Staffordshire County Council (20 007 513)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 07 Sep 2021

The Ombudsman's final decision:

Summary: Mr X complained about some aspects of the homecare Mr P received by a care provider who had been arranged by the Council. I upheld Mr X’s complaint. The Council has agreed to provide a partial refund of the fees Mr P paid for his care and apologise to Mr X for any distress he has suffered. The Council will also share the lessons learned with relevant staff.

The complaint

  1. The complainant, whom I shall call Mr X, complained on behalf of (the late) Mr P. Mr X complained the care provider contracted by the Council (Companion for Care Services Ltd), failed to provide some of the care Mr P needed. He said it:
    • Failed to provide the oral hygiene Mr P needed, and which was identified in the care plan. As a result, he developed Thrush in his mouth, which was uncomfortable and affected his ability to eat and drink.
    • Failed to spot a bedsore and failed to alert him (Mr X) of this, which resulted in the affected area having become much worse than needed. It showed the care workers had failed to check Mr P’s body regularly, as required in the care plan.
    • Only stayed for 5 minutes at times, even though they should have stayed for 30 minutes. On those occasions it was not, as claimed, because “they had provided all the support needed at that time and there was nothing else to do”, as suggested by the Council.
  2. Mr X said the Council also failed to consider paying compensation for the lack of care provided by the care provider.
  3. Mr X also complained the Council failed to change the care provider when he asked for this.

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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 the information I received from Mr X and the Council. I shared a copy of my draft decision statement with Mr X and the Council and considered any comments I received, before I made my final decision.

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What I found

The complaint about oral hygiene

  1. Mr P’s care package consisted of four double-up care support visits per day. His support plan from January 2020, and the instructions for care workers, clearly included the need to provide oral hygiene to Mr P.
  2. However, Mr X said:
    • The care provider failed to provide the oral hygiene Mr P needed, and which was identified in the care plan. He said the care workers would only clean Mr P’s dentures on those occasions when he (Mr X) would tell them. On most occasions, he himself had to clean Mr P’s dentures.
    • He believes the lack of oral hygiene resulted in Thrush developing in Mr P’s mouth. Mr X first noticed something white in Mr P’s mouth in April 2020 but did not realise what it was or that it needed treatment. He says the Thrush became uncomfortable (affecting Mr P’s ability to eat and drink) by June 2020.
    • The hospice told Mr P it was Thrush on his admission in July 2020. A doctor in the hospice gave Mr P antibiotics, which cleared it.
  3. The Council subsequently received a call from the hospice, to ask if poor oral health was part of the safeguarding enquiry it had started into Mr P’s care. The hospice also asked if this was included in Mr P’s support plan.
  4. Mr X told the safeguarding investigator (hereafter referred to as ‘the investigator’) that he had taken over the cleaning of Mr P's dentures as the care workers did not seem to want to do this.
  5. The Council’s safeguarding investigation obtained input from:
    • A nurse, who reported that: when someone is at this advanced stage of palliative decline, they will not be eating and drinking, and their mouth would be very dry as a result. As such, care workers should moisten the inside of the mouth by using moist flannels etc.
    • The care provider, who said that:
        1. The care workers had tried to moisten Mr P’s mouth and maintain his oral hygiene as best they could. However, he would not allow them to clean inside his mouth.
        2. Mr P had found it painful to have his teeth cleaned with a toothbrush by care workers. The investigator said the care agency should have discussed this with the District or Palliative Care Nurses.
  6. The safeguarding report said the records suggested that care workers were trying to keep Mr P's mouth clean. The District Nurses said that this, like other areas of his care, could have been quite challenging. However, Mr X maintained that even before Mr P was this ill, care workers were not cleaning his teeth
  7. The care workers and the nurses agree that Mr P could be difficult to care for. He was not a passive patient. He knew what he wanted and at times he was in too much pain to want to be cared for or nursed, which was understandable. The overall impression is that it has been difficult to determine in sufficient detail what was happening with Mr P’s care during the periods under question.
  8. However, if care workers were finding it difficult to provide some / consistent support in some areas, they should have discussed this with the district nurses, which did not happen.

Analysis

  1. I reviewed the care records of February and May 2020 and found no evidence that care workers provided, or at least tried to give, oral hygiene support to Mr P (brushing his teeth). This is fault. The Council’s safeguarding investigation confirmed this and concluded that care workers had failed to provide the oral hygiene support as indicated in Mr P’s care plan.
  2. However, it appears this may not have been the reason for the Thrush developing. According to the medical professional consulted, Mr P’s care workers should have moistened the inside of his mouth by using moist flannels etc. However, I have not seen evidence that care workers did this, or at least were trying to. This is fault.
  3. It appears the care provider had not instructed care workers to try and regularly moisten Mr P’s mouth. According to the medical professional the Council consulted, this would have increased the chance of Thrush developing in Mr P’s mouth due to his mouth being too dry.

