Summary: The Care Provider acknowledged failings in the management of Mrs Y’s care before the involvement of this office, but it failed to offer an appropriate remedy for the injustice caused.

The complaint

1. Mrs X complains the Care Provider:

• failed to provide the care as set out in the contractual agreement;
• failed to keep records of calls, meetings or assessments relating to home care provision between November 2020 to May 2021;
• failed to provide a rota of regular carers;
• failed to provide suitably experienced staff to provide with dementia care and failed to provide Mrs Y with necessary stimulation.

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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 can decide whether to start or discontinue an investigation into a complaint within our jurisdiction. (Local Government Act 1974, sections 24A(6) and 34B(8), as amended)

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How I considered this complaint

4. I have:

• considered the written complaint and discussed it with Mrs X;
• considered the Care Provider’s response to the complaint;
• considered relevant legislation;
• offered Mrs X and the Care Provider an opportunity to comment on a draft of this statement, and considered the comments made.

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What I found

Relevant legislation

5. 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.
6. Regulation 9 Person Centred Care says Care Provider must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate and meets their needs.
7. Regulation 12 Safe Care & Treatment says people must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Care Providers must assess the risks to a person’s health and safety during any care or treatment and make sure care staff have the qualifications, competence, skills and experience to keep people safe.

Key Facts

8. Mrs Y lives in her own home and has dementia.
9. The Care Provider was commissioned to provide live-in care between October 2020 to May 2021.
10. Mrs Y could at times be challenging which needed careful management. Because of this the Care Provider agreed to provide carers experienced in dealing with people with dementia It also agreed to provide a rota of three regular carers to promote familiarity and ensure a consistent approach. Mrs X says this did not happen. She says Mrs Y had seven different carers over eight months, with some staying as little as two weeks. She says this caused Mrs Y distress and resulted in increasingly challenging behaviour. Mrs X believes some of the carers left because they had insufficient experience of dealing with people with advanced dementia and challenging behaviour
11. Mrs X says one the carers told her she had just finished a two-week training course in dementia, which was the only experience she had. Mrs X contacted the Care Provider on 23 December 2020 to say she was concerned about the carers lack of experience. She says her concerns were brushed aside.
12. Mrs X says the Care Provider failed to provide Mrs Y with appropriate social stimulation, which contributed to a deterioration of her condition. Mrs X accompanied Mrs Y on a visit to an NHS memory clinic. She says the clinician said Mrs Y needed more stimulation and provided some ideas. Mrs X says she shared the information with the Care Provider, but it was not acted on. She says Mrs Y did nothing more than sit in a chair watching the television for most of the day.
13. In February 2021, the carers reported Mrs Y began refusing to take her medication. A carer informed Mrs X and she attempted to provide support over the telephone. Mrs X says she understood that carers cannot force people to take medication, but the matter should have been escalated and reported to Mrs Y’s GP.
14. Mrs X contacted Mrs Y’s GP on 16 April 2021. Following this a plan to administer covert medication was implemented. Mrs X says she cascaded the GP’s advice to the carers. She says matters did not improve and the Care Provider failed to act when the situation deteriorated, and this placed the carer at risk.
15. Mrs X says Mrs Y began making distressing calls to family and friends, so she contacted the Care Provider on 13 May 2021 to insist it visit Mrs Y to review the care and the overall situation.
16. A care coordinator visited Mrs Y the following day, a Friday, Mrs X says she had to contact the care coordinator the following Monday to ascertain the outcome of the review.
17. Mrs X says the situation reached crisis point and the Care Provider suspended the care without notice on 28 May 2021. Mrs Y waited 24-hours for an ambulance and was taken to A&E.
18. Mrs X says although the carer kept detailed daily records these were not reviewed by the Care Provider and had this been done, the care provided could have been reviewed and appropriate care and intervention may have prevented the crisis
19. Mrs X complained to the Care Provider saying it had failed to meet its contractual obligation and that Mrs Y had paid for a service she did not receive. She asked the Care Provider to reimburse care fees from the date Mrs Y was admitted to hospital.
20. The Care Provider responded to Mrs X on 25 June 2021. I have had sight of a copy of the letter. The author, also the investigating officer, responds in detail to each point raised and said providing care to Mrs Y had been challenging and “...there were challenges with your mothers rapid decline in her condition and as such the care plan was live, being adapted to meet your mothers care need”, And, it had worked “...collaboratively with our professional partners we had no options but to cease care to ensure your mothers safety first and then the carers. It was abrupt and couldn’t not have been avoided at that time”.
21. The officer acknowledged the company had not always communicated directly with Mrs X and said this was because there were other family members and it had requested a single point of contact. The officer said there was no evidence to show the company’s processes, procedures and management plans had failed. And, that Mrs X’s request for a refund from the ‘Friday onwards’ had been refused.
22. Mrs X was dissatisfied with the response. Following the exchange of numerous emails, and a further telephone conversation with the investigating officer on 20 July 2021, she received a second complaint response dated 23 July 2021. On this occasion the officer upheld Mrs X’s complaint and said, that after further investigation the company, “…identified that during the period where we provided care for your mother, we had not adhered to our contractual obligations regarding reviewing the Care Record Books, specifically recordings for a 4-weekly period. I consider that this may have impacted on our knowledge and understanding regarding your mother’s medication administration. By reviewing the information regarding your mother’s medication administration could have meant that the office staff could have provided additional support and/or training or intervention”. The company also identified the need to improve the training it provided to carers on lone working, “…Specifically looking at the need for carers to identify strategies and risk management when working in environments which escalate quickly”. The officer acknowledged its communication with Mrs X had not always been timely and to her expectation but said it would not alter its policy on communicating with large families, that it would continue with two points of contact, and it would ensure that families were aware of this.
23. The officer went onto say she believed the carer should be paid for her time, but as a gesture of goodwill, the company would reimburse Mrs Y a service fee of £281.14.
24. Mrs X believes the amount offered to be insufficient, she says Mrs Y did not receive the care that was agreed and for which she paid, and this contributed directly to her decline.
25. In response to my enquires, the Care Provider said it had found it difficult to find a positive outcome to the complaint, that during discussions with Mrs X she “did not know what she wanted… If it were a financial resolution [Mrs X] had wanted, I would have entered discussions to positively resolve the complaint”.

Analysis

26. People have a right to expect safe, effective, and appropriate care that meets their needs. This is not what happened here.
27. By its own admission, the Care Provider acknowledged it failed to meet its contractual obligations, and that this impacted on Mrs Y. The errors in record keeping had a direct effect on Mrs Y’s medication and impacted on her behaviour. The frequent change in carers did little to promote consistency. It is well established that consistency in dementia care is essential, that it reduces anxiety and fosters better communication. The NICE Guidelines – ‘Dementia: assessment, management and support for people living with dementia and their carers’ published in June 2018, recommends that “Staff delivering care and support should maximise continuity and consistency of care”.
28. Mrs Y did not receive consistent care, neither was the care properly monitored and reviewed. It is more probable than not that this contributed to a decline in her condition. Mrs Y suffered a tangible injustice which requires a remedy.
29. The Care Provider’s offer to reimburse four days service provision does not go far enough. Its comment that the carer should be paid for her time is inappropriate. It is not the carer that was responsible for the failings in Mrs Y’s care, it was the management of that care, and in any event an individual carer is not responsible for failings in service delivery, it is the company’s responsibility to ensure care provision meets an individual’s needs.
30. Mrs X also suffered an injustice. She witnessed Mrs Y’s decline and the uncertainty of wondering if, with the correct management of care, the crisis could have been prevented.
31. Mrs X invested considerable time and effort complaining to the Care Provider. She received two vastly different complaint responses written by the same person. The first response refutes all allegations of service failure, and the second acknowledged fault. This calls into question the efficacy of the initial investigation and understandably fuelled Mrs X’s mistrust.
32. In response to my enquiries the investigating officer, also the author of the two complaint responses, said investigating the complaint had been difficult, not least because Mrs X did not know what she wanted “as a desired outcome… If it were a financial resolution that [Mrs X] had wanted, I would have entered discussions to positively resolve the complaint”.
33. It is clear from the officer’s own complaint response that she was aware Mrs X was seeking a reimbursement of care fees from the Friday onwards. Such contradictions are evident in other areas and demonstrate a lack of understanding and coordination.

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Agreed action

34. The Care Provider will within four weeks:

• provide Mrs X with a written apology for the failings set out above;
• pay Mrs X £250 to acknowledge the time and trouble she has been put to pursuing the complaint with the Care Provider and this office;
• reimburse Mrs Y three months care fees;
• provide evidence of the above to this office and include evidence of all service/procedural changes implemented as a result of this complaint.

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Final decision

35. The Care Provider acknowledged failings in the management of Mrs Y’s care before the involvement of this office, but it failed to offer an appropriate remedy for the injustice caused.
36. The above recommendations are suitable way to remedy the injustice caused to Mrs Y and Mrs X.
37. It is on this basis; the complaint will be closed.
38. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

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Investigator's decision on behalf of the Ombudsman