Summary: Ms C complains about the homecare her (late) husband received while she was away for a week. The Ombudsman found fault with regards to the care Mr C received. The care provider has agreed to provide an apology to Ms C and reduce the outstanding invoice.

The complaint

1. The complainant, whom I shall call Ms C, complains on behalf of herself and her (late) husband. Ms C complains about the home care her husband received while she was away for a week. Ms C says the care provider failed to:
• Provide her a choice of potential carers
• Keep to her husband’s daily routines.
• Give her husband’s medication at the appropriate times; and occasionally forgot to give them at all.
• Provide meals in line with her suggestions.

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The Ombudsman’s role and powers

2. 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)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. 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)

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How I considered this complaint

5. I considered the information I received from Ms C and the care provider. I shared a copy of my draft decision with Ms C and the Council and considered any comments I received before I made my final decision.

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What I found

Relevant law and guidance

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
7. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
8. Regulations 12 says care and treatment must be provided in a safe way for service users. This includes: Medicines must be administered accurately, in accordance with any prescriber instructions and at suitable times to make sure that people who use the service are not placed at risk.
9. Regulation 14 says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed. This should be monitored and recorded appropriately.
10. Regulation 17 requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

What happened

11. Ms C organised a live-in carer for her husband through a homecare provider, to ensure he would continue to receive the support he needed while she was away for a week. However, she is unhappy with the support he received.

Ms C’s complaint about the process of allocating the live-in carer worker

12. The care provider has explained that the usual process is to provide a profile to the client of two or three potential carers (where possible) and allow the client time to choose one.
13. Ms C said:
• The care provider only sent a one-page profile about one carer to her. This meant she did not have any choice.
• She received it a day or two before the start of the care, and only after she asked for it.
• The carer was not a good match. He told her he had only worked for six months, and only previously supported people with physical disabilities. He did not have experience supporting clients who had capacity and communication problems.
14. The care provider says:
• There is no email or record that shows Ms C had to ask for the profile.
• However, it accepts it did not allow Ms C enough time to request a different carer, if she was unhappy with the proposed one.
• The ability to propose more than one carer depends on the availability of carers and the match with the potential client. Due to this there were limited carers available.
• Ms C did not express a concern about the suitability of the proposed carer. The carer had a good range of experience for the placement. His personal profile showed he had provided direct support to a person with Parkinson’s for six years. He also had five years’ experience providing support to a person with Dementia. Both posts were provided as a live-in carer and it obtained referenced and recommendations from previous employers.

Assessment

15. The care provider has acknowledged it did not provide Ms C with enough time to review the profile and request a different carer if she was unhappy. However, there is no evidence in the records that Ms C expressed a concern about the suitability of the carer. Furthermore, the care provider established the carer had previous experience supporting people with Parkinson’s and Dementia.

Ms C’s complaint that the carer failed to keep to her husband’s routine

16. Ms C’s husband had dementia and difficulty communicating (speaking and hearing) and mainly communicated through body language. Ms C told me she stressed to the care agency and the carer that it was very important for her husband’s wellbeing, to keep his routine. It would distress him if this would be interrupted.
17. Based on Ms C’s information, the care provider produced a detailed 40+page care assessment and care plan, to ensure her husband would receive the care he needed. However, Ms C says the carer told her there was too much information in this document to read everything. In response, the care provider said the carer confirmed to them he read the care plan and notes written by Ms C. He refutes the statement that he claimed there was too much to read.
18. Mr C’s care assessment and care plan says, amongst others, that:
• He is used to his care starting at 8. The carer needs to assist him with washing (a shower).
• He enjoys walking, watching TV in the evening, playing board games, and being read to.
• His carer should prompt him to drink as he may otherwise not drink enough. This was mentioned three times and highlighted in red. He is at risk of dehydration and would need the carer to keep a fluid chart to record how much he drank.
• He usually goes to bed between 9-10pm.
19. According to records and other documents:
• Mr C would mostly get up at 9-9:30am.
• He would have a shower but was not supported by the carer with this.
• Meals were given at regular times
• There is reference to Mr C going out, watching TV and playing some games. It does not mention the carer read to him.
• He would go to bed at a regular time (between 9-9:30pm)
• The care failed to keep a fluid chart.
20. However, Ms C says that on some occasions when she called in the morning, her husband was still in bed around 10am. The carer either said her husband wanted to stay in bed, or that the carer was unable to convince him to get up and he asked her to convince him.
21. The care provider told me it has reviewed the care plan and compared it to the written daily notes. It said:
• The carer failed to fully follow the strict routines that Mr C was used to. However, it would have been difficult to maintain these, in the absence of his main carer, and the presence of a carer who Mr C was not familiar with. This would have resulted in some confusion, upset and distress to Mr C, which affected his behaviour and had an impact on his routines. This was also recognised by the Council’s social worker, who suggested it may be more suitable for Mr C to go into a care home for respite care.
• It explained to Ms C the family should tell the office if there were any concerns, during the week of respite care. This would enable the care provider to implement any corrective actions. However, nobody contacted the care provider during the week.
• The carer admitted that he did not keep a record of fluids, as he did not realise that he should have. He said he encouraged Mr C to drink.
22. Ms C has expressed doubts about the accuracy of the care records.
23. A care manager carried out a visit after three days to see how the care plan was being implemented and if there were any issues. The care provider acknowledged the care manager failed to pick up that the carer was not completing a fluid chart and there were issues with the legibility of the daily records. The care provider says it has since reviewed the training and instruction for Care Managers to reduce the likelihood of this happening again.

Assessment

24. Although Ms C has reservations about the accuracy of the daily care records, they are an important source of evidence to consider when trying to come to a view about what happened.
25. The records indicate that:
• Mr C received his meals on time and went to bed on time. However, the carer’s records and Ms C’s statement showed he got up later than usual on most occasions.
• Mr C did not receive support with his shower, even though his care plan mentioned this should happen. This was fault. However, there is no indication Mr C suffered an injustice or experienced any harm as a result of this.
• The carer did not read to Mr C, even though the care plan said he liked this. This was fault.
• The care provider failed to keep a fluid chart, which was fault. I am therefore unable to conclude that Mr C received regular and enough fluids during the week.
26. The fact that the carer ‘did not know’ that he should have kept a fluid chart, something which was clearly highlighted in the care assessment/plan, indicates the carer did not read some of Mr C’s care plan. This was fault.
27. The care provider has accepted the carer did not sufficiently keep to Mr C’s strict daily routine. However, I agree the absence of his regular carer would have made it more difficult at times to keep Mr C to these routines.
28. Mr C’s care was not in line with Regulation 9 of the 2015 Regulations. The carer did not monitor and record Mr C’s fluid intake, which was not in line with Regulation 14.

Ms C’s complaint about her husband’s medication management

29. Ms C said it was important her husband got his medication on time. If not, he would be at an increased risk of high blood pressure; a bleed in the brain and being in pain. However, Ms C complains her cleaner told her she had observed that the carer had not given Mr C’s medication on time and was very concerned about this. The cleaner raised the following concerns with Ms C:
• Monday: she arrived at 11/12am and noticed Mr C had not received his morning medication yet and reminded the carer. However, Mr C’s daily care records says: 8:15 “He had his medication”.
• Tuesday:
1. She noticed Mr C had not received his Monday evening medication. However, Mr C’s daily care records say: Monday 18:15 “Had given medication”.
2. She left at 2pm, by which time Mr C had not yet received his lunch medication. Mr C’s daily record does not say he received his lunch medication.
• Thursday morning: Mr C had not received his morning medication when she arrived at 11am. However, his daily record says: 9.30am “Had his medication”.
30. Ms C also says the carer gave her husband sleeping pills every night, even though she had stressed it should only be given as a last resort if her husband failed to settle.
31. The care provider’s Medication Risk Assessment Form said:
• It is important to check his skin, as part of his cleaning and dressing routine. Cream: apply frequently. Lotion: use when required (as a wash and moisturiser).
• Zopiclone (sleeping tablet): one to two at night when needed
• Paracetamol: two tablets every four to six hours up to four times daily
• Co-amoxiclav (anti-biotic): one tablet three times a day at regular intervals
• Amlodipine (for high BP): one a day
• Gabapentin (nerve pain): one tablet three times a day
• Mirtazapine (depression/anxiety): two at night
• Solifenacin / Tamsulosin: once a day
32. The Medicine Administration Record (MAR) sheets state that:
• Cream: given every morning.
• Lotion: not mentioned at all.
• Zopiclone (sleeping tablet): Mr C received this on Sunday, Monday and Friday. It does not say if he received one or two tablets on those occasions.
• Paracetamol: not given
• Amlodipine: given every day in the morning
• Gabapentin: Mr C received this thrice a day, except on Thursday (evening) and Friday (afternoon and evening).
• Mirtazapine: given every night
• Solifenacin / Tamsulosin: provided every day except on Friday.
33. The carer said that, on those occasions where there was no record, he had provided the medication but forgot to record it.
34. Mr C’s daily care records mentioned ‘cream applied’ on Tuesday, Thursday, Friday and Saturday morning.
35. Ms C expressed doubts about the accuracy of the MAR sheets considering the observations of the cleaner. Furthermore, her husband would have received his sleeping tablets more frequently, because his packet was empty when she returned.
36. The care provider has said that:
• Mr C received sleeping tablets on three occasions. It was given on an ‘if and when needed’ basis.
• It considered the statements from the cleaner and the live-in carer. It accepts there are discrepancies between what the carer has reported and recorded and what the cleaner has reported. It is unable to determine exactly what occurred as there are clear records that medication was given, but also the cleaner's word that it had not been given. As such, this aspect of Ms C’s complaint was ‘inconclusive’.

Assessment

37. I agree with the care provider’s conclusion that there is contradictory evidence, as a result of which it is not possible to come to a conclusion on what exactly happened. On the one hand, the records indicate that Mr C received (most of) his medication, and received this on time. However, the cleaner says she observed that this was not the case on the days / times she visited.
38. However, I found fault with regards to the following:
• The carer provider failed to ensure that Mr C received lotion, either during or after Mr C’s shower.
• There is no evidence the carer checked (and recorded) Mr C’s skin condition
• Mr C received sleeping tablets on more than three occasions, which the carer failed to record (based on the empty packet on Ms C’s return)
• Gabapentin was missed on three occasions and Solifenacin / Tamsulosin on one.
39. This was not in line with Regulations 12, which says medicines must be administered accurately and in accordance with instructions.
40. Mr C did not receive any Paracetamol. However, this was to be given on an ‘if and when needed’ basis. I am unable to come to a view if or when he needed this during this week.
41. Mr C did receive cream in the morning, after his shower. While it is mentioned it should be applied frequently, it does not say if this should be more than once a day.

Ms C’s complaint about Mr C’s meals

42. Ms C says she put some basic meal suggestions on the white board in the kitchen (jacked potatoes, pasta etc) and told the carer she bought all the ingredients for these. However, she says the carer did not follow these and mostly cooked garlic potatoes and salmon for him.
43. The care provider has said that:
• It considered statements from the carer and the Client Services Manager who attended the handover meeting on the first day. They both confirmed that Ms C did not provide a meal plan. The manager recalled Ms C showing the fridge and its contents.
• It cannot confirm if there were meal instructions on the white board, and therefore if the carer followed these.
• The care plan “My eating and Drinking” says Mr C can choose his own breakfast items. He does not eat meat, but only fish. The daily notes show the carer followed this type of diet. The carer cooked salmon on three occasions, in response to Ms C’s comments that her husband enjoys this.
• The carer has said that Mr C chose what he wanted to eat. He said he cooked peas, tuna salad, soup, and salmon.
• It did not uphold the complaint, because there was insufficient evidence there was a clear meal plan to follow, or that Mr C did not enjoy the food he received.

Assessment

44. I agree with the care provider’s conclusion, that there is insufficient evidence to conclude the carer did not follow a specific meal plan or did not enjoy his food.
45. This aspect of the care was provided in line with Regulations 14.

Agreed action

46. The care provider has offered to reduce the outstanding care fees bill by 25%, in recognition of the failure to deliver support at the expected level of service. It has also already provided an apology for some of the faults identified above.
47. I recommended the care provider should, within four weeks of my decision:
• Provide an apology to Ms C for any additional faults identified above and the distress these have caused her.
• Share the shortcomings and the lessons learned with its managers and carers.
48. The care provider has told me that it has accepted my recommendations.
49. I found that the reduction in fees proposed by the care provider was reasonable and it should therefore now ensure this is carried out.

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Final decision

50. For reasons explained above, there was fault with regards to the actions of the care provider. I am satisfied with the actions the care provider will carry out to remedy this and have therefore decided to complete my investigation and close the case.
51. Under the terms of our Memorandum of Understanding with the Care Quality Commission (CQC), I have shared a copy of my final decision statement with the CQC.

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Investigator's decision on behalf of the Ombudsman