Summary: Miss Y complained about how the Council met her late mother, Mrs X’s care needs. The Council was at fault for not acting on a swelling it observed on Mrs X’s ankle, delay in reviewing her care and support needs and delay in carrying out a safeguarding investigation. It was also at fault for the failure of Mrs X’s personal alarm. The Council will apologise to Miss Y and pay her £200 in recognition of the distress, uncertainty and frustration these faults caused her.

The complaint

1. Miss Y complained about how the Council met her late mother’s care needs. She says her mother’s personal alarm did not work after she had a fall, the Care Provider acting on behalf of the Council failed to act on her mother’s swollen ankle and it delayed responding to her request for a care plan review.
2. Miss Y says this caused her and her mother significant distress.

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The Ombudsman’s role and powers

3. 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)
4. Service failure can happen when an organisation fails to provide a service it should because of circumstances outside its control. We do not need to show any blame, intent, flawed policy or process, or bad faith by the Council to say service failure (fault) has occurred. (Local Government Act 1974, sections 26(1), as amended)
5. 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, section 25(7), 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)
7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

8. I have considered:
• all the information Miss Y provided and discussed the complaint with her;
• the Council’s comments about the complaint and the supporting documents it provided; and
• the Council’s policies, relevant law and guidance and the Ombudsman's guidance on remedies.
9. Miss Y and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

Care and support plan

10. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan for a person with eligible needs. The care and support plan sets out the person’s needs, what support they need as a result, and how that support will be delivered. Councils must conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.

Safe care

11. Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) says care providers must ensure care and treatment of service users must be appropriate and meet their needs.

Safeguarding

12. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse.
13. There are no set timescales for responding to a safeguarding referral. The Council is part of a safeguarding board which brings together relevant local organisations under a single safeguarding policy. The policy notes the Council should act on a principle of ‘no delay,’ where safeguarding enquiries are carried out promptly, with regard to the level of risk the person may be exposed to.

What happened

14. This section sets out the key events in this case and is not intended to be a detailed chronology.
15. Mrs X lived in a supported living placement, which is run by the Care Provider. She had a large care package in place, funded by the Council. Care workers visited to help with tasks including heating up food for her to eat. Mrs X had a personal alarm which alerted care workers nearby when she needed help.
16. In August 2021, Miss Y contacted the Council and asked it to increase Mrs X’s care package to include 15 minute welfare checks after breakfast and lunch. Miss Y was concerned Mrs X was not able to eat her food safely or cleanly.
17. The Council contacted the Care Provider to ask if it would increase Mrs X’s care package or lengthen the existing visits. It said the increase would be short term and it would carry out a review of Mrs X’s care and support plan as it appeared her needs had increased.
18. In early September, the Care Provider agreed to do one welfare check to start with. The Council told Miss Y the Care Provider had agreed to the welfare check.
19. A few days later, the supported living placement told the Council it would not agree to do the welfare check because it did not think it was necessary. The Council suggested instead that care workers help Mrs X to change her clothes if they were soiled and help her to wear an apron when eating.
20. In late September, Miss Y became aware the supported living placement had not agreed to the welfare check and contacted the Council. It agreed to carry out a face-to-face review of Mrs X’s care and support plan.
21. In mid-October, the Care Provider contacted the Council to say Mrs X’s needs had increased due to a pressure sore and it felt she needed nursing care.
22. In late October, Mrs X slipped out of her chair while alone at home. She pressed her alarm but did not receive a response. Several hours later, Miss Y found Mrs X at home and alerted the care workers. Mrs X was ultimately taken to hospital for treatment.
23. Miss Y sent the Council a safeguarding referral in early November about the incident and several other concerns she had. She said:
• when Mrs X had tried to press the personal alarm it was not working;
• Mrs X had developed a swollen ankle in the days before her hospital admission, but care workers did not act on it; and
• she had been asking for a review of Mrs X’s care package for months. She had been passed between the Care Provider and Council repeatedly and was unhappy the Care Provider had advised the Council no extra support was needed.
24. In early December, Mrs X died. Her death certificate notes a blood clot as one of the causes of her death. Miss Y tells me the blood clot was the cause of Mrs X’s swollen ankle.
25. The Council did not act on the safeguarding referral until late April. It spoke to Miss Y, the alarm provider and the Care Provider. It found:
• Mrs X did not receive a response to pressing the personal alarm because it did not raise an alert with the alarm service. This was likely due to a technical fault as the Care Provider noted it had been having technical difficulties with the alarm system recently. The alarm service had confirmed all alarms were now working properly and it had a system in place to regularly check the alarms;
• the care workers should have contacted Mrs X’s GP or the district nurse and told her family about her ankle swelling; and
• the Council had spoken to the Care Provider in mid-November 2021 about Mrs X’s needs. The Council was satisfied it had responded properly to Miss Y’s request for extra care. It said it had provisionally decided to increase her care package by an extra 30 minutes.
26. Miss Y remained unhappy following the safeguarding investigation and complained to the Council. The Council responded to Miss Y’s complaint to say:
• there had been a significant delay in carrying out the investigation, and Miss Y had had to chase it for a response several times. It was sorry for the delay and made changes to its process to improve how it responds to safeguarding referrals. This included changing its processes to ensure referrals which needed to be allocated to a social worker for further work were acted on promptly;
• it was likely a care worker had accidentally failed to hang up the personal alarm after Mrs X had last activated it. This prevented her new alert going through to the alarm service. It accepted this caused a delay in Mrs X receiving help and that this was distressing for her;
• it agreed the care workers had not acted properly on Mrs X’s ankle swelling. The Care Provider would carry out staff training as a result.
• In late September it became aware Mrs X had been spilling food onto herself. It contacted the Care Provider who said an increase in the care package was not necessary. The Care Provider agreed to put an apron on Mrs X at mealtimes. In mid-October 2021, the Care Provider asked the Council to review Mrs X’s needs and care plan. It had been unable to carry out the review because it needed to be face-to-face and Mrs X was taken into hospital before an appointment could be arranged.

