Summary: Mr V complained on behalf of his late mother, Mrs R. He said the Council failed to correctly assess her care needs or provide her with an appropriate standard of care. He also said it failed to check the Care Provider had completed tasks in line with her plan. We find fault with the Council for completing short hours and for delay in investigating concerns raised. This caused Mr V uncertainty and put him to the time and trouble of complaining. However, we do not find fault with the Council in how it assessed Mrs R’s care needs or how it completed tasks in line with her plan. The Council has agreed with our recommendations to remedy the injustice caused to Mr V.

The complaint

1. Mr V says the Council failed to correctly assess his late mother, Mrs R’s care needs. He also says it failed to provide her with an appropriate standard of care or check its commissioned Care Provider had completed tasks and duties in line with her plan. Mr V also said the Care Provider told untruths about him and did not follow up his concerns.
2. He says this caused his mother distress and anxiety. He also says this has caused him distress and put him to time and trouble in bringing the complaint.

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The Ombudsman’s role and powers

3. 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)
4. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. If we are satisfied with an organisation’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)
6. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

7. 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)
8. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
9. 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.

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How I considered this complaint

10. I read Mrs R’s complaint and spoke with her representative, Mr V about it on the phone. I made enquiries of the Council and considered information it sent me.
11. Mr V and the Council had the opportunity to comment on the draft decision. I have considered their comments before making a final decision.

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What I found

Relevant law and guidance

Fundamental standards

12. 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.
13. Regulation nine states the care and treatment of service users must: be appropriate; meet their needs; and reflect their preferences.
14. 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. This rule is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm.
15. Regulation 17 states that providers must securely keep accurate, complete, and detailed records about each person using the service.

NICE Guidance: Home Care Delivering Personal care and Practical Support to older people living in their own homes.

16. I have also considered the National Institute for Health and Care Excellence. Namely the following sections:

• 1.4.11 – Risks associated with missed or late visits and take prompt remedial action. Recognise that people living alone or those who lack capacity may be vulnerable if visits are missed or late.
• Ensure checking of missed and late visits is embedded in quality assurance systems and discussed at contract monitoring meetings.

What happened

17. I have set out a summary of the key events below. It is not meant to show everything that happened.
18. Mr V’s mother, Mrs R, received domiciliary care arranged by the Council. The Council completed Mrs R’s Care and Support Plan in April 2021. This specified she needed support from two care workers at every visit, four times a day. The care plan also noted Mrs R’s medication and listed her diagnosed illnesses.
19. Mrs R had limited standing tolerance and needed full support when mobilizing. Mr V and the care workers were using a stand aid when transferring Mrs R from her bed to her chair. The care workers also helped Mrs R to use the toilet with the aid of a moveable commode.
20. The Care Provider raised concerns with the Council about moving and handling issues in April 2021. It said the hoist had become unsuitable due to a decline in Mrs R’s ability to weight bear. It noted it was ‘drag lifting’ Mrs R and causing pain and discomfort under her arms.
21. The Council’s notes show it recorded this referral, however, no action was taken at the time.
22. A further referral was made to the Council in September 2021 about the use of the hoist and the impact this was having on Mrs R’s health.
23. On the same day, the Council sought an urgent assessment about the use of the hoist. It consulted with an occupational therapist (OT) who advised that due to the concerns raised, Mrs R should receive bed care until the Council had completed its assessment.
24. Around a week later the Council completed a moving and handling assessment. It noted Mrs R’s medical conditions and considered the risk of injury to both her and her carers. It decided that Mrs R’s current hoist was no longer suitable and recommended a mobile hoist and a loop reclined sling. The moving and handling coordinator said Mrs R should continue to receive bedbound care until delivery of the new hoist.
25. The Council revisited Mrs R and completed a further moving and handling assessment and showed Mr V and the care workers how to use the new hoist. The Council also returned the following day with extra equipment and again demonstrated the correct use of the hoist. It said that Mr V was present.
26. The following week, the Council attended Mrs R’s home again. Mr V reported the new hoist was making his mother feel nauseous and unwell. The Council said it asked Mrs R and Mr V to consider a H frame or ceiling hoist. The Council said Mrs R and Mr V refused this. It also said that it watched the carers use the new hoist and noted there was no suggestion that Mrs R was unwell due to the procedure.
27. The Council’s notes show Mr V raised concerns about the use of the new hoist and said Mrs R preferred her old standing hoist. The notes also suggest Mr V said the carer’s use of the hoist had not injured his mother. The Council said it noted Mrs R and Mr V’s wishes and said it would arrange a further assessment to consider using a different model of standing hoist.
28. The Council completed a further assessment using an alternative model of standing hoist in October 2021. The Council decided the new hoist was not suitable, however, it would consider a further assessment in a few months. The Council said it explained to Mrs R the standing hoists were not suitable due to the potential to cause her a shoulder injury. It also told Mr V that it had considered his concerns about his mother’s sickness and his representations that Mrs R preferred her old standing hoist. However, it said following its assessment and home visits it had decided the old hoist was not suitable.
29. In October 2021, concerns were raised about the use and safety of the moveable commode. The referral noted there was a risk of injury to both Mrs R and the care workers in using this equipment. A static commode was ordered.
30. Mr V said he believed the Council and the Care Provider did not consider his mother’s views and wishes. He said she did not want a static commode in the living room where she slept and ate her meals. Mrs R said she felt this compromised her dignity.
31. The Council reviewed Mrs R’s care package in November 2021.
32. Mr V complained to the Council on behalf of Mrs R in December 2021. He said:

