Royal Borough of Kensington and Chelsea at fault due to poor communication, delay in assessments and delay in care and support.

Date of decision: 18/03/ 2020

What Happened

Ms X complained on behalf of her grandmother, Mrs Y.

Mrs Y had previously had a council funded care package, which included 3 care visits per day.

In December 2018, Mrs Y was admitted to hospital after a fall. Before she was discharged back home, an assessment identified that Mrs Y needed two carers to visit 4 times a day, and for a hospital bed to be put in her home.

Mrs Y’s family made a number of complaints about the preparation for going home and about care that she received after being discharged on the 14th February 2019.

  • The day Mrs Y arrived home, she complained that she was left sitting on her chair from 5pm until 7pm when the carers arrived.
  • Mrs Y’s family thought she needed additional equipment, including a fall sensor.
  • Ms X said that the carers were leaving Ms Y in a high backed chair between visits, which made her feel unsafe.
  • Ms X also complained that the carers were not arriving on time, nor doing the chores they should.

There was no evidence that the Council ever responded to Ms X’s concerns or requests.

The Council were also unable to provide the LGSCO with evidence that an Occupational Therapist was consulted when assessing Mrs Y. 

Mrs Y was admitted to hospital again on the 5th March after falling out of bed.

Before she was discharged, a social worker assessed Mrs Y’s capacity. During this meeting Ms X highlighted that she was concerned Mrs Y did not have a continuity of carers, and they were not doing enough to get Mrs Y up and motivated. From the report, it seems that Ms X expressed these concerns to the social worker during the meeting. Again, there was no evidence the Council considered her statements.

On the 19th March an assessment concluded again that Mrs Y needed two carers, 4 times daily. It said that an OT would review her needs when she was at home. Mrs Y was discharged the next day.

For reasons not explained in the report, Mrs Y was admitted to hospital again on the 25th March, which was before the OT could visit. Ms X complained to the Council. She, again, raised concerns about the carers, stating that they had failed to complete the log book, left Mrs Y without food and drink and Mrs Y had suffered numerous falls

On the 29th March Mrs Y left hospital. Mrs X asked the Council who would be providing the care, and the Council told her it would be the same care agency as before, but they would review the situation in the following days. The report did not explain the reason for continuing with the same agency, and the LGO found no evidence the Council considered the quality of care provided, or updated Ms X on any review.

At the end of April, Mrs Y was admitted to hospital for the fourth time (again the report did not clarify for what reasons); once more, Ms X complained to the Council about her concerns surrounding the care she was receiving.

The Council completed a care and support plan on 22 May which said Mrs Y would be bedbound and cared for in bed, and that an OT will later assess her. Ms X challenged this position in June, stating that she should have a hoist, and that she already had severe pressure sores.

Mrs Y was due to leave hospital on 21 May but after contacting her family, the hospital found they were unaware of this, so delayed discharge until 23 May.

On 24 May Mrs Y’s family asked for the Carers to lift Mrs Y out of bed to alleviate the sores, but the Council said the OT would have to make an assessment first, which was arranged for the 6th June.

By the 23rd June an OT still had not visited, and Ms X complained to the Council about the lack of appropriate care and equipment.

The OT visited on the 27th June and ordered a mobile hoist to assist Mrs Y to leave her bed. We do not know how long it took to put this support in place.

Mrs Y went into hospital again on 3 July, and the hospital raised safeguarding concerns.

A multi team meeting on 9th July stated Mrs Y sores may have arisen due to lack of care from carers as reported by Ms X.

On the 14th August Mrs Y was discharged to a care home to continue treatment of her pressure sores. The LGO did not go into further analysis as to whether this was avoidable, or how the decision was made.  

The Council recorded the hospital’s safeguarding alert on 19 August (they had raised concerns on the 4th of July). It stated Mrs Y’s pressures sores deteriorated while at home despite the care package and district nurse involvement. The Council decided to fully investigate the concerns. It planned a safeguarding meeting on the 30th October, but it did not actually take place until mid-December because of a lack of availability of relevant persons.  

Ms X sadly passed away on 4th October.

The safeguarding meeting concluded that:

  • The allegation of neglect was substantiated.
  • There was evidence of a multi-agency delay in the provision of care and support.
  • The neglect could have been avoided if the care was organised in a timely manner by Community Health and the Council.
  • The cumulative result of lack of communication, delay in assessments by the District Nurses, Social Work Team and Occupational Therapy service, amounted to neglect in care.
  • However, the neglect did not cause or accelerate Mrs Y’s death.

As a result, the safeguarding team stated:

  • Different services should coordinate more robustly with each other and respond more swiftly in case of emergencies.
  • The communication between hospital and community-based service needed to improve to avoid delay in assessments and service provision.
  • The Manager asked the Council to complete a Lessons Learnt exercise and an Action Plan for improvement

The Council agreed it should have responded more swiftly. It said they would do this by using an escalation process to inform the manager in case there is a risk of neglect or delay in service provision.

What was found

There was no evidence the Council actually considered or responded to Ms X’s repeated concerns about the quality of care provided. This was fault.

The Council did not always complete OT assessments at the appropriate times in order to ensure she would be safe at home after discharge from hospital. This was fault.

Mrs Y was bedbound when she left hospital on 23rd May and therefore at risk of pressure sores. The OT did not assess her and order a mobile hoist until 27 June. This was fault.

Overall, the LGO stated that the Council neglected in its care of Mrs Y due to poor communication, delay in assessments and delay in care and support. This was fault.

Despite this, the LGO could not recommend a remedy for Mrs Y, as she had since passed away. Furthermore it could not say that the Council’s actions caused her death, as the Coroner’s Court was the appropriate place for that sort of finding.  It did however recommend that the Council pay Ms X £500 in recognition of the distress and uncertainty she suffered.

The LGO was satisfied that the Council had sufficiently recognised its faults, and the need for better communication with service users and family members. It had already started working on an action plan to address faults with delays and service provision, which the LGO asked for a copy of.

Points for the public, service users, family and peer supporters, advocates, and councils etc

This Council initially failed to assess Mrs Y’s needs properly upon discharge from hospital.

There was no evidence that the Council involved the right professionals at the right time which would have included the input of an occupational therapist (OT).

Mrs Y’s family expressed concern that she had been discharged without equipment and identified soon after discharge that the care provider was failing to meet Mrs Y’s needs, which included leaving her sat in a chair. 

These concerns were not taken seriously by the council, in fact the LGSCO could find no evidence that the Council responded at all. The only explanation must have been shortage of staff: the report is redolent of NON-discharge of functions, not merely poor discharge of what was expected of any council.

In fulfilling its legal responsibilities, councils’ members have a duty under s.6(6) Local Authority Social Services Act 1970 to ensure that where they have appointed a Director of Social Services, the authority ‘shall secure the adequate provision of staff for assisting him in the exercise of his functions’.

This complaint highlights a shortfall in this area that resulted in significant risk to Mrs Y’s well-being.

This complaint covered a period in which Mrs Y had several falls resulting in hospital admission. Had the Council responded properly when concerns were first raised and reviewed her needs, it would have recognised that this lady was at risk of falls and provided a care plan that was sufficient to meet her needs and ensure her safety. Unfortunately, when the OT did get round to visiting in March 2019, Mrs Y had suffered another fall and was further admitted to hospital.

There were further delays in OT input following later hospital admissions and coupled with delays in input from community health services and social work involvement, the safeguarding meeting in October 2019 quite rightly found that neglect by the care agency was substantiated but exacerbated by the cumulative effect of poor joined up working.

Upon discharge in March 2019, Mrs Y received care from the same agency. Ms X complained again about the quality of care, but there is no evidence that direct payments were offered to enable Mrs Y to have a choice about who supported her. There was also no evidence that Ms X was ever given information about how to make a safeguarding referral. The Care Act 2014 (S.4(2)) outlines the responsibilities of councils to ensure that they establish an information service that must provide:

…information and advice on the following matters in particular—

  • the system provided for by this Part and how the system operates in the authority’s area,
  • the choice of types of care and support, and the choice of providers, available to those who are in the authority’s area,
  • how to access the care and support that is available,
  • how to access independent financial advice on matters relevant to the meeting of needs for care and support, and
  • how to raise concerns about the safety or well-being of an adult who has needs for care and support.

After further admissions and further complaints about the care agency, as Mrs Y had developed significant pressure sores, a multi-agency meeting resulted in a safeguarding referral being made in July 2019 which then took the Council four months to respond to! Ms X had already been raising concerns since February 2019 which in our view represents an unconscionable delay.

For a person experiencing that a council that will not listen to concerns raised there is a further option little known of, by those with a complaint, in our experience. Under the Local Government and Housing Act 1989, councils are required to appoint a ‘Monitoring Officer’. This person has the role of ensuring that councils carry out their functions lawfully, which includes a duty to report to Members if there is a contravention of any local government related statute or rule of law.  Contact with the Monitoring Officer to identify where a council is failing to meet legal obligations may be sufficient to draw prompt attention to issues such as a vulnerable person’s safety.

Mrs Y sadly passed away in October 2019, before the safeguarding meeting took place. The LGSCO considered that a personal remedy for the distress she experienced at the hands of the council would have been appropriate had she not passed away. We at CASCAIDr suspect that this would have been a significant financial remedy in lieu of the poor quality care and support provided to Mrs Y by this council.

If you want help, please consider seeking advice from CASCAIDr via our referral form on the top bar menu of the site.

The full Local Government Ombudsman report of the Royal Borough of Kensington and Chelsea’s actions can be found here

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