Summary: Mrs C complains that care provided to her mother by Bluebird Care (Wiltshire South) was of poor quality. The Ombudsman finds there was some fault by the care provider in this case, causing injustice for which a remedy has been agreed.

The complaint

1. The complainant, whom I shall call Mrs C, complains on behalf of her mother Mrs B that care she received from Bluebird Care (Wiltshire South), run by Yarrowside Limited, between 9 December 2019 and 6 January 2020, was of poor quality and as a result placed her at risk.

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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 or others. 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. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
5. 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)
6. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share our decision with CQC.

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How I considered this complaint

7. I considered all the information provided by Mrs C about the complaint. I made written enquiries of the care provider and took account of the information it provided in response.
8. Mrs C and the care provider had an opportunity to comment on two drafts of this decision and their comments have all been considered.

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What I found

Legal and administrative information

9. 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.
10. 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.

What happened in this case

During the period of care

11. Following a spell in hospital after suffering a stroke, Mrs B’s family contacted the care provider to enquire whether it could provide the care she needed on discharge home. The provider visited Mrs B in hospital and assessed her care needs. It also visited her home address to assess the accommodation. Mrs B subsequently commissioned the provider to arrange care via a live-in carer.
12. The provider says that time was spent with the carer briefing her on the care plan ahead of Mrs B’s discharge to the home address as well as once Mrs B arrived home on 9 December 2019.
13. On that date, Mrs B signed a care assessment and agreement document. This set out the support Mrs B would need as well as information about the terms and conditions of the contractual agreement including details of the ‘cooling off’ period which sets out the right to cancel within 14 days. Mrs B also signed to say she had received the customer guide, welcome pack, and price list.
14. Initially there was a problem with the carer accessing the provider’s electronic care records system, used to log the care given. The manager agreed she would return to the home to resolve this.
15. On 10 December Mrs C and her sister telephoned the care provider. The provider reports that it was difficult to understand all concerns being raised as the two family members were talking over each other and passing the telephone between them. But a concern that was noted was that the family felt the carer was too small to carry out the necessary manual handling for safe transfers for Mrs B properly. A manager agreed to go out to the home, and did so on 12 December. The care provider reports that the family was shouting and hostile, though Mrs C says this was not the case although the family was upset and assertive. In addition to concerns about manual handling, other concerns noted were that the carer would not take Mrs B’s dogs out, was not able to cook meals adequately for Mrs B, and that it had not been explained that the carer would be an agency worker.
16. An occupational therapist (OT) attended the meeting on 12 December and observed the carer carrying out safe transfers for Mrs C. Following the meeting the care provider replied in writing to the concerns which had been raised. It confirmed safe manual handling had been observed, that the carer had confirmed she was happy to deal with the dogs, and that access to the electronic car records had been set up so Mrs C would be able to see them. The provider said that spot checks are carried out and that a minimum of two visits would be made by the carer’s supervisor in the next few days to observe care given and provide feedback.
17. On 16 December Mrs C telephoned and emailed the care provider again, raising concerns that the carer had not been given adequate information by the provider before starting the placement; that the carer was a smoker which was against Mrs B’s wishes; that the carer had not been able to access the electronic care recording systems for four or five days at the outset; and that Mrs B had been made to sign the agreement documents without being given an opportunity to read them. Mrs C requested a meeting to discuss the family’s concerns.
18. A manager and the care supervisor went to Mrs B’s home the same day to meet with Mrs B and Mrs C and the carer. The provider reports that Mrs B and her family agreed that they were happy to proceed with the care. They were advised that if they did not feel satisfied with the service they could cease the care package and the cancellation fee would be waived due to the cooling off period. The care provider says that after a period to consider, on 19 December Mrs B re-signed the terms and conditions having agreed that they would like to continue with the care with the current carer in place, having had more time to read through the paper copy supplied and having the benefit of the OT’s assessment that the carer was competent to complete the manual handling tasks required to meet needs. Mrs C says that her mother did not re-sign and that the contract was simply re-dated, but the outcome in any event was the same. The care provider followed the meeting up with an email on 21 December in which it said it was not minded to agree to a request for a reduction in fees for the first period of care.
19. On 23 December, Mrs C emailed the care provider reporting that the carer had wrongly administered Mrs B’s medication. She said this was the second occasion this had happened: the first instance had not been reported to the care provider. On receiving notification of this the care provider took immediate action and went out to complete the next morning’s medication with the carer.
20. On the same date Mrs C emailed the provider rejecting its response to the issues raised, and saying the family was not prepared to pay the fees for the first three days of care. Mrs C noted the family was pleased complaints had been listened to and action taken to put measures in place to mitigate the majority of concerns, but said there had been two occasions in the last week when medications had bene wrongly administered by the carer, which meant that she had taken some too early and others not at all that day. The provider responded the same day advising that a meeting with one of the directors had been arranged for after the Christmas period: a final decision on the billing would then be communicated. The provider confirmed that the supervisor had completed a face to face visit with the carer to ensure compliance with the medication policy going forward.
21. On 29 December Mrs C contacted the care provider and said Mrs B wanted a different carer: she no longer wished to have care provided by the person who had been with her since her discharge from hospital. But she said she did not want the carer to be informed while arrangements were made to find another carer to take over the role. On 31 December, the care provider spoke to Mrs C and agreed care would remain in place until a new carer could take over. Since Mrs B had re-signed the contract on 19 December, the cooling off period applied and she would not need to pay the 28-day cancellation fee.
22. On 3 January 2020 Mrs C sent an email advising the care provider that a new care agency could take over care from 6 January. The last day Bluebird Care provided care for Mrs B was therefore 5 January 2020.

After the period of care

23. On 21 January 2020 Mrs B submitted a complaint to the care provider in which she set out concerns previously raised, as noted above, and raised further issues about the care she had been received. These included, but were not restricted to, allegations that the carer:

• had gone out without ensuring Mrs B had access to her pendant alarm;
• had failed to clean out the bedpan properly after each use, and sometimes failed to flush the toilet;
• had failed to report a small tear to Mrs B’s skin caused by her nails on dressing;
• had failed to clean Mrs B’s teeth and did not offer to wash her hair;
• had failed on occasion to ensure Mrs B was dressed in clean clothes;
• had failed on occasion to support Mrs B to complete her daily exercises;
• had failed on occasion to use the arm sling Mrs B required during transfers;
• had failed on occasion to ensure Mrs B had access to water to drink;
• had failed to compete the necessary tasks for Mrs B’s pets as frequently she should have done; and
• had allowed food to go mouldy in the fridge.

24. The provider acknowledged the complaint and on 30 January issued its response. In this the provider referred to the matters which had been dealt with while the care was still in place and said that while it could not uphold all of her complaint it acknowledged there had been some disruption at the start of the care package. It apologised and agreed to waive £900, the fees for the first invoice period.
25. Mrs B responded expressing her disappointment that the provider had not acknowledged the many concerns raised. She was also dissatisfied that the provider had left her in a position where she had to retain the carer for a week until she found a new one, rather than providing a replacement straight away. She considered a further reduction in the outstanding fees was appropriate.
26. In its final response on 3 March the provider said it had investigated and responded to the complaint, that it had worked closely with Mrs B to resolve any issues, and she had confirmed when asked that she had wanted to continue with the care. No further reduction in the outsaying fees was agreed and Mrs B was asked to pay the balance within 14 days to avoid legal action to recover the debt. Mrs B had paid £1500; £900 had been waived; the balance outstanding was £1,950.

Analysis

27. On the matter of the signing of the care agreement, Mrs B has capacity to make her own decisions and she did sign the agreement on 9 December. It is the case however that she was only just out of hospital, and while the documents states the conditions should be read carefully before signing, it would have been appropriate for the member of staff to ensure that Mrs B had done so before signing. But in any event, Mrs B was caused no injustice because she had the opportunity to read the document before she signed again on 19 December, and this allowed for a further ‘cooling off’ period.
28. When initial concerns were raised about the care by the family within a few days of commencement, these were dealt with promptly by the care provider who also took steps to ensure that an occupational therapist observed and assessed the carer’s manual handling as safe. When additional issues were raised on 16 December they were again dealt with promptly by the care provider and Mrs B agreed she was happy to continue with the care. When the medication error was raised with the care provider, it again reacted immediately and appropriately. I have not seen evidence that Mrs B was caused injustice because of the error.
29. Further concerns about the care provided were not raised until after the care package had ended, and as such the provider had no opportunity to address them other than retrospectively, in dealing with the complaint. The care provider’s response to the complaint did not provide sufficient detail to address the concerns raised and did not set out what investigation had been carried out. The final response did not signpost Mrs B to the Ombudsman.
30. Some of the issues about which Mrs B complained cannot be evidenced, for example allegations that the carer could not cook properly, was bad tempered with Mrs B and had little interaction with her. However, comparing the daily care records with Mrs B’s care plan, there are areas where the care given is called into question. Two of the points raised by Mrs B in her complaint concerned hair washing and oral care. Mrs B’s care plan stated that Mrs B should be assisted to wash her hair two or three times a week: the daily care records do not record that the carer ever provided this care. On one occasion the records show her hair was washed by her daughter, and on all other occasions the notes in respect of hair-washing states ‘not required’. They do not say for example that this care was offered and declined. For oral care, there is no specific reference in the daily care records prior to 19 December, when a note states that Mrs B’s daughter provided this care, and after this date it was marked as done on 20 and 21 December but thereafter marked as refused except where Mrs B’s daughter completed it. Mrs B was of course entitled to refuse care, but taking the records overall into consideration, there is a degree of uncertainty about their accuracy in some respects. On Christmas day the family reports that Mrs B went to relatives, and that the carer accompanied her. But the daily care records for that date show no change of routine or meals for example. The care provider’s complaint investigation, or its supervision of the carer while she was in the placement, did not note any concerns about these matters.
31. In responding to my draft findings on the complaint, Mrs C has provided some photographs which were not given to the care provider during the complaint process. These photographs show for example food which has been allowed to go mouldy, a bedpan which has not been properly cleaned, and cigarette ends in coffee cups and plants in the porch to Mrs B’s home. As such, they support the complaints made by Mrs B in January 2020 about the carer’s poor hygiene practices. These failings in hygiene were fault.
32. Also in response to my draft findings, Mrs C has noted that the care provider has said, in response to my enquiries on the complaint, that there had been no communication to the office that Mrs B had a tear to the skin on her bottom. Mrs C says that the District Nurse attending Mrs B had drawn this to the family’s attention, medicated the wound and covered it with a dressing. Mrs C did not consider it necessary to report this to the care provider, since the care plan set out that the carer should report any issues of skin viability. On balance I consider it more likely than not that Mrs B did have a skin tear which should have been reported, and the carer’s failure to do this was fault.
33. I do not find fault in the failure to provide an immediate replacement for the carer when this was requested. The practicalities of sourcing an alternative live-in carer especially over a holiday period were a relevant consideration here.

Injustice to Mrs B

34. Mrs B has been billed for some aspects of care that the provider cannot evidence were either provided, or were offered and declined, or which were not of the required standard. She may have been caused some distress during the period of care, and she was put to some avoidable time and trouble in pursuing her complaint.

Agreed action

35. In recognition of the fault and injustice identified above, I recommended that within four weeks of the date of the final decision on this complaint the care provider:

• Provides Mrs B with a formal written apology; and
• Pays Mrs B £500 (which it may show as a credit against the outstanding bill and issue a revised invoice).

36. I further recommended that within three months of the date of the final decision the care provider reviews lessons learned from this complaint, including in terms of complaint-handling. It should take steps to ensure that complainants are signposted to the Ombudsman where appropriate.
37. The care provider should provide evidence to the Ombudsman that the above steps have been completed.
38. The care provider has agreed to these recommendations.
39. The care provider has confirmed that provided the outstanding debt for care fees is settled promptly once this complaint investigation is concluded, it will not seek to recover any interest charges in addition to that debt.

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Final decision

40. I have completed my investigation on the basis set out above.

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Investigator's decision on behalf of the Ombudsman