The complaint about a pressure sore developing

  1. Mr X said care workers were supposed to regularly inspect and check Mr P’s body and report any problems to him, so he could alert the district nurse. However, he said the care workers failed to spot a bedsore in July 2020. He said a nurse discovered the bedsore by chance and described it to him as “very bad and it was red and purple”. This failure by the care workers, had resulted in the bed sore having become much worse.
  2. The Council’s safeguarding report said that:
    • The hospice had called the Council in July 2020 to check if its safeguarding investigation was looking at the grade 3 pressure sore Mr P had on admission.
    • Mr P’s support plan states that care workers should support him every morning with a full strip wash, an incontinence pad change, and application of prescribed creams to any red/dry areas.
    • On two of the daily log entries supplied, care workers specified they creamed Mr P's bottom with barrier cream and washed him etc. This is in the days just preceding Mr P's admission into the hospice, when his sores were discovered.
    • A SSKIN chart was provided by the district nurses and care workers had filled it in twice a day. A turn chart was provided during the last days and care workers also filled that in.
    • However, there is no reference to the condition of Mr P's skin condition during these last few days. The care workers also did not contact the District Nurse, even though the Support Plan Diary Sheet says they have to if they had any concerns.
    • A nurse who was consulted said it was probably more likely a grade 2 sore. She added it is difficult to ensure there is no skin breakdown in a patient in such an advanced palliative state.

Analysis

  1. Although the care records indicate the care workers provided the support Mr P needed, they failed to record in what condition Mr P’s skin was and failed to alert the district nurses when it developed into a pressure sore. This is fault.

The complaint about not staying long enough

  1. Mr X said:
    • Care workers only stayed for 5 minutes sometimes, even though they should have stayed for 30 minutes. On those occasions this was not because “they had provided all the support needed at that time and there was nothing else to do”, as indicated by the Council.
    • He told the Council he has two videos showing carers only staying 5 min instead of 30.
  2. In response, the Council told me that:
    • Mr X did not raise this concern with the Council’s Commissioning Team at the time. Instead, it was addressed by the Midlands Partnership NHS Foundation trust (MPFT), with involvement from the social worker.
    • It has obtained all the records, which show the care workers did not stay the full time. Following a review of the records, the Council noted there were 311 calls that were not for the full 30 mins. The Council has therefore now agreed to refund these calls, to the amount of £3,884.
    • The Council did not receive any videos from Mr X.

Analysis

  1. The Council has reviewed the records and found there were 311 calls that were not for the full 30 mins. It has said it will reimburse these calls.

The complaint about changing care provider

  1. Mr X says he asked the Council to change the care provider. However, he says the Council refused this and said this was not possible as this was the only agency in his area. Mr X told me this was not correct as (for instance) the hospital team that provided the nurse sitting service said the hospital also had a care workers team that could have provided the care package.
  2. In response, the Council told me that all requests to change care provider are usually referred to the Council’s Commissioning Team. However, the team did not receive this request from the social worker. The records have been checked and there is no evidence of Mr X making such a request.
  3. According to the Council’s records, Mr X told the Council on 13 May 2020 that: he was not happy with the agency as they didn't do what was asked of them and they did not stay the time they were supposed to. He asked if he could change to another agency, so I gave him the phone number for [the local] Duty Team.
  4. Mr X subsequently called the team but, according to the records, the call was only about care concerns and did not mention a wish to change agency. The records state that Mr X: “suggested that he had spoken with the care agency by phone and email about these issues but that he felt that he did not wish to keep doing so without our input as he feels they 'ignore him'”.
  5. The Council spoke to the care provider about Mr X’s concerns and fed back the outcome to him. The records state that:
    • Mr X asked if the care provider could be changed
    • The social worker explained the Council would not usually agree to change a care provider unless there was a major issue of neglect / omission of care duties that led to a safeguarding referral being raised.
    • They discussed that Mr P was paying for the full cost of his care package and Mr X therefore had the option to look for another agency, without the Council getting involved. Mr X was keen to consider this, and the social worker sent a link to the Council’s Care services Directory.

Analysis

  1. Contrary to the Council’s statement, Mr X did ask the Council to change care provider, because he was unhappy with the service they provided, despite his attempts to discuss this with the provider. As such, the Council should have tried to identify another care provider.

The complaint about compensation

  1. On 5 November 2020, the Council discussed the outcomes of its safeguarding investigation into the above concerns, with Mr X. It said that: what stood out was the lack of recording, lack of communication with the District Nursing Team, and short calls.
  2. Following the outcome of the safeguarding investigations, Mr X asked the Council for compensation in relation to the shortcomings in care it identified. However, the Council said this was not something it could facilitate and referred to the following reasons:
    • it does not provide compensation in relation to the outcome of safeguarding enquiries and
    • Mr P was a self-funder so he should address this with the care agency.

Analysis

  1. This is fault. This was something the Council should have dealt with. It contracted the care provider to provide a service, so was therefore responsible for ensuring Mr P’s needs were met.
  2. If, following the safeguarding investigation, Mr X wanted a financial remedy for the injustice he and Mr P experienced, the Council should have considered this through its complaint process. The Council has since acknowledged this. REC; share lesson with relevant teams.

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Agreed action

  1. When a council commissions a care provider to provide services on its behalf, it remains responsible for those services and for the actions of the care provider. So, although I found fault with the service of the care provider/organisation, I/we have made recommendations to the Council.
  2. I recommended that, within four weeks of my decision, the Council:
    • Should provide an apology to Mr X for the additional faults identified above.
    • Share the lessons learned with its staff, especially around how to deal with a request for a financial remedy following a safeguarding investigation and how to respond to requests to change care provider.
  3. The Council has told me it has accepted my recommendations.
  4. The financial remedy now offered by the Council is sufficient to remedy any injustice that has been caused to Mr X and (the late) Mr P.

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Final decision

  1. For reasons explained above, I have upheld Mr X’s complaint. I am satisfied with the actions the Council will carry out to remedy this and have therefore decided to complete my investigation and close the case.
  2. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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Investigator's decision on behalf of the Ombudsman

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