Ombudsman’s Report 03/C/17141 Blackpool Borough Council

The report concerned a complaint about the standard of care provided to K, a 79-year old lady receiving personal care from Home Support, a private care provider with whom Blackpool Borough Council (Blackpool) had contracted to provide a significant amount of personal care.  K used a wheelchair, having had both her legs amputated from below the knee.  She had generalised arthritis, diabetes controlled by diet and was hard of hearing.  Blackpool classed her as “Priority 1” which meant she was highly dependent and required daily contact.

Following the failure of a Home Support worker to visit K (as required by the care plan), she had a fall which went unnoticed until the attendance of the police and ambulance service. K was taken to hospital and died 8 days later having suffered a stroke, a heart attack, and hypothermia in the hours after she had fallen.  K’s neighbour complained about the failure to attend and provide care, but received no response from Home Support.  Blackpool had previously received a catalogue of complaints about the quality of the care provided by the Home Support, including missed visits, but had not taken effective action to achieve an improvement in its services.

Given what was known about the poor performance of the provider, Blackpool’s annual review of the service provided to K, which was carried out by telephone, was seen as perfunctory.  A more detailed check on the care being delivered was required.  Blackpool was well aware of the failings of Home Support: inappropriate and untrained staff a failure to log in or out or report to the company’s office; the failure of a telephone back-up system; and the failure to ensure carers had access to a care plan explaining entry and emergency arrangements.  It failed to recognise the risks inherent in this situation.  It failed to notice an increase in the number of missed visits by Home Support staff and the danger in which it placed service users.  Blackpool failed properly to consider the risks posed to vulnerable service users by the deficiencies in the care service provided by the company.  It made only contractual interventions to deal with the situation.  Had it properly considered the evidence before it and the separate obligation it had to its service users, it would have realised that it should have identified the most vulnerable service users and carried out risk assessments regarding leaving them with that provider.

Blackpool failed to consider moving vulnerable service users to a more reliable provider, and the fact that it did so successfully later, demonstrated that this would have been entirely possible.  Blackpool should not have continued placing vulnerable people with Home Support, nor should it have tolerated an unsatisfactory standard of care to older people.  Blackpool also failed to carry out a thorough investigation of the situation either after K’s admission to hospital upon receipt of the original complaint.

Blackpool’s failings were maladministration and it was recommended to make financial compensation to K’s estate, the complainant and to waive outstanding home care charges.  It was also required to carry out extensive procedural and policy changes to ensure such a situation did not occur again in the future. A fitting memorial to the deceased was recommended as well.

NB In another LGO report, in 2012, a complaint has been upheld against Kent County Council with significance for all councils. It did not properly investigate how a man had come to be seriously injured during an altercation with another resident of his care home. It took a safeguarding ‘investigation’, a complaints investigation, an internal Council investigation, and a complaint to the Ombudsman before a second internal Council investigation properly looked at whether the incident involving Mrs B’s father could have been avoided.

The Council’s own second internal investigation found serious cause for concern: The Council had not reviewed Mr B at all in 2009 because of pressure on the Long Term Residential team and reviewed him only by post in 2010 – relying on a response from the Home to judge whether he was properly cared for and content.

The Ombudsman recommended that the Council pay the daughter £7,500 and that councillors should have oversight of the monitoring arrangements for all the council’s contracted-for clients, referring back to THIS previous finding of the LGO about monitoring responsibilities arising out of the death of one of Blackpool’s clients, when the home care worker failed to attend when due.