Hertfordshire County Council (19 009 394)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 06 Mar 2020

The Ombudsman's final decision:

Summary: Mrs Y complained about a carer from First Choice Medical Solutions, providing home care to her father, Mr X. This care was arranged by the Council. The carer recorded they had visited her father, checked on him and provided care. Mr X had died earlier that day, before the visit. The carer falsified records and did not provide the care they said they had. The Council carried out a safeguarding investigation, made recommendations and is following up action with First Choice. It has agreed to apologise to Mrs Y, summarise its learning from what happened and how it has applied this learning to prevent reoccurrence for others. It has also agreed to provide us with the outcome of its further inspection.

The complaint

  1. Mrs Y complained that a carer from First Choice Medical Solutions, providing home care, arranged by the Council, visited her father, Mr X in July 2019 to provide him with home care. The carer falsified care records to show they had visited, seen Mr X and given him breakfast. Whereas in fact, Mr X had died earlier that day.
  2. First Choice Medical Solutions accepts this is what happened and has made changes to its work arrangements because of this. Mrs Y is extremely distressed by what happened, wants those responsible to accept responsibility and to apologise.

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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. 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 we find fault with the actions of the care provider, we have made recommendations to the Council.
  3. 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)
  4. 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. I wrote to Mrs Y about her complaint and explained why we considered it was a complaint against the Council that arranged the care.
  2. I gave the Council and Mrs Y the opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Background

  1. Having left hospital Mr X was receiving care in his home, arranged by Hertfordshire County Council, from First Choice Medical Solutions.
  2. In July 2019 a carer visited Mr X’s home for a morning visit. The carer filled in the care log to show they had visited that morning, seen Mr X, and had given him care before leaving him.
  3. Later that day Mr X’s neighbour called emergency services because they had found Mr X had died. Mr X had died sometime during the previous night, before the carer’s visit.
  4. After Mrs Y (Mr X’s daughter) complained, the care provider carried out an investigation. It wrote to her later to explain it had decided:
    • The carer had failed to notice Mr X was deceased when she visited. The carer had not carried out duties required by Mr X’s care plan. The carer had assumed Mr X was sleeping but not checked on his wellbeing.
    • The carer had falsified daily care notes to show they had checked on Mr X’s wellbeing and provided care.
    • The carer had a minor accident earlier that morning, had told the office about this, but said they would still be able to visit Mr X.
    • To suspend the carer while investigating what happened. It had reported the incident to Hertfordshire County Council who had investigated and concluded that First Choice had responded appropriately.
  5. Because of what had happened the care provider told Mrs Y it now:
    • Cancelled shifts for the rest of the day for carers who report they have been involved in an accident.
    • Retrained carers on how to deal with finding a service user who had died.
    • Ensured care staff had counselling if this happened.
  6. The Council held a safeguarding investigation to review the incident and decide on what actions to take. It followed this up, visiting the care provider to check on record keeping, recruitment and supervision. It required First Choice to tell all staff that if they falsify records they can be dismissed. The Council checked on what had happened to the specific carer involved and was satisfied with the action taken.
  7. However, after reviewing First Choice’s actions following the incident the Council was concerned that its training still did not adequately stress the importance of honesty and accuracy for carers, or the need to ensure service users care plans are accurately followed.
  8. Because of these outstanding concerns, the Council has required First Choice to deliver more training to staff. The Council commissioning team has booked a further planned inspection of the care provider in the next month to check what actions is has taken. It will remind all the other carer providers that it uses about the seriousness of falsification of records and likelihood of disciplinary action.
  9. The Council has, in response to my enquiries, also offered to apologise to Mrs Y for the serious failure in service standards by First Choice.

My findings

  1. The carer’s actions, providing care commissioned by the Council, were wholly inappropriate, causing severe and avoidable distress to Mrs Y. The care provider’s written response did not include an apology to Mrs Y as it should have done. The Council’s offer to apologise to Mrs Y for what happened is appropriate to help remedy the distress and upset caused. It should also summarise what action is has taken to learn from what happened.
  2. The Council promptly carried out a thorough safeguarding investigation into what happened. It made appropriate recommendations for improvement action by First Choice. The Council has kept the case under review and its planned further inspection is appropriate to ensure compliance with recommendations. Its plan to remind other care providers about the seriousness of what happened is also important learning. It should write to the Ombudsman after the inspection to summarise corrective action taken and any outstanding recommendations for the care provider it has.
  3. The Ombudsman cannot require councils or organisations providing services on their behalf to take action against staff. The Council has appropriately satisfied itself about what has happened concerning the carer.

Agreed action

  1. Within one month of my final decision the Council will:
    • Write to apologise to Mrs Y for the carer’s actions, summarising the action it has taken to learn from the incident and prevent its reoccurrence for others.
  2. Within three months of my final decision the Council will:
    • Provide the Ombudsman with the outcome of its inspection of First Choice, summarising key actions taken and any remaining recommendations required as a result of the incident.

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Investigator's decision on behalf of the Ombudsman

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