Summary: Miss A complained about Cambridgeshire County Council and Willow Care and Support Limited in respect of the service received under s117 of the Mental Health Act while in supported accommodation. The LGSCO found fault with the support provided by Willow Care which posed risks to Miss A’s physical and mental health.
What happened
Following a prior section 3 (treatment order) under the Mental Health Act for admission to hospital, Miss A was eligible for s117 aftercare upon her subsequent discharge from hospital.
In 2022, at the age of 18, Miss A moved to supported accommodation run by Willow Care and funded under s117 by Cambridge and the Integrated Care Board (ICB). Her care plan provided for support with daily activities and medication.
In 2023, following concerns raised by Miss A and her parents about Willow Care and the accommodation, Cambridge moved Miss A to a new placement.
Miss A subsequently complained to the LGSCO stating that between April 2022 and April 2023 Cambridge ought not to have utilised the company as it had been rated as a ‘requiring improvement’ by the Care Quality Commission (CQC). She also said that Willow’s care staff lacked first aid training, made medication errors, failed to check on her regularly, failed to communicate effectively and slept while working.
The complaint included that the company had failed to replace a broken oven for months; failed to provide instruction on the operation of the heating; failed to properly lock or secure the property; ignored a questionnaire regarding Miss A’s thoughts on her care and told Miss A she would be liable for unpaid rent as she had not signed a tenancy agreement – and that a manager had shouted at staff in front of her.
Furthermore, Miss A said Willow Care organised a move to a new property which fell through due to the lack of prior Council permission. She said that the sum of the neglectful care had caused distress, pain and she had attempted suicide several times.
In respect of Cambridge, Miss A complained of the failure to move her quickly despite safeguarding risks and said she would like both the Council and Willow Care to ‘take ownership’ of these failings, apologise and make improvements to ensure no other vulnerable patients were similarly affected.
What was found
In relation to Cambridge Council:
Concerning the utilisation of Willow Care as a Provider, despite its CQC rating and the delay in moving Miss A, Cambridge said it did not generally use placements with this rating; that at the time in question it had been working intensively with Willow towards improving sufficiently so as to be able to work with Miss A and that throughout the time frame covered by Miss A’s complaint, Cambridge had conducted meetings with both the family and Willow to resolve matters.
The LGSCO highlighted that Cambridge had provided Willow Care with an improvement plan prior to it providing care for Miss A and that it had also sought alternative providers. Therefore no fault was found as Cambridge was trying to work with Willow Care to meet Miss A’s needs.
Additionally, in July 2022, three months after Miss A took up residence with care from Willow Care, the Council said it would terminate its arrangement with them as soon as it found an alternative provider and had since done so, precluding similar situations from recurring for other service users.
Furthermore, by July 2022 Miss A had left the accommodation more than once when staff struggled to find her.
Cambridge – who made 11 safeguarding referrals to the council where the tenancy was situated – acknowledged such incidents placed Miss A at risk of harm but said that as Miss A was living in a different area at the time, any section 42 safeguarding duties were owed by the council in the second area who in turn advised Cambridgeshire to address the situation under complex case management.
Therefore the LGSCO found no fault with this aspect of the complaint as Cambridge was not responsible for safeguarding.
Concerning efforts to source an alternative provider:
In July 2022, Cambridge contacted 16 providers. By September 2022, some providers had been asked if they were able to address the mental health needs. In November 2022, feeling Willow Care was improving, Cambridge paused its search; however, the company then indicated it intended to end the service.
In December 2022 Cambridge produced a new care plan and resumed its search for a new provider which was found in February 2023 thereby permitting Miss A to move as a new tenant in April 2023.
The LGSCO therefore found that despite the significant delay, Cambridge appeared to have made efforts to find an alternative provider for Miss A but had received no positive responses and that even on the balance of probabilities, there was insufficient evidence to find Cambridge at fault for the delay in finding an alternative provider.
In relation to the Agency:
Willow Care told the LGSCO that all employees formerly involved in Miss A’s care had left and that a poor standard of record-keeping prevented any dispute as to whether the events raised by Miss A took place. It thereby admitted faults in relation to the care provided to Miss A which led to a deterioration in her mental health and a risk to her physical health.
In response to this the Agency said that it will be undertaking thorough internal reviews with lessons identified from Miss A’s experience. This will include and develop any areas of concerns that require improvement.
The Agency went on to say it has:
- put in place a robust recruitment process and staff training. It said it is recruiting qualified staff through a rigorous hiring process,
- provides ongoing training and professional development to ensure staff competency and keep them updated on the latest industry standards,
- has a monthly medication auditing system in place which allows managers to track any shortage or surplus of medication; and
- uses a new digital feed record system for daily activities which allows Managers to check daily notes and any medication errors.
In addition, the Agency had put in a system in place for checking potential service users’ suitability for services.
These changes on the face of it satisfied the Ombudsman that the Agency has taken sufficient action to prevent this happening again.
The Agency also offered Miss A £500 for the time taken making this complaint.
The LGSCO elected not to investigate each facet of Miss A’s complaint and instead focused on whether the outcomes Miss A hoped for could be achieved and examining the actions taken by Willow Care to prevent any reoccurrences.
The company was required to provide Miss A with details and results of the reviews carried out as a result of the complaint; and with detailed information about the changes it has made to recruitment, medication, service user assessments, training and daily note-taking to prevent this situation happening again.
The Council has outlined improvements it has made since the complaint and offered Miss A and her parents £500 due to the time and trouble taken during the complaint process.
Points to note for councils, professionals, people using services and their carers, advocacy groups, members of the public
The formal outcome of this report was that the complaint was not upheld, even though fault was found on the part of the agency. The only reason must have been that it admitted fault because all of its staff had left and could not dispute the facts, but had also committed to improvement.
We are surprised the acceptance by the Ombudsman of the Council’s attempts to commission a service when it clearly failed to provide the essence of aftercare, because generally the Ombudsman regards councils as unable to avoid the duty to provide aftercare, just because they have contracted it out.
We’re also surprised that the Ombudsman does not regard the poor provision as service failure and find fault in relation to the intensity of the commissioning attempts to make the provider improve or find an alternative, in light of the duty under s117 being enforceable by individuals.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Cambridgeshire County Council (23 011 874) report.
If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
Did you enjoy this analysis? Want to stay informed with our weekly Alert Service?
Then do click here to find out how you can receive the latest insights from experts and commentators and stay updated on key judicial decisions, ombudsmen’s reports, and critical law and policy changes, all for just £50 per YEAR and sent straight to your inbox or WhatsApp!