Summary: Ms X complained about the standard of care provided to her brother, Mr T over forty days in summer 2021 by Kirstens Care Ltd. There was fault in Kirstens Care’s record keeping and complaint handling which caused Ms X uncertainty about the level of care received by Mr T and frustration. Kirstens Care Ltd agreed to apologise to Ms X for the frustration and uncertainty and to make service changes to prevent a reoccurrence of events.

The complaint

1. Ms X complained about the standard of care provided to her brother, Mr T, over forty days in summer 2021 by Kirstens Care Ltd (the Care Provider). Ms X says the Care Provider was neglectful, failed to administer medication to Mr T and failed to return the key to his property after a visit. Ms X states the poor care caused Mr T confusion and distress.

Back to top

The Ombudsman’s role and powers

2. 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)
3. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
4. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
5. 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.
6. 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)

Back to top

How I considered this complaint

7. I read the documents provided by Ms X and discussed the complaint with her on the telephone.
8. I read the documents the Care Provider sent in response to my enquiries.
9. Ms X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

Domiciliary Care

10. Domiciliary care is defined as the range of services put in place to care for and support people in their own homes. Support to people at home might include personal care, medication, access to the community, shopping or household tasks such as cleaning and meal preparation. This help and support can be provided by daily visits from a carer.

Standards of care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services, including domiciliary care must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
12. Regulation 16 states complaints to a provider must be investigated thoroughly and any necessary action taken where failures have been identified.
13. Regulation 17 states providers must securely maintain accurate, complete and detailed records about each person using their service.

Capacity

14. The Mental Capacity Act code of practice defines capacity as the ability to make a decision. Someone who lacks capacity cannot make a particular decision, or take a particular action, for themselves at the time the decision or action needs to be taken. Capacity is time and decision dependant, which means someone may have capacity to decide whether to eat a meal but not where to live.

Care provider’s policy

15. The Care Provider’s medication policy sets out how medicine should be administered and recorded. It says the medication administration record (MAR) registers when medication has and has not been administered in line with the prescription. It states if the label of the medication and the MAR chart do not match the care worker should not give the drug. They should seek clarification from their manager or the out of hours service.

What happened

16. In May 2021 Mr T lived alone in his own home. Mr T had Alzheimer’s and Vascular Dementia and needed care and support to live independently. Mr T was supported by his sister, Ms X and his niece, Ms N who lived nearby. Mr T had a key safe on the outside of his house with a combination lock. Anyone needing access could open the safe and use the key.
17. Ms X approached the Care Provider to care for Mr T at home. The Care Provider met with Mr T and Ms X and wrote a care plan which identified Mr T’s needs and the support it would offer him to meet those needs. Ms X agreed to the care plan and signed the contract of service with the Care Provider.
18. The care plan stated Mr T wanted to remain as independent as possible while living at home. It said Mr T could do most things himself, such as showering, cleaning and making cups of tea but needed to be reminded to do those things. Mr T needed three visits per day.
19. In the morning the care plan stated the carer would:
• administer medication;
• prompt Mr T to wash, clean his teeth, shave and get dressed;
• help Mr T make his breakfast and drinks; and
• help Mr T to sort his laundry out.
20. In the afternoon the carer would support Mr X to choose and make his tea and sort his laundry out.
21. In the evening the care plan stated the carer would:
• administer medication;
• prompt Mr X to shower, clean his teeth and help him into his pyjamas; and
• support Mr X to sort his laundry and get his clothes ready for the next day.
22. Mr T’s MAR chart recorded the care workers should give Mr T medication in the morning and in the evening. Mr T also had a cream for a skin condition which he needed to use intermittently.
23. The Care Provider began providing care for Mr T on the same day it completed and agreed the assessment with Ms X. Ms X and Ms N continued to visit Mr T regularly. The carers used handwritten notes to communicate with Mr T’s family members and each other. The carers also used an electronic care record to record the activities they completed during their visits and any extra notes.
24. In the first week of providing care the record shows the carer who visited Mr T at bedtime found his medication pack for that evening was empty. The carer phoned the on-call supervisor to ask for advice. The supervisor advised the carer not to administer the medication. The MAR chart shows the carer did not administer the medication that evening. The carer left a note for Ms X and Ms N to say they had not administered the medicine.
25. The following week Ms X rang the Care Provider and asked it to ensure all carers prompted Mr T to wash in the morning and clean his teeth. She said if Mr X was wearing a jumper on hot days the carers should ask him to put on a t-shirt.
26. A few days later the carer completing the bedtime visit found Mr T was naked and confused. They recorded he was unsteady on his feet and there was faeces on several surfaces. The carer recorded they had phoned and told Ms N that Mr T was confused and cleaned up the faeces. The carer phoned the on-call supervisor and reported Mr T’s confusion and unsteadiness. Ms N stated she did not receive a call from the carer. The following day Ms N wrote a note that she had cleaned up faeces from the bathroom and dining room.
27. Three weeks after the Care Provider began providing care for Mr T, Ms X contacted it and said she was worried carers were not prompting Mr T to wash in the morning. She said carers were taking Mr T’s word for it that he had eaten breakfast in the morning. Ms X asked the Care Provider to provide a further visit every afternoon for companionship for Mr X. The Care Provider agreed to provide an extra visit starting the following day and reminded all staff to prompt Mr T to wash and eat breakfast every morning.
28. In June the carer visiting Mr T at 5pm found the key was not in the key safe. The carer phoned the on-call supervisor and told them. The Care Provider found the carer on the previous visit had accidentally taken the key home with them. The carer who visited Mr T at 7.30am the following morning returned the key to the key safe.
29. Towards the end of June Ms X and Ms N went on holiday and did not visit Mr X for eight days. Ms X says when she returned and visited Mr T, which was day 38 she was concerned about the level of care provided to Mr T. Ms X phoned the Care Provider and cancelled the contract on day 40. The Care Provider agreed to waive the two-week notice period.
30. The Care Provider spoke with the carers who visited on the morning of day 38 and 39 and identified two carers attended on those days. A new carer was shadowing an existing staff member. The records show the new staff member completed the electronic records on those days.
31. In July Ms X complained to the Care Provider. She said when she visited Mr T on days 38 and 39:
• he was wearing a jumper that was not suitable for the hot weather;
• his bed was soiled and had not been changed;
• there was no evidence he had washed or cleaned his teeth; and
• he had not had a shave for two or three days.

Ms X stated she had reviewed the notes in the care plan and complained that:

• Mr T’s medication had not been professionally managed;
• carers had known about the faeces in Mr T’s home in June and had ignored it;
• the Care Provider was negligent when the carer mistakenly removed Mr T’s front door key; and
• the Care Provider had not provided the level of care specified in the care plan for the whole period of care.
5. The Care Provider responded to Ms X. It did not provide an explanation or tell her how it had investigated the complaint. It stated none of Ms X’s complaints identified neglect of Mr T. It said it worked in line with the care plan it had agreed with Ms X and with the Mental Capacity Act 2005. It did not uphold any of Ms X’s complaints. It stated:
• checking and re-making Mr T’s bed was not part of the care plan;
• it was Mr T’s choice to wear a jumper as he chose his clothes;
• it was Mr T’s choice not to shave and he had locked himself in his bedroom when carers had pushed him to do so previously; and
• it did not know why the carer had not followed the care plan on days 38 and 39.

Electronic record

33. The electronic record shows the carers provided care in line with the care plan agreed with Ms X for 38 of the 40 days. Some mornings when carers arrived Mr T had already dressed himself and said he had washed. On those occasions the carers ensured that Mr T cleaned his teeth. Occasionally Mr T declined a wash or shave in the morning. The carers ensured Mr T had a shower every evening they provided care.
34. On day 38 and 39 the record does not show the carer offered or gave any personal care on the morning visit or enquired if Mr T had already washed.
35. On day 38 the record shows the carer who visited in the afternoon helped Mr T to make his bed. On day 40 the carer changed Mr T’s bedsheets as they were soiled.
36. The record shows when Mr T was wearing his clothes back-to-front, the carers encouraged him to put them on correctly. There is no record of carers prompting Mr T to remove a jumper in hot weather.

My findings

37. When the carer found the correct medication was not available, they sought advice and did not administer any medication to Mr T. The carer told Ms X and Ms N about the matter using the agreed note pad. The Care Provider acted in line with its policy and there was no fault in its actions.
38. A carer mistakenly took Mr T’s key home. The Care Provider located and returned the key at the earliest opportunity. In the meantime, the carers continued to visit as Mr T opened the door for them. There was no fault in the Care Provider’s actions.
39. I have seen no evidence carers were aware of faeces being present in Mr T’s house and did not clear it up. As Mr T spent most of his time at home alone it is possible the faeces occurred between carers’ visits. When a carer found faeces in the property, they acted to support Mr T and cleaned the property and informed the supervisor. There was no fault in the Care Provider’s actions.
40. Mr T had the capacity to decline to wash, clean his teeth and shave as was his personal choice. The records show Mr T would often wash and shave when prompted to do so. On days 38 and 39 the care records do not show if Mr T had already washed and dressed, or if the carer prompted him or supported him to do so. On those days a new carer completed the electronic record while shadowing an experienced carer. On all other occasions the experienced carer prompted Mr T to wash and clean his teeth. On the balance of probabilities, I find Mr T was encouraged to wash, clean his teeth and shave. However, the records are incomplete and that is not in line with regulation 17 of the fundamental standards. The lack of record keeping caused uncertainty to Ms X about whether the carers had encouraged Mr T to complete his personal care on those days.
41. Mr T had the capacity to choose his own clothes and dress himself. However, he needed some support to ensure his clothes were on correctly. Ms X asked the Care Provider to ensure carers prompted Mr T to put on a t-shirt on hot days. There is no record of carers prompting Mr T to change into a t-shirt on hot days. However, there is no record of what Mr T was wearing on each day or what the weather was like. I cannot make a finding about whether there was fault on this matter. Further investigation is unlikely to result in a different outcome.
42. I have reviewed the care records for the time the Care Provider supported Mr T. The records show the Care Provider cared for Mr T in line with his personal preferences and the care plan. There was no fault in the standard of care the Care Provider provided to Mr T.
43. I have seen no evidence the Care Provider’s investigated Ms X’s complaint or acted when it identified there had been a fault on days 38 and 39. Its response stated Mr T had locked himself in his bedroom when pushed to shave, however there is no account of this in the records. The lack of investigation and inaccurate complaint response was fault and was not in line with regulation 16 of the fundamental standards. This caused Ms X frustration.

Back to top

Agreed actions

44. Within one month of this decision the Care Provider agreed to:
• write to Ms X and apologise for the uncertainty caused by the incomplete records, and frustration caused by its lack of investigation and poor complaint response;
• remind staff of the importance of complete and accurate records, particularly when inducting new staff members; and
• remind relevant staff of the importance of completing robust investigations into any complaint it receives.
45. The Care Provider will provide us with evidence it has done so.

Back to top

Final decision

46. I have completed my investigation. I found fault leading to injustice and the Care Provider agreed to my recommendations to remedy that injustice.

Back to top

Investigator's decision on behalf of the Ombudsman