Summary: Miss X complains about the standard of care provided to Mr Y. The Council is at fault as NDH Care Ltd provided inadequate care to Mr Y which caused his admission to hospital and failed to identify and seek medical intervention for pressure sores. The Council also did not give adequate consideration to whether a safeguarding referral indicated Mr Y had received poor care. The Council has agreed to apologise and make a payment to Miss X to acknowledge the distress caused to her and ensure the care provider makes service improvements.

The complaint

1. Miss X complains that NDH Care Ltd failed to provide adequate care to Mr Y. In particular Miss X complains carers:
1. Bought high sugar items when carrying out Mr Y’s shopping despite him suffering from diabetes and NDH Care Ltd failed to respond to Miss X concerns which she raised in September 2019
2. Failed to prompt or give Mr Y his medication which resulted in his admission to hospital;
3. Failed to properly wash Mr Y with soap and flannels;
4. Failed to use the cricket hoist for transferring Mr Y;
5. Failed to regularly carry out his laundry and left dirty laundry in his property after he was admitted to hospital;
6. Failed to keep his property clean and tidy.
2. Miss X considers that as a result of the poor care Mr Y’s health deteriorated and he was suffering with pressure sores and lice when admitted to hospital in January 2020.

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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. The Council commissioned and arranged Mr Y’s care under its duties set out in the Care Act 2014 to meet his eligible needs. So any fault in the care provider’s service is fault by the Council.
5. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
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)

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How I considered this complaint

7. I have:

• Considered the complaint and the information provided by Miss X;
• Discussed the issues with Miss X;
• Made enquiries of the Council and considered the information provided;
• Invited Miss X and the Council to comment on the draft decision. I considered any comments received before making a final decision.
• 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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What I found

8. The Council’s service specification sets out the standards it expects from the care providers it commissions to provide care. This includes requirements for record keeping, including clearly recording any medication taken, refused or spilt and care providers should not remove or dispose of medication and records. It also provides all medication records/medicine administration records (MAR) must be clear and legible and record details including timing of medication, type of medication given and dates and signatures. It also provides the daily care records should be clearly legible and set out the tasks undertaken during the call.
9. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)

What happened

10. Mr Y had a number of health conditions including epilepsy and diabetes and lived alone. In August 2019 the Council commissioned NDH Care Ltd to provide home care to Mr Y.
11. The care provider drew up a care plan for Mr Y which set out the required care. He required four calls per day with two carers to assist his transfers. The care included assisting Mr Y with a strip wash every morning, support with transfers using the cricket aid, assistance with cleaning, laundry and shopping. The care plan also provided that carers must ensure Mr Y had access to his medication at each call so he could take his prescribed medication as required. Mr Y was required to take his anti epilepsy medication in the morning and at 18:00 each day.
12. In September 2019 Miss X contacted the care provider to raise concerns that carers were buying high sugar items for Mr Y when doing his shopping. I understand the care provider informed the carers that high sugar items should not be bought for Mr Y due to his diabetes.
13. Miss X sent an email to the care provider in December 2019 again raising concerns about that Mr Y’s shopping included high sugar items and that his laundry had not been done. The care provider did not respond.
14. Mr Y was admitted to hospital following a seizure on 28 December 2019. Carers had completed the MAR chart for December up to 22 December 2019 which noted they had given Mr Y his medication to take at each call. The MAR chart also recorded that carers should prompt and observe Mr Y taking his medication. There are no further entries on the MAR chart after 22 December 2019. The Council has provided Mr Y’s daily care records up to 22 December 2019. Miss Y has provided the records from 23 to 28 December 2019. There are no records for the following calls:

• 24 December 2019 – lunchtime and bedtime calls
• 26 December 2019- bedtime call.
• 27 December 2019 – morning, tea and bedtime calls

15. The record for the tea-time call on 26 December does not record the carer gave Mr Y his medication. The record for the lunchtime call on 27 December 2019 does not record the carer gave Mr Y his medication.
16. Mr Y remained in hospital until 17 January 2020. The hospital discharge letter states Mr Y was admitted to hospital with a seizure which was suspected to be secondary to poor compliance with his anti-epileptic medication.
17. The care provider reinstated Mr Y’s care package when he was discharged from hospital on 17 January 2020. The care provider carried out a review of Mr Y’s care plan. The revised care plan noted Mr Y could not mobilise independently. He liked to transfer using the cricket aid but his health wasn’t good so he liked to stay in the bed. Once he felt better he would like to transfer to his chair. The care plan provided carers should monitor Mr Y’s skin and report to the district nurse if they had any concerns. The care provider also carried out a skin mark review on 21 January 220 and noted Mr Y had swollen legs. The care provider did not identify Mr Y was suffering with pressure sores.
18. The daily care records from 17 to 30 January 2020 record carers washed Mr Y in a morning and two carers attended.
19. Mr Y was admitted to hospital on 30 January 2020 by ambulance. Miss X says the hospital told her Mr Y also had body lice in addition to pressure sores when he was admitted.
20. Mr Y sadly passed away on 19 February 2020 while in hospital.

Safeguarding complaint

21. The ambulance service made a safeguarding referral to the Council on 31 January 2020. The Council’s records note the safeguarding referral said the carer had called for the crew as Mr Y was unable to move, his skin was stuck to a plastic mattress and he had a lot of pressure sores on back, upper legs and bottom which were blistering. The referral also noted there was old food and what looked to be burnt food and carer had noticed Mr Y had not had his incontinent pad changed in a long time.
22. The Council’s records show it tried to contact Miss X to discuss the referral on her mobile phone but were unable to do so. It referred the matter to the area team. The Council’s decision making record shows a manager gave instructions for gathering further information to make the enquiry decision. The next entry on the record is dated 17 March 2020. It says Mr Y had passed away on 19 February 2020. The social worker had contacted bereavement services at the hospital and been informed Mr Y’s cause of death was pneumonia. In response to my enquiries the Council has also said the hospital were not concerned about the pressure sores being a consequence of neglect but this is not noted on the record. The record notes the Council closed the case as Mr Y had passed away so no further action was required.

Complaint

23. Miss X made a complaint to the care provider about the standard of care delivered to Mr Y. This included her concerns about carers buying high sugar items, not buying flannels and soap to wash Mr Y, buying shave gel for Mr Y which he did not need, not cleaning or doing the laundry and not using the cricket hoist. The care provider said:

• It was unaware of Mr Y’s pressure sores and body lice. Its skin assessment carried out on 21 January 2020 did not find Mr Y was suffering from pressure sores.
• No medications were missed by Mr Y but carers visited Mr Y earlier or later than they should have done on some occasions.
• Mr Y did not want to use the cricket hoist after his discharge from hospital in January 2020 due to pain in his legs.
• The property was cleaned on 16 January 2020 but the vacuum cleaner was not working. Carers reported this to Miss X.
• A carer had also informed the family of a bag of soiled laundry which needed to be thrown away as the laundry would not wash them.
• A carer had mistakenly bought shave gel. Carers had bought basic personal care items for Mr Y but lost receipts for initial items purchased. The Council has said there are no receipts for flannels and soap.
• Some of the daily care communication logs for Mr Y were missing.

The care provider also said it was unaware Mr Y had passed away until June 2020 when Miss X made her complaint. It had no record of the Council contacting it about the safeguarding referral.

24. The care provider advised Miss X of service improvements it would make in response to her complaints. These included implementing a system for tracking log sheets, carers to take pictures of receipts and send to the care provider as evidence, a system for ensuring it chased late calls and a system for auditing shopping lists and the expenditure.
25. Miss X remained unhappy so contacted CQC and made a complaint to the Ombudsman.
26. In response to my enquiries the Council has said the care provider’s records do not meet its service standards and will need to be urgently addressed with the care provider. It acknowledges there are a number of missing records but has verified the visits to Mr Y took place.

Analysis

27. Miss X has raised a number of issues about Mr Y’s care. The key issues are the care provided to Mr Y between 23 December and his admission to hospital on 28 December 2019 and the care provided up to his admission to hospital on 30 January 2020.

23 to 28 December 2019 - medication

28. In accordance with the Council’s service standards, the care provider is required to record the care provided to the service user, including the medication provided and the time it was administered. The care provider’s record keeping in the days before Mr Y’s admission to hospital is poor. Carers did not complete the MAR chart after 22 December 2019. The daily care records after this date note Mr Y was given his medication although some records do not include the time carers gave the medication to Mr Y or clearly show which carer administered the medication. There are also records which do not record carers gave the medication to Mr Y at the tea-time call. This is crucial as this is the time Mr Y should have received his anti epilepsy medication. There are also records missing.
29. The hospital discharge letter shows Mr Y was admitted to hospital with a seizure caused by poor compliance with his medication. The poor record keeping by the care provider means it cannot demonstrate carers consistently gave Mr Y his medication in accordance with the care plan. I therefore consider, on balance, carers did not consistently give Mr Y his medication in accordance with the care plan and this caused Mr Y’s admission to hospital. This is potentially a breach of the CQCs fundamental standard to provide safe care.

January 2020 – admission to hospital

30. The care provider carried out an assessment of Mr Y’s skin integrity on 21 January 2020 which did not show any pressure sores. The ambulance service’s safeguarding referral of 31 January 2020 states Mr Y was covered in pressure sores and stuck to the mattress. So, Mr Y must have developed pressure sores between 21 and 30 January 2020 when he was admitted to hospital. The care records note carers washed Mr Y on the morning calls, including during the morning call on the day he was admitted to hospital. The care plan also required carers to monitor Mr Y’s skin integrity and this was particularly important as Mr Y was bedbound. It is therefore inexplicable that carers did not notice Mr Y was developing pressure sores if they were carrying out his personal care in accordance with the care plan. On balance, I conclude the care provided to Mr Y was inadequate and not in accordance with the care plan. This is potentially a breach of the CQCs fundamental standard to provide safe care.
31. Mr Y may have developed pressure sores even if the carers had delivered care to him in accordance with the care plan given he was bedbound. But it is likely the care provider would have sought medical intervention for the pressure sores sooner such as referring Mr Y to the district nurse and taken steps to make him more comfortable.
32. Miss X has also complained the carers did not use the cricket hoist to transfer Mr Y. The care plan notes Mr Y was bedbound following his discharge from hospital in January 2020 and did not want to be hoisted so the cricket hoist was not used. The key issue here is the fact carers did not identify Mr Y was developing pressure sores.
33. I do not know if Mr Y had body lice when admitted to hospital but I will not investigate this matter further. This is because I consider the care of Mr Y was inadequate in the run up to his admission to hospital in January 2020 and further investigation will not add to this finding.
34. I consider the poor care will have caused Mr Y’s hospital admission in December 2019 and will have caused distress to Mr Y in the lead up to his admission to hospital in January 2020. Unfortunately, it is now not possible to seek a remedy for Mr Y’s injustice as he has passed away. But the knowledge that Mr Y received poor care will have caused distress to Miss X and her family which the Council should remedy.

Other care issues raised by Miss X

35. Miss X has complained carers bought high sugar food for Mr Y despite him being diabetic. Mr Y had capacity to make decisions about his diet. So, the care provider could not prevent him from including high sugar items on his shopping list and impose a different diet on him. Miss X disputes Mr Y would have asked carers to buy high sugar items for him. I cannot know if this was the case and I do not consider further investigation will establish if carers bought Mr Y high sugar items without being asked to do so.
36. Miss X has said carers could not have washed Mr Y with flannels and soap as there is no evidence they bought them for Mr Y. The Council has acknowledged there are no receipts for flannels and soap but I cannot know if such items were in Mr Y’s property. It is not proportionate to pursue the matter further as I have concluded the care of Mr Y was inadequate.
37. Mr Y’s care plan provides the cleaning and laundry call should be weekly. The records for January 2020 show there were cleaning calls on a weekly basis from Mr Y’s discharge on 17 January to his readmission to hospital on 30 January 2020. Miss X disputes a cleaning call was carried out on 16 January as the care provider told her carers could not enter the property if Mr Y was not there. The records clearly show a cleaning call was carried out on 16 January so, on balance, I consider it was carried out.
38. The records do not clearly show Mr Y’s laundry was carried out in accordance with the care plan. On balance, I consider this to be fault and could have prevented Mr Y from having an adequate supply of clean clothes. But this injustice cannot be remedied as Mr Y has passed away.

Complaint handling by the care provider

39. I consider the consideration of Miss X’s complaint by the care provider to be inadequate. Miss X’s complaint raised concerns about poor care, in particularly in relation to Mr Y’s medication and pressure sores. I acknowledge the care provider was not aware Mr Y had been admitted to hospital with pressure sores until a few months after he had passed away. But the care provider did not address itself to why Mr Y had developed pressure sores, whether there was evidence of poor care or a training need. This is surprising given the potential seriousness of this complaint and this omission will have caused some frustration to Miss X.

Safeguarding

40. The Council closed the safeguarding referral as Mr Y had passed away. But the safeguarding referral raised a number of indicators of poor care in addition to the pressure sores. The Council commissioned Mr Y's care and is ultimately responsible for the quality of that care. So, it is surprising the Council did not consider if it needed to investigate the indicators of poor care raised by the safeguarding referral and whether this could affect other service users who received commissioned care from the care provider. On balance, I consider this is fault. Had the Council investigated at this time it would have at least established the care provider’s records did not meet its service standards. But I do not consider this fault to cause significant injustice to Miss X.

Agreed action

41. 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 have found fault with the care provider, my recommendations are for the Council.
42. The Council will:
1. Within one month of the final decision send a written apology and make a payment of £300 to Miss X to acknowledge the distress caused to her and her family by the inadequate care provided to Mr Y and the frustration caused by the care provider’s inadequate complaint response.
2. Within one month of the final decision, ensure the care provider’s documents meet its core service standards.
3. Within two months of the completion of b) above, carry out quality assurance check of a sample of records for care it has commissioned from the care provider. This is to ensure the care provider’s record keeping is adequate and in accordance with the core service standards.
4. Within two months of the final decision, ensure the care provider provides training to carers on checking for and recognising the signs of pressure sores and the appropriate action to be taken.
5. Within three months of the final decision, review its procedures to ensure officers consider investigating the standard of care provided by a commissioned care provider in the event a safeguarding referral raises indicators of poor care but a safeguarding investigation is not warranted.
43. The Council should provide evidence to the Ombudsman of the action taken to satisfy these actions.

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Final decision

44. The Council is at fault as NDH Care Ltd provided inadequate care to Mr Y which caused his admission to hospital and a failure to identify and seek medical intervention for pressure sores. The Council also did not give adequate consideration to whether a safeguarding referral indicated Mr Y had received poor care. The Council has agreed to apologise and make a payment to Miss X to acknowledge the distress caused to her and ensure the care provider makes service improvements. This is a reasonable and proportionate remedy so I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman