Gloucestershire County Council (18 001 614)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 05 Feb 2019

The Ombudsman's final decision:

Summary: There is evidence of fault in this complaint. The Council failed to properly monitor the quality of domiciliary care provided to Mrs Y. It also failed to address reports about Mrs Y’s son’s inappropriate behaviour. This caused an injustice in terms of the quality of care Mrs Y received and to her family in terms of worry and uncertainty she was not being cared for properly.

The complaint

  1. Ms X complains the Council failed to properly investigate her complaint about poor quality domiciliary care provided to her grandmother. She complains about carers not keeping to allocated times, late calls, missed calls, and care tasks not being completed. She also complains a revised care plan was not actioned.

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The Ombudsman’s role and powers

  1. 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)
  2. 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)

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How I considered this complaint

  1. I have:
  • considered the complaint and discussed it with Ms X;
  • considered the correspondence between Ms X and the Council, including the Council’s response to the complaint;
  • made enquiries of the Council and considered the responses;
  • taken account of relevant legislation;
  • offered Ms X and the Council an opportunity to comment on a draft of this document.

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What I found

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 apply to care providers. The Care Quality Commission (CQC) monitors, inspects and regulates adult care services providers to ensure they meet fundamental standards of quality and safety.
  2. The CQC has provided guidance on the regulations which says that:
  • The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
  • Any complaint must be investigated and necessary and proportionate action must be taken in response to any failure identified (regulation 16).
  • Service users must be protected against unsafe or inappropriate treatment by keeping of accurate records (regulation 17)

What Ms X says

  1. Ms X complains on behalf of her grandmother Mrs Y. Mrs Y is in her sixties. She has physical health and mobility difficulties. She received domiciliary care from Comfort Call Care Agency (the Agency) commissioned by the Council since October 2016. She had two calls daily.
  2. Mrs Y’s son, Mr Z, lives close to Mrs Y. He visits regularly throughout day and assists with practical tasks. Ms X does not live close but has regular contact with both Mrs Y and Mr Z.
  3. Mr Z told Ms X that carers were either turning up later than agreed, or not all, and that some personal care tasks were not being completed. Mr Z was frustrated and would call the Agency to complain. The Agency accused Mr Z of being rude, aggressive and intimidating to carers and office staff. Ms X says she took over dealing with complaints to the Agency and the Council.
  4. Ms X complained to the Agency about carers timekeeping and record keeping. She says carers were not accurately recording the time they arrived or how long they stayed. She also complained some care tasks were not completed. For example, Mrs Y’s hair was sometimes not washed and skin creams not applied. Bedding was not changed unless prompted by family. Incontinence pads were left in the house.
  5. Ms X first raised a complaint with a manager from the Agency in March 2018. She with a manager from the Agency on 8 March 2018 to discuss her concerns and to revisit Mrs Y’s care plan. Ms X does not live close to Mrs Y and travelled a considerable distance to attend the meeting. She says the manager was twenty minutes late to the meeting. She was accompanied by a senior carer.
  6. During the meeting Ms X says the manager sought to blame Mr Z for carers not completing care tasks, and for occasions carers missed visits. The manager said Mr Z was sometimes rude, intimidating and swore at carers. Ms X says carers had a laugh and a joke with Mr Z, she does acknowledge that Mr Z’s frustration with the situation can get the better of him. The manager told Ms X she would investigate the issues raised. Ms X also complained about a specific carer. The manager told her the carer had left the Agency. Ms X says the manager agreed to refer Mrs Y for an Occupational Therapy assessment, a fire assessment, and contact the Council’s housing team about an issue with Mrs Y’s hot water.
  7. Ms X says the manager then had a private discussion with Mr Z in the kitchen. Following this the manager left the meeting and the senior carer stayed to discuss Mrs Y’s care plan.
  8. Ms X went through the care plan with the senior carer and an agreement was reached about call times and regular carers. Ms X says the senior carer telephoned the office to find out which carer would visit Mrs Y that evening but no one in the office had this information. The carer told Ms X she would do that evenings visit. She told Ms X she had to take the revised care plan back to the office so the manager could read and confirm it. Ms X says the carer did not do the evening visit to Mrs Y as she said she would.
  9. Later the same month Ms X telephoned the care agency and the telephone was answered by the carer who the manager said had left. Ms X made a complaint about this on 4 April 2018 but she did not receive a response.
  10. On 6 April 2018 Ms X visited Mrs Y. She arrived at 9pm. On arrival Mr Z told Ms X a carer turned up around 8:30pm, went into the lounge, sat down without acknowledging Mrs Y, telephoned the office, cried and left. Ms X telephoned the office at 9:00pm to ask why the carer left without completing the care tasks, and to ask if a replacement carer had been arranged. Ms X says the person she spoke to could not answer her questions.
  11. Ms X telephoned the office a further three times the following day, a Saturday, to speak to a manager but the call was not answered.
  12. On 9 April 2018, Ms Y contacted the agency and spoke to a manager. The manager said Mr Z’s behaviour towards carers was creating difficulty. Ms X enquired if the agency had made a referral to OT, as she said she would. The manager said she would ‘look into it’
  13. Following this Ms X says carers did not keep to agreed times, and did not inform Ms X or Mr Z if they were running late. On occasions carers turned up after 11am.
  14. On 24 April 2018 Ms X says the carers turned up at 7pm and ‘demanded’ Mrs Y went to bed. Mrs Y didn't want to but felt she had no choice. Mrs Y was very upset by this. Following this Ms X telephoned the office to complain and asked to speak to a manager. She was told the manager was on leave and would contact her when she returned to work.
  15. Ms X says outcomes of investigations into complaints made in March 2018 and April 2018 were not communicated to the family.
  16. The care agency gave Mrs Y notice in May 2018. Ms X believes this is because there was an ongoing complaint.

What the care records show

  1. As part of this investigation I considered the daily care records completed by carers. The time of the morning visit varied between 8.15am and 10.45am. On some of the visits Mr Z had assisted Mrs Y to dress before carers arrived.
  2. The records show on occasions Mr Z was said to be rude to carers.
  3. On 16 January 2018, the care agency completed an investigation about a missed evening call to Mrs Y, incontinence pads being disposed of in the kitchen bin, and that some carers handled Mrs Y roughly.
  4. I have seen a copy of the investigation report completed by the care agency which shows:
  • the reason for the missed call and the action taken by the agency.
  • that carers were disposing of incontinence pads in the kitchen bin but this was as instructed by Mr Z. Following the investigation, the agency instructed carers to dispose of pads in the outside bin only.
  • three carers were allocated to Mrs Y until a regular carer could be identified
  • the care agency was in the process of arranging a meeting with Mrs Y’s family.
  1. In March 2018, a carer did not arrive until 11.45am. Mrs Y was then assisted to wash and dress. On another occasion, 1 April 2018, a carer arrived at 11.20am. On this occasion Mrs Y was already up and dressed, Mr Z had assisted her with support from a female neighbour. The carer recorded Mr Z’s dissatisfaction with the late call.
  2. It appears some time entries of the daily care log have been ‘written over’.
  3. The records show Mr Z was present during some carer’s visits. Many occasions there were no issues recorded about his behaviour, on others his dissatisfaction about timings is recorded, some records report him to be rude to carers and on one occasion threatening the Agency office staff. All relate to poor service or late/missed visits.
  4. On 24 April 2018, the records show Mr Z a telephoned the Agency to complain about a carer arriving late than morning. Mr Z said had “kicked her [the carer] out”. The Agency said it would investigate why the carer was running late and get back to him. Following the call, the Agency telephoned the Council to express concerns about Mr Z’s behaviour.
  5. The Agency’s investigation into a carer demanding Mrs Y go to bed on 24 April 2018 found the allegation to be true. The Agency said the carer was new to her role and required additional training.

What the Agency says

  1. The Agency says it began receiving complaints from Mr Z in March 2018. It says there was agreement that when care was provided to Mrs Y that Mr Z would not be present. From around March 2018 Mr Z was often present when carers arrived. He could be ‘vocal’ and intimidating towards carers. One carer alleges Mr Z attempted to sell her stolen goods.
  2. The Agency says on some occasions carers arrived Mr Z had completed the care tasks and would send the carers away. On one occasion, a carer arrived for an evening visit and Mr Z “screamed at her and was very aggressive. She rang the on call because she was so scared, on call could hear the son in the background, and advised her to leave without delivering the care. On call stayed on the line with her until she was in the car and advised her to lock doors and drive away. As son was already there, on call did not feel it appropriate to send another carer into an already volatile environment”.
  3. The Agency says when Mr Z telephoned the Agency to complain he would sometimes use aggressive and threatening language. On one occasion, he threatened to go the office and “sort the office staff out”. On another occasion, a previous manager of the Agency and a social worker attended a meeting at Mrs Y’s home, when they arrived Mr Z was present. The meeting had to be halted because of Mr Z’s aggressive behaviour.
  4. A second meeting was arranged with a new manager and senior carer. It was agreed Mr Z would not be present. When the manager and senior carer arrived Mr Z was there. During this meeting, the senior carer completed a new care plan, and this was agreed by the family. The new care plan was implemented the following day.
  5. The Agency says it continued to receive threatening telephone calls from Mr Z, and he continued to turn carers away. It contacted the Council and subsequently gave two weeks’ notice to end the contract.
  6. The Agency says it did not agree to arrange an OT assessment because there were no concerns about Mrs Y’s mobility.

What the Council says

  1. The Council says its investigator met with the Mrs Y’s family to go through the complaint. It says it believes the family’s views were considered and balanced against the evidence of the Agency. It says no physical evidence was provided by the family.
  2. During its investigation, the Council says it did not comment on the content and conduct or meetings and discussions between the family and the Agency, but tried to present a balanced view based on the evidence seen.
  3. The Council acknowledges there were areas of concern with the Agency’s record keeping. It found partial fault by the Agency because of this.
  4. It says it saw evidence in the Agency’s files of Mr Z’s alleged behaviour. No risk assessment was completed by either the Agency or the Council.
  5. The Council says the Agency is rated as ‘Good’ by the Care Quality Commission.


  1. When a council commissions care services for a person it remains liable for any service failures of the care provider. Council’s should ensure care providers keep proper daily care records, including the start and end time of visits so it can be assured that the service is reliable and timely.
  2. Timely visits to vulnerable people in their own homes are an important part of meeting individual needs and ensuring their wellbeing.
  3. In this case the Council failed to respond properly to complaints about timings of visits. Although I accept that there may be a few occasions when the carer may be running late, this should be the exception, not normal practice. Regular late visits are not acceptable, as they leave individuals feeling anxious and potentially at serious risk.
  4. A visit should be considered late where an individual has not received a visit within 30 minutes of the scheduled time. Where there is a delay the Agency should at the very least contact the individual or carer to advise of the delay.
  5. In this case visits to Mrs Y regularly varied by more than 1 hour. On at least two occasions carers did not arrive until after 11am. Start times were erratic which meant Mrs Y never knew when carers would arrive. This is fault. This caused Mrs Y and her family worry and uncertainty.
  6. I have seen no evidence of any agreement that Mr Z would not be present during carer’s visits.
  7. The Agency says Mrs Y was often up and dressed when carers arrived, and on occasions Mr Z turned carers away. This occurred because Mrs Y and Mr Z had no certainty about the arrival of carers. Mr Z’s frustration is understandable, however that does not make abusive or intimidating behaviour acceptable. Such behaviour jeopardises a care package.
  8. The Council was aware of allegations about Mr Z’s behaviour. The Agency reported its concerns and records show that a social worker was present during a meeting that needed to be halted due to Mr Z’s behaviour. The Council failed to respond to this properly. It should have completed a full risk assessment and referred the matter to safeguarding. Allegations made about Mr Z offering a carer stolen goods should have been reported to the police.
  9. Mrs Y’s family made numerous complaints to the Agency about late calls and carers not completing care tasks properly. The Agency investigated and records show most of the issues were found to be valid. It is not clear from the records if the Agency informed the family about the outcome.
  10. In April 2018, the family complained to the Agency saying a carer demanded Mrs Y go to bed at an evening visit. The Agency investigated properly, and took appropriate action. Records show the Agency telephoned the family to discuss the outcome, but there was no answer. It recorded that letters were not being sent to “the address” due to Mr Z’s aggressive behaviour. There is no logic to this. Whether the family were informed by telephone or letter Mrs Y’s family, including Mr Z, had a right to know the outcome of their complaint. Given the care agency’s concerns about Mr Z’s behaviour a written response would have been appropriate. Had it done so the family may have been reassured it had conducted a proper investigation.
  11. I have seen no evidence to show the Council properly addressed the various issues Mrs Y’s family complained about. Neither did it properly address the issue of Mr Z’s behaviour. Consequently, the problems went unresolved, the situation escalated and the Agency gave notice.

Agreed action

  1. The Council will within four weeks of the date of the final decision:
  • provide Mrs Y with a written apology for its failure to monitor the timeliness and quality of a service it commissioned;
  • provide Ms X with a written apology and make a payment of £250 to Ms X to reflect the time and trouble pursuing the matter, including this complaint;
  • ensure effective monitoring of commissioned domiciliary services, and complaints about the same are properly investigated.

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Final decision

  1. The Council failed to properly monitor the quality of care provided to Mrs Y. It also failed to address complaints about this, and failed to address reports about Mr Z’s inappropriate behaviour.
  2. This caused an injustice in terms of the quality of care Mrs Y received and to her family in terms of worry and anxiety she was not being properly cared for.
  3. The Council also failed to properly address allegations about Mr Z’s inappropriate behaviour.
  4. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman

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