Summary: Mrs C complained about the homecare Mr F received. She complained about the timing of visits, the cleanliness of Mr F’s property and an alleged delay in involving the GP on two occasions. The Ombudsman found there were incidents when it took too long in the morning for Mr F to receive his breakfast or personal care. The care provider has agreed to provide an apology for this.

The complaint

1. The complainant, whom I shall call Mrs C, complains on behalf of her father in law, whom I shall call Mr F. Mrs C complains his former homecare provider failed to:
• Adhere to the agreed arrival times.
• Provide the level of cleaning support agreed in the contract, especially with regards to: cleaning the kitchen floor, hoovering and keeping the bathroom clean.
• Notice that Mr Fs’ abscess needed to be seen by a GP.
• Notice that Mr F had a fungal infection in his groin that needed to be seen by a GP.

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What I have investigated

2. Mr F received live-in care from the care provider between 25 May 2019 and 21 June 2019. I will focus my investigation on what happened after 22 June 2019, when he continued to receive support from the same provider (four visits a day), as the issues complained about would not likely have occurred while he received live-in care support.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. If we are satisfied with a care provider’s actions or proposed actions, we can complete our investigation and issue a decision statement.

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How I considered this complaint

6. I have considered the information I received from Mrs C and the care provider. I shared a copy of my draft decision statement with Mrs C and the care provider and considered any comments I received, before I made my final decision.

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What I found

Background:

7. Mr F was supported by the care provider between 11 March 2019 and 29 August 2019. The care package was set up by Mr F and Mrs C’s brother in law. Mrs C only became involved with Mr F’s care in early August 2019, the last few weeks of the homecare support.
8. The care provider says that Mr F had capacity to make decisions about his care package and he made changes when he felt he wanted these. It said Mr F and his son were able to express their views and concerns but did not raise any concerns (for instance about the timing of visits). As such, the care provider says it did not have any reason to believe it needed to make any changes during this time.
9. Mrs C told me that her brother in law did not visit Mr F and would therefore not have been aware, or have first-hand observations, of the actual support Mr F was receiving during this time.
10. A record from June 2019 states that the care provider spoke to Mr F’s GP, after he had assessed Mr F. The GP said: they didn’t find anything wrong with him. He spoke to Mr F who seemed very well and not confused at all. He seemed very orientated and understood everything that was happening. There was nothing wrong with him and he did not feel he had to go ahead and carry out a formal capacity assessment.
11. Mr F’s most recent care plan said that:
• He needed support with all aspects of daily care, including personal care in the mornings and incontinence care: I may require some assistance with personal care, such as a strip wash. I will tell you if I would like your help. I am not always open to have assistance as I like to remain very independent.
• I am incontinent of urine. Carers to encourage the need for changing incontinence support tools.
• Medication: I am independent and do not require support at this time.
• Mr F needed support with all meal preparation throughout the day.
• Full support with all housekeeping, including: bed making, clothes washing, hoovering, cleaning the bathroom, cleaning the kitchen, taking the rubbish out, and any other required housekeeping tasks.
• Mr F was very independent and wanted to remain so, although there were some things he struggled with and needed help with.
• Mr F did not always make the best decisions. However, this was not because of a lack of capacity, it was his personality. As such, staff had to gently encourage him to see another point of view. If he would be told he shouldn't do something, he would do it even more.
• He could be unsteady on his feet at times: I can walk independently but am steadier when using my Zimmer frame. I can independently use the steps in the house and walk down the ramp but need the use of my Zimmer frame. I use the stair lift to go upstairs and can use the stair lift without any assistance
• Medication:
1. Does the person know and understand what medicines they should be taking and why? – yes
2. Does the person usually remember to take their medication at right? – yes
3. Is there any known medical reason why self-medication should not be agreed? – No
4. Will continue to administer own medication (signed by Mr F)
• Mental Capacity Assessment tool: “No evidence of lack of mental capacity to make these decisions. I recently had a doctor to review this and there were no concerns. Customer has good understanding of the decisions he needs to make. He is also aware of the implications of unwise decisions. Mr F understands consequences of making or not making decisions but he also sometimes doesn't care. He is stubborn and if he wants to do something he will. He is very aware of unwise decisions.”
12. Mr F’s care package consisted of four visits a day:
• 1st visit (9am): To assist Mr F with getting dressed and assist or prompt him to have a strip wash. Prepare breakfast, check if he is wearing his lifeline (all visits); and change his pads. Leave drinks and snacks in living room. Carry out housekeeping tasks, including: cleaning the bathroom, hoovering, and cleaning the kitchen floor.
• 2nd visit (1pm): To provide lunch, assist with changing pads, housekeeping, and ensuring drinks and snacks are left in the living room.
• 3rd visit (5pm): To provide dinner, housekeeping and assist with changing pads
• 4th visit (9pm): Offer to help Mr F undress and change his pads. Housekeeping tasks. Check all doors and lock.
13. If the evening visit was at 9pm and the morning visit at 9am, this would leave a gap of 12 hours between both visits. The records do not make it clear if it was Mr F’s preference to have his first visit at 9am, or if this was the only time the provider could offer.
14. The care provider says Mr F agreed that visits could be flexible and that his morning visit could be between 8.30am and 10.30am. However, I have not seen a record that showed if/when this was discussed or agreed. The care provider said that Mr F never mentioned that he had a problem with the actual timings of visits; this was only raised by Mrs C in August 2019.

Mrs C’s complaint about arrival times

15. Mrs C was unhappy about the arrival times of carers. She said that, whilst on the whole the carers were acceptable, the time frames were clearly inadequate and fell very short of the contracted times. In particular, the gaps between the night visit and the morning visit was often too large. Furthermore, the gaps between daytime visits were regularly too short, or too long, according to the agency’s timesheets. Mrs C said this put Mr F at an increased risk, with regards to the following:

Mobility and risk of falls:

16. Mrs C says that:
1. Mr F was unable to help himself in between visits as he was unable to mobilise. He could only take a few steps with his walker, while being supervised. As such, he depended on carers coming regularly to provide him with all his support.
2. Furthermore, Mr F was at risk of falls. He would get up most mornings around 5.30am. During July / August 2019 he fell twice before the first visit of the day, because he was mobilizing unsupervised trying to do things without support. As such, it would have been important to have the first visit as early as possible to try and prevent such falls.
17. The care provider said that:
1. His assessment and care records showed Mr F was able to walk around his house independently. The daily care records contain regular references to him being able to mobilise around the house and go upstairs and downstairs. He had a Zimmer frame, which he occasionally chose not to use. He also had a stair lift in place.
2. There is no evidence that Mr F got up most mornings at 5:30am. Furthermore, the records say that he was often still asleep when carers arrived.
3. It referred him to the Falls Prevention Team following a fall in July 2019.
18. The daily care records show that Mr F was able to mobilise around the house, without the need of a carer being there to supervise him when mobilising, until 14 August 2019 when the records note that he had suddenly become more unsteady.
19. Analysis: A late visit in the morning did not put Mr F at an increased risk of falls. Mr F had a lifeline which he could use if he had a fall. Mr F had two falls in the morning, one of which happened on a day when the carer arrived at 730am.

Diabetes management:

20. Mrs C says that Mr F had type 2 diabetes, which needed to be controlled via his diet. As such, she says it was especially important for him to have regular meals to regulate his blood sugar levels. However, Mrs C says he did not receive his main meals during the day at regular times / intervals.
21. The care provider says that Mr F, nor his son or Mrs C, have ever said that Mr F had diabetes. I did not find any reference about this in the records either.
22. Overall, guidance about type 2 diabetes says that a patient should have three main meals a day and eat healthy snacks when needed. It contains advise about what to eat but is not prescriptive about the timings of main meals.
23. Although there is no evidence to indicate there was a specific need for Mr F to have his meals at certain times or intervals in relation to diabetes, there is a general expectation for all clients, that they should receive their main meals at reasonable times and intervals:
• The records show that Mr F received his breakfast too late on several occasions; around 25% of the breakfast visits after 22 June 2019, were 90 minutes late (after 10.30am).
• As a result of these late morning visits, there was often not enough of a gap until Mr F’s next main meal (the lunch visit). Around half of the lunch visits were only one or two hours after his breakfast visit.
• There were no significant issues with regards to the third (dinner) visit of the day.
• Furthermore, Mr F did receive three meals a day and snacks were left for him to eat in between visits. There is no indication he was left hungry.
24. Analysis: Overall, carers ensured Mr F had three meals a day and other food to eat throughout the day. However, there were times when Mr F received his breakfast about 90 minutes too late (after 10.30am). This also resulted in his subsequent lunch (visit) would be too soon after. I recognise, and take into account, that Mr F had capacity but did not complain about these incidents at the time and, if he had, the care provider could have considered making adjustments where possible. I am unable to come to a view, on the balance of probabilities, why he did not do this. Nevertheless, these particular incidents fell short of what was agreed in the care plan and what a client should be able to expect from their care provider, and therefore resulted in an injustice. Furthermore, while he did not make a complaint then, he has made a complaint now, via Mrs C.

Medication management:

25. Mrs C says that the updated care and support plan from 25 June 2019 said that all medication should be given by the carer. Mr F’s medication was kept in a cupboard and he was unable to access it. As such, irregular visit times had a negative impact on Mr F receiving his medication regularly.
• The care provider says that:
1. Mr F was self-administering medication. He wanted to exercise his own choice to be independent with this. When Mr F said he wanted help with this, the care agency started to support him from 16 August 2019 onwards.
2. None of Mr F’s medication was time specific.
• Mr F’s latest care plan says (7.1.1 Generic Care and Support Plan), with regards to medication, that: I am independent and do not require support at this time.
26. Analysis: I did not find fault with regards to this aspect. As of 22 June 2019, the care agency would have had a good understanding of what Mr F was capable of, having just provided him with a period of living in care support. Furthermore, Mr F did not say that he wanted or needed support in this area, at that time. As such, the carers were not involved with providing Mr F’s medication until 15 August 2019, other than applying creams. According to the records, Mr F asked the care agency on 15 August 2019 to start helping him with this aspect of his care, as a result of which this was included in his care package.

Incontinence management:

27. Mrs C says that Mr F preferred to use incontinence pull-up pants to manage his incontinence. However, she said that, due to unreasonable long gaps in between visits he was regularly left in soiled pads for too long.
28. The records showed that carers would check, remind, and offer Mr F support with changing his pads during visits and were flexible and supportive with regards to his wishes as to what products to use and how to use them. There were regular occurrences when Mr F refused help with this aspect of his care. However, on those occasions that carers arrived (very) late in the morning, this resulted in a delay in carers offering Mr F with help in this area, as well as being washed.
29. The care agency has said that:
• The care plan had indicative start times that it aimed to work towards. However, at times, it was unable to provide the visits at the time indicated in the care plan, due to issues around staff availability, staff familiarity with the customer etc. Mr F was not classed as “high dependency”, because he was able to mobilise and not completely dependent on carers. Mr F demonstrated independence by getting up and down the stairs and washing and (un)dressing himself at times. As such, it occasionally had to prioritise visits to other clients that were more dependent than him.
• At the care review on 3 July, 10 days into his new care package, Mr F said he was happy with the carers and did not raise any concerns. We have never had reason to believe Mr F was less than happy with his care.
30. Analysis: The agreed gap between the night visit and the morning visit (the next day) was already 12 hours. However, the delays in receiving support in the morning, resulted in Mr F having to wait even longer to be changed and cleaned. I recognise, and take into account, that Mr F had capacity but did not complain about these incidents at the time, nor did he mention them at review meetings. If he had, the care provider could have considered making adjustments where possible. I am unable to come to a view, on the balance of probabilities, why he did not do this. Nevertheless, these particular incidents fell short of what was agreed in the care plan and what a client should be able to expect from their care provider. It therefore resulted in an injustice. Furthermore, while he did not make a complaint then, he has made a complaint now, via Mrs C.

The complaint about cleaning

31. Mrs C said the care agency failed to provide the level of cleaning support as agreed in the contract. This was especially noticeable with regards to cleaning the kitchen floor, hoovering and keeping the bathroom clean. She also said the two-hour weekly cleaning visit did not appear to involve cleaning bathrooms or indeed very much of the house at all.
32. The care agency said:
• There was no separate 2 hour a week cleaning slot in the care plan; there was only one for shopping.
• Each of the housekeeping tasks was electronically monitored at each care visit, with each care worker confirming they had completed the tasks in question. 
• There is evidence throughout the care notes that cleaning took place within the home, although it is not always evidenced what cleaning took place. Carers will usually focus on the living areas of that customer, such as bathrooms/toilets used by the customer, bedroom, living room, kitchen etc.
• It never received complaints about the standard of cleaning from Mr F or his son. The review visit in July 2019 did not highlight any concerns about housekeeping and the cleanliness of the house.
33. The care plan said that carrying out housekeeping tasks should be part of each visit. The care provider used an electronic record system to record, for each task, if it had been done (green) or not (orange). Furthermore, the care worker would also include some personal comments to explain what had been done. The care records showed that housekeeping tasks were done on all visits (the task was highlighted as ‘green’). Furthermore, the additional notes specifically mentioned hoovering (around the house) more than 20 times. Cleaning the kitchen floor and the bathroom were mentioned specifically more than ten times.

Analysis:

34. Mrs C’s view about cleanliness was based on the last two weeks of Mr F’s care in August 2019. I did not see evidence that Mrs C complained about this to the care provider at the time.
35. The daily care records for the period I have investigated, show that carers overall assessed what needed to be done in terms of housekeeping and carried out relevant tasks as such. I am unable to conclude, merely based on the records, whether or not this resulted in the property (including the kitchen and bathroom) being kept to a reasonable clean standard at all times.

The complaint about the alleged failure to alert a GP to review Mr Fs’ abscess

36. Mrs C says that:
• Mr F had a severe abscess on his back. However, carers failed to spot this. It was eventually a paramedic who visited Mr F on 14 August 2019 following his fall, who noticed it and said it seemed infected and to call GP. Mrs C says the care workers should have spotted this through their regular personal care.
• When the GP came to visit, he prescribed medication and told carers to contact the GP surgery if/when the abscess would become worse. However, even though it became much worse, and Mr F was in severe pain by 19 August 2019, the carers failed to do this. Eventually she herself had to involve the GP again. Mrs C says the care workers should have spotted the deterioration between 14 and 19 August. The delays caused significant suffering to Mr F.
37. Mr F’s antibiotics course started on 15 August. A review of the records shows the carers failed to record any observed changes in the visual appearance of the wound. There are only two records:
• 17 August (breakfast): “Complaining of back still being sore, 2 Paracetamol given see notes”.
• 17 August (dinner) “X2 soluble paracetamol given. Mr F said back still painful”.
38. The care agency says: the GP prescribed antibiotics which the carers ensured Mr F received, along with pain relief where required. The carers are not medically trained but aware that antibiotics do not cure something immediately. The carer reported on 18 August that Mrs C was staying with Mr F and would take him to GP appointments. Paramedics visited on 17 August following a fall and would have also checked over Mr F. Overall, the records show that carers recorded changes in health conditions and took action when needed.
39. The GP recorded on 19 August 2019 says that the affected area had become worse and it was clear by then that the first medication was not working. He prescribed another medication and recorded “if non-responsive hospital admission for surgery”.

Analysis

40. I am unable to determine, and based on records only, how clear it should have been, to a non-medically trained person (the carers), that on/before 14 August 2019 Mr F’s abscess needed to be seen by a GP.
41. However, I would have expected the carers to have kept a regular record of observations after 15 August 2019, of any visual changes in the appearance of the affected area, to determine if it was improving. As such, there is insufficient evidence they monitored this.
42. Mrs C, who is not medically trained herself, was very concerned about the deterioration of the affected area and involved the GP on 19 August. There is no evidence in the records to show the carers were concerned as well and/or would have done the same. The GP subsequently confirmed that the abscess had become “sufficiently worse”. As such, on the balance of probabilities, the carers should have raised a concern with the GP (earlier). However, I am unable to determine exactly, on the available evidence, how much earlier. It is unlikely to have been more than one or two days. As such, any injustice to Mr F was limited.

The alleged failure to spot and refer Mr F’s fungal infection to the GP

43. Mrs C says the care agency failed to spot that Mr F had a fungal infection in his groin that needed to be seen by a GP. The carers should have spotted that when changing his pads. It was only when the GP came on 14 August 2019 that Mrs C asked the GP to also have a look at his groin. The carers should have spotted and escalated this earlier.
44. The care agency said that: Mr F was prone to fungal infection in the groin area from the start of our care. From the outset he was prescribed Betnovate on a PRN basis to be applied to the scrotal area when it became red and itchy.
45. The daily care records showed care workers noticed issues with Mr F’s groin area and applied various creams to relieve redness, itching and any discomfort. The carers recorded the following:
• 1 August 2019 (breakfast visit): Cleaned groin area and applied cream. Very sore.
• 1 August (lunch): Used cream on groin area. Very red and looking sore.
• 8 August (am): Creams applied. Groin looking very red and swollen.
• 8 August (lunch): Cream applied as Mr F said very sore
• 8 August (dinner) Red rash looks very sore, self-administered cream
• 9 August (dinner) Rash still looking sore. Applied cream
• 10 August (dinner): Mr F very itchy skin. Looking blotchy and red. Applied cream.
• 12 August (am): Applied cream to groin as very inflamed and itchy.
• 12 August (lunch): Groin area red and sore looking. Mr F wanted cream applied as it was itchy.

Analysis

46. It was clear that Mr F’s groin had become very itchy, red and sore between 1 and 12 August 2019. Although the carers applied cream, this did not result in any improvement. As such, my view is the carers should have kept the office informed of that, who could then have made a decision whether or not to involve the GP already to assess the area.

Agreed action

47. I recommended that, within four weeks of my decision, the care provider should:
• Provide an apology to Mr F for the faults identified above.
• Deduct an amount of £200 from the care fees Mr F still owes the care provider.
• Share the lessons learned with its frontline staff, about wound recording and escalating concerns to the office.
48. The care provider has told me it has accepted my recommendations.

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Final decision

49. For reasons explained above, there was fault with regards to some of 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.
50. 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