Summary: Mrs Y complains about the quality of care provided to Mr X by Wisteria Care, on behalf of the Council. The Ombudsman has found fault by Wisteria Care causing injustice. The Council has agreed to remedy this by making a payment to Mrs Y to reflect the distress, time and trouble caused by the fault, and provide evidence of the implementation by Wisteria Care of recommended service improvements.

The complaint

1. The complainant, who I am calling Mrs Y, complains about the quality of the care provided to her late father, Mr X, by Wisteria Care (WC) on behalf of the Council. Mrs Y is unhappy the Council has not fully answered the family’s questions about his care.

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The Ombudsman’s role and powers

2. 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)
3. 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)
4. 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

5. I have spoken to Mrs Y, made enquiries of the Council and read the information Mrs Y and the Council have provided about the complaint.
6. I invited Mrs Y and the Council to comment on a draft version of this decision. I considered their responses before making my final decision.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Relevant law and guidance

8. Under the Care Act 2014, councils have a duty to assess adults who have a need for care and support. They must then provide a care and support plan setting out the services required to meet any eligible needs identified by the assessment. And if asked to do so, councils must arrange a care package.to meet these needs.
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards registered care providers must achieve, and below which care must never fall. The CQC, as the statutory regulator of care services, has issued guidance on how to meet these standards.
10. These regulations require providers to:

• make sure they provide care in a way that ensures people’s dignity and treats them with respect at all times. (regulation 10)
• assess the risk to people’s health and safety during any care or treatment and make sure staff have the qualifications, competence, skills and experience to keep people safe. (regulation 12)
• deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times and other regulatory requirements. (regulation 18)

What happened

Background

11. Mr X required care at home after his wife, Mrs Y’s mother, was admitted to hospital on 3 April 2020 with COVID-19. Mrs Y and her sister lived nearby but were unable look after him because they were self-isolating.
12. The Council arranged for the Community Rehabilitation Support team to make daily care visits to Mr X from 4 April, while it carried out an assessment of his care and support needs and found a care provider to take on the care package.
13. On 7 April WC was booked to provide Mr X’s care package from 9 April. The Council confirmed he needed three visits a day and a social worker would contact them directly with details of the care required. The Council told Mrs Y WC would be taking over Mr X’s care from 9 April.
14. The Council’s records show a social worker contacted WC on 8 April. He had not had time to complete the written assessment of Mr X’s needs but confirmed the following:

• WC were commissioned to provide Mr X’s care from the next day, 9 April.
• Details of the daily care visits required. These were stated as (i) morning visit of one hour to provide Mr X support with personal care, dressing and breakfast, going downstairs and prompting medication and incontinence care. (ii) lunchtime visit of 30 minutes to make Mr X lunch and change pads if necessary. (iii) evening visit of 30 minutes to support Mr X upstairs to bed and change pads if necessary.
• Mr X’s wife had passed away with COVID-19 and all carers should wear personal protection equipment.

Mr X’s care provision from 9 April 2020

15. WC took over Mr X’s care on 9 April. Mrs Y called them that day to confirm they had her contact details. She asked them to let her know if there were any problems with Mr X’s care.
16. WC’s care plan for Mr X included Mrs Y’s contact details, confirmed his wife had passed away from COVID-19 and he had only just been made aware of this. It instructed all carers to wear full PPE. The plan confirmed Mr X required support with all his personal care, nutritional needs, fluid intake and incontinence care. And more information would be added as soon as it was received.
17. WC made the three care visits on 9 April. When Mrs Y spoke to Mr X that evening all seemed well. However, WC say the carer on the evening visit reported the next morning her concern Mr X had refused support to go upstairs to bed.
18. The morning visit to Mr X on 10 April was missed. WC said this was due to an error in the way the visit allocation was communicated to the carer. When this was realised, they arranged for another carer to make an early lunchtime visit.
19. There is no log record of the lunchtime call. But WC provided a statement from the carer who had been asked to visit. He said:

• He attended Mr X’s lunchtime visit. Mr X told him he could not stand as it was slightly painful.
• He made Mr X lunch and a drink but forgot to fill in the care log as he was running really late for his next call.

20. WC said (in response to the Council’s enquiries) the carer reported Mr X had been reluctant to accept care at the lunchtime visit and they arranged for two carers to carry out the evening visit.

Accounts of the evening visit on 10 April 2020

21. WC provided the Council with reports and statements from its manager and staff who were on call or visited Mr X.
22. The evening carers, one of whom had carried out the lunchtime visit, said:

• They visited Mr X about 7pm. They found him slouched in the chair and were unable to move him. They noticed his feet and legs were swollen like balloons.
• Mr X asked them to get help from his family. They both went to Mr X’s daughter’s house. She told them she was unable to help as the family were self-isolating.
• They returned to Mr X. They found he was short of breath, unable to move and hot to the touch. They called 111 who sent an ambulance and Mr X was taken to hospital. They informed the family and WC of this.

23. The on-call staff member said the carers phoned to say they had found Mr X slumped in his chair. They were advised Mr X could be weak and to give him food and fluids. The carers called again to say Mr X had asked them to visit his family as he was feeling very unwell. Finally, the carers called to say an ambulance had arrived and it was suspected Mr X had COVID-19.
24. WC’s manager says they are not allowed to ask the ambulance service for assistance to lift a client up from the floor. Their practice is to ask family to call for an ambulance. Carers can only call if a client on the floor appears to be injured or have hit their head. The ambulance service issue reports if they consider carers have called for an inappropriate reason.
25. Mrs Y’s sister says:

• At about 7pm two carers came to her house asking them to go round to Mr X because he had slid out of his chair and they could not lift him. She explained why they could not help and asked them to call 111. The carers said they were not allowed to do this, and the family would have to make the call.
• The carers phoned WC’s office from outside her house for advice about what to do. The calls went on for some time, the carers made comments, which could be heard by others, about Mr X’s physical condition and care issues.
• She called 111 to ask for help. They arranged an ambulance and advised the carers should return to her father and call 111 from there. She received a call from Mr X’s neighbours who had seen the ambulance arrive, before the carers got back to his house.

26. Mr X passed away in hospital with COVID-19 some days later.

Mrs Y’s complaint

27. Mrs Y and her family were unhappy about the quality of care provided to their father by WC and raised their concerns with the Council. The Council investigated and provided information and statements obtained from WC and its staff.
28. In early June the Council discussed their findings with Mrs Y’s family. It said the safeguarding team had not found neglect, but WC would now be subject to quality and improvement monitoring. The Council also apologised for the situation.
29. WC’s manager wrote to Mrs Y on 12 June 2020 and said:

“ I would like to apologise for any distress and upset caused to you and your family by Wisteria Care. I am sorry we have added to the distress you are already coping with…….I would like to inform you that we are now refreshing our intensive training to all carers to ensure they are aware of the correct procedures to follow in similar situations.”

30. Mrs Y and her family were not satisfied with the response to their concerns. They complained directly to WC, and also to the Council.
31. The Council replied in August. It confirmed its safeguarding team had not found evidence of neglect, but had made the following recommendations to WC for practice improvements:

• Staff to have retraining on dignity and respect to address issues about inappropriate comments, and choice and confidentiality;
• Systems to be put in place to ensure carers have received and acknowledged changes to the rota;
• All assessments to be completed prior to commencing care;
• Care will not start until after receipt of care plan and assessment from the Council;
• Every care worker will attend training for person centred care; and
• WC will ensure every care worker has the necessary information to be able to carry out the correct level of care, including information passed on by family and advocates.

32. The Council also said:

• The information had been shared with the Council’s Quality Improvement Team who would follow up on the recommendations during their monitoring visits to WC.
• Concerns and Outcomes had also been shared with the CQC.
• WC should respond directly to them about the concerns regarding Mr X’s care.

33. Mrs Y heard nothing further from WC in response to their complaint. The family were not satisfied with the Council’s response and felt their questions about Mr X’s care on 10 April had not been properly answered. In September 2020, Mrs Y brought her complaint to us.

Analysis – was there fault by the Council or WC causing injustice?

34. Mrs Y and her family complain there are still unanswered questions about Mr X’s care on 9 and 10 April, his last two days at home before being admitted to hospital. I understand their concern. But our role here is to determine whether there has been fault by the Council or WC which has caused injustice, and if so to propose a remedy for this. While there may still be some unanswered questions, my view is we have sufficient information from our investigations to make these findings.
35. Although the Council did not provide the completed written assessment before WC took over Mr X’s care, it provided information about Mr X and details of the care package required. WC had the opportunity to ask the Council or Mrs Y for any further information it considered it needed before starting to provide Mr X’s care.
36. The Council and WC accepted there were failures in the standard of care WC provided Mr X. Based on the evidence I have seen, I consider these included failures to:

• carry out the morning visit on 10 April, and record the lunchtime visit
• respond to the concerns raised following the evening visit on 9 April
• contact Mrs Y about concerns with Mr X’s care
• consider whether Mr X’s condition at lunchtime and evening on 10 April was caused by COVID-19 and take appropriate action
• take appropriate action when the carers arrived for the evening visit and found Mr X unwell. WC did not provide the carers with appropriate guidance when they called the office for help. The carers left Mr X alone and behaved inappropriately by discussing Mr X’s condition in public. WC failed to contact Mrs Y to alert her to the concerns about Mr X’s condition.

37. In my view WC failed to provide care to Mr X in a way that kept him safe and ensured his dignity, most significantly in the way it dealt with the emergency on the evening of 10 April. This is fault.
38. I consider WC failed to ensure its staff had all the available information about Mr X and the family’s situation and the appropriate skills, training and experience to meet Mr X’s care needs at all times, and in particular in an emergency situation. This is fault.
39. The faults by WC in its care of Mr X, are, in my view, likely to have caused him distress. Sadly, we are unable to put this right for Mr X now. But I consider these faults also caused Mrs Y and her family distress, and time and trouble in raising their concerns, at a particularly difficult time for them.

Agreed action

40. 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 propose finding fault with the actions of Wisteria Care, I made recommendations to the Council.
41. I have noted WC’s apology to Mrs Y for adding to the distress she and her family were already experiencing, and the recommendations made by the Council for practice improvements.
42. In addition to this, to remedy the injustice caused by the above faults, and within four weeks of the date of our final decision, the Council should:

• Pay Mrs Y £300 to acknowledge the distress, time and trouble caused to her and the family by WC’s failings in Mr X’s care.
• This figure is a symbolic amount based on the Ombudsman’s published Guidance on Remedies.

43. And within three months from the date of our final decision, provide evidence from its Quality Improvement Team about the action taken by WC to implement the recommended service improvements.

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Final decision

44. I have found fault by Wisteria Care causing injustice. I have completed my investigation on the basis the Council will take the above action as a suitable way of remedying the injustice.

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Investigator's decision on behalf of the Ombudsman