Summary: The Ombudsmen will not investigate a complaint about a care provider or a Council’s safeguarding procedure because it is unlikely we would achieve a different outcome. We will not investigate an Integrated Care Board because there is insufficient evidence of fault with how it considered its continued commissioning of care from a care provider.

The complaint

1. Mrs X complains about the care provided to her later father, Mr Y. She says the carer from Saints Care left Mr Y covered in vomit when they finished their shift. Mrs X says Saints Care, Leicestershire County Council (the Council) and NHS Leicester, Leicestershire and Rutland Integrated Care Board (the ICB) have all failed to take suitable action to address her complaints. Mrs X wants the organisations to accept responsibility, apologise and improve services to prevent others having a similar experience.

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The Ombudsmen’s role and powers

2. 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).
3. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe:

• it is unlikely they would find fault, or
• the fault has not caused injustice to the person who complained, or
• it is unlikely they could add to any previous investigation by the bodies, or
• they cannot achieve the outcome someone wants.

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

4. I considered information provided by the complainant, the Council, the ICB and Saints Care.
5. Mrs X had an opportunity to comment on a draft decision statement and I considered her comments before reaching a final decision.

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My assessment

6. Mr Y had a care package in place funded by the ICB through Continuing Healthcare. Part of the care package was a night-time carer from Saints Care. A different care agency provided Mr Y’s daytime care.
7. When the daytime carers arrived on 9 July 2022 the Saints Care carer was outside the property. When the carers went inside they found Mr Y with vomit down his front.
8. Mrs X complained to Saints Care about the way the carer had left her father. She also complained to the ICB and the Council.

The Council

9. The Council did not commission the care but had responsibility for completing a safeguarding enquiry. I have seen evidence it gathered information from Mr Y’s care plan, relevant care records and information from Saints Care. It also sought views from the agency that provided the daytime care. The Council found there was a small timeframe between the carer leaving Mr Y and the morning carer taking over. It considered it was therefore not possible to say conclusively whether the night-time carer had knowingly left Mr Y after he had vomited.
10. However, the Council’s safeguarding enquiries found the care records the carer completed were of a poor standard and did not support the version of events they later reported. A possible reason identified for this was that the carer could not complete electronic records because there had been a problem with the network coverage. However, they did not complete any manual records either. The Council noted Saints Care had since upgraded its record keeping system so notes can be made even when there is no access to a network signal.
11. Saints Care also confirmed it provided staff with up-to-date training for end of life care and safeguarding. The Council found the safeguarding enquiry was “substantiated” based on the number of failings found relating to Mr Y’s care.
12. From the correspondence I have seen it appears Mrs X initially understood the Council had some responsibility for the care provision. The Council could have possibly explained its role more clearly and sooner, and that this was limited to safeguarding. There were also some delays starting the safeguarding enquiries. However, the information I have seen suggests the Council followed its safeguarding procedures appropriately and considered various relevant information to reach its conclusions. It also reported its findings to the CQC and the ICB. There was no continuing risk identified and therefore no further follow-up indicated.

Saints Care

13. Saints Care accepted there was fault and that Mr Y should never have been left the way he was. It immediately removed the carer from Mr Y’s care and started disciplinary proceedings against them. However the carer resigned as a carer before this process ended.
14. The safeguarding report shows Saints Care participated fully in the enquiry, accepted the faults and took measures to learn from the issues raised.
15. There is no dispute that Mr Y should not have been left in the way he was and I appreciate this must have been distressing for him and his family. However, it is unlikely we could achieve more than the actions identified in the safeguarding and complaints processes. Saints Care has accepted fault and it acted quickly to remove the risk when this was identified. It has also made changes to improve its service. I acknowledge Saints Care’s complaint response and apology could have been better, but it would not be proportionate to investigate on this basis alone.

The ICB

16. The ICB commissioned care. This was the only complaint about the care provider it was aware of and considered this was a one-off incident. The CQC inspected Saints Care in November 2022. The CQC rated it overall as “good”. In the absence of the CQC or the safeguarding team reporting any further concerns, it had no reason to stop commissioning services from Saints Care.

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Final decision

17. The Ombudsmen will not investigate this complaint. This is because there is insufficient evidence of fault with the Council’s safeguarding enquiries and it is unlikely we would reach a different outcome. We are also unlikely to achieve more from investigating Saints Care’s actions. Additionally, there is no indication of fault in how the ICB considered whether to continue commissioning services from Saints Care.

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Investigator's decision on behalf of the Ombudsman