Summary: The Ombudsmen found there was fault by a Council and a care provider with supervision levels. The care provider took action which remedied this issue satisfactorily. We found fault by a care provider with weight monitoring and foot care, but we were unable to say this caused an injustice. The Ombudsmen also found fault with how the care provider reported accidents involving a resident’s Motability car. The care provider has agreed to our recommendation that it makes a payment to address the financial loss an insurance claim would not cover.

The complaint

1. Mrs D complains about Staffordshire County Council (the Council) and Precious Homes Limited (Precious Homes) on behalf of her son, Mr E. She complains about the care provided to her son between May 2019 and March 2021. In particular Mrs D complained that Precious Homes:
• frequently left Mr E alone when he should have had supervision of two staff during the day;
• did not adequately monitor Mr E’s weight and diet;
• did not treat Mr E’s foot condition with the medication prescribed; and
• allowed its staff to cause significant damage to Mr E’s car and failed to report accidents appropriately.
2. Mrs D says the failings meant Mr E was left distressed and unsafe, causing her worry. She says he had an 8 stone weight gain in 22 months and was left in pain with his foot condition, that later needed private treatment. Mrs D says Mr E’s car was also badly damaged.

Back to top

The Ombudsmen’s role and powers

3. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
4. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
5. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

Back to top

How I considered this complaint

6. I have considered information from Mrs D, including her written complaints and a telephone discussion about the complaint. I have also considered information from Precious Homes and the Council, including care records and complaint responses.
7. When Mr E moved to Precious Homes in May 2019 his care package was Council funded. In October 2019 his care was funded by the CCG through Continuing Healthcare (CHC). The issues raised in this case cover the full period and therefore apply to the Council and Precious Homes as a health provider (from CCG funded care).

Back to top

What I found

Brief background

8. Mr E is a young adult with complex needs. He has a diagnosis of autism, severe learning disabilities, attention deficit hyperactivity disorder (ADHD) and Post-traumatic stress disorder (PTSD). He moved to a supported living placement at Mulberry Court when he was 17 years old with a view to remaining there when he transferred to Adult Care services.
9. The Council arranged the placement, but in October 2019 Mr E became eligible for CHC funding. His care plan was for 2:1 carers during the daytime and 1:1 during the night.
10. Mr E’s care plan included the need for dietary support and continuing treatment for verrucae.
11. Mr E had a Motability car which Precious Homes staff used to transport him. Mrs D said staff caused damage to the car and did not properly inform her when there had been accidents in May and October 2020.
12. Mr E moved out of Precious Homes in March 2021. Since moving to Precious Homes Mrs D says he had gained 8 stone in weight and his verrucae were uncontrolled, causing him pain.

Legal and administrative context

Care planning

13. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan. The care and support plan should consider what the person has, what they want to achieve, what they can do by themselves or with existing support and what type of care and support may be available in the local area.  When preparing a care and support plan the council must involve any carer the adult has. The care and support plan may include a personal budget, which is the amount of money the council has worked out it will cost to arrange the necessary care and support for the person.
14. NHS Continuing Healthcare (CHC) is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. CHC funding can be provided in any setting and can be used to pay for a person’s residential fees in some circumstances.
15. The Department of Health’s National Framework for NHS Continuing Healthcare and NHS‑funded Nursing Care (November 2012 (Revised)) (the National Framework) is the key guidance about Continuing Healthcare. It states that where an individual is eligible for Continuing Healthcare funding the CCG is responsible for care planning, commissioning services and case management.

Use of vehicles

16. Precious Homes has a Use of Vehicles at Work Policy that its staff should follow. This covers using Motability cars owned by residents. The policy says staff should log all incidents and must understand the procedure for reporting accidents.

Motability scheme

17. The Motability Scheme helps disabled people get mobile by exchanging their mobility allowance to lease a vehicle.
18. If individuals return the car in good condition, they may be eligible for a Good Condition Bonus. For a three-year lease, this is £600. Motability accept a car may show signs of wear and tear including minor scratches and dents and may still pay the bonus if there is no sign of serious damage. It says the bonus may also be payable even if there has been an insurance claim.

Analysis

Supervision levels

19. Mr E’s care plan states he needs support from two staff for 15 hours a day and 1:1 through the night. The plans states staff should be aware of his whereabouts at all times and that they take all threats of absconding seriously. It notes Mr E is high risk of going missing and has a missing person procedure in place.
20. It would be difficult to say whether Mr E was supervised by two staff at all times during his time at Precious Homes. Records are only likely to show any issues if there were any reported incidents.
21. In Mrs D’s complaints, she noted occasions where she found Mr E by himself, in particular one occasion where staff had left him alone while he was cooking.
22. Precious Homes provided the Ombudsmen with information about this issue. It accepts there were occasions where Mr E did not have adequate support in 2019. It said its investigation identified the issues happened when two particular staff members and an agency worker were on duty. Precious Homes confirmed it dealt with the two staff members through its disciplinary procedures and they were subsequently dismissed.
23. The Ombudsmen cannot consider the appropriateness of disciplinary procedures. However, Precious Homes’ investigation identified times where it did not supervise Mr E in accordance with his care plan. It also found that staff had left agency workers to look after Mr E alone.
24. It is not possible to identify all occasions where Mr E may not have had the right level of supervision. However, I am satisfied there is evidence Precious Homes’ actions were not in line with Mr D’s care plan. This is not in accordance with the Care Act and was therefore fault.
25. Mrs D says the fault this left Mr E at increased risk, particularly as she says there were times he managed to leave the building. The risk to Mr E was increased and this clearly caused Mrs D additional worry and distress. Fortunately I have seen no evidence Mr E came to harm on any occasion he was left alone or managed to leave the property.
26. Precious Homes recognised failings in its service in 2019 and acted to address the faults with staffing levels. It also apologised to Mrs E in its complaints response for the concerns she raised. In addition to the disciplinary action taken with specific staff, Precious Homes told the Ombudsmen it has implemented additional measures to improve its processes and how it monitors these.
27. Precious Homes said it has made significant improvements with staffing levels and it worked with Mrs D to improve the service it provided to Mr E. Mrs D has accepted there was improvement with how Precious Homes managed staffing levels before Mr E moved in March 2021. I have also seen evidence in the records from Precious Homes of a collaborative approach with staff rotas for Mr E. For these reasons I consider the actions taken by Precious Homes to address the fault and injustice this caused are appropriate and proportionate.

Weight monitoring

28. Mr E’s care plan says he can eat independently, but needs reminding to slow down and needs help with portion control. This is because he cannot tell when he is full. The care plan says staff should encourage to buy small or medium-sized fizzy drinks if he is getting a takeaway. It also says he needs support to plan a healthy and varied diet and that staff should support him to eat healthy snacks. The care plan also notes that staff should record Mr E’s weight monthly.
29. The records show that Precious Homes recorded Mr E’s weight shortly after he moved into Mulberry Court. He was 26 stone.
30. I have seen evidence in the records of regular weight monitoring in 2019. This shows Mr E’s weight was steady to January 2020. However, the records do not include any weight monitoring between January and September 2020. An entry in July 2020 that says the scales needed replacing and the following month staff noted Mr E refused to be weighed.
31. In September 2020 Mr E weighed 28 stone. Precious Homes recorded two further readings in November and December 2020. The December record showed Mr E’s weight was 28.5 stone.
32. There are gaps in the weight recording. On some occasions Mr E declined to be weighed, but there was a six-month period where staff did not appear to complete any weight monitoring. This was not in line with Mr E’s care plan and is fault.
33. In considering the impact of the fault, I have reviewed the records and considered Precious Homes’ response to my enquiries. I have considered
34. I note Precious Homes has Supporting Healthy Meals Guidance to help residents make healthier choices. It said it was trying to help Mr E to choose healthy meal options and it also referred him to a dietician in September 2020. This is supported by the records. Unfortunately the dietician service advised that it had a long waiting list due to wider funding issues, so Mr E was unable to access this service while he was at Precious Homes.
35. The records show Precious Homes regularly encouraged Mr E to exercise, particularly a daily walk. There are frequent entries recording that Mr E would often refuse to go for walks and discussions with staff about when he would exercise. Also, during this period there were restrictions due to Covid-19 which meant Mr E’s exercise options were limited, in particular he could not go swimming as often.
36. A reduction in exercise is likely to have contributed to some weight gain. Precious Homes is not responsible for the lack of activities available when restrictions were in place due to Covid-19 or the waiting times for the dietician. It also had an obligation to respect Mr E’s wishes while still giving encouragement. However, because it was not monitoring Mr E’s weight closely, it had no reliable way of it checking whether Mr E’s weight was changing.
37. Precious Homes therefore could have been alerted to Mr E’s increasing weight sooner and been able to consider other options to help manage his diet and exercise.
38. Mrs D said Mr E gained 8 stone while he was at Precious Homes. However, the records do not support this. Between the two periods of weight monitoring, Mr E gained around 2 stone.
39. I consider the fault by Precious Homes may have led to a small weight gain, but given other factors not within its control, it is difficult to say to what extent. It had already taken appropriate action to address Mr E’s reluctance to engage with healthy meal choices with the dietician referral and it had also restarted weight monitoring shortly before Mr E moved out. Mr E was also going for walks more regularly in the few months before he moved.
40. The records also show that from December 2020, Precious Homes completed a daily food chart for Mr E so they could monitor his food intake and meal planning better. I am therefore satisfied the Home recognised the issues and took appropriate action to resolve these. I do not consider there is a unremedied injustice linked to the fault identified.

Foot condition

41. Mr E had gel prescribed to treat a verruca in March 2020. Mrs D raised concerns in April 2020 as she felt Mr E’s verruca was getting worse. Precious Homes investigated this complaint in May 2020. It found that staff had been applying the gel, but until Mrs D raised concerns, they had not been filing the top layer before reapplying the gel.
42. Precious Homes said it updated the protocol in Mr E’s record to advise staff to file before reapplying the gel. It ensured all staff applying the gel were aware of the updated protocol and the records show staff were following this guidance.
43. In September 2020 the records show Precious Homes spoke to Mr E’s GP. They advised that because Mr E was picking at his verruca, it would not heal and would allow it to spread.
44. A further GP contact in November 2020 advised Precious Homes to monitor Mr E’s foot for infection.
45. Precious Homes completed a foot care check from December 2020, which also included taking photographs of his foot to record any changes. This seems good practice and in line with the advice given by Mr E’s GP. The records note the gel treatment had finished, but shows staff regularly filed Mr E’s feet and checked for any changes or problems. Staff recorded that Mr E’s foot was improving and that Mr E reported that it felt better.
46. There are two references to a verruca in the foot care records in early January 2021, both entered by the same member of staff. However, the daily entries following the GP’s review only refer to areas of dry skin. Also, the staff member was not a clinician. I therefore consider, on the balance of probabilities, it is likely the staff member mistakenly referred to the dry skin as a verruca in the notes.
47. Precious Homes has accepted there were issues applying the verruca gel soon after Mr E had this prescribed. However, it quickly addressed these issues and from April 2020, staff knew how to apply the gel correctly.
48. The records show Precious Homes stopped the treatment in late 2020, but this was following a GP consultation. It then followed the GP’s advice to monitor the condition of Mr E’s feet. Therefore Precious Homes is not at fault for stopping to apply Mr E’s verruca medication.
49. In early 2021 Precious Homes recorded that Mr E told staff his feet were better and declined foot care and monitoring on a number of occasions. However, the records show it continued with close monitoring and filing when Mr E would allow. The records do not show Mr E complained about problems or pain with his feet and staff did not note any further concerns immediately before his move out of Mulberry Court.

Car

50. Mrs E says Precious Homes staff caused considerable damage to Mr E’s Motability car. She says this included at least two accidents and said Precious Homes would not say who was driving or take responsibility for these.
51. I have reviewed Precious Homes’ vehicle check record between March 2020 and March 2021. While it is not possible to say if staff completed this on every occasion they drove the car, there are entries for most days. This records the driver and any damage to the car.
52. The records show there was some cosmetic damage caused to the car on several occasions. Precious Homes attributed some of this to where it kept the bins and a low wall close to the car park entrance. There were also two accidents, one in May 2020 and the other in October 2020.
53. From the evidence I have seen, the accidents aside, Precious Homes followed its policy for using Motability cars by recording use and any damage.
54. For the accident in May 2020 I can see Precious Homes gathered information from the staff members present and shared this with Mrs D by email. She sent further emails to Precious Homes asking for further details about the incident so she could pass this on to Mr E’s insurance company. Precious Homes said it would provide this information, but I have not seen evidence this was done.
55. Precious Homes has not followed its own policy in recording specific information about the accident and sharing this with Mrs D. This is fault. In Precious Homes’ response to the Ombudsmen’s enquiries, it accepted it was ultimately responsible for the damage to Mr E’s car. It said it offered to pay to repair the damage in September 2020 but Mrs D declined this offer on the basis the insurance company would cover the repairs.
56. I consider this would have effectively remedied this part of the complaint. However, I note Mrs D did not have the repairs completed and on 29 October 2020, a further accident happened.
57. I have seen that Precious Homes told Mrs D about this accident and provided some brief information about the driver by email. Mrs D asked for more details about the accident so she could report this to her insurance company. I have not seen evidence this happened. Again this was not in line with its policy and is fault.
58. Mrs D was responsible for making a claim to the insurance company Mr E’s behalf. I have seen no evidence that Mrs D asked Precious Homes again for the extra information she wanted. However, this would not have prevented her from making a claim. The insurance company could have advised if it needed further information to process the claim.
59. Insurance is in place to cover losses caused by damage. A road traffic accident is an insurable event. Therefore any injustice linked to the damage to the car or the cost of repairing this would be covered by an insurance claim, less any insurance excess payable. If Mrs D has not made an insurance claim, this is not the fault of Precious Homes and I do not consider it is responsible for the cost of repairs.
60. In addition to the cost of repairs, Mrs D says the damage to the car means Mr E will not get a £600 good condition bonus when he hands the car back to Motability. I consider this a moot point because if the damage was repaired, this would not be an issue.

Back to top

Agreed actions

61. Precious Homes has agreed to pay Mr E’s insurance excess for the claim related to damage that happened when he was resident at Precious Homes, if an excess was payable. Mrs D will need to provide evidence to Precious Homes of the excess amount and that this has been paid.
62. Within one month of the date of the Ombudsmen’s final decision statement Precious Homes will contact Mrs D to ask for evidence an excess has been paid by Mr E related to this claim. Once Precious Home receives confirmation of the excess paid, it can repay this amount to Mr E.

Back to top

Decision

63. There was fault by Precious Homes and the Council with supervising levels, which Precious Homes has already accepted. Precious Homes has taken appropriate action to address this.
64. There was fault by Precious Homes with weight monitoring. However, given other factors we cannot say that this led to significant weight gain by Mr E.
65. Precious Homes accepted it did not apply verruca treatment correctly in March 2020. However it addressed this quickly and ensured its staff knew how to apply the gel properly. There was no fault in Precious Homes’ treating and monitoring of Mr E’s foot condition from April 2020.
66. There was fault in how Precious Homes followed its policy on reporting car accidents. However, Precious Homes accepted responsibility for damage to the care and offered to pay for this. Mrs D advised the insurance would cover the cost of repairs.
67. Precious Homes has agreed to repay the excess costs on the insurance claim if Mr E paid this. I have therefore completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman