Summary: There was no evidence of fault in the way the agency’s carer provided care to Mr and Mrs D while she lived with them.

The complaint

1. Mrs C complains on behalf of her parents, Mr and Mrs D. She says the carer employed by Home Instead Senior Care in Worcester did not provide appropriate care to her parents and did not know how to care for people with dementia.

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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)

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How I considered this complaint

3. I have discussed the complaint with Mrs C. I have considered the documents that she and the agency have sent and both sides’ comments on the draft decision.

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What I found

Guidance and policies

4. 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.
5. 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 CQC has issued guidance on how to meet the fundamental standards below which care must never fall.
• 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).
• The care provider must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17).

What happened

6. Mr and Mrs D are an elderly couple who needed a live-in carer to provide them with care and support. Mr D had difficulty with his mobility and needed support in all aspects of his care. Mrs D had dementia. She had no sight in one eye and very poor eyesight in the other eye. She was also prone to urinary tract infections (UTIs).
7. The care plan said that the carer had to:
• Provide personal care and toileting care to Mr D.
• Support Mrs D in her personal care and toileting but she would like to be as independent as possible.
• Put pads in Mrs D’s pants and leave prepared pants with pads in the drawer for Mrs D to use them when she needed them.
• Provide the couple with three meals a day and a mid-morning and mid-afternoon snack.
• Prepare and serve all meals, tidy away, wash up, dry up and put the pots and pans away.
• Provide the couple with their medication and record this is the Medication Administration Record (MAR) chart.
• Change the linen when necessary, but at least once a week.
• Do laundry and light cleaning duties around the house.
8. The carer was entitled to a break of two hours every day when a friend of the family who was also a carer, Mrs E, provided care.
9. Mr and Mrs D had a Respect document which said they should not be split up or taken to hospital except in particular circumstances. The GP held the document.
10. The carer worked for Mr and Mrs D from 2 September 2019 until 16 September 2019.
11. The carer’s notes showed the carer found the placement difficult and she felt that Mr and Mrs D’s combined needs were often too high for a carer to cope with on their own. The notes show that Mr D needed a lot of practical care whereas Mrs D needed a lot of support in response to her behaviour linked to the dementia.
12. This is the information that I have seen on the records which is relevant to the issues and incidents which Mrs C complained about.

Medication administration record (MAR) chart

13. The MAR chart for Mrs D shows Mrs D was to have her medication every day in the morning, at mid-day and the evening. The UTI prevention medication was given in the evening.
14. The MAR chart shows Mrs D took her medication every day except on 7 September 2019 (evening) and on 11 September 2019 (midday) as Mrs D refused her medication on those occasions. There were three times when Mrs E administered the medication and one occasion where the paramedics administered the medication.

Cleaning

15. The care plan only mentioned ‘light cleaning duties’ which was not very specific. The carer’s notes show she cleaned the kitchen and the bathroom on average every other day.

Nutrition

16. The notes give the details of 3 meals and food that were provided to Mr and Mrs D every day.

6 September 2019

17. The occupational therapist visited Mr D at 11:00 am to re-assess his mobility. Mrs E also attended as she could contribute in terms of Mr D’s history. The manager of the care company attended so that she could make the necessary amendments to Mr D’s care plan.
18. The OT introduced herself to Mr and Mrs D and sat with them as it was felt that having too many people at the assessment would confuse Mr and Mrs D.
19. The notes show that everybody (except Mr and Mrs D) then went to the kitchen to discuss the plan. They were still sitting at the kitchen table at 14:00 so the carer took Mr and Mrs D’s lunch to them on a tray in the lounge. Mr D ate his lunch and Mrs D did not. Everybody left at 15:00.

7 September 2019

20. Mrs E helped the carer for most of the day. The carer went on her break from 12.15 until 14.15 so Mrs E provided the lunches to Mr and Mrs D. The carer prepared dinner which Mrs D refused to eat. The carer put the dinner in the oven and continued to try to persuade Mrs D to eat but she refused.

8 September 2019

21. Mrs D refused any breakfast. She also did not want any biscuits or snacks. The carer was concerned as Mrs D had not eaten any dinner the night before.

10 September 2019

22. Mrs E prepared the lunch that day and the carer went on her break at 13:00.

11 September 2019

23. There were a few incidents on that day where Mrs D put herself or the carer at risk and the carer rang the paramedics for help. They attended and called Mrs D’s GP for advice. The GP advised the paramedics not to give Mrs D any sedatives and suggested that Mrs D should go to hospital. Mrs D’s regular GP was not in on that day so it was a different GP who gave the advice.
24. Mrs D was taken to hospital where she was diagnosed with a UTI. She remained in hospital for several days.
25. The agency stopped providing care on 16 September 2019. Mrs C provided the care after that, but decided in November 2019 that it would be better if Mr and Mrs D moved into residential care and this happened in December 2019.

The complaint

26. Mrs C made the following complaints. I have summarised her complaint and the agency’s responses insofar as they are relevant to the complaint she has made to the Ombudsman.
27. Mrs C said:
• The carer failed to always provide Mr and Mrs D with their medication.
• The carer did not clean the toilet and kitchen.
• The carer spent a lot of her time sitting outside smoking for hours and hours, talking loudly about Mr and Mrs D. The carer also smoked inside the house.
• The carer failed to provide Mr and Mrs D with lunch every day.
• The carer disregarded Mr and Mrs D’s wish not to be split up when Mrs D was taken to hospital.
• The carer did not provide Mrs D with the pants with pads in the drawer as set out in the care plan.
• On 6 September 2019 the carer had a meeting with lots of different people at the house but excluded Mrs D which increased Mrs D’s anxiety. The carer did not provide Mr and Mrs D with any lunch on that day.
28. The agency’s manager replied and said:
• The medication was administered in line with the prescription as recorded in the MAR chart. There were two occasions when Mrs D refused her medication and four occasions where the medication was administered by other people. The carer recorded the two times when Mrs D refused her medication in the MAR chart and reported this to the office.
• The carer ensured the bathroom, toilet and kitchen were cleaned after mealtimes.
• The carer took her breaks outside and discussed Mr and Mrs D on the phone, but did this in a quiet tone, away from the fence so the neighbours could not hear. The carer smoked in the garden, while on her break.
• The carer smoked inside the house on 11 September 2019, outside of the window. This was after the incident involving Mrs D.
• The carer provided 3 meals every day with extra food on top. There were times when Mrs D refused her food.
• The carer was professional throughout but she was anxious on occasion, because of Mrs C’s behaviour.
• The decision to take Mrs D to the hospital was taken on the advice of the GP. That was a decision only a healthcare professional could make. The agency and the carer were not informed of the Respect document.
• The carer regularly checked Mrs D’s incontinence pad. She left pads in pants for the day and night as per the instructions.
• The meeting on 6 September 2019 was to decide on the correct equipment that Mr D needed, on the advice of the OT. Mrs D was not included as the professionals did not want to increase her anxiety. The couple were provided with lunch which Mrs D refused.
29. In its response to the Ombudsman the agency has confirmed that the carer attended dementia training. The agency also said that the carer had provided care for other dementia clients in the past.
30. Mrs C feels the carer’s failures in terms of providing the medication to prevent UTIs and to providing the pads in the drawers meant that Mrs D developed a UTI. She says Mrs D was hungry a lot of the time as the carer did not provide enough food. She says the carer did not keep the house clean and the oven was spilt with food.

Analysis

31. My investigation is based on the evidence that Mrs D and the agency have sent. The records were detailed which was helpful.
32. I have not found fault in the administration of Mrs D’s medication. There was only one time before 11 September 2019 when Mrs D did not take her medication which was on 7 September 2019. The records show the carer tried to give Mrs D her medication, but she refused. The carer could not force Mrs D to take the medication. The carer took appropriate action in terms of recording and reporting the refusal.
33. In terms of the carer meeting Mrs D’s continence needs, I have not found evidence of fault. The notes show that the carer gave Mrs D support in this area on a daily basis. Mrs D tried to dress herself in the morning and get herself ready in the evening and the carer assisted if there was any problem. The carer checked that Mrs D was wearing a clean pad.
34. In terms of nutrition, the record includes details of at least three meals every day and snacks. There were occasions when Mrs D refused meals and there was evidence the carer tried to convince Mrs D to eat them later or to eat a snack. Mrs E helped provide the lunches on a couple of occasions.
35. It is difficult for the Ombudsman to comment on how clean the house was, but the records show the carer cleaned the kitchen and bathroom at least every other day.
36. I understand Mrs C is upset that her parents were separated on 11 September 2019 and that Mrs D was taken to hospital. She says this was not in line with the Respect document. I can only investigate the carer’s actions, not the GP’s actions. The GP said Mrs D had to be taken to hospital and I cannot find fault in the carer following the GP’s advice.
37. In terms of the events on 6 September 2019, I cannot add anything further than what the agency has said. There was evidence that the carer offered Mrs D lunch and that Mrs D refused. I accept that Mrs D was angry that she was not included in the discussion in the kitchen, but the professionals thought it would make her more anxious if she had been included.

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Final decision

38. I have completed the investigation and have not found evidence of fault.

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Investigator's decision on behalf of the Ombudsman