Sheffield Council found at fault for the poor standard of care given to ‘vulnerable’ woman

In a report published by the ombudsman, a woman described as Mrs C was said to have a care plan of four care visits daily by Hallam24 Healthcare, on behalf of Sheffield Council.

In mid-April 2023, the council visited Mrs C but her daughter, named Miss B in the report, told the council about her concerns about the standard of care her mother had been receiving – the concerns raised included finding untaken pills and carers forgetting to give Mrs C breakfast.

Mrs C, according to Miss B who moved into Mrs C’s home a month later, was unable to move and communicate independently. Miss B told the council that she had concerns about “Hallam24 Healthcare not completing all care tasks during care visits”.

The ombudsman found that Miss B had asked for a short-term review of her mother’s care.

A month later, the council visited Mrs C again to review her care needs and Miss B agreed to meet with the care managers from Hallam24 Healthcare.

However, a few days later “Miss B reported to the council carers had been arriving late to care visits and had not been giving Mrs C her breakfast”.

In September, Miss B met the care managers to raise her concerns with them.

The report said: “A few days later, Miss B contacted the council to report Mrs C had had a missed care visit. The council made safeguarding enquiries with Hallam24 Healthcare about the incident.

“In response, Hallam24 Healthcare told the council:

The carer had transport issues, so it had arranged for replacement carers to complete the care visit. The replacement carers said they did not complete the visit as it was not on their rota.

It had had one-to-one discussions with the carers, and it would be closely monitoring them.”

In late October, the ombudsman added, Miss B had reported further concerns about the care given to her mother (this included the carers not changing Mrs C’s incontinence pads, and carers leaving her in unsafe lying positions in her bed).

The report said in late November 2023, Hallam24 Healthcare had informed Miss B it had arranged a meeting with the carers in question about the issues with Mrs C’s positioning in bed, the length of care visits, and incontinence pad changes.

However, in January 2024 Miss B raised a complaint with the council about the poor standard of care Mrs C had received and the handling of the matters.

Also, a few days later, Miss B reported concerns to Hallam24 Healthcare about how the carers had been giving Mrs C her medication. It said it would discuss this with the carers.

The report added: “On March 11, 2024, the council sent Miss B its final response to her complaint and acknowledged there had been delays.

“It told her it had been unable to update her about the concerns she had raised and the safeguarding investigations because it had been waiting on information to do this.

“Mrs C died in early May 2024.”

The ombudsman said in early June 2024, the council received information from Hallam24 Healthcare in response to the safeguarding enquiry it made in November 2023.

Hallam24 Healthcare told the council:

Carers had said Mrs C was difficult to position in bed on occasion. It said it was unable to ask for further information about why she was left in a poor lying position as the carers in question had since left Hallam24 Healthcare. However, at the time of the incident, it said the carers were spot-checked at Mrs C’s property to ensure there was not a reoccurrence, although Miss B said in response to my (the ombudsman’s) draft decision the carers observed at the spot check were not the carers who had left Mrs C in a poor lying position.

Mrs C refused to take medication on occasion.

Later that month, Miss B brought her complaint to the ombudsman.

In August 2024, the council informed Miss B of the outcomes of its safeguarding investigations and apologised for the delay in giving her this information.

The ombudsman said it had seen evidence where:

Mrs C had not had her medication;

there were over 12 hours between a night-time care visit and the following day’s morning care visit;

Mrs C was left in an unsafe lying position in her bed;

Mrs C had unchanged incontinence pads; and

there had been missed care visits altogether.

The ombudsman added: “The care services given to Mrs C by Hallam24 Healthcare on the council’s behalf fell below an acceptable standard. This was fault.

“This fault meant Mrs C experienced a lack of care on several occasions. This fault also caused avoidable worry and stress to Miss B and meant at times she had to provide care to Mrs C herself.

“It also meant she continued to contact the council to ensure the care plan accurately reflected Mrs C’s needs, and she moved in with Mrs C as she was uncertain Mrs C’s care would improve and she would be safe.”

The council said it had worked with Miss B to explore the option of changing the care provider – something Miss B said she did not wish to do.

The ombudsman added the council took appropriate action at the times Miss B reported concerns to it about Mrs C’s care, and responded to her communications to let her know what it would be doing.

The council updated the care tasks in Mrs C’s care plan for extra clarity; arranged a visit for Miss B to discuss her concerns with Hallam24 Healthcare; and carried out safeguarding investigations.

The council made appropriate safeguarding enquiries with Hallam24 Healthcare, and they both took suitable actions as a result.

However, the council has accepted there was a delay in reviewing Mrs C’s care needs.

“This was fault”, said the ombudsman.

The ombudsman added: “The council also delayed informing Miss B of the outcome of its safeguarding investigations. It said this was due to waiting for information it needed to complete its enquiries.

“The safeguarding process began in September 2023, and it shared the outcomes with Miss B in August 2024, after Mrs C had died. This was fault, which caused uncertainty to Miss B.”

Sheffield Council agreed to apologise to Miss B for the care given to Mrs C, the delays and lack of communication.

The council also has to pay Miss B a symbolic payment of £500 “to acknowledge the uncertainty, stress and worry caused by the fault” the ombudsman identified.

The council will have to provide staff training about good communication and issue a briefing to remind the council and Hallam24 Healthcare staff of the importance of reassessing and completing reviews of care plans in a timely manner; following care plans; and raising concerns about care plan tasks when necessary to avoid tasks being uncompleted.