Summary: Mr F complained Apex Prime Care Ltd failed to provide the agreed domiciliary care for Mrs X, and the care it did provide was not to a suitable standard. As a result, he said she experienced distress and lived in unhygienic conditions. He also said he experienced distress when he found out about the standard of care it provided her. We found the Care Provider at fault as it failed to provide all the care set out in its agreement with Mr F. This caused Mr F distress and uncertainty. It may also have caused Mrs X an injustice, but we cannot remedy the injustice for someone who has since died. The Care Provider has agreed to apologise and make payment to Mr F to acknowledge the distress it caused.

The complaint

1. The complainant, whom I shall refer to as Mr F, complained about the care his mother (Mrs X) received from Apex Prime Care Ltd (The Care Provider). He said it failed to provide the agreed domiciliary care to Mrs X and the care it did provide was not to a suitable standard.
2. As a result, Mr F said Mrs X experienced distress and lived in unhygienic conditions. He also said he experienced distress when he found out about the care Mrs X had received and the conditions she lived under.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
4. If we are satisfied with a care provider’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)
5. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

7. As part of my investigation, I have:
• considered Mr F’s complaint and the Care Provider’s responses;
• discussed the complaint with Mr F; and
• considered the information the Care Provider shared with me in response to my enquiries.
8. I gave Mr F and the Care Provider an opportunity to comment on a draft version of this decision, and I have considered the comments I received.

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What I found

Relevant Law and guidance

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) 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.

The Care Quality Commission

10. 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.
11. Regulation 12 is about safe care and treatment. The guidance says care providers must:
• assess the risks to people’s health and safety during any care or treatment;
• make sure staff have the qualifications, competence, skills and experience to keep people safe; and
• make sure the premises and any equipment used is safe.
12. Regulation 13 is about safeguarding service users from abuse and improper treatment. The guidance says this includes:
• neglect; and
• subjecting people to degrading treatment.
13. Regulation 15 is about clean and suitable premises. The guidance says:
• the premises and equipment used to deliver the care and treatment must be kept clean and maintained where required; and
• where the person who receives the service owns the equipment needed to deliver the care, the provider should make every effort to make sure it is clean, safe and suitable for use.

Background

14. Mrs X lived alone. She had health conditions which caused her difficulty with balance and mobility. She was also incontinent and had memory problems.
15. Mrs X was hospitalised after a fall in 2020. Soon after, she was discharged into the care of a care provider.
16. In June 2020, Mrs X started to receive care support in her home from Apex Prime Care Ltd (the Care Provider). The support was funded under the NHS Continuing Health Care Covid funding until January 2021, when she became a self-funder.
17. Mrs X’s Care Plan said she needed support four times each day of the week. Each visit should last 30 minutes to provide support with personal care, food and fluid intake, medication, change of bedding, washing and drying clothes, and keeping her home clean and tidy.
18. Mrs X’s Agreement with the Care Provider said it would provide the support set out in her Care Plan. It also said its carers would:
• do light domestic cleaning tasks;
• remove expired contents from her fridge; and
• check for hazards and safety issues.
19. Mr F had authority to make decisions about Mrs X health and wellbeing, and her financial matters. The Care provider agreed he was the next of kin and the person to contact about Mrs X’s care. He also ordered her groceries and other essentials. However, he was not able to visit Mrs X’s during the period due to COVID-19.
20. The Care Provider stopped providing care to Mrs X in the end of January 2021. This was because she was admitted to hospital. When she was discharged a different care provider looked after her care needs.
21. Mrs X died in summer 2021.

What happened

22. In early January 2021, a carer from the Care Provider contacted Mr F to raise her concerns about the care Mrs X received from other carers. This included her bed being left wet and dirty after morning visits, which meant she had to return to a wet bed if she needed a nap. Mr F raised his concerns with the Care Provider.
23. The Care Provider told Mr F it had not previously been told about the concerns, so it could not have done anything. However, it would make changes to the care tasks to ensure it addressed his concerns. It also told the Carer to in future report issues to it, and to stop unauthorised calls to Mr F and block his calls.
24. When Mrs X went into hospital again, Mr F went to her home to make it ready for her discharge. He said he found the house to be unhygienic and dirty because:
• the kitchen was filthy and expired food was left in the cupboards;
• the food trolley was stained, and its undershelf was covered in old food bits;
• floors had not been hoovered and the bedroom was covered with tiny bits of tissue;
• clothes were piled unfolded on the bed in the front room, including some stained sheets and mattress covers; and
• there were faeces on walls and doorways, the bathroom was dirty, and the sink had not been cleaned for months.
25. Mr F took pictures of the conditions and said it took four days to clean the house.

Mr F’s complaint

26. Mr F complained to the Care provider about the unhygienic conditions Mrs X had lived in and shared his pictures. He said this did not meet the standard of care he expected from it, in particular during COVID-19. He also said it had left her bed wet and unchanged in the mornings, which meant she could not go back to bed.
27. In response, the Care Provider agreed the hygiene of Mrs X’s home was not acceptable based on the information he had provided. It said their agreement was for care visits and not for domestic cleaning. However, it accepted it had a duty to provide a light level of home hygiene and increased awareness during COVID-19. It also said:
• it had asked it staff to ensure they clean surfaces as well as food preparation areas, but some staff may not have followed their duties;
• hoovering was not a part of Mrs X’s care plan, but its staff should have reported the floors were unkept and dirty. It said it would have expected its carers to hoover until it could arrange a domestic cleaning of the home with Mr F;
• its care notes show carers often changed bedding, recorded wet sheets and clothing. Including, washing and drying the bedding and clothing. However, it was not clear in the case notes that staff were not putting away clothing in the designated areas;
• it was appalled to see faeces on the walls and door frames. It said its staff should never have left Mrs X’s home in such a state. It acknowledged it looked as though the faeces had been left for some time, and found this to be basic level home hygiene which it had trained its carers to be proactive about;
• it apologised for the poor hygiene and the time it had taken Mr F to correct this before Mrs X returned home from hospital.
• it had since reminded relevant carers of their duties and the procedures it expected them to follow. It also said it would spot check its carers to ensure they treated its clients’ homes with respect and followed hygiene protocols.
28. Mr F was not satisfied with the Care Provider’s response and complained again. He said:
• Mrs X’s neighbour had told him its carers did not stay for the duration set out in the Agreement;
• it had left expired food in the cupboards and in the fridge, and the cupboards were dirty and unhygienic; and
• it had left wet sheets on Mrs X’s bed, and it put 4 or more pads on Mrs X at night.
29. The Care Provider shared its care notes of Mrs X’s care with Mr F. It found its carers had provided the agreed care. It said some visits were shorter than agreed, but other visits were longer.
30. The Care Provider sent Mr F a further response to his complaint. It said its carers had raised concerns to Mr F, which it believes contributed to the care conditions of Mrs X’s home. It said its carers told him:
• there were no cleaning products made available and no toilet roll on many occasions;
• Mrs X had run out of food essentials;
• Mrs X had developed a bowel problem over recent months and had taken to smearing the wall in her own faeces; and
• The heating in the property was not working properly.
31. Mr F is unhappy with the Care Provider’s handling of his concerns. So, he asked the Ombudsman to consider his complaint.

Analysis

Hygiene in Mrs X’s home

32. The Care Provider agreed the hygiene conditions of Mrs X’s home was not acceptable and apologised to Mr F. It said some of its carers had failed to follow its procedures and complete light level home hygiene. This included:
• cleaning of surfaces and equipment;
• removal of faeces on walls, doorways and sinks; and
• folding clothes and putting this in the designated areas.
33. It also said it did not expect its carers to do domestic cleaning of Mrs X’s home. However, they should have reported concerns about the unkept floors and the general need for cleaning of her home to the Care Provider.
34. I have therefore found the Care Provider at fault for failing to ensure it kept Mrs F’s home clean and tidy as set out in her care plan and as required by the fundamental standards.
35. I acknowledge the agreement did not require carers to do domestic cleaning of Mrs F’s home such as hoovering. However, it is clear her home needed cleaning and the unhygienic conditions could pose a risk to her health. The carers should have reported this to the Care Provider and Mr F, so cleaning of her home could be arranged. The Care Provider was therefore also at fault for failing to ensure the premises were clean and safe to deliver its care to Mrs X.
36. In addition, Mrs X’s care plan also said the Care provider should check and dispose of expired food. While the plan refers to refrigerated food, my view is such care includes the food stored in Mrs X’s kitchen. I therefore also found the Care Provider at fault for failing to dispose of some food in Mrs X’s kitchen. This is because, the evidence available shows, it had left some expired food in the kitchen cupboards. However, as Mrs X’s diet was limited to some purchased items and the ‘meals on wheels service’, there is no evidence to suggest Mrs X’s ate expired food.

Did Mr F contribute to the unhygienic conditions?

37. The Care Provider said Mr F failed to ensure there were cleaning products, toilet roll and food available. It said its carers regularly raised this with him and this contributed to the unhygienic conditions of Mrs X’s home.
38. I have seen no evidence the Care Provider or its carers contacted Mr F with concerns about the lack of cleaning products, toilet rolls or food for Mrs X. Also, the case notes make no reference to any of these issues. I have therefore not found Mr F contributed to the poor hygienic conditions Mrs X lived under.

The care visits

39. Mr F said the Care Provider failed to provide the agreed duration of care for each visit to Mrs X. It agreed some visits were shorter than agreed, but also found other visits were longer.
40. Based on the care notes, the Care Providers morning care visits to Mrs X were often longer than the assigned 30 minutes. This is likely to be due to the amount of care she needed at those visits. However, many of its other care visits were shorter than the agreed 30 minutes assigned. The notes show this was because:
• the carer believed they had completed the required tasks for Mrs X, or she did not need some tasks completed during the visit;
• Mrs X did not want the task completed or wanted to go to sleep; or
• Mrs X gave the carer permission to leave early.
41. I am satisfied the Care Provider did provide Mrs X’s with personal care, ensured she received food, nutrition and medication, and ensured washing was completed as set out in her care plan. This is because the care notes show these were generally always completed or attempted.
42. However, I found the Care Provider failed to ensure it kept Mrs X’s home clean and tidy. I am satisfied they could have done so if its carers had stayed the full duration of the care visits.
43. I understand Mrs X gave carers permission to leave early at times, however, this was based on the understanding all task, including cleanliness and tidying up. had been completed as set out in the care plan. The Care provider was therefore not at fault for failing to provide the duration of care, but it was at fault for providing all the support set out in her care plan.
44. Mr F also said the carers at times failed to change Mrs X’s wet bedding, which meant she could not go back to bed, or had to return to a soiled bed. The care notes show Mrs X’s bedding was regularly wet and changed by the carers, but the heating was not working properly to dry the mattress if this had been soiled. I found the Care Provider regularly changed Mrs X’s bedding and I have not seen enough evidence to support Mr F’s allegation. I have therefore not found it at fault on this matter.

Injustice

45. I acknowledge Mr F believes Mrs X’s may have experienced an injustice as a result of the Care provider’s faults. However, we cannot normally remedy fault which caused an injustice to someone who has since died.
46. Mr F also said he experienced distress when he found out about the unhygienic and unsafe conditions Mrs X had lived under for up to six months. In particular, as he had been unable to visit and support her in person for some time due to COVID-19. I am satisfied Mr F experienced some distress due to the uncertainty about how this impacted on Mrs X’s wellbeing and dignity.
47. The Care Provider has taken steps to address the concerns raised in Mr F’s complaint. It has reminded relevant carers of their duties and the procedures it expects them to follow. It has also spot checked its carers to ensure they treat its clients’ homes with respect and follow hygiene protocols. I am therefore satisfied the Care Provider has addressed any service improvement remedy I would have proposed.

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Agreed action

48. To remedy the injustice the Care Provider caused to Mr F, the Care Provider should, within one month of the final decision:
1. Apologise in writing and pay Mr F £400 to acknowledge the distress and uncertainty he experienced as a result of its failure to ensure Mrs X’s home was clean and hygienic when it provided her care support.

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Final decision

49. There was fault leading to an injustice. It is on this basis I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman