Mrs Jane Marie Somai (18 005 154)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 13 Feb 2019

The Ombudsman's final decision:

Summary: Mrs X complained about the care her mother-in-law, Mrs Y, received from the Care Provider, and about how it responded when she raised concerns. The Care Provider was not at fault in how it cared for Mrs Y. However, there were insufficient records, including around risk assessments and complaint investigation. The Care Provider did not respond to parts of Mrs X’s complaint. These faults did not cause Mrs Y to suffer any harm. However, they led to uncertainty and time and trouble for Mrs X. The Care Provider has agreed to apologise to Mrs X and pay her £150. It has also agreed to review how it handles complaints and update its complaint response letters. In response to my recommendations the Care Provider has already issued a staff reminder about the importance of record-keeping and updated its complaints policy.

The complaint

  1. Mrs X complained on behalf of her mother-in-law, Mrs Y. She complained about several issues with Mrs Y’s care package and about how the Care Provider responded when she raised concerns. She complained, in particular, the Care Provider:
    • Left Mrs Y’s front door open after a care call, leaving her at risk.
    • Moved items out of Mrs Y’s reach, including a white board, telephone and drinks. This left her at risk of anxiety and dehydration, and caused concern to the family.
    • Left Mrs Y with her recliner's foot rest up, causing her to slide downwards and experience pain.
    • Did not keep proper records meaning the family was not sufficiently updated about Mrs Y’s wellbeing.

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The Ombudsman’s role and powers

  1. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
  2. If an adult social care provider's actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
  3. If we are satisfied with a care provider’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)
  4. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
  5. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

  1. For this investigation, I:
    • considered the information Mrs X provided and discussed the complaint with her;
    • made enquiries of the Care Provider and considered the comments and documents it provided;
    • looked at the relevant law and guidance, including the Health and Social Care Act 2008;
    • considered the Ombudsman's guidance on remedies; and
    • wrote to Mrs X and the Care Provider with my draft decision and considered their comments.

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What I found

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
  2. One of the fundamental standards (regulation 12 of the regulations for service providers and managers) is about safety. This says people receiving care should not be put at risk of harm that could be avoided. It says care providers should be able to demonstrate they have taken all reasonable steps to ensure the health and safety of those receiving care. It says they should complete risk assessments and create plans for managing risks.
  3. Another standard (regulation 16) is about complaints. This says care providers must thoroughly investigate complaints. This includes keeping records of complaints and actions taken. The CQC guidance says care providers must make complainants aware of how to take further action if they are not satisfied after the provider has responded to their complaint.
  4. Another standard (regulation 17) is about good governance. This includes keeping accurate, complete and detailed records about people receiving care, including records of care provided and decisions made relating to care.
  5. The Care Provider’s complaints and compliments policy says when it receives a written complaint, it will investigate and respond within 28 days. It says this response will give details for the complainant to write to the Care Quality Commission if they remain unsatisfied. There is not a second stage of the complaints process. The Care Provider’s policy does not signpost complainants to the Ombudsman.

What happened

Mrs Y’s care package

  1. Mrs Y, Mrs X’s mother-in-law, received a package of home care from January 2018 after a hospital admission. Mrs Y’s needs assessment and care plan noted she was not fully mobile and so there was a key safe for carers to get into the property. It noted carers should record what she ate and they should make sure she was having enough to drink. It recorded she had back pain, and she generally liked to go back to bed in the morning, then get up at lunch time to sit in her chair which would help to relieve the discomfort.
  2. The Care Provider’s daily records note that one day at the beginning of January 2018, Mrs Y told carers she was in too much pain to be moved to her chair at lunch time. Carers gave Mrs Y her nutritional supplement drink and cups of tea during visits. The notes do not say whether these were left within her reach when carers left. There is no record of what food carers offered to Mrs Y that day, and if she accepted it.
  3. One day at the end of January, the Care Provider recorded Mrs Y wanted to go to bed at midday, so they helped her back into bed for the afternoon. The carer encouraged her to eat but she refused. The notes do not say whether drinks were left within Mrs Y’s reach when carers left. Carers later recorded she was very unsteady on her feet at the next visit that afternoon, and gave her tea and her nutritional drink.
  4. One day in mid-February, Mrs X called the Care Provider to say the pharmacy had found Mrs Y’s front door open when delivering her medication. The Care Provider explained it would investigate this and speak to the carers. It did so the following day. Carers said they had not left the door open. They explained Mrs Y’s family member often visited that day of the week and it could have been them. Mrs X says the family member did not visit that day. The Care Provider recorded it could not establish who left the door open, however it had reminded the carers to check doors.
  5. On another day in mid-February, the daily records noted Mrs Y refused to get up and wanted to stay in bed. The carer recorded they gave her toast which she hardly ate, and gave her tea and a nutritional drink. The notes do not say if drinks were left within her reach when carers left.
  6. On two occasions in February, a carer recorded they could not transfer Mrs Y to her chair because they did not have the correct equipment to do so on days when she could not bear her own weight. On both occasions, the carer gave Mrs Y food and drink, and her nutritional drink. The notes do not say if drinks were left within her reach when carers left.
  7. On another date in February, a carer recorded Mrs X said she did not feel well enough for getting up. On this occasion, they recorded they left food and drink “as close as we could”.
  8. There is no mention in the daily records of carers moving Mrs Y’s white board or telephone. The Care Provider says it was not made aware of these concerns until Mrs X made a formal complaint. There is no record of carers leaving the foot rest of Mrs Y’s recliner up.
  9. The family arranged with the Care Provider for the contract to end in March. The Care Provider said in an email to a family member “Again I apologise for the mistake the carer made, she has been spoken to regarding this”. I asked the Care Provider what this referred to. It said this was in relation to the incident with the door, however it was not an admission of fault as it said it had not yet completed its investigation at that time.

Mrs X’s complaint

  1. Mrs X complained to the Care Provider in April 2018. She highlighted the risk to Mrs Y when the door was left open. She listed several other issues, for example:
    • Carers had moved the white board which included important information for
      Mrs Y, and her telephone. This caused Mrs Y and the family anxiety.
    • Carers left Mrs Y in bed without access to food and drink on two occasions. Dehydration worsens Mrs Y’s confusion and the Care Provider knew this was important.
    • Carers left Mrs Y in her chair with the recliner footrest up on one occasion and she slid down during the day, causing great discomfort. Carers were aware
      Mrs Y had neck and spine issues and she could not reposition herself.
    • Carers records were poor.
  2. The Care Provider replied to Mrs X at the end of April. It said:
    • It had spoken to another family member after the incident with the door, and it asked its carers to complete an incident report. The carers had said they thought the door was closed when they left, but the Care Provider had made clear to carers it was important to double-check the door when leaving.
    • On the dates when Mrs Y stayed in bed, the carers gave her food and drinks during their visits. They had not left food and drink on the table by her bed for health and safety reasons. Mrs Y would have to lean to get to the table and there were no side rails on her bed.
    • The Care Provider could not investigate the incident when Mrs Y slid down during the day, because Mrs X had given no date. Foot rests were generally recommended to reduce leg swelling, and the Care Provider was confident the carers were acting in Mrs Y’s best interests.
    • The Care Provider was happy with the quality of record-keeping.
  3. The Care Provider did not comment on the issues Mrs X raised about the white board and telephone. The Care Provider told me this is because it had no evidence to prove the allegation. The Care Provider did not signpost Mrs X to the Ombudsman.
  4. Mrs X sent another letter to the Care Provider in mid-May. She said:
    • She wanted the Care Provider to further investigate what had happened when the door was left open, and policies to be put in place to prevent it happening to someone else. Nobody had spoken to the other family member about this.
    • The family did not consider it would have been a risk to leave a drink on the table by Mrs Y’s bed, because the bed was low.
    • Mrs Y did not have issues with leg swelling. The incident with the foot rest caused worsening of Mrs Y’s back problem.
  5. Mrs X says the Care Provider signed for the letter but did not reply, and so she contacted the Ombudsman in July 2018.
  6. The Care Provider told the Ombudsman it had no evidence carers did anything wrong or that care plans were inadequate. It told the Ombudsman it had not wished to get into a “he said she said” situation, so it had not responded to Mrs X and it did not intend to do so. The Care Provider said it had apologised on a few occasions, mostly verbally and in an email, and it did not feel it could do more than this. Mrs X says the Care Provider did not apologise over the telephone, like it says. I have seen evidence it apologised via email.


  1. There is insufficient evidence for me to say how Mrs Y’s door came to be left open. The Care Provider took the action I would expect to investigate. In the absence of any substantive evidence, I do not see there is more it could have done to investigate what happened. Mrs X says the family member did not visit that day and so it could not have been them that left the door open. However, there was no substantive evidence to say who did and the Care Provider could not come to a sound conclusion. The Care Provider reminded its carers to check doors. It offered apologies to the family although it says this was not an admission of fault. It responded appropriately in its complaint response. The Care Provider was not at fault. In any event, Mrs Y did not come to harm.
  2. I also cannot say whether, and if so why, Mrs Y’s white board and telephone were left out of her reach and her recliner’s foot rest was left up. These issues were not included as part of Mrs Y’s care plan and so I would not expect carers to have made specific records about these issues in their daily notes. Mrs X did not raise these concerns until she complained. The Care Provider responded about the foot rest in its complaint response, however due to insufficient information it could not come to a decision on this element of Mrs X’s complaint.
  3. The Care Provider told me it did not comment on the issues of the white board and telephone being moved because there was no evidence to support these allegations. I would expect the complaint response to have commented on these issues. If an investigation found there was no evidence, it would have been sufficient for the Care Provider to say this. I have not seen any contemporaneous evidence of how the Care Provider investigated these allegations, nor has it retrospectively explained its investigation when I asked it what steps it took. On balance, the Care Provider did not properly investigate these concerns and it did not cover these points in its complaint response. This is fault. This led to uncertainty for Mrs X and time and trouble in her having to bring her complaint to the Ombudsman. The Care Provider lost the opportunity to resolve these matters. Considering the time elapsed since the events, it could not be guaranteed that carers’ recollections would now be sufficient for it to reach a sound conclusion.
  4. The Care Provider acknowledged food and drinks had been left out of Mrs Y’s reach on those occasions she stayed in bed. The records show, generally, that carers ensured they offered her food and drinks whilst they were present providing care. However, some records lacked this detail. I cannot say carers did not offer Mrs Y food and drink on those visits. Carers did not, on all occasions, record what Mrs Y had eaten and what they had offered her. The care plan said carers should record this. This is fault.
  5. The Care Provider told Mrs X food and drink were left out of Mrs Y’s reach for health and safety reasons, however there is no risk assessment showing how the Care Provider made this decision. Given its note in Mrs Y’s care plan that it should ensure she had enough to drink, I would expect it to have produced a risk assessment for the decision to leave drinks out of her reach. There is no evidence it weighed up the risk of Mrs Y leaning over to her side table without bed rails, against the risk of dehydration. A decision not to leave drinks on the table, in itself, would not necessarily be fault if the decision was reached properly. The Care Provider has not evidenced how it considered the risk to Mrs Y and how it made this decision. Therefore, the Care Provider is at fault. The lack of records and risk assessment led to uncertainty for Mrs X about what support had been provided to Mrs Y and why.
  6. The Care Provider’s complaints policy and complaint responses did not signpost Mrs X to the Ombudsman. This is fault. Mrs X went to the time and trouble of contacting CQC before being signposted to the Ombudsman as the appropriate body. CQC does not consider individual complaints, but uses such reports to inform its inspections of care providers.
  7. There is no evidence the Care Provider did not give Mrs Y appropriate care. There is no evidence Mrs Y came to harm. However, there were issues with the Care Provider’s response to concerns and its record-keeping, causing injustice to Mrs X who was complaining on Mrs Y’s behalf. I have therefore made recommendations for the Care Provider to remedy this.

Agreed action

  1. The Care Provider has given apologies in relation to Mrs X’s concerns about care. I recommended the Care Provider also apologise to Mrs X and pay her £150 to acknowledge the uncertainty and time and trouble caused to her by the faults I identified. It has agreed to take these steps within one month of my final decision and it should provide evidence to the Ombudsman. The Care Provider has sent evidence to the Ombudsman of an apology to Mrs Y, but this recommendation requires it to apologise to Mrs X.
  2. I recommended the Care Provider issue a staff reminder about the importance of record-keeping. It agreed and has completed this recommendation.
  3. I recommended the Care Provider review how it records its investigation of complaints. It has agreed to do so within three months of the date of my final decision and it should provide evidence to the Ombudsman.
  4. I recommended the Care Provider review its complaints policy and complaint response letters to make sure they signpost complainants to the Ombudsman as the appropriate body to investigate individual complaints. It agreed to do so within three months of my final decision. The Care Provider has provided evidence it has updated its complaints policy and this part of the recommendation is complete. It should provide evidence of its updated complaint response letters to complete this recommendation.

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Final decision

  1. I have found fault causing injustice to Mrs X. The Care Provider has agreed to my recommended action to remedy this. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman

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