Summary: Mrs X complained her mother paid Midshires Care Limited for specialised dementia care which she did not receive. The failings in the care service provided to Mrs X’s mother have caused Mrs X and her mother an injustice.

The complaint

1. The complainant, whom I shall refer to as Mrs X complains her mother, Mrs Y, paid Midshires Care Limited for specialised dementia care which she did not receive. She is concerned that failings in the care Mrs Y received placed her at unnecessary risk of falls and could have affected her health and wellbeing.
2. In particular, Mrs X is concerned:
• Carers failed to follow Mrs Y's care plan;
• There was a lack of continuity of care with up to 16 different carers supporting Mrs Y over the course of a week;
• Carers failed to give Mrs Y her medication or ensure that she took it;
• Carers left Mrs Y’s zimmer frame out of reach;
• Inappropriate behaviour by the carers; and
• Personal items went missing from Mrs Y's house.

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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 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)
5. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), 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 this decision with CQC.

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How I considered this complaint

7. As part of the investigation, I have:
• considered the complaint and the documents provided by Mrs X;
• made enquiries of the care provider and considered the comments and documents the care provider provided;
• Mrs X and the care provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

8. Mrs Y lives alone and receives a package of care and support which, with her family’s assistance she privately arranges and funds. In July 2019 Mrs X arranged for the care provider to take over Mrs Y’s care package. She states she chose this care provider as they advertised as specialist dementia care providers and CQC had rated them as good.
9. Within a few weeks Mrs X had concerns about the care Mrs Y was receiving, and carers not following the care plan. Mrs X states carers repeatedly left Mrs Y’s zimmer frame out of her reach. As Mrs Y cannot safely mobilise without the zimmer frame this posed a risk of falling. Mrs X was also concerned carers were not ensuring Mrs Y took her medication. Mrs Y’s care plan asked carers to dispense Mrs Y’s medication from the blister pack and to place it in her hand to ensure she took it. Mrs X states she found Mrs Y’s medication left in a pot on her table, on the floor, and in Mrs Y’s bed and armchair. She also provided photographs of Mrs Y’s blister packs packed with tissue to retain medication carers had failed to give to Mrs Y.
10. As Mrs Y has dementia, Mrs X states they were keen to ensure she had continuity of care. Although the care provider agreed to this, Mrs X complains that up to 16 different carers visited Mrs Y over the 28 scheduled calls each week, and that additional new carers would visit the following week. Mrs X was also concerned that carers were not completing the agreed care within the time allowed for each visit.
11. In November 2019 Mrs X complained that a carer had used Mrs Y’s commode, rather than the toilet, and had not cleaned the commode before Mrs Y then used it. She was also concerned that items had gone missing from Mrs Y’s bedroom.
12. The care provider responded to Mrs X’s complaints in December 2019. It stated it had carried out an internal investigation and found:
• carers had no knowledge of the missing items and did not enter Mrs Y’s upstairs bedroom. The care provider had not yet been contacted by the police regarding the missing items. It confirmed it had notified the Care Quality Commission (CQC) and the local authority regarding the allegation of theft.
• A carer used Mrs Y’s commode as the upstairs toilet was out of order and they did not think they would fit in the second toilet located under the stairs.
• A carer had failed to administer Mrs Y’s medication correctly on 25 November 2019 and had been dismissed from the care provider’s employment.
• A carer failed to watch Mrs Y take her medication on 30 November 2019. The carer apologised and understood they should have ensured Mrs Y took her medication.
13. The care provider confirmed it had retrained staff around the correct use of medication.
14. The care provider also notified Mrs X it was terminating its care services and gave 30 days’ notice. It stated that after the concerns raised it no longer felt it could meet Mrs Y’s care needs or satisfy the family. Mrs X asked the care provider to continue to support Mrs Y until they had found another agency to support Mrs Y, but the care provider refused.
15. As Mrs X was unhappy with care provider’s response to her complaint and its actions in terminating its services, she complained to the Chief Executive Officer (CEO). The CEO discussed Mrs X’s concerns with her and then wrote to her setting out their findings. They noted it could not be proved or denied how the alleged theft occurred but sought to reassure Mrs X that all their staff were strictly vetted, and they carried out reference and DBS checks.
16. In relation to a carer using Mrs Y’s commode the CEO accepted this was not satisfactory but noted there was a duty of care to ensure suitable toilet facilities were available for the carers. The CEO apologised the carer had not cleaned the commode between uses.
17. The CEO acknowledged they had failed regarding Mrs X’s medication and reiterated that the carer who had failed to administer Mrs Y’s medication no longer worker for the company. The CEO was however satisfied the care provider had taken appropriate action in checking with the pharmacy regarding timeframes for administering the missed medication. And that it had not had a detrimental effect on Mrs Y’s health.
18. In addition, the CEO accepted the care provider should have responded to Mrs Y’s increasing needs by reassessing her care plan rather than waiting for the scheduled review. They also agreed the care provider should have offered to support Mrs X and Mrs Y in sourcing a new care provider.
19. The CEO apologised that the care provider had not met their expectations and confirmed lessons learnt from Mrs X’s experience would be used for training purposes.
20. As Mrs X remains unhappy, she has asked the Ombudsman to investigate her concerns about the failings in Mrs Y’s care. In response to my enquiries the care provider states the majority of its staff followed Mrs Y’s care plan. When staff did not follow it, for example in missing Mrs Y’s medication it took immediate action to prevent it happening again. The carer involved failed their probation and all other staff visiting Mrs Y were retrained in the safety of administering medication.
21. In relation to Mrs Y’s zimmer frame, the care provider states staff were constantly reminded to leave it within Mrs Y’s reach. It states staff are now reminded at team meetings who needs their zimmer frame/ walking aid within reach, and the importance of this.
22. The care provider states there was a lack of continuity of care as carers asked not to return to Mrs Y’s property as the felt under pressure and as though they were being watched via the CCTV. Mrs Y’s family also asked that certain staff did not return. The care provider states its relationship with Mrs X broke down and it was unable to meet Mrs Y’s needs in the timeframe Mrs X wanted.
23. The care provider accepts it should have reviewed Mrs Y’s care plan as soon as Mrs X highlighted issues. It also acknowledges the situation may have been avoided if it had met with the family and fully documented discussions of the care plan/ care provided.
24. In response to the draft decision, Mrs X has reiterated her concerns about the care provided to Mrs Y. She asserts most carers did not read Mrs Y’s care plan and were unfamiliar with her needs. There were failings in the administration of Mrs Y’s medication almost every month and Mrs X’s zimmer frame was left out of reach on numerous occasions. Mrs X also disputes the downstairs toilet was unsuitable and states the carer had used it on previous visits. She is concerned the care provider viewed the carer’s use of the commode as trivial.
25. In addition, Mrs X states the care provider had not informed them that carers objected to the camera or that they had felt under any pressure at Mrs Y’s home. Mrs X states the camera was installed as Mrs Y frequently, unintentionally activated her fall alarm. The camera allowed the family to check whether she needed assistance before the alarm service called the emergency services.
26. Mrs X states the new care provider did not make any changes when it took over Mrs Y’s care plan and has not had any problems in implementing this care.

Analysis

27. It is clear from the documentation available, and the care provider acknowledges that there were failings in the care and support provided to Mrs Y.
28. The care provider has provided copies of Mrs Y’s Medication Administration Records (MAR) charts, but these are all blank copies and do not confirm the carers properly recorded administering Mrs Y’s medication.
29. Carers have recorded giving Mrs Y her medication in the logs of their visits. The logs of most but not all visits record that carers gave Mrs Y her medication. This does not replace the need to complete the MAR charts but does suggest the failings in administering Mrs Y’s medication were sporadic, rather than a regular occurrence.
30. The care provider has taken appropriate action in response to Mrs X’s reports of missed medication, in contacting the pharmacy and retraining its staff who continued to care from Mrs Y.
31. There were occasions where, despite clear instructions, carers left Mrs Y’s zimmer frame out of reach and she was unable to safely mobilise. While this is clearly not acceptable, the documentation again suggest it was an intermittent error rather than a regular practice.
32. Mrs X and the care provider disagree about the suitability of the downstairs toilet at Mrs Y’s property. But irrespective of the size and suitability of the facilities, we would not expect the carer to use Mrs Y’s commode and fail to clean it before assisting Mrs Y to use it.
33. The care provider acknowledges it should have reviewed Mrs Y’s care plan when Mrs X began raising issues with her care. And that it could have ensured a better continuity of care by aligning the competency of carers with Mrs Y’s needs. It also accepts that having decided it could no longer deliver a safe service and served notice terminating its care service, it should have supported Mrs X in sourcing a new care provider.
34. These failings in the service have caused Mrs X and Mrs Y a significant injustice. Although there is no evidence of adverse effects on Mrs Y’s health or wellbeing due to missed medication, this will clearly have been a cause of concern. As will the risk of falls when Mrs Y’s zimmer frame was left out of reach, which will also have restricted Mrs Y’s ability to move around her home. In addition, Mrs X has been put to unnecessary time and trouble in trying to resolve this matter.
35. Mrs X has complained that items are missing from Mrs Y’s bedroom. She has reported this to the police, and the care provider has informed CQC and the local authority. This is not an issue the Ombudsman can resolve.

Agreed action

36. The care provider has agreed to apologise to Mrs Y and pay her £150 in recognition of the failings in the service she received.
37. The care provider has also agreed to apologise to Mrs X and pay her £150 in recognition of the uncertainty and anxiety she has experienced and the time and trouble she has been put to in resolving the matter.
38. The care provider should take this action within one month of the final decision on this complaint.

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Final decision

39. The failings in the care service provided to Mrs Y have caused Mrs Y and Mrs X an injustice, which the care provider has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman