Summary: Mrs B complains that the Council did not properly provide domiciliary care to her mother Mrs G. Mrs G’s medication was missed and incorrectly administered, Mrs B’s complaints were not dealt with properly, Mrs G’s care plan was not updated properly, the Council did not inform Mrs B of safeguarding outcomes and Mrs B was not given the option of continuing care provision during the interim period after notice was given to stop Mrs G’s care. The Council has agreed to apologise to Mrs B, pay Mrs B £250 for Mrs B’s distress, ensure complaint procedures are made available, review safeguarding cases and provide guidance to staff.

The complaint

1. The complainant, whom I shall refer to as Mrs B, complains the Council did not properly provide her late mother’s, Mrs G’s, care because:
1. Mrs G’s medication was missed and irregularly administered;
2. 17 tablets were not administered to Mrs G on one weekend;
3. Carers arrived late in the evening to give medication having missed in the daytime causing irregular spacing of medication and overdosing;
4. Carers failed to turn up;
5. A manager arrived at 7am to check medication without informing the family;
6. Managers found no evidence of missing medication although Mrs B has photographic evidence of records being altered;
7. Mrs G’s care plan was not updated properly;
8. Complaints raised with her care provider were not acknowledged or acted on, and Mrs B was not given any information about how to raise a formal complaint;
9. Mrs B was not given any information about the investigation and outcome of two separate safeguarding alerts;
10. Carer’s made improper jokes about Mrs G;
11. There was no record of how an injury occurred to Mrs G’s leg which took over six months to heal; and
12. Mrs B was given seven days’ notice of the decision to withdraw provision even though Mrs G’s care needs had not changed.
2. Mrs B says she was unable to have a break or a holiday because Mrs G was not receiving proper care, she and other family members had to check what care had been given and when the care provider gave only seven days notice, provide all the care Mrs G needed until such time another care provider could take over the care package.

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The Ombudsman’s role and powers

3. 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)
4. 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)
5. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
6. 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)
7. 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

8. I have spoken to Mrs B about her complaint and considered the information she has provided to the Ombudsman. I have also considered the Council’s response to her complaint and its response to my enquiries as well as a response from the Care Provider.
9. Mrs B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
10. The Ombudsman has exercised discretion to investigate Mrs B’s complaint even though the Council has not dealt with it through its complaints process because the Council has had an opportunity to do so.

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What I found

Care Act 2014

11. Local authorities are required to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to all people regardless of their finances or whether the local authority thinks an individual has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. Where local authorities have determined that a person has any eligible needs, they must meet these needs. (Care Act 2014 s9, s10 and s18)
12. The Act also gives local authorities a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what the person has, what they want to achieve, what they can do by themselves or with existing support, and what care and support may be available in the local area. (Care Act 2014 s24)

Local Authority Social Services and National Health Service Complaints (England) Regulations 2009

13. Councils should make arrangements to investigate complaints made to it in a manner to resolve it speedily and efficiently and keep the complainant informed as to the progress of the investigation.

Definition of an Adult Social Care Provider (the Care Provider)

14. An adult social care provider within our jurisdiction is one which carries out ‘regulated activities’ relating to providing adult social care. The activities include personal care or other practical support provided in the place where the person lives.

Fundamental Standards of Care

15. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. These include:
16. Regulation 9 of the 2014 Regulations says care and treatment of service users must be appropriate and meet their needs.
17. Regulation 12 of the 2014 Regulations says care and treatment must be provided in a safe way for service users including assessing risks, mitigating them as far as reasonably practicable and ensuring persons providing care or treatment have the necessary qualification, skills, knowledge and experience.
18. Regulation 13(4) of the 2014 Regulations says care or treatment for service users must not be provided in a way that significantly disregards the needs of the service user for care or treatment.
19. Regulation 16(1) of the 2014 Regulations says any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation.
20. Regulation 16(2) of the 2014 Regulations says Care Providers must establish and effectively operate an accessible system for identifying, receiving, recording, handling and responding to complaints.

Care Quality Commission (CQC)

21. 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.

What happened

22. Mrs G was 78 years old and lived at home with her husband. Mrs G suffered from multiple serious medical conditions which required her to take a range of medication daily. The Council arranged for her to receive several care visits each day to administer medication and deliver care.
23. Mrs G received care from January 2018. The company originally delivering her care ceased trading in late 2018 and Mrs G began to receive care from A&B Healthcare, whom I shall refer to as the Care Provider.
24. Mrs B raised issues about Mrs G’s care with the Care Provider in 2018 and 2019. Mrs B attended a meeting with the Care Provider in May 2019 to discuss the issues she had raised about Mrs G’s care. Mrs B informed the Council of her concerns at around the same time. The Council raised a safeguarding alert.
25. In July 2019, Mrs B attended another meeting with both the Council and the Care Provider, to follow up and agree outcomes from the meeting in May.
26. Mrs B was still concerned that there were continuing problems with Mrs G’s care.
27. The Care Provider cancelled Mrs G’s package of care in July 2019. The Council found another Care Provider to deliver care to Mrs G, but they were unable to deliver all the care straight away.
28. Mrs G has since passed away.

Analysis

Complaint 1 and 2: Mrs G’s medication

29. The Care Provider has upheld Mrs B’s complaints. It says there were discrepancies found in Mrs G's medication. It says these have been addressed internally through management action and retraining. The Care Provider says it was unable to identify missed medication from the records.
30. The Council says electronic call monitoring data demonstrates that call times were irregular which would have led to irregular administration of medication. The legibility of entries on medication records on those dates make it difficult to understand exactly what medication and how much has been administered.
31. One of Mrs G’s care workers has provided a statement that she made a mistake with medications which were not administered.
32. This is fault by the Council. Mrs G did not have her medication delivered as it should have been. Some medication was missed placing Mrs G at risk of harm. The issues occurred when Mrs G’s main two carers were not available.

Complaint 3: Carers arrived late causing irregular spacing of medication

33. The Care Provider has partially upheld Mrs B’s complaint. It says it identified a small number of occasions where care was delivered outside the agreed times.
34. The Council says electronic call monitoring data demonstrates that calls were not consistently planned at the same times and that carers did not always arrive at the planned times. This could have contributed to the irregular spacing and potential overdosing of medication. The electronic call monitoring data also shows although scheduled call times were consistent following the meeting in July 2019 the morning call was often scheduled to end more than four hours before the lunch time call starts meaning that Mrs G would not receive medication within the required 4 hours.
35. This is fault by the Council. Mrs G had her medication incorrectly administered placing her at risk of harm.

Complaint 4: Carers failed to turn up

36. The Care Provider did not uphold Mrs B’s complaint. It says Mrs G’s family sometimes cancelled care calls and it is not aware of any missed calls.
37. The Council says care providers are required to submit amendments to the Council’s Contract and Review Team where calls have not taken place. The Council says it has not received an explanation from the Care Provider about why some care calls were not made.
38. I have seen evidence from the Care Provider about some of the cancelled calls. The remaining incidences were either missed calls, or the Care Provider failed to record its reasons for not providing care. This is fault by the Council. Mrs G missed care calls and the reasons for this are unclear.

Complaint 5: Check by a manager

39. The Care Provider did not uphold Mrs B’s complaint. It says a care co-ordinator attended a morning care visit having been requested by Mrs G’s family. The Care Provider says its staff entered Mrs G’s home with consent and there were no objections. The Council says it is unable to comment.
40. I have seen copies of text messages that show Mrs B was not informed before the care co-ordinator attended an early morning care visit. The messages show Mrs B said she was happy that the Care Provider was taking action. There is insufficient evidence for me to determine whether consent was given by Mrs G. I have therefore not been able to make a finding on this part of the complaint.

Complaint 6: Missing medication and altered records

41. The Care provider has partially upheld Mrs B’s complaint. It says it was unable to identify missed medication from the records. The Council says it is unable to comment. The Care Provider has already upheld Mrs B’s complaint about medication being missed as part of complaints 1 and 2 and so I have not investigated this as part of complaint 6 again.
42. I have reviewed the copies of medication records provided by both Mrs B and the Care Provider. It is difficult to draw any conclusions from the documents about whether they were doctored. On the balance of probabilities, the medication records have not been deliberately altered. This is not fault by the Council.

Complaint 7: Mrs G’s care plan

43. The Care provider has partially upheld Mrs B’s complaint. It says Mrs G’s care plan was updated in February 2018 and July 2019. The Care Provider agrees this was outside the normal timescales, it should be updated at least annually, and says this was due to exceptional circumstances. It has not provided any evidence to show what those circumstances were.
44. The Council says Mrs G’s care plan was regularly reviewed and her care and support plans updated as required. I have seen care and support plan reviews provided by the Council dated March 2018, June 2019 and October 2019.
45. The documents provided show that Mrs G’s care and support plan were not reviewed within 12 months. This is fault by the Council. Mrs G did not suffer any injustice because her long term support needs were unchanged.

Complaint 8: Complaints to care provider

46. The Care Provider did not uphold Mrs B’s complaint. It says the complaints process was contained in Mrs G’s original care plan, issues were discussed face to face and over the telephone, all issues were dealt with and it received a letter saying Mrs G’s family were happy with the care provided.
47. The Council says it was aware of issues from July 2019 and a meeting was held with Mrs B and the Care Provider. One of the outcomes was for the Care Provider to send Mrs B a copy of its complaints procedure, which was completed.
48. The Council also says it did not receive a formal complaint from Mrs B. Records show Mrs B brought her concerns to the attention of the Council in April 2019.
49. I have reviewed the contents of Mrs G’s care plan. The document dated from February 2018 does contain a complaints process. However, this relates to an earlier care provider who has ceased trading and is therefore not applicable. The care plan issued by the Care Provider A&B Healthcare did not include a complaints procedure.
50. There is no evidence that the Care Provider informed Mrs B of the complaints procedure before July 2019. The Care Provider has not provided copies of its complaints book, where it should have recorded all complaints dealt with through its complaints procedure. On the balance of probabilities, the Care Provider did respond to concerns but did not do so through its complaints procedure.
51. The Council made a safeguarding referral when it was informed of Mrs B’s concerns about Mrs G’s care. It did not deal with those concerns through a formal complaint. This is fault by the Council. Mrs B’s concerns were not properly investigated.

Complaint 9: Information about safeguarding

52. The Council accepts that its safeguarding enquiry was not signed or completed and has subsequently not been sent to Mrs B, the CQC and its Contracts and Quality Assurance Team. This is fault by the Council. Mrs B did not receive information about the safeguarding concerns that had been raised concerning Mrs G.

Complaint 10: Improper jokes about Mrs G

53. The Care Provider did not uphold Mrs B’s complaint involving comments about smoking and dementia. It says it has no record of this having been raised with it and has no knowledge of the alleged incident.
54. The Council says it has no record of any relevant diagnosis, records or risk assessments about dementia or smoking which may be relevant to the complaint. The Council’s social care worker involved at the time no longer works there. There is insufficient evidence for me to determine what happened. I have therefore not investigated this further.

Complaint 11: Injury to Mrs G’s leg

55. The Care Provider says the incident happened before it took over Mrs G’s care. One of Mrs G’s care workers states that Mrs G’s injury was known to her doctor and district nurses dressed her wound.
56. I have seen emails from October and November 2018 which show Mrs B raised concerns about a leg injury to the previous care provider, who is no longer in business. No additional records are available.
57. The Council says it recorded a further safeguarding concern in October 2019 which referred to Mrs G’s leg injury in 2018. The Council has agreed that further enquiries should have been made about this at the time. This is fault by the Council. Mrs G did not suffer any injustice because her injury had already healed by this time.
58. Mrs B says the carer involved in the incident regarding Mrs G’s leg injury told her she had knocked against Mrs G’s leg with her own leg and it tore the skin.
59. There is insufficient evidence for me to determine what happened in respect of the original injury in late 2018. I have therefore not made a finding for this part of the complaint.

Complaint 12: Notice to withdraw care provision

60. The Care Provider did not uphold Mrs B’s complaint. It says it decided there had been a breakdown of communications and it was no longer able to provide the package of care Mrs G required. It says it stated it was willing to work alongside the Council until a new provider was appointed. The Care Provider did not believe this was necessary due to its understanding that a new provider was appointed to commence after the expiry of the notice period.
61. The Council says it made arrangements for another provider for Mrs G to commence three days after the notice period had ended. It also says Mrs G was happy to accept the new provider and confirmed that the family were happy to assist with Mrs G’s night time care call until the new care provider was able to attend.
62. There was a three day period between the end of the notice period from the Care Provider and the beginning of the new care package. There is no evidence an offer for the Care Provider to continue working alongside the council to cover any gap in provision was made to Mrs B or Mrs G. This is fault by the Council. Mrs B had to provide some degree of care for Mrs G until the new care provider was able to deliver all care calls to ensure her needs were met.

Standards of care

63. Mrs G was not given the correct standard of care when she was provided with care by A&B Healthcare. A&B Healthcare potentially breached the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in particular regulations 9, 12, 13, and 16.
64. The faults identified put Mrs G’s health at risk intermittently over several months, have caused distress to her family and left them to provide care so her needs were met.
65. I note that the Care provider has already taken action to interview staff, provide refresher training/competency checks and update computer software to track and monitor medication issues.

Agreed action

66. To remedy the injustice caused by the fault I have identified, the Council has agreed to take the following action within 12 weeks of my final decision:
• Apologise to Mrs B;
• Pay Mrs B £250 for her distress;
• Ensure the provider’s complaints procedure is made available to all care recipients when a new care package is commissioned;
• Review policy and practices around transition to new care providers to ensure there are no gaps in care provision;
• Provide guidance to its staff about identifying and dealing with complaints through its complaints procedure; and
• Review all outstanding safeguarding enquiries to ensure they have been correctly signed off, completed and sent to relevant parties.

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Final decision

67. I have found fault by the Council that caused injustice to Mrs B and Mrs G. I have now completed my investigation.

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Investigator's decision on behalf of the Ombudsman