency started by the end of December 2019 (agency E). The Broker advised Ms C, who had concerns about how medication would be managed, to provide clear instructions about what medication is to be given when. Ms C said her PA would help with this.
42. Ms C told the Council on 3 January 2020 that she told the Council in September 2019, that agency B gave her a double dose of medication once. However, the Council says there is no evidence she raised that concern in September 2019.
43. On 6 January 2020, the Broker told the Council that Ms C had reported safeguarding concerns about agency E about: inexperienced carers, language barriers, and carers not being allowed to administer medication. As such, Ms C asked the Broker to ask the care agency for a competent carer with experience. The Council raised this with its safeguarding team who decided to investigate the concerns. The Broker also suggested to Ms C that she should meet with the agency as arranged and discusses these concerns thoroughly with them. The Broker also advised that if there are clear instructions about what medication is to be given and when, the care agency may feel more comfortable supporting her with it. Ms C said her PA could help with doing this.
44. Following the meeting in mid-January 2020, the Council provided several detailed instructions about what carer workers should do with regards to managing and recording medication in line with the Council’s medication policy.
45. The Council has said that:
• Although Ms C’s PA advised the Ombudsman that she noticed anomalies because she regularly counted the medication in the blister packs, neither Ms C nor her PA advised the Council of this. 
• It was apparent from the discussion on 16 October 2019 that Ms C was self-administering her medication, which the Council addressed in its response to her complaint. Its Head of Service checked the support plan in January 2020, which showed Ms C was continuing to self-administer her medication whilst expecting prompts when carer workers were present. This was a cause of confusion, which was addressed in the response of 14 January 2020.
• Ms C was often not at risk anymore because she had already given notice to change care agency. She was also very capable of identifying issues around her medication and acting on it.
46. The Broker arranged a new care agency to start mid-January 2020 (Agency F). It also arranged an interview with a candidate for Ms C’s weekend PA role. Ms C said the interview went well and she decided to employ the applicant. However, the new PA did not turn up at the start of February.
47. The Council provided a response to Ms C’s complaint about the first two care providers. The Council said that:
• The management of the medication was complicated because Ms C wanted to self-administer some of her medication but prompting with other medication.
• Care workers should not complete a MAR sheet for medication they have not witnessed Ms C taking, or where care workers only prompt a client.

Analysis

Concerns raised / safeguarding issues:

48. In August 2019, Ms C told the Council she was not happy with some aspects of the support she was receiving from care agency B. She did not indicate she wanted help with this and instead said she would change care agency, which would address the issue.
49. When Ms C raised the same issue again about agency B in mid-October 2019, the Head of Service used her professional judgement and decided this would best be resolved by asking her ILA to organise a meeting with the care agency. There was no fault in this.
50. However, on at least two occasions (28 October and 11 November 2019), the Broker raised concerns about Ms C not receiving medication at the weekend, which had resulted in her feeling very ill and in pain. Ms C also told her social worker again in mid-November 2019 that the issues around medication had not been resolved. She asked the Council for help in addressing this by indicating she believed this was a safeguarding concern. The above meant there were recurring missed medication or administration errors that had caused some harm, and with the potential to cause further harm. Furthermore, Ms C had been unable to solve this with the care provider. However, the Council decided, during the phone call itself, that this did not meet the criteria for a safeguarding enquiry. The Council says the relevant officer was aware there would be a meeting between agency B and Ms C to discuss the issues. The officer subsequently discussed with Ms C what actions the agency said it would take. As such, the officer considered the information available and concluded there was no need for it to be dealt with under safeguarding, in addition to what was already happening. I cannot question the decision the Council has made as there was no fault in the steps it followed. As such the decision is merits (see paragraph 5 above).
51. When Ms C raised issues with the Council in early December 2019 about agency C, she said there would be a meeting with the agency to discuss this and she was planning to move care agency. As such, the Council did not feel this needed its involvement at this stage.
52. Ms C subsequently called the Council on 5 December 2019 and provided an overview about the negative experiences she had with two care providers over the last two months. However, she had since changed care provider. Ms C wanted the Council to investigate these as safeguarding concerns. However, Ms C was not at imminent risk of coming to harm. As such, the Council decided this should be dealt with as a complaint instead.
53. The Council carried out a safeguarding enquiry into the concern CQC raised about a medication issue that resulted in Ms C’s hospital admission. When Ms C raised concerns about agency E, the Council organised a meeting mid-January 2020 to discuss medication management.
54. The records show the Broker responded to any concerns Ms C would raise. There would be a meeting with the care provider to discuss these and her ILA would support her. The ILA also always supported her in changing care agency.

Help finding a Personal Assistant:

55. The Broker employed several strategies to try and find a suitable PA for Ms C. It also suggested an alternative strategy to the Council in May 2019, which was to put Ms C’s advert on various high-profile websites. This was put in place in October 2019.
56. The broker found suitable candidates in July 2019, December 2019 and January 2020.
57. I found the Broker has carried out an appropriate amount of support to Ms C to try and find a suitable PA.

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Final decision

58. For reasons explained above, I did not uphold Ms C’s complaint.

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Parts of the complaint that I did not investigate

59. I did not investigate Ms C’s complaint about her needs assessment and the amount of her personal budget, because the Council had not yet completed the assessment, at the time Ms C made her complaint to us. If Ms C is unhappy with the outcome of that assessment, she should first make a complaint to the Council before coming to the Ombudsman.

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Investigator's decision on behalf of the Ombudsman