Summary: The Ombudsman has found fault with the agency’s care records and its provision of care and medication. The Ombudsman recommends that the Council, which commissioned the care, apologises to Ms B and pays her £300. The Council should also refer the agency to the CQC guidance on record keeping.

The complaint

1. Ms B complains about Homecarers Liverpool Limited care agency. She complains on behalf of her mother, Mrs C, who has sadly passed away. She complains about the Agency’s records on 4 August 2018, which she says did not correspond to the actions of the carer. She says there were previous incidents of poor recording of care and medication and failure to provide care and medication.

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The Ombudsman’s role and powers

2. 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)
3. We investigate complaints about councils and certain other bodies. 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)
4. 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

5. I have discussed the complaint with Ms C. I have considered the documents she and the Council have sent, the relevant policies and guidance and both sides’ comments on the draft decision.

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What I found

6. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve.
8. The CQC has issued guidance on the regulations. This says that:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).
• The nutritional and hydration needs of the service user must be met. (regulation 14).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The care provider must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

Background

9. Mrs C was an elderly woman who suffered from dementia. She lived at home with a package of care which the agency provided, paid for by the Council.
10. The agency started to provide care on 16 February 2017. The support plan said the carer should attend twice a day for one hour, at 10:00 and at 17:00. The morning call was later changed to a lunch time call. The carer had to assist Mrs C with:
• Personal care tasks such as washing and getting dressed.
• Meal preparation and preparation of drinks.
• Providing breakfast in the morning and then prepare a microwave meal at lunch and leave a sandwich for dinner.
• Taking prescribed medication from a lockable box and supervise and prompt with medication.
11. There were initially a few incidents where Mrs C would not allow access to the house.
12. There were also some difficulties with the medication as the lock on the medication box was broken. The family then replaced the box with a digital safe.
13. There were still problems however with the medication as the family said one of the carers had left the safe open. The family complained on 8 May 2017 that one of the carers had not given Mrs C her inhaler in the morning and the inhaler had not been kept in the medication safe, but was found in Mrs C’s handbag. The agency then noted that the correct inhaler was not on the medication administration record (MAR) and the incorrect inhaler was on their care recording system. On 17 May 2018 the family found a tablet in the hallway.
14. There were recurring problems with Mrs C refusing care and putting food in different places around the house.
15. The main incidents which are the subject of Ms B’s complaint were in March 2018, April 2018 and August 2018.

20 March 2018

16. Ms B made a safeguarding referral to the Council on 20 March 2018. She said:
• Mrs C was admitted to hospital on 19 March 2018 and was discharged on the same day.
• She rang the agency around 16.40 on 19 March 2018 and told them Mrs C was being discharged.
• She cancelled the afternoon call for that day, but said Mrs C would need her morning call the following day as usual.
• She rang the agency at 17:00 on 20 March 2018 as the agency had missed both calls and this meant that Mrs C had not received any care that day and had missed her medications.
17. The Council started a safeguarding investigation into the incident. The agency said:
• It rang the hospital on 20 March 2019 and the hospital staff said that Mrs C was still in the hospital.
• It rang the hospital again in the afternoon and was told the same thing.
• The agency tried to Mrs C’s three granddaughters but could not get through to them.
• The agency thought that Mrs C was still in hospital and did not provide her with any care.
18. The Council concluded that the safeguarding allegation was substantiated. Ms B had told Agency K that Mrs C needed care from 20 March 2018 and the agency failed to provide it. Agency K agreed that it should have followed the family’s information. Agency K said it would ensure it always contacted the family directly in any future hospital admissions.

25 April 2018

19. The carer attended the lunch time call on 25 April 2018 and failed to give Mrs C her medication, but said she had done so on the recording system. A different carer found the medication in the lid of one of the nutrition drinks and reported this. The agency informed the family. The agency informed the Council on the following day.
20. Ms B made a complaint about the incident.
21. The agency’s internal investigation said:
• A referral should have been made to the Council and the CQC on the day of the incident.
• The incident had not been properly recorded in the agency’s records as there should have been an incident report.
• The agency should have called the family back earlier to update them on the outcome of the complaint.
• The carer who failed to give the medication had been told she should not attend Mrs C’s house.

4 August 2018

22. Agency K uses a digital recording system which lists the care services the carers should be providing and then asks them to confirm whether the actions have been done or not. It is both a prompt and a record of what happened.
23. In terms of food and drink, there are four different headings in the system:
• Nutrition.
• Hydration.
• Food chart.
• Encourage Mrs C to eat.
24. It is my understanding there was also a written food chart but I have not seen a copy of that chart. The records for the day before Mrs C went into hospital say the following:
25. 4 August 2018 – lunch time call:
• ‘[Mrs C] in bed on arrival. Went up to her. Not good on her feet today. She also has a big bruise on each hand. All tasks carried out and completed. Meds administered and taken. Had to leave Mrs C upstairs in bed as couldn’t get her downstairs. Office and family informed. No other care required. Upstairs in bed on leaving.’
• Nutrition: cheese sandwiches and sausage roll, quavers, lemon cake bar, cup of tea with milk.
• Hydration: water, juice, nutrition drink, cup of tea with milk. The carer answered ‘yes’ to the questions ‘fluid taken during visit’, ‘fluid taken since last visit’ and ‘fluid left’
• Food chart: cheese sandwiches, lemon cake bar, quavers, sausage roll, cup of tea with milk, nutrition drink, glass of water, glass of juice.
• Encourage to eat: ‘Encouraged her to eat but she has refused. Kept trying but would not eat. Had little sip of nutrition drink and water.’
26. 4 August 2018 - tea call:
• ‘[Mrs C] did want to eat. I encourage her but still said no.’ (I assume the first sentence is meant to say, ‘Mrs C did not want to eat.’)
• Nutrition: ‘Did not want to eat.’
• Hydration: The carer said ‘no’ to the questions ‘fluid taken during visit’, ‘fluid taken since last visit’ and ‘fluid left’.
• Food chart: Toast with cheese, tea with milk, nutrition drink and one left for glass of juice.
• Encourage to eat: sausage roll, bread and cheese, cake.
27. The carer who attended on the following day found Mrs C to be confused and delusional. She rang an ambulance and Mrs C went to hospital.
28. Ms B made a safeguarding referral to the Council on 8 August 2018 and made a complaint to the agency on the same day. She said the carer had said in her record that she had provided Mrs C with cheese on toast, sausage rolls, a cup of tea, juice and so on. She said she had seen the CCTV of the evening call and the carer did not give Mrs C any of the food or drink that she recorded she did. All she did was give her water and her medication. The carer also went upstairs for long periods of time and there was no need for her to do so.
29. She said Mrs C was in hospital with dehydration and an infection and Ms B felt this was because of the agency’s neglect.
30. The Council started a safeguarding investigation.
31. The agency’s manager replied to the complaint on 20 August 2018. She said:
• She had reviewed the care records for Mrs C for 4 August 2018, but, as she did not have access to the CCTV, she could not comment on any difference between the CCTV footage and the records.
• The care worker had shared her concerns about Mrs C on 4 August 2018 and the agency had contacted the family to let them know.
• She told the family about the bruising on Mrs C’s hands, the pain in her legs and the fact she was staying in bed.
• The records showed that Mrs C was still well on the days before 4 August 2018. She said the staff had all been trained appropriately.
32. Sadly, Mrs C passed away on 29 August 2018.
33. The Council completed its safeguarding investigation on 11 February 2019. It said the evidence showed abuse occurred and said the allegation had been substantiated.
34. It said there was evidence in the records that Mrs C refused personal care and food in the days before her admission to hospital and there was accelerating frailty, weight loss and meals being left, disposed of or hidden.
35. It said there was ‘no clarity in between visits of what food was left from the previous evening and what was eaten the next day, not clear of fluid volume from one day to the next… Fluid and nutritional charts in situ recorded on 14 June 2017 went missing on 3 July 2017. No evidence of review of fluids or nutrition and no evidence of the charts being replaced. What is clear from the evidence viewed is that [Mrs C] did miss her medication and carers failed to administer her inhaler on a few occasions. CCTV evidence confirms that on that particular day with a particular carer food or fluids were not observed being given records however dispute the visual evidence.’
36. The Council made the following recommendations to the agency as a result of the safeguarding investigation. The Council said the agency should:
• Review its policy on how it responds to concerns raised by family and staff to ensure that the appropriate agencies are alerted in a multi-disciplinary way.
• Review its policy on how it manages medication.
• Provide staff training regarding medication and the difference between administering medication and prompting medication.
• Carry out its own investigation into the actions of the staff involved, including care staff and management.
37. The Council informed the CQC and the police of the outcome of the investigation so that those agencies could take further action if needed.
38. The agency wrote to the Council on 11 March 2019 to confirm its response to the recommendations. It included the following documents:
• A spreadsheet showing the medication and safeguarding training that the individual staff members received.
• Its responsive services policy.
• Its policy on how it responds to complaints and safeguarding concerns.

The records

39. I asked the Council what the difference was between the four different headings for nutrition and liquids in the records. The Council informed me that the heading ‘Encourage Mrs C to eat’ was added to the recording system to remind carers not only to provide Mrs C with food and drinks, but to encourage her to eat.
40. I have looked through the daily records for Mrs C for several weeks and there are a lot of differences between the carers in the entries they make under each heading. Some carers listed the food they had prepared, the food Mrs C had eaten and the food that they had left out for the future. There was a lot of variation about what information was put under what heading. For example, under the heading ‘food chart’ some carers put ‘filled out’ whereas other put a detailed list of the food given. Some repeated the same information three times under the different headings and made no reference to whether the food was eaten or left out.

Analysis

41. The Council has already upheld the safeguarding investigation into the incident on 20 March 2018 and I agree there was fault. The agency failed to provide any care for the day as it had not taken a proper record of Ms B’s instructions. As a result, Mrs C did not receive any care, drink, food or medication that day.
42. There was also fault in the way the agency administered and recorded medication.
43. I appreciate that some of the issues like failure to gain access or problems with the safe, which led to the agency staff not being able to administer medication were not the agency’s fault.
44. However there continued to be issues even after the safe was replaced. There was a discrepancy with the MAR chart in terms of the inhaler and loose tablets were found.
45. The CQC has detailed guidance on the administration of medication. It is vital that the right medication is provided at the right time and that this is accurately recorded. Any failure can be potentially life threatening.
46. The incident on 25 April 2018 was particularly concerning as the carer failed to provide the medication but then recorded that it had been provided. That may have been a potentially dangerous situation as any other carer would rely on that record and the service user may miss out on vital medication.
47. The agency also failed to follow the correct recording process once the mistake had been discovered.
48. I agree with the Council’s safeguarding investigation following the referral in August 2018 that there was fault in the agency’s records, particularly relating to food and drink. The recording system and the way the carers were using it was confusing and did not give a clear picture of what had been provided.
49. Firstly, the carers had a different understanding of what information had to be put in each heading and what detail to provide. There was a lot of variation in the quality of the carers’ records.
50. Secondly, it was difficult from the charts to find out what food and drink had been prepared, what food/drink had been consumed and what food/drink had been left for later consumption as a lot of carers simply put in a list of food with no explanation.
51. Finally, there was no indication that anybody was checking or adding up how much food or drink Mrs C was consuming on a daily basis.
52. The recording on the 4 August 2018 was an example of the problem.
53. The carer at the lunch time call prepared the food but recorded that Mrs C refused to eat any food, although she had a little sip of water and the nutrition drink.
54. The carer at the tea-time call recorded that Mrs C did not eat any food as she did not want to eat. However, under the sections ‘encourage Mrs C to eat’ and ‘food chart’, the carer listed the foods that the previous carer had left out for Mrs C which led to confusion.
55. Mrs C suffered an injustice as a result of the fault as it was not clear from the records what food and drink she had consumed. This meant consumption was not properly monitored and nobody was checking whether the care plan was still meeting her needs.
56. Ms B also commented that, during the evening call, the carer should have given Ms C some fresh food and drink in any event as it was a hot day and any food and drink from lunch time would have gone stale. The carer should also have informed the family that Ms C had not taken any food or drink during the evening call. I agree that this would have been good practice and the carer failed to do this.

Agreed action

57. 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 agency, I have made recommendations to the Council.
58. Sadly, Mrs C has passed away so any injustice she has suffered cannot be remedied. Therefore any remedy I suggest to the family is symbolic to reflect the injustice.
59. I recommend the Council takes the following actions within one month of the final decision. It should:
• Apologise in writing to Ms B for the fault.
• Pay Ms B £300 for the distress caused by the fault.
60. I have also considered whether there should be any service improvements. I note the Council has made recommendations about medication training, internal reviews and policies to address the concerns raised.
61. There has not been any recommendation to address the problems with the records. The Council has agreed to refer the Agency to the CQC guidance on record keeping to ensure the agency staff comply with the requirements.
62. I will also send a copy of this report to the CQC. It is the regulatory body and it is best placed to deal with any performance aspects.

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Final decision

63. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman