Summary: Mrs B complains that her son’s care provider did not provide adequate care to her son before he was admitted to hospital and says there was poor communication from the care provider. She also says the Council did not properly investigate her complaints or communicate with her. We have found fault as there were instances of poor communication from the care provider and from the Council and this would have added to the distress the family experienced. The Council has agreed to apologise to the family and to ensure that the service improvements that had previously been agreed have been implemented.

The complaint

1. Mrs B complains on behalf of her son, Mr C. Mr C lives in supported housing accommodation at Park House in Maidenhead. Mr C’s support is provided by Optalis (the Care Provider) and funded by the Council.
2. Mrs B’s complaint relates to events that happened in February 2023 when Mr C was admitted to hospital. Mrs B says:
• The care provided by the Care Provider in the days before the hospital admission was poor and led to the hospital admission.
• Staff did not travel with Mr C in the ambulance and did not stay overnight with him.
• There was poor communication from the Care Provider.
• The Council failed to properly investigate their safeguarding concerns and the Council’s communication with the family was poor.

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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 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)
4. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
5. 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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What I have and have not investigated

6. Following a meeting to discuss their complaint, Mr and Mrs B also complained about the actions of a Council officer, but I have not investigated these complaints as they relate to matters that are either outside of the Ombudsman’s jurisdiction or which could be better investigated by another agency.

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How I considered this complaint

7. I have discussed the complaint with Mrs B and I have considered the documents that she and the Council have sent and both sides’ comments on the draft decision.

Law, guidance and policies

8. The Care Act 2014 and the Care and Support Statutory Guidance 2014 set out the Council’s duties towards adults who require care and support.

Meeting needs

9. The Council has a duty to assess adults who have a need for care and support. If the needs assessment identifies eligible needs, the Council will provide a support plan which outlines what services are required to meet the needs. Depending on the financial assessment, councils have a duty to meet the needs.

Care Quality Commission

10. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards.
12. This says that:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• The care and treatment must be provided in a safe way for service users. (regulation 12).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).

Safeguarding

13. Section 42 of the Care Act 2014 says the local authority should start a safeguarding enquiry if an adult in its area:
• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
14. The objectives of an enquiry are to:
• establish facts
• ascertain the adult’s views and wishes
• assess the needs of the adult for protection, support and redress and how they might be met
• protect them from the abuse and neglect, in accordance with the wishes of the adult
• make decisions as to what follow-up action should be taken with regard to the person or organisation responsible for the abuse or neglect
• enable the adult to achieve resolution and recovery

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What I found

15. Mr C is an adult man who lives in a flat in supported housing accommodation funded by the Council. Mr C has a mild learning disability and a diagnosis of asthma.
16. Mr C is employed in a kitchen four days a week and has activities during the other three days.
17. I have summarised the events relating to the complaint. The information is obtained from the care provider’s records, staff’s statements and Mr and Mrs B’s accounts of what happened.

27 January

18. Mr C was reported to be coughing and did not feel well.

29 January

19. Mr C went shopping at the local supermarket during the day. Later in the day, Mr C did not feel well and did not attend his scheduled activities. In the evening he helped in cooking his dinner.

30 January

20. Mr C went to work and was fine in the morning but became unwell in the afternoon. The manager took him to the treatment room. A nurse checked Mr C’s temperature, blood pressure and pulse. All the observations were fine, within the normal range, but, as Mr C worked in the kitchen and was coughing, it was suggested that he should go home and stay home for a few days. Mr C sent texts later saying he felt better and wanted to return to work the next day.

31 January

21. Mr C stayed at home. A support worker checked Mr C in the morning. He said Mr C ‘was still coughing but looked fine’. The support worker spoke to Mrs B and told her Mr C was still coughing and had run out of cough mixture. Mrs B suggested he should buy more cough mixture, which he did. The support worker spoke to Mrs B again later that day and updated her. He said that, if the coughing did not improve, they would seek an appointment with the GP the next day. Mrs B agreed to this.
22. The Care Provider’s manager went to see Mr C around lunchtime and Mr C said he was fine. The Care Provider said staff monitored Mr C throughout the day. The support worker also said he visited Mr C throughout the day.

1 February

23. In the morning, Mr C came downstairs to pick up his mobile phone charger. The support worker who had supported Mr C on the previous day said Mr C’s coughing was ‘more chesty’ and he was coughing more. The support worker spoke to Mrs B and said he would hand over to the day staff and ask them to book an appointment for Mr C to visit the GP that day.
24. A different member of staff rang the GP surgery at 9:27 am, explained the situation and asked for an urgent appointment for Mr C. The GP surgery offered a telephone appointment at 4:30 pm.
25. The Care Provider said that, during the day, Mr C was checked throughout the day. The record showed that Mr C was mostly in the lounge looking at his phone or trying to sleep when staff checked him. Mr C had some soup around lunch time.
26. The surgery rang the placement at 4:57 pm and said the GP needed to see Mr C in person.
27. Mrs B said she rang Mr C around 4:45 pm for an update and he told her that he was going to see the GP.
28. A support worker took Mr C to the GP around 5:00 pm. The GP carried out several checks on Mr C and noted that Mr C’s blood oxygen level was low. The GP tried to improve the blood oxygen level by using a nebuliser and administering oxygen, but was unable to raise them to a safe level. The GP then said Mr C needed to go to hospital and called an ambulance.
29. Mrs B said Mr B rang Mr C around 5:00 pm and the phone was handed to the nurse who explained that Mr C needed to go hospital. The Care Provider said the support worker rang Mr B to update him and Mr B spoke to the nurse, the support worker and the GP. The Care Provider’s notes also referred to a further telephone conversation between Mr B and the support worker once the ambulance had been called.
30. The manager sent another member of staff to the GP surgery with Mr C’s hospital passport so that Mr C would have his hospital passport at the hospital.
31. Another resident at the placement was already at the hospital and was being supported by a support worker. As this support worker was already at the hospital, the manager decided that nobody would travel with Mr C in the ambulance. The manager asked the support worker to stay at the hospital and wait for Mr C.
32. Mrs B rang the Care Provider and the manager informed her that a member of staff was with Mr C at the GP and that another member of staff would meet him at the hospital. The support worker who was at the hospital met Mr C as soon as he arrived at the hospital.
33. Mrs B rang the Care Provider at 7:50 pm. The manager had gone home and a member of staff said the manager had told her to cover for him.
34. Mrs B rang the Care Provider again at 8:45 pm to obtain the mobile number for the support worker who was at the hospital. The Care Provider told Mrs B that Mr C was going to be admitted to hospital and gave her the mobile number. The Care Provider said Mrs B had told them that her daughter would go to the hospital that evening. This is not mentioned in Mrs B’s account.
35. Mrs B’s daughter contacted the support worker at the hospital at 10:16 pm and the worker told her that Mr C was in the emergency department’s resuscitation room and that she was going home.

2 February

36. Mrs B rang the Care provider at 7:45 am while travelling to the hospital to visit Mr C. The Care Provider said it would ring with an update but never rang back.
37. Mrs B found out Mr C’s ward in the hospital by ringing him and speaking to the nurse. Mr and Mrs B visited Mr C at 9:00 am. Mrs B said Mr C was in ‘an extremely anxious state.’ Mrs B said the consultant told them they considered moving Mr C to the intensive care unit and putting him on a ventilator, but would see first how Mr C was responding to the treatment he was receiving which was oxygen and antibiotics.
38. The manager said staff ‘got through’ to the hospital at 11:30 am (but did not say when they started to ring the hospital) and were told to call back in 30 minutes. The manager rang the hospital at 12:30 pm and spoke to a doctor on the ward. The doctor said he needed Mr C’s consent to share information.
39. A staff member said he spoke to Mr B at the placement as Mr B was picking up some items for Mr C. He asked whether it was ok for him to visit Mr C but Mr B said he did not want staff to go as family members were visiting.
40. Mrs B emailed the Council and informed them that Mr C had been taken to hospital and had been diagnosed with severe asthma and pneumonia. She said there had been a ‘series of errors’ by the placement and a safeguarding meeting was needed. The Council asked Mrs B to set out what her safeguarding concerns were.

3 February

41. Two support workers visited Mr C in hospital. One of the support workers stayed a few hours and met Mr and Mrs B when they arrived to visit Mr C. Mr and Mrs B came to the placement later that day and spoke to staff and the manager.

4 February

42. This was a Saturday and there were no spare staff available to visit Mr C. The Care Provider said staff had a conversation with Mr C in the morning.

5 February

43. The manager planned to visit Mr C that day but Mr and Mrs B said it was not appropriate as the family was there. One of the staff members also contacted Mrs B as he wanted to visit Mr C but Mrs B told him that it would be too crowded as family was visiting.

Mrs B’s complaint / safeguarding referral

44. Mrs B emailed her complaints / safeguarding referral to the Council on 5 February and said:
• She did not know that Mr C was on his way to the GP until she rang him.
• She was not informed that an ambulance had been called. She rang Mr C and the nurse at the GP surgery informed her.
• Nobody from the placement accompanied Mr C in the ambulance and Mrs B was not informed of this.
• She rang the Care Provider around 8:00 pm and obtained the number for the staff member who was at the hospital. Nobody from the Care Provider rang her the entire evening.
• The Care Provider left Mr C on his own at the hospital after 10:00 pm.
• Mrs B rang the placement in the morning around 7:30 am and nobody knew where Mr C was or what had been happening.
• The Care provider did not ring the hospital to find out what was happening with Mr C until lunch time on 2 February.
• There was a lack of communication from the Care provider in the following days (up until 5 February).
45. Mrs B summarised her concerns as following: ‘Safeguarding required re lack of communication between management and us or the hospital. Also, unaccompanied in ambulance, arrival at hospital and ‘abandonment’ in the A&E department. Lack of information at Park House regarding [Mr C’s] current health.’

6 February

46. Mr and Mrs B went to Mr C’s placement in the morning and staff offered to come up (presumably to Mr C’s flat) but Mr and Mrs B refused. A member of staff from the Care Provider rang the hospital for an update and spoke to the nurse and Mr C.

7 February

47. A support worker took a few items to Mr C in hospital as the family was not able to visit that day and had asked him to do so. The support worker spent the afternoon with Mr C. Mr C was breathing without a mask, but was still coughing. The nurse told the support worker that Mr C would have to remain in hospital for at least another 48 hours. The support worker updated the family.

8 February

48. A staff member rang Mr C to check how he was and whether he needed anything. Mrs B went to the placement in the evening and spoke to staff.

9 February

49. A staff member rang Mr C to check how he was and Mr C said he was a lot better. Mr C said he was due to be discharged the following day but did not know the time. A member of staff visited Mr C in the afternoon.

10 February

50. A staff member spoke to Mrs B who was in hospital with Mr C. Mr C was discharged later that day.
51. The Council put in place an interim support plan while Mr C was still recovering. This included increased monitoring of Mr C during the day and a decrease in his activities.

The Council’s safeguarding enquiry

52. The Council summarised the safeguarding referral as follows:
• ‘Concern raised by family that [Mr C] was not supported properly by staff at Park House during a recent bout of illness. Family believe if staff had acted more quickly [Mr C] would not have needed to go to hospital and not been as unwell.’
53. The outcome of the enquiry was:
• ‘[Mr C’s] parents do not believe he received sufficient care whilst at Park House and this meant his condition deteriorated necessitating a hospital admission. Park House staff have produced evidence of the care they offered. Should the care have been provided at the level the information Park House suggest then it would be adequate care. The family do not believe that care was delivered in the way suggested. It is not possible to resolve what care was provided as there is no-one else to consult to verify the contested claims.’
54. The Council said the aim of safeguarding was to ensure Mr C was safe on discharge and this had been achieved . The Council closed the case on 10 February and said: ‘No further action. Unable to resolve contested claims about support.’ It said a plan would be agreed before discharge to ensure correct care was put in place. The report noted that, when the outcome was explained to the parents, the Council would suggest the complaints route to them to pursue their complaints.
55. The Council noted on 10 February 2023 that there would be a meeting with the parents to discuss what happened.

Meeting – 21 March 2023

56. On 21 March 2023 the Council held the meeting with the parents to discuss the complaints and safeguarding referrals that Mr and Mrs B had made. The outcomes of the meeting were as follows.
57. Care provided prior to the hospital admission.
• The Council set out the actions the Care Provider took in the days before Mr C’s admission to hospital. Although the Council did not say so explicitly, it did not raise concerns about the actions.
58. Mr C was not accompanied in the ambulance.
• The Council said it was not always possible to fund staffing to be available to accompany people in the ambulance. The Council’s position was that Mr C was safe in the ambulance and a member of staff was waiting for Mr C at the hospital.
59. Nobody stayed with Mr C overnight at the hospital.
• The Council said a member of staff stayed with Mr C until 10:00 pm and did not criticise the Care Provider for not providing a support worker to stay with Mr C overnight.
60. Communication with the family
• It was noted that the support worker informed the Care Provider that she was going home around 10:00 pm but nobody called the family to let them know. The Council agreed that the family should have been informed.
• The family’s other complaints regarding communication were discussed but the Council did not uphold any of the complaints, as far as I can see from the minutes.
61. The Council agreed these tasks at the end of the meeting:
• Staff to carry out mental capacity and best interest assessments when Mr C was unwell as Mr C did not always fully understand his own health care needs.
• The Care Provider to establish a procedure for Mr C to have non-prescribed medication and record any non-prescribed medication in the care plan (Staff were not allowed to buy this).
• The care plan should set out how Mr C should be supported when he is unwell.
• The Care Provider should put in place guidelines on communication with family and clarify what support was available to those in hospital.
• All health information should be up to date.

Further information

62. Hospital passports can be used by people with learning disabilities. The purpose of the hospital passport is to help hospital staff to understand the person’s needs and make any reasonable adjustments that are required.
63. Mr C was provided with his hospital passport dated November 2022 when he went to hospital in February 2023. The passport did not include any additional requirements in terms of transport by ambulance or overnight stays in hospital. No additional requirements were added when the passport was updated in July 2023
64. I asked the Care Provider to send me any policies regarding what action it would take when a person was taken ill to hospital, including any policy regarding communications with the relatives.
65. The Care Provider replied and sent a policy dated 16 July 2021 which sets out what actions staff should take when there has been a health-related incident or emergency. This policy says, among other things:
• ‘Ensure that the customer is accompanied to the hospital, where appropriate (and where possible), by a responsible person and that they contact the organisation’s main office after arrival at the hospital, to give updated information on the condition and location of the casualty.’
• ‘The responsible line manager ensures that arrangements are made for relatives or friends of the casualty to be advised fully of the situation.’

Analysis

Actions before the hospital admission

66. I have considered the care provided to Mr C in the days before his hospital admission. I am aware that I am looking at the facts with the benefit of hindsight. I can only consider how the Care Provider provided care and the actions it took, based on the information it had at the time.
67. Mr C had a cough, but was medically checked on 30 January 2023. Mr C’s temperature, blood pressure and pulse were all within the normal range so, presumably, he was not seriously ill yet at that stage. The Care Provider monitored Mr C all day on the following day, 31 January, and there was no indication that his condition had significantly deteriorated. However, he still had a cough and the Care Provider decided that, if this cough had not improved by the following day, then they would take Mr C to the GP.
68. The Care Provider contacted the GP on 1 February 2023 as Mr C’s cough had not improved and had become ‘more chesty’. The GP did not give Mr C the emergency appointment that staff asked for but offered Mr C a telephone appointment in the afternoon. Staff monitored Mr C during the day. The GP was aware of Mr C’s medical background and his diagnosis of asthma. It is not known why the GP changed their mind in the afternoon and then decided they needed to see Mr C in person.
69. I note that, once Mr C was at the GP, the GP called the ambulance after the GP tried to improve Mr C’s blood oxygen level by using a nebuliser and administering oxygen, but was unable to raise it to a safe level. This suggests that, even for the GP, Mr C’s presentation was not so bad that he immediately required an ambulance.
70. Therefore, given all this information, I cannot say there was fault in the Care Provider’s actions. The Care Provider had contacted the appropriate medical staff and acted on their advice. It continued to monitor Mr C during the day.

Travel in ambulance

71. The Care Provider’s policy says a staff member should accompany a client to the hospital, if appropriate and if possible.
72. I agree that it may have been preferable for a member of staff to accompany Mr C in the ambulance. Mr C has a learning disability and was very unwell. I accept that Mr C may have been frightened and confused at the time and that a familiar face could have been comforting.
73. However, that does not mean that there was fault in the Care Provider’s decision to allow Mr C to travel to hospital unaccompanied. Ultimately, the Care Provider could make that decision. The Care Provider could consider other factors such as staff requirements. I accept that the Care Provider was dealing with two emergencies at the time and this would have been a factor in the decision making. Most importantly, a support worker was already at the hospital and was able to meet Mr C as soon as he arrived at the hospital.
74. I also note that there was no entry in Mr C’s hospital passport to say that he had to be accompanied in an ambulance or that he became upset in ambulances. No changes were made to the hospital passport in that respect after the hospital admission. Therefore, although I agree it may have been preferable for someone to travel with Mr C in the ambulance, I cannot say there was fault in the Care Provider’s decision.
75. Mrs B also complained that the support worker did not stay with Mr C after 10:00 pm. I cannot say that was fault. Mr C had been admitted to hospital and was in a safe environment. There was no indication from his hospital passport that he needed someone to stay with him overnight.

Care Provider’s communications with the family

76. The Care Provider’s policy says the manager should ensure that the family stays fully informed in situations such as Mr C’s. Mr and Mrs B were, understandably, extremely worried about what was happening. Mr C was a vulnerable adult with a learning disability who had been taken to hospital.
77. I would have expected the Care Provider to provide regular updates to Mr and Mrs B.
78. Therefore, I do not understand why neither the support worker, who was with Mr C in the hospital for the entire evening, nor the Care Provider’s manager rang Mr and Mrs B even once that evening to provide them with an update. I have checked the records and I cannot find any evidence that the Care Provider rang Mr and Mrs B on 1 February, after the decision had been made that Mr C had to go to hospital. That was fault.
79. I note Mrs B had to ring the Care Provider twice that evening to obtain any information and she then had to obtain the contact details for the support worker who was at the hospital. If she had not done so, she presumably would not have received any information about Mr C from the Care Provider.
80. In terms of the actions of the Care Provider in the following days, I find no fault overall. I note that a member of staff from the Care Provider visited Mr C or offered a visit (which was declined) on most days that he was in hospital. I would not expect the Care Provider to visit Mr C on every single day. Also, the family were visiting Mr C at the hospital and were speaking to the Care Provider and hospital staff in person. So overall I find no fault in this respect.

Council’s safeguarding enquiry and communications

81. The main purpose of a safeguarding enquiry is to decide whether the vulnerable adult is at risk of harm and, if so, to take action to address the risk. Safeguarding enquiries are not about apportioning blame, punishing or delivering justice. This often leaves complainants dissatisfied as they expected people or organisations to be held accountable similar to a criminal prosecution or trial.
82. However, the Council still had a duty, during the safeguarding enquiry, to establish facts i.e. to determine whether abuse or neglect took place. It is this decision which then informs whether any action needs to be taken to address the problem.
83. I note several positives in the enquiry. The Council obtained all the relevant evidence to carry out the enquiry. The Council gave Mr and Mrs B an opportunity to set out their concerns. The Council obtained statements from the staff and obtained the Care Provider’s daily records of the care provided and records on contact between the Care Provider and Mr and Mrs B. The Council held a meeting with Mr and Mrs B to discuss the outcome.
84. I think there was however, some fault in the enquiry. Firstly, Mr and Mrs B had raised several safeguarding concerns in their email dated 5 February 2023, but the Council’s safeguarding enquiry only referred to their first concern which was that the care provided led to the hospital admission.
85. It is not clear what the Council’s position was in relation to the other concerns Mr and Mrs B had raised. The concerns were discussed during the meeting on 21 March 2023 but not in the report. I presume that the Council’s position was that the other concerns raised did not meet the threshold for a section 42 enquiry, but the Council could have made that clearer in its report.
86. I also think the conclusion was not properly communicated in the safeguarding document. The Council said the Care Provider’s records showed that the care it provided to Mr C before he went to hospital was adequate. However, the Council then seemed to question whether the records were true and then concluded that it was unable to make any findings. That was an odd position to take particularly as the Council had no evidence to suggest that the Care Provider’s records were, in some way, false.
87. So there were some problems with the safeguarding enquiry, particularly in terms of communication. However, the Council then held a meeting with Mr and Mrs B on 21 March 2023 which did cover all the complaints/concerns that they had raised and which clarified the Council’s position better. Therefore the initial injustice caused by the poor communication was limited.
88. I have also checked whether the Care Provider carried out the actions that were agreed at the meeting on 21 March 2023. I note that the Care Provider made changes to Mr C’s care plan in terms of actions to take when Mr C is unwell although I cannot find any reference to the purchase of non-prescription drugs. I also could not find evidence that the Care Provider changed its policies in terms of communicating with relatives and what happens when a person is in hospital. The policy I received was last reviewed in 2021.

Injustice and remedy

89. Mr C has not suffered any significant injustice from the fault I have found, but I accept that Mr and Mrs B have suffered some distress from the faults in communication that I have found. I therefore recommend that the Council apologises to Mr and Mrs B.
90. I note that the Council had agreed some actions with the Care Provider after the meeting on 21 March 2023. As the Care Provider has not shown that it has carried out all the actions, I recommend the Council checks that the Care Provider has taken all the agreed actions and confirms this with the Ombudsman.

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Agreed action

91. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise in writing to Mr and Mrs B for the faults I have identified.
• Confirm that the Care Provider has taken the actions agreed at the meeting on 21 March 2023.

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Final decision

92. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman