The Ombudsman's final decision:
Summary: Mrs B complains that home care services commissioned by the Council for her sister in law were unsafe and of a poor standard, and that carers damaged property in the home. The Ombudsman finds there was fault causing injustice, for which a remedy has been agreed.
- The complainant, whom I shall call Mrs B, complains on behalf of her sister in law, Mrs C, that Watershed Care Services, commissioned to provide services on behalf of the Council, provided care which was unsafe and of a poor standard. She also complains that carers damaged Mrs C’s property.
The Ombudsman’s role and powers
- We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
- The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended)
- Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
- If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
How I considered this complaint
- I considered all the information provided by Mrs B about this complaint. I made written enquiries of the Council and considered all the information and evidence it submitted in response. I provided Mrs B and the Council with a draft of this decision and gave them the opportunity to comment on it.
What I found
- Mrs C has multiple sclerosis and requires care services at home. The Council arranged for her to receive a package of care consisting of four care calls per day from Watershed Care Services (WCS), which agreed it could meet Mrs C’s care needs. WCS were responsible for providing Mrs C’s care between 22 September 2017 and 13 November 2017.
Mrs C raises concerns about her care
- On 27 September 20017 Mrs C telephoned the Council raising concerns about the new care provider and asking for a change. She said she had already called the agency herself and the manager had visited but improvements had not been made. nothing had changed. Mrs C needs to be hoisted for transfers. She raised concerns about unsafe transfers, about carers banging the hoist into walls, and about carers not wrapping soiled incontinence pads for disposal. Mrs C said she felt carers were sometimes hurrying her during toileting, and on longer calls they were sometimes playing games on their mobile phones when their care tasks were completed. The Council said it would discuss the issues with WCS.
- The Council rang WCS the following day. WCS said it had visited Mrs C the previous day. It said the two carers involved with the hoist issue had been taken off field work pending the completion of retraining. It said all carers had been asked to dispose of pads in a bag to be put into the main bin at the end of each call. WCS said it would continue to address concerns and check regularly for improvements.
- WCS’s response in respect of the hoisting issue indicates that staff without relevant and up to date training had been using the hoist for Mrs C’s transfers. That was unacceptable, and was fault. In addition to making Mrs C feel unsafe and to lose confidence in her carers, it potentially placed her at risk of injury. It is possible that this also contributed to damage to Mrs C’s home: I will return to this point later in this statement.
- WCS’s response in respect of the disposal of used pads indicates that prior to the issue being raised with them, staff had as Mrs C asserted been placing them unwrapped in the bathroom bin. This basic hygiene failing was unacceptable, and was fault. In addition to impacting on Mrs C’s dignity and causing embarrassment, such a practice placed Mrs C and her young family at risk of infection.
Further contact about Mrs C’s concerns
- Later on 28 September, Mrs B sent an email to the Council on Mrs C’s behalf, setting out the concerns already discussed, including the matter of damage to door paintwork and furniture.
- The Council’s records indicate no further action until mid-October. On 18 October, the Council spoke to Mrs C. The Council noted Mrs C was unhappy with the agency providing her care and agreed to ask the brokerage team to look for an alternative agency. The Council’s records indicate an email was sent to brokerage on 30 October: it accepted the referral and began to look for an alternative care provider.
- Also during the call on 18 October, the Council noted Mrs C said the hoisting had improved but she wondered who would pay for the damage to her home. The Council’s notes said: “She will need to raise this with the agency”. Later, in January 2018 the Council told Mrs that this was essentially an issue between her and the agency, and that the Council was not in a position to resolve it. This was not correct, because the agency had been commissioned by the Council and was acting on its behalf.
- On 24 October, the Council again spoke to Mrs C after WCS reported Mrs C was happy with her care and had no concerns apart from being frightened when hoisted. The Council called Mrs C to check this. In this call Mrs C said damage of paintwork and furniture had got worse, with carers hitting doors frames and furniture with items when walking past. The Council’s records of the call show Mrs C also still had a concern about carers sitting using their phones after completing their tasks, and not interacting with her. The issue with the disposal of used pads appeared to have been resolved. The Council then called WCS to discuss the concerns raised, and WCS said it would look into it.
- On 30 October, the Council called Mrs C. She raised another hygiene concern, about flannels being used to clean her after toileting rather than disposable wipes. She also referred again to the damage being caused to her home, indicting this was an ongoing issue. The Council then instructed the agency to carry out a full investigation.
- On 7 November, the Council identified a new provider to take over Mrs C’s package of care and arrangements were made for this change to be implemented. Mrs C asked again about the damage to her home and who she should talk to about this. The Council said it was awaiting the outcome of WCS’s investigation.
The care agency’s investigation
- On 13 November 2017 WCS sent the Council the findings from its purported investigation. The response, which included no supporting evidence, was as follows, with none of the points of complaint being upheld.
- The first point addressed related to catheter care: this was not a point of complaint Mrs C had raised.
- The second related to the bathroom bin: the investigator said carers had said they emptied the bin when it was half full, and Mrs C had said she wanted it emptied every day. No other issues relating to cleanliness in the bathroom and hygiene measures were mentioned in the response.
- The third point related to the use of flannels and of disposable wipes. It said Mrs C had asked carers to stop using the flannel after her daughter had been caused an infection by using it, and carers had then started instead to use wipes.
- The final point concerned carer’s time and the use of their phones. It said the agency used a logging system which meant carers had to input data to their phone after each call. The response did not address Mrs C’s concerns about carers spending time playing games on their phones during their calls.
- The Council rightly considered WCS’s response was inadequate and requested a fuller response. WCS then provided its ‘investigation report’. Scant reference was made to supporting evidence for the responses provided and the quality of the investigation was poor. The issue of damage to Mrs C’s home was not addressed at all.
- On 6 December Mrs C again asked the Council about the damage to her property. She was advised to await the outcome of WCS’s investigation.
- WCS provided its complaint response to Mrs C in mid-December. Mrs C was dissatisfied with the response and wrote back to WCS setting out her reasons. The response was very poor and did not comply with the standards set out in its own complaints procedure. That was fault.
- The Council called and emailed the agency several times to chase issue of damage to Mrs C ‘s property without reply. On 5 March 2018 WCS said it had not been aware of damage being a concern earlier: the evidence shows this was not true. The Council said it would not close the case until the issue was resolved. However, despite chasing, by 26 April 2018 the Council had heard nothing more from the agency.
Damage to property
- The issue of damage to paintwork and furniture was raised to the Council on 28 September. Mrs B offered photographs. Even when Mrs B made it clear the matter was unresolved and the agency were failing to address it, no steps were taken to see the damage or correctly advise Mrs B about routes of redress open to her. Mrs B could pursue a claim for damages against the Council’s insurance and ultimately through the court, although she has never been so advised by the Council, which is fault. Notwithstanding Mrs B’s right to go to court, having had regard to all the circumstances of the case I have exercised discretion to look at this issue. While I cannot conclude with certainty that damage was caused by the carers, what is clear is that the failure to act on the reports of damage and deal with the matter properly was fault. The opportunity to resolve the matter at an earlier stage was lost.
Carers using their phones during care calls
- I cannot reach a view on whether carers were using their phones inappropriately during care calls. The agency has said carers needed to log tasks on their phones for the last few minutes of a call, which is reasonable. However, it is clear that the investigation of this matter by the agency was inadequate and the evidence the agency relied on to support its conclusion did not address the actual complaint being made.
- On the evidence so far seen the agency’s record keeping was poor. A care plan, which was not provided to me despite my request for it, had another service user’s name within it. Responses to the complaint, to the Council, and to the Care Quality Commission (CQC) appear to lack substantiating evidence. Of particular concern is WCS’s response to the CQC’s enquiries, which alleges that it had come to light during the first four days of care that Mrs C ‘did not want to be touched by a certain race’. It also refers to a request from the family for a contribution towards the cost of rectifying damage as a gesture of goodwill ‘since it is Christmas’. These remarks were not relevant and may be seen as seeking to discredit Mrs C and the validity of her complaint, and they ought not to have been made. I have seen no evidence to support the assertions made.
Injustice to Mrs C
- As set out above, the hoisting by staff without up to date training caused Mrs C to feel unsafe and to lose confidence in her carers, and it potentially placed her at risk of injury. The poor hygiene practices placed Mrs C and her family at risk of infection, and caused Ms C embarrassment. The inadequate complaint handling and the failure to address the issue of damage to property caused Mrs C distress and to feel they were not being listened to. Mrs C and her representative were put to unnecessary time and trouble pursuing the complaint.
- When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the care provider, I made recommendations to the Council.
- In recognition of the injustice caused to Mrs C by the faults identified by my investigation, I recommended that within four weeks of the date of the decision on this complaint the Council takes the following action:
- Pays Mrs C a total of £500 (£200 for potentially unsafe hoisting; £100 for unhygienic practices; £200 for the failure to address the damage issue, compounded by poor complaint handling); and
- Issues her with a formal written apology.
- In addition, I recommended that within three months of the date of my decision the Council reviews lessons learned from this complaint in terms of complaint handling where an agency acts on its behalf in delivering services.
- The Council has agreed to my recommendations.
- I have completed my investigation on the basis set out above.
Investigator's decision on behalf of the Ombudsman