Royal Borough of Kingston upon Thames (20 002 541)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 19 Jan 2021

The Ombudsman's final decision:

Summary: The Council failed to provide adequate domiciliary care to a vulnerable adult. Its safeguarding investigation found poor practice by the Care Provider it commissioned to meet Mr D’s adult social care needs. Mr D received rushed care which did not always meet his needs and contributed to his skin breakdown leaving him uncomfortable. The Council missed opportunities to resolve the issues at the earliest stage and misplaced a complaint. This protracted the upset and frustration for Mr D’s wife and daughter. The Council will refund the care fees, pay £200 each to Mr D’s wife and daughter, and remind staff of the importance of accurate record keeping and responding to correspondence.

The complaint

  1. The complainant, who I will call Ms C, says the Council failed to address concerns of poor care provided by the care agency it commissioned to meet her father (Mr D’s) care needs. Ms C says:
  • Carers were frequently hours late and missed several visits without notification; and
  • Carers did not spend 30 minutes per visit as per the package of care. Average time spent was 15 minutes; and
  • Carers falsified times to give the impression they were staying for 30 minutes; and
  • Carers provided poor personal care, leaving Mr D dirty and smelling of body odour; and
  • Carers did not apply the conveen correctly. On three occasions carers stated it was not their job and refused; and
  • Other health professionals spent time correcting poor care that carers provided or when they did not turn up; and
  • Carers were confrontational and intimidating towards her mother.
  1. Ms C also says the Council lost her complaint of 25 February, so she had to send it again. This delayed the Council’s response.
  2. Ms C says the poor care caused distress to her and her mother (Mrs D) as Mr D’s wellbeing suffered. Mrs D was anxious and felt she could not relax in her home as she never knew when the carers would turn up, she would telephone Ms C which was then upsetting for Ms C to hear her mother distressed as Ms C lives a distance from her parents. It has been hard to make the complaint and re-live the issues, Ms C has been unable to move on and to grieve the loss of her father. The Council’s actions in the complaint handling made this worse. Ms C and Mrs D would like an apology, a refund of the care fees, and compensation for their distress.

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The Ombudsman’s role and powers

  1. 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)
  2. 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)
  3. 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)

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How I considered this complaint

  1. I considered:
    • Information provided by Ms C, including during a telephone conversation.
    • Information provided by the Council in response to my enquiries.
    • Information provided by the District Nurses.
  2. 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. I considered the CQC fundamental standards and its most recent inspection report of Caremaid Services Ltd.
  3. Ms C and the Council 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

  1. Mr D was bed bound and could not manage his own personal care. Mr D lived with his wife, he had care workers from Caremaid services Ltd visiting in the morning and evening to help with:
  • Full wash in bed using slide sheets and including hair care, oral care and skin care.
  • Continence care/change of pad, and dressing.
  • Carers to reposition and monitor skin health closely and report signs of change to District Nurses.
  1. The Council assessed Mr D needed four calls per day, but Mrs D only agreed to two. District Nurses were visiting twice a week.
  2. Mr D used a conveen sheath for urinary incontinence which needed changing daily. The District Nurse records show that the use of the conveen was discussed with the care workers and they were happy to apply it every 24 hours. The notes say the District Nurses will liaise with the Care Provider to ensure it is added to the care plan, but I have no evidence this happened. However, the District Nurse records show the care workers were applying it.
  3. A month after the care package started the District Nurses first noted a concern that the care workers had not fitted the conveen correctly and Mr D smelt of body odour despite the care workers having visited an hour previously. The District Nurse’s evidence shows they contacted the Council, though the Council has no record of this.
  4. The Council did a home visit five days later when Mrs D and the District Nurses raised concerns that the Care Provider had not reported a pressure sore and were not washing Mr D properly. The Care Provider then met with Mrs D who told the Council she was happy it had listened to her concerns.
  5. Ms C says this pressure sore should have triggered a safeguarding investigation, the Council explains a grade three pressure ulcer is usually the threshold for a safeguarding concern, and as this was a grade two it did not trigger the safeguarding process. I have looked at the ‘London Multi-Agency Adult Safeguarding Policy & Procedures’ which confirms a grade three, or higher, pressure ulcer, or multiple grade two ulcers would be the trigger.
  6. Over the next month there is evidence Mrs D was raising concerns with District Nurses about the care workers consistently coming late, the District Nurses were concerned about Mr D’s skin integrity. But there is no evidence these concerns were raised with the Council or Care Provider. The District Nurse then left two messages for the Council, but it did not return her calls.
  7. Mrs D then contacted the Council about her concerns, as did the District Nurses. The Council completed a safeguarding investigation; it found poor practice by the Care Provider and changed care provider. Mrs D was happy with the service of the new care provider. Mr D died a few months later.
  8. Ms C made a complaint to the Council, which the Council was responding to. Ms C then sent a further complaint e-mail, the Council forwarded her e-mail to the wrong internal mailbox which meant it was not dealt with. Ms C had to chase the Council to get a response and send her complaint again. Once the Council realised the error it removed the incorrect e-mail address to prevent the risk of it happening again. The Council apologised to Ms C.

Was there fault by the Council causing injustice?

  1. Because the Council commissioned the care, the Care Provider is acting on its behalf. I find it more likely than not the Care Provider was frequently late. This is based on the notes of the District Nurses, the finding of the safeguarding investigation and the Care Quality Commission’s report from earlier that year which said users of the service consistently commented on staff lateness. This is fault. The impact was that Mrs D felt she could never settle as she did not know what time the care workers would turn up. The lateness likely contributed to Mr D’s conveen leaking and affecting his skin as he was then sitting in urine.
  2. The Council acknowledges the care plan was not specific about what continence care was required and does not refer to the need for a conveen sheath. The Council says health tasks can be delegated to the Council as part of the care plan, with its agreement. It was wrong of the District Nurses to discuss the conveen application with the Care Provider and not with the Council. To stop this happening again, the Council will develop a protocol for identifying which health tasks can be delegated, how agreement and decision will be made, and how these tasks will be monitored and reviewed. This will include what training is needed to undertake the agreed health tasks, and who will be responsible to provide the training.
  3. The Care Provider says it was not responsible to change Mr D’s conveen, however evidence from the District Nurses shows care workers agreed to do it after the District Nurses showed them what to do. There is evidence in the Care Provider’s records that care workers were sometimes changing the conveen, which indicates they accepted it was part of their role. I find it more likely than not given this evidence, and the fact the District Nurses were only visiting twice weekly and therefore would not be changing the conveen daily, that changing the conveen was part of the Care Provider’s role in this case. It was included on the care plan when the new care provider took over, which further indicates it was part of the Care Provider’s role. If the Care Provider felt its staff needed more training, or could not provide this service, it should have contacted the District Nurses or Council accordingly.
  4. The impact of this is that Mr D was often laying in urine, which affected his skin. As he could not move himself, he was already prone to skin breakdown and did develop pressure sores, the Care Provider’s actions made the problem worse. The Care Provider failed to notify the District Nurses of a grade two pressure sore that developed. As the District Nurses were visiting regularly, it is unlikely the Care Provider’s failure caused much delay in the identification of the pressure sore and appropriate treatment.
  5. Ms C says the care workers were always rushing and did not wash Mr D properly. The District Nurse records show concerns about body odour despite care worker visits. The Care Provider says Mr D washed with a cream, which would never be sufficient to take away the body odour. I find it more likely than not the Care Provider’s service was poor. It is accepted the care workers were often late, which means they were probably rushing to finish and move on to the next job.
  6. The Care Provider may not have acted in accordance with the CQC requirements for person-centred care and dignity and respect. The Care Provider’s service was not always appropriate, did not always meet Mr D’s needs and preferences, and did not treat Mr D with dignity and respect if rushing his care.
  7. To improve its service regarding lateness the Care Provider has put in place a monitoring system. The Care Provider spoke with relevant staff during supervision meetings to prevent future reoccurrence of errors.
  8. The Council has a Quality Assurance team; it was fault of its officer not to highlight this case to that team. In future where there are concerns about poor quality of care this will be logged with the Quality Assurance team so issues can be resolved and monitored more closely if needed and an assessment of whether a safeguarding referral is needed.
  9. The Council missed opportunities to resolve concerns at the earliest opportunity. The Council failed to return calls to the District Nurse, and its records do not correlate with the District Nurse records. This is poor record keeping by the Council and is fault.
  10. Mr D has died, so the Ombudsman cannot remedy his injustice. However, the poor service in this case was to the extent Mr D received no real service at all. I find therefore we can recommend a refund of fees to his Estate.
  11. It was very difficult for Mrs D to see her husband receiving poor care, and she also felt unsettled in her own home due to the tardiness of the care workers, and then their rushed nature when in attendance. Mrs D became very stressed and would telephone Ms C for support. It was hard for Ms C, who lives some distance away, to hear what her parents were going through and feel she could do little to help.
  12. Ms C had the time and trouble of making the complaint to the Council, and the frustration when her complaint was lost.

Agreed action

  1. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Care Provider, I have made recommendations to the Council.
  2. To acknowledge the impact of the identified faults, and to prevent future problems, the Council will:
      1. Refund the care fees Mr D paid for Caremaid’s service in 2019. The refund should be made to the Executor or Personal Representative of his Estate.
      2. Pay Mrs D and Ms C each £200.
      3. Remind relevant staff of the importance of contemporaneous record keeping, and to return telephone calls when necessary. The Council will include record keeping on its 2021 training plan, and complete an audit of case files to monitor the quality of record keeping.
  3. The Council should complete the agreed actions within one month of the Ombudsman’s final decision. The Council should evidence compliance of agreed actions to the Ombudsman.

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Final decision

  1. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we have shared the final decision with CQC.
  2. I have completed my investigation on the basis the agreed actions are sufficient to acknowledge the impact of the fault in this case, and to prevent future reoccurrence. This is in addition to steps the Council has already taken.

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Investigator's decision on behalf of the Ombudsman

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