Housing 21 (202220722)

REPORT

COMPLAINT 202220722

Housing 21

21 April 2023

Our approach

The Housing Ombudsman’s approach to investigating and determining complaints is to decide what is fair in all the circumstances of the case. This is set out in the Housing Act 1996 and the Housing Ombudsman Scheme. The Ombudsman considers the evidence and looks to see if there has been any ‘maladministration’, for example whether the landlord has failed to keep to the law, followed proper procedure, followed good practice or behaved in a reasonable and competent manner.

Both the resident and the landlord have submitted information to the Ombudsman and this has been carefully considered. Their accounts of what has happened are summarised below. This report is not an exhaustive description of all the events that have occurred in relation to this case, but an outline of the key issues as a background to the investigation’s findings.

The complaint

1. The complaint is about the landlord’s response to the resident’s concerns over the handling of a welfare incident.

Background

2. The resident is a tenant of the landlord of a flat in a retirement living court with a court manager during the working week. The landlord is aware of several vulnerabilities experienced by the resident, including a lung condition, insulin-dependent diabetes, poor mobility, and a hearing impairment.
3. In accordance with the landlord’s housing and court manager service managers toolkit, it has a responsibility to carry out daily welfare checks on all of the residents in the resident’s retirement living court, unless they advise it otherwise, on each of the court manager’s working days. It is required to do so via their preferred contact method, which could either be via its call monitoring system, or personal or discreet visits. This included a daily call to the resident at around 9.30am, in which the court manager was confirm that the resident was well.
4. On 17 August 2022, the resident was found to have fallen at his bedside, and he had been unable to get up by himself when he had also had a stroke. He was discovered at around 2pm that afternoon, when his family was notified and an ambulance was called, after which he was hospitalised.
5. The resident informed his family that he had fallen at around 2.30am on 17 August 2022 after he had got up, gone to the bathroom, and fallen on his return. However, the landlord’s court manager reported that they had made an intercom call to the resident as part of the daily welfare check at 9.30am on 17 August 2022, and had received verbal confirmation from him that he was well. His family disputed whether this could have been the case, however, as they believed that, from his explanation and the circumstances in which he was found, he must have been there since the early hours of the morning without being checked by it.
6. The resident’s family therefore complained to the landlord that the court manager’s daily welfare checks had been lacking, that they had not spoken to him at 9:30am on 17 August 2022, and that they had “assumed” that he was still asleep after not receiving verbal confirmation from him that he was well. They had also confirmed that their welfare check calls were not recorded, and so his family requested that such calls be archived for peace of mind. This was outlined in the resident’s stage one complaint of 22 August 2022, which was made on his behalf by his family.
7. The landlord’s stage one complaint response of 20 September 2022 explained that there was evidence from its daily welfare call documents that its court manager had appropriately called the resident at the expected time, and that he had emergency pendants for his increased risk of falling. Although it acknowledged that the accounts were conflicting and that his pendants were out of reach at the time of his fall. The landlord added that the welfare calls were not primarily for emergencies, but were a brief check since the previous day, and that it could not explain the circumstances in which the resident was found that disputed that he had been called. However, its evidence suggested that he had been mistaken about this, and it would update its system for this in a few years.
8. The resident’s family’s final stage complaint on his behalf of 26 September 2022 nevertheless continued to dispute the accuracy of the landlord’s court manager’s description of having made a daily welfare call to him on the morning of his fall. Its subsequent final stage complaint response of 15 November 2022 acknowledged the plausibility of his account of this, yet it explained that the court manager had repeated that they had spoken to him.
9. Additionally, the landlord confirmed that its call logs showed that the court manager had called the resident at 9.30am on 17 August 2022, with his neighbours only reporting hearing his calls for help when he was later discovered. It was therefore unable to confirm that there had been any failure in its conduct regarding welfare check calls. Although the landlord confirmed that a more comprehensive call recording system that was able to record calls in the way requested by the resident’s family would replace its current system at the end of its serviceable life in the next few years.
10. The resident’s family then complained to this Service on his behalf that he felt that the landlord’s court manager was being “dishonest” with it, that he had recorded his description of the events surrounding his fall on the day after this had happened, and that its response was unjustified. He also expressed concern that its calls were not recorded and that he wanted this to be changed. We subsequently requested and received evidence of the above events in the resident’s case from the landlord, which included its records at the time stating that its court manager had called and made contact with him via intercom at 9.30am on 17 August 2022.

Assessment and findings

Scope of investigation

11. It is very concerning that the resident experienced a serious fall and stroke that left him on the floor without assistance until he was later discovered, his account of which is not disputed by this Service. We do not, however, have the authority or expertise to determine which account of the events surrounding this was correct, as we are not bound by the legal rules of evidence that are necessary to do so. Therefore, as the Housing Ombudsman Scheme states that we may not consider complaints where the resident is seeking an outcome which is not within our authority to provide, a confirmation of the description of his fall and welfare check call is outside the scope of this investigation to decide. This will instead determine whether the landlord’s response to the reports about its handling of welfare check calls at that time was fair, reasonable and appropriate.
12. Additionally, this Service cannot accept complaints about individuals, such as the landlord’s court manager, and we may not consider complaints concerning their terms of employment or other personnel issues under the Housing Ombudsman Scheme. Therefore, the scope of this investigation is limited to considering actions or omissions made by or on behalf or the landlord, and not in an individual capacity or concerning the terms of employment or personnel issues of its staff.

The landlord’s response to the resident’s concerns over the handling of a welfare incident

13. The landlord’s housing and court manager service managers toolkit obliges it to attempt to make immediate contact with its residents by urgently attending their accommodation, if it has been unable to confirm their safety and wellbeing during a daily welfare check call, after completing all of its other calls. It is also obliged to provide support for them in emergencies by contacting their relatives and any necessary medical or other professional support required.
14. Following the concerns raised by the resident’s neighbours, who had heard his calls for help at around 2pm on 17 August 2022, it would have been appropriate for the landlord to have urgently attended his accommodation, and to have contacted his relatives and any necessary medical or other professionals. The fact that it did so at that time by informing his family and calling an ambulance, after which he was hospitalised, meant that it responded to these concerns suitably by following its housing and court manager service managers toolkit.
15. However, the landlord would additionally have been obliged by its housing and court manager service managers toolkit to have urgently attended the resident’s accommodation earlier, if his daily welfare call check at 9.30am on 17 August 2022 had been unable to confirm his safety and wellbeing at that time. While he and his family understandably disputed that it had confirmed this, given that he was found that afternoon having fallen, been unable to get up and having had a stroke after he had described this as occurring at around 2.30am that morning, there was no other evidence of this apart from its records.
16. As the landlord explained that its call recording system was unable to record calls, including its daily welfare check call to the resident on the morning of his fall, it is not possible to determine that it failed to make the call or that it otherwise handled this unreasonably. This is because its records from that time showed that its court manager called and made contact with him at 9.30am on 17 August 2022, in line with its housing and court manager service managers toolkit, and there is no documentary evidence to the contrary. Moreover, as outlined above, it is not possible for this Service to investigate or determine the circumstances in which the resident was found that might otherwise contradict this.
17. The landlord also explained that its daily welfare check calls were not primarily for emergencies, but were a brief check since the previous day, which was appropriate as these did not notify it of emergencies at any time of day. It instead outlined that the resident had emergency pendants for his increased risk of falling, which were out of reach at the time of his fall, but that could otherwise have reasonably been expected to have informed it of this. As the landlord did not receive such a notification on 17 August 2022, it appears that it was not possible for it to have known that it had to attend his accommodation urgently for his fall and stroke until his neighbours reported hearing his calls for help.
18. It is nevertheless very concerning that the resident had to rely on this for assistance that might not have reached him if his neighbours were unable to hear him or if he could not call for help. The landlord has therefore been recommended below to carry out a review of his case to identify learning points for it to seek to prevent its residents at his court from being left without immediate access to urgent assistance again, particularly those with increased risks such as from falling, and to provide him and his family with the outcome. It has additionally been recommended below to give them a clear timescale for its introduction of a more comprehensive call recording system at the resident’s court, as well as details as to how it proposes to verify its daily welfare check calls until then.

Determination

19. In accordance with paragraph 52 of the Housing Ombudsman Scheme, there was no maladministration by the landlord in its response to the resident’s concerns over the handling of a welfare incident.

Recommendations

20. The landlord is recommended to:
    1. Carry out a review of the resident’s case to identify learning points for it to seek to prevent its residents at his court from being left without immediate access to urgent assistance again, particularly those with increased risks such as from falling, and to provide him and his family with the outcome.
    2. Give the resident and his family a clear timescale for its introduction of a more comprehensive call recording system at his court, as well as details as to how it proposes to verify its daily welfare check calls until then.