Findings

Delay in the safeguarding investigation

27. The Council significantly delayed considering and acting on Miss Y’s safeguarding referral. It took over six months to instigate an investigation, by which time Mrs X had died. The Council lost the opportunity to speak to her and seek her views. This was fault and caused Miss Y frustration. During that time, Miss Y contacted the Council several times to chase its response, which was avoidable time and trouble. I am satisfied the improvements the Council has made to its service following Miss Y’s complaint are appropriate so have not made further recommendations to prevent the fault occurring again.

Personal alarm

28. The Council has given Miss Y two possible reasons why Mrs X’s personal alarm did not work as it should have. I am not going to be able to make a finding on what the cause of the issue was, but regardless of this, the alarm service did not work as it should have. This was ‘service failure’ and was fault. The Council has accepted this delayed Mrs X receiving help after she slipped out of her chair, which would have caused her distress. I cannot remedy any injustice to Mrs X because she has since died. However, the delay caused Miss Y distress, which the Council has not addressed. I have therefore made a recommendation to remedy that injustice below.

Swollen ankle

29. The Council accepts the care workers failed to act promptly to refer Mrs X’s ankle swelling to her GP or the district nurse and to alert her family. The Care Provider did not comply with Regulation 9 of the Health and Social Care Act 2008, which was fault. The Council confirmed the Care Provider would carry out staff training as a result of the fault, which is an appropriate action to prevent the fault occurring again.
30. Miss Y says the blood clot was the cause of Mrs X’s ankle swelling and contributed to her death. I cannot say this, nor can I say that but for the fault, Mrs X may not have died. However, the fault caused Miss Y significant uncertainty about what the outcome might have been had the Care Provider made the referrals promptly.

Review of care package

31. Miss Y had concerns Mrs X was not able to eat safely or cleanly while unattended and was at risk from choking. The Council received a request from Miss Y to increase Mrs X’s care package in August 2021. It initially acted appropriately to seek a short term increase in Mrs X’s care package while it arranged a review of her care and support needs. However, after agreeing, the Care Provider later refused the increase in care. The Council did not tell Miss Y, who only became aware in late September. This delay was fault and caused Miss Y distress.
32. In addition, given Miss Y’s concerns, the Council should have carried out a review of her care and support needs promptly after the Care Provider refused to do the welfare visit. It did not, and by the time Mrs X was admitted to hospital in mid-October, it had still not arranged the review. This delay was further fault, which caused Miss Y avoidable uncertainty about whether her mother was being properly cared for.
33. The Council's safeguarding investigation response and complaint response both considered whether it acted properly in how it responded to Miss Y’s request for a change in care package. I do not consider either response addressed the issue with appropriate thoroughness or accountability. The safeguarding investigation referred to a provisionally agreed 30 minutes of extra care, which is not evidenced in the Council's records. Neither the safeguarding investigation nor the complaint response identified Miss Y had been asking about an increase in care package since August 2021 and there had been undue delay in arranging one. The poor responses to Miss Y’s concerns was fault, which caused her distress and uncertainty about the quality of the Council's answers.
34. Mrs X has since died and therefore any injustice caused to her by the faults identified cannot be remedied. However, as set out above, these faults caused Miss Y injustice in the form of distress, frustration, time and trouble and have left her with a sense of uncertainty over what would have happened had the faults not occurred. This injustice cannot generally be remedied by a payment, so we seek a symbolic amount to acknowledge the impact of the fault.

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Agreed action

35. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the care provider, I have made recommendations to the Council.
36. Within one month of the date of my final decision, the Council will:
• apologise to Miss Y for the distress, uncertainty and frustration she experienced and the time and trouble she had to go to as a result of the fault identified in this decision; and
• pay Miss Y £200 in recognition of that injustice.
37. The Council should provide us with evidence it has complied with the above actions.

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Final decision

38. I have completed my investigation. I have found fault leading to personal injustice. I have recommended action to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman