City of Bradford Metropolitan District Council (20 005 052)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 09 Aug 2021

The Ombudsman's final decision:

Summary: Mr B complains about the care provided to his late father, Mr C, by carers commissioned by the Council. The Council was at fault in that the care provider acting on its behalf failed to provide an adequate service to Mr C causing distress to him and his family. In recognition of the injustice caused, the Council has agreed to apologise to Mr B and make a payment.

The complaint

  1. Mr B complains that the Council failed to ensure his father received appropriate care to meet his assessed needs. In particular, he says carers commissioned by the Council failed to:
    • attend all scheduled visits;
    • safely administer and record his father’s medication;
    • provide adequate personal care; and
    • identify and seek appropriate treatment for his father’s wounds.

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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. 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)
  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. 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.

How I considered this complaint

  1. I have considered all the information provided by Mr B, made enquiries of the Council and considered its comments and all the documents it provided. I have also considered documents provided by the care provider.
  2. Mr B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

What I found

Legal and administrative background

  1. Sections 9 and 10 of the Care Act 2014 require local authorities to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to all people regardless of their finances or whether the local authority thinks an individual has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
  2. Where local authorities have determined that a person has any eligible needs, they must meet these needs.

Fundamental standards

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
  2. Regulation 9 states that the care and treatment of service users must: be appropriate; meet their needs; and reflect their preferences.
  3. Regulation 12 states providers must assess the risks to people’s health and safety during any care or treatment and make sure staff have the qualifications, confidence, skills and experience to keep people safe. The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm.
  4. Regulation 17 states that providers must securely maintain accurate, complete and detailed records in respect of each person using the service.

Key facts

  1. Mr B’s late father, Mr C, had multiple long-term health conditions and needed support with personal care and changing his catheter. He lived at home with his adult son and his wife who was partially sighted and was struggling to care for him. Mr B contacted the Council for assistance in June 2019.
  2. The Council referred Mr C to the Bradford Enablement Support Team (BEST) which provides short-term support to people who cannot care for themselves easily because they are ill or disabled. The service aims to help people maintain their independence and stay in their own home. It is a free service and lasts for up to 6 weeks to enable a period of assessment. Mr C’s assessment period ended in mid August 2019 following which BEST continued providing care for him until the Council sourced a care provider.
  3. Mr C’s assessment stated he was receiving a care package from BEST consisting of a 30 minute call each morning for personal care, changing the night catheter to a day catheter, administering medications and making a drink. He was also receiving an evening call by one carer for 15 minutes to change the day catheter bag and attach the night catheter bag.
  4. The new care provider, CRG Home Care, began providing two care calls per day on 11 September 2019. It completed an initial assessment plan which stated that the assistance of one carer was needed to support Mr C with personal care, changing his catheter and assisting with transfers.
  5. CRG completed a care plan which stated that during the morning call the carer would: assist Mr C out of bed; empty the catheter bag and change it to a day bag; assist Mr C with a full body wash; apply his prescribed cream; dress him and make the bed. The care plan stated that Mrs C would make Mr C’s breakfast and give him his medication: “my wife takes care of all my fluid and nutritional needs along with supporting personal care and medication”.
  6. The care plan stated that at the evening visit the carer should: assist with undressing Mr C and changing him into nightwear; apply prescribed creams; empty and change the catheter bag to a night bag and make a warm drink.
  7. On 7 October 2019 Mr B raised concerns with the Council saying the care provider had missed a couple of calls. He also stated his view that his father needed two carers for transfers rather than one. Mr C’s social worker discussed this with the care provider who said that, as Mr C now had a low-profile bed, one carer was adequate and it was not necessary for two carers to attend the call. The social worker agreed with this. The social worker’s notes record that on 5 November 2019 she spoke to Mr B who agreed one carer was able to care for, move and transfer his father.
  8. A re-assessment of Mr C’s needs was completed after he was hospitalised and became bedbound.
  9. On 10 January 2020 Mr B contacted the Council stating the carer had not turned up.
  10. On 20 January 2020 Mr B Mr B contacted the Council asking whether Mr C would receive a refund for a missed call in November 2019 and two missed calls in January 2020. The Council advised this was unlikely because the cost of the service was £72.18 and Mr C’s contribution was £37.50 per week.
  11. On 4 February 2020 the NHS completed an assessment for continuing healthcare (CHC) funding. It decided Mr C was eligible for full CHC funding which would start on 5 February 2020.
  12. The same day the social worker discussed with Mr B his complaint about the care provided to Mr C. He said he had complained to CRG but had not yet received a response.
  13. On 25 February 2020 Mr B raised a safeguarding concern about Mr C’s care. At the time Mr C was in hospital having developed a urinary tract infection (UTI). Mr B was concerned about missed calls and failure to administer medication to Mr C and was worried about his declining health which he felt was due to lack of care. CRG accepted:
    • there had been some missed calls;
    • the initial assessment advised that the blister pack medication was to be supported by family but it had not reassessed this support following a request by the family for this task to be completed by care staff; and
    • the care plan did not accurately detail the support required each week in relation to Mr C’s catheter bag change.
  14. CRG says it completed refresher training with staff including record-keeping practice and catheter care training. It also increased medication competency checks for care staff providing care to Mr C. It says it reviewed Mr C’s care and support plan to ensure all his needs were met, particularly in relation to catheter care and support. However, Mr C sadly died in early March 2020.

Analysis

Scheduled visits

  1. Mr B says carers failed to attend one call in November 2019 and two calls in January 2020.
  2. CRG accepted there were missed calls on 10 and 13 January 2020. It says these were in relation to one member of staff and an internal investigation was conducted at the time. The staff member subsequently resigned.
  3. There are no entries in the daily care log for 13-18 November 2019. There may have been one or more missed calls during this period but it is impossible to say as there is no information. There is no entry on 23 November 2019 for the morning call so this may be the call Mr B refers to.
  4. The Council’s safeguarding report also refers to a communication from Mr B on 12 February 2020 indicating there had been three missed evening calls in the previous seven days. There is no entry in the daily log for the morning or evening calls on 5 February 2020. There are also no entries for the morning or evening calls on 12 February 2020. This tends to support Mr B’s assertion.
  5. I find, on a balance of probabilities, that there were several missed calls. This was fault.

Missing records

  1. CRG has been unable to provide daily records for the period 3 -13 October 2019 and 3 December 2019 to 31 January 2020.
  2. Under Regulation 17, the care provider is required to maintain accurate, complete and detailed records. Failure to do so was fault and causes uncertainty about the care Mr C received during the periods where there are no records.
  3. When a council commissions care services for a person it remains liable for any service failures of the care provider. Councils should ensure care providers keep proper daily care records, including the care given and start and end time of visits so it can be assured that the service is reliable and timely.

Medication administration

  1. Mr B says CRG failed to safely administer and record Mr C’s medication. He says some carers would give Mr C his tablets but others would not saying they were not allowed to do so. He says carers sometimes handed medication to Mr C but did not check whether he took it and the family often found tablets on the floor and in the bed. Mr B says he raised his concerns with Mr C’s social worker but was told to contact CRG. He says Mr C suffered with dementia and was not able to administer his own medication; Mrs C is partially blind so it was not safe for her to administer it.
  2. The care plan completed by CRG at the outset states, “family administer from blister pack, carers to administer prescribed creams”. So, carers understood the family were administering Mr C’s tablets and they were only to support with the application of creams.
  3. Mr B says that, previously, when BEST was providing the care, the carers administered medication as well. This is correct. But this is not what was set out in the care plan completed by CRG.
  4. I find there was confusion about who should administer Mr C’s medication. I find no fault in the carers failing to do so because the initial assessment and care plan stated that the blister pack medication was to be administered by family. However, CRG was at fault in failing to reassess this following Mr B’s request that this task be completed by carers.

Personal care

  1. Mr B says CRG failed to provide adequate personal care for Mr C. He says Mr C required his catheter to be changed every week because of risk of infection. He says carers emptied the bag daily but did not change it resulting in Mr C suffering frequent UTIs causing him severe pain and distress and even hospital admission on a couple of occasions. Mr B says it was extremely distressing to see his father in so much pain and he raised this issue several times with CRG and the carers. He asked that carers clearly document when the leg bag was changed so other carers could track this. However, this was not done.
  2. The district nurse left a message on the daily logbook on 1 March 2020 stating, “Please change leg bag weekly and ensure it’s attached to a different leg each week”. This supports Mr B’s assertion that the weekly bag change was not being done.
  3. Mr C’s care plan did not mention the weekly bag change. The only tasks in relation to catheter care were for carers to attach and detach the night bag at each visit. The fact that the weekly bag change was not included in the plan led to confusion about when this should be completed. This was fault. The care plan should have accurately set out all the support required by Mr C each week.
  4. Mr B also says that during the evening visit, carers were supposed to attach Mr C’s night bag onto his leg bag and ensure the tap was released so urine could flow into the night bag. He says carers often left the tap closed so urine was not being drained into the night bag. This caused Mr C severe pain because urine was backing up into his bladder and the weight of the leg bag pulling down caused a pressure ulcer on his penis. Mr B says he raised this with CRG and the carers but it continued to happen. He also says he raised this with Mr C’s social worker but nothing was done.
  5. A note in the daily log on 1 March 2020 from the district nurse says, “his night bag was not attached last night make sure his bag is attached and draining. This happened on a few occasions and on evening visit it’s the only job!!!”. This supports Mr B’s assertion that this was not being done. This was fault.
  6. Mr B also raised concerns that Mr C’s personal care was not being completed appropriately and referred to an incident in February 2020 when one of the carers recorded finding hard faeces at the bottom of Mr C’s bed. This is evidenced by the daily care records. Failure to properly clean up faeces was fault.

Identification and treatment of Mr Y’s wounds

  1. Mr B says carers failed to identify and seek appropriate treatment for Mr C’s wounds. He says they failed to mention the pressure ulcer on Mr C’s penis to the family or the district nurses who visited until it became an open wound.
  2. The first reference in the daily care records to the wound was on 9 November 2019. The notes states “infection in penis seems worse… penis washed and gel applied, sons informed, recommended contacting medical professional”. Over the next couple of days there are several references to cleaning the wound and applying gel. There is then no further mention of this wound until 27 November 2019 when the entry states “applied cream to penis”. There are similar entries on 28, 29 and 30 November 2019 and on 1 and 2 December 2019.
  3. The next entry relating to this is on 29 February 2020 which states “penis skin has completely split and seems infected, family informed and doctor being called”.
  4. I am satisfied that carers informed the family about the issue on 9 November 2019 and recommended contacting a medical professional. I am also satisfied they informed the family again on 29 February 2020 and a doctor was called. The evidence therefore shows carers did act on the situation. However, the first note referring to this states, “infection seems worse” which suggests the infection was present prior to this but there is no mention of it in earlier notes. This was fault. The infection should have been noted and monitored from the outset. Failure to make complete notes about this was fault.
  5. Mr B questions whether carers applied the prescribed cream to the wound on Mr C’s penis twice a day as directed by the GP. He says that, if they had done so, the wound would have healed. Many of the entries in the available notes do not state whether or not the cream was applied and, as referred to in paragraph 33 above, I have been unable to view the daily records for the period 3 December 2019 to 31 January 2020. Due to this lack of evidence, I am unable to reach a view on whether the cream was applied properly.

Safeguarding investigation

  1. The Council’s safeguarding investigation began in February 2020 after Mr B raised concerns. A social worker from the safeguarding adults team, Officer X, requested information from Mr B, CRG and Mr C’s social worker. CRG completed an internal investigation and accepted fault. However, it appears the investigation report was not passed onto the Council. Officer X noted on 2 March 2020 “Awaiting information from both [social worker] and CRG”.
  2. On 9 March 2020 Officer X telephoned CRG chasing the safeguarding enquiry response. She advised that she would proceed to stage 3 as she could not wait any longer and asked CRG to prioritise its response.
  3. On 16 March 2020 Officer X noted “case to proceed to Stage 3… The Provider are undertaking an internal investigation. Awaiting receipt of the report which needs to be reviewed by the Enquiry Officer and decide what further actions, if any, are required”.
  4. In November 2020 the case was allocated to an enquiry Officer for a Stage 3 response. The notes state “investigation does not appear to have been received so this will need to be chased up with the Provider”.
  5. On 2 December 2020 the enquiry officer wrote to CRG asking for the outcome of its internal enquiries.
  6. On 1 February 2021 the enquiry officer noted she had received no response so officers decided to hold a meeting with CRG. The Council wrote to CRG requesting a meeting on 10 February 2021 but received no response.
  7. On 8 March 2021 the Council wrote to CRG requesting additional information. CRG responded on 21 April 2021. The enquiry officer and a safeguarding manager reviewed the information and noted some discrepancies. So, they invited CRG to a meeting to clarify the evidence provided. A meeting took place on 3 June 2021.
  8. The safeguarding team identified lessons and actions to be put in place to reduce future risk. It recommended the following learning for CRG:
    • families to be contacted once a month to discuss whether there are any problems;
    • backup staff to be put in place to reduce the risk of missed calls;
    • care plans to clearly record whose responsibility it is to provide medication;
    • learning from this case to be shared with staff.
  9. The safeguarding team also recommended the following learning for its own team:
    • closer monitoring of safeguarding concerns awaiting allocation in the longer-term team where provider investigations are pending/outstanding;
    • this case to be discussed in the staff forum/team meeting to reinforce the importance of maintaining contact with the service user and/or their family to keep them updated throughout the safeguarding process.
  10. The safeguarding team contacted Mr B in June 2021 to share the outcome of the safeguarding enquiries.
  11. There was a significant delay in completing the safeguarding investigation. The Council has explained this was caused by CRG’s failure to cooperate with the enquiry and by having to prioritise resources to deal with the Council’s response to the COVID-19 pandemic. It says that, under normal working practices, when the social worker decided to proceed to stage 3, the case would have been allocated to a safeguarding officer in the longer-term team. However, this coincided with the start of the COVID-19 pandemic which brought about uncertainty and change to the standard procedure. The safeguarding adults team suspended routine visits and was forced to use all staff to manage its response to the pandemic. The Council had deemed the case as non-urgent and so delayed the safeguarding as it was obliged to prioritise work based on urgency.
  12. I am satisfied with the Council’s explanation for the delay in completing the safeguarding investigation. The safeguarding team was entitled to prioritise work based on urgency during the pandemic. From November 2020 onwards the Council progressed the investigation but was hampered by CRG’s failure to respond to enquiries and meeting requests. However, the Council did not contact Mr B between March 2020 and June 2021 to inform him about the delay. Failure to do so was fault.

Injustice

  1. I find the Council’s commissioned care provider did not provide the level of care Mr C and his family had the right to expect. The inadequate catheter care, in particular, was a significant matter and caused Mr C avoidable pain and suffering. Mrs C and Mr B also experienced avoidable distress and anxiety in witnessing this. They also suffer the uncertainty of not knowing whether the failures in care contributed to the decline in Mr C’s health.
  2. The care provider’s inadequate record-keeping causes uncertainty about the care Mr C received. Its failure to cooperate with the safeguarding investigation adds to this uncertainty.
  3. The missed calls caused avoidable distress and inconvenience to the family. Mrs C had her own health conditions and struggled to support Mr C when carers did not turn up, so he did not receive all the care he needed on those occasions.
  4. I find the Council’s failure to contact Mr B between March 2020 and June 2021 to inform him about the delay in the safeguarding investigation caused him and Mrs C further distress.
  5. 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 we found fault with the service of the care provider, we have made recommendations to the Council.

Agreed action

  1. The Council has agreed that, within one month, it will:
    • pay Mr C’s estate £500 in recognition of the inadequate service he received; and
    • send a written apology to Mr B and Mrs C for the avoidable distress and anxiety they suffered because of its failings and pay them £500 each.
  2. The Council has also agreed that, within three months, it will provide evidence of how the safeguarding team has complied with the recommendations in the safeguarding report.

Final decision

  1. I find the Council was at fault in that the care provider it commissioned failed to provide an adequate service to Mr C.
  2. I have completed my investigation on the basis that the Council has agreed to implement the recommended remedy.

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Investigator's decision on behalf of the Ombudsman

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