• Care Staff were completing short hours which were not in line with Mrs R’s care plan.
• He had reported incidents involving a specific carer when using the static hoist to a social worker. Mr V said this had caused Mrs R to ‘shout out in pain.’ Mr V said the issue with the static hoist was how it was operated by the carer.
• The Council had not provided any solutions and had only recommended Mrs R stay in bed. He said this had caused deterioration in her ability to weight bear and he believed it was no longer safe to transfer her to the car.
• Mrs R was unhappy with the hoist which made her sick and dizzy. However, he said the stark choice was either stay in bed or use the new hoist.
• The Care Provider was aware of drugs found at Mr V’s home that he believed had been left by a care worker. Mr V said he had reported this to the police.
• The Council had failed to consider all of Mrs R’s health conditions when assessing her for the new hoist.
• The Council had failed to take Mrs R’s wishes into account when considering a static commode. Mr V said this compromised Mrs R’s dignity.
• Reports and concerns raised by the Care Provider that out-of-date food was in the fridge or served to Mrs R were untrue.

33. The Council said it received Mr R’s complaint in early January 2022. It looked into Mr R’s concerns and replied to him in February. The Council said:

• it upheld his complaint about staff completing short hours. However, it said this had been due to the Covid-19 pandemic, with staff leaving as soon as tasks had been completed to minimise infection. It recognised staff had continued to incorrectly work this way.
• It also said there was a 30-minute leeway either side of Mrs R’s bedtime call.
• It had completed all tasks inline with Mrs R’s care plan.
• It did not uphold Mr V’s complaint about the hoist. It said it had explained to both Mrs R and Mr V that following an assessment with a moving and handling officer, the static hoist was assessed to be unsafe.
• The Council did not uphold Mr R’s complaint about the mobile commode. It said a static commode was needed for safety reasons. It said it had noted Mrs R’s comments and said she was satisfied with current arrangements.
• The Care Provider had been notified of a safeguarding incident, it had spoken with the staff member on duty at the time but there was no evidence to support Mr V’s allegation. It noted the Council had not been told of a safeguarding incident. The Council said it had received no reports of staff being unprofessional and continued to tell Mr V he needed to leave the sell by date on purchased foods when unwrapping them.
• The Council said staff were required to read and adhere to Mrs R’s care plan.

34. The Council said it had spoken with the Care Provider to address Mr V’s concerns. The Care Provider had assured the Council it would work with other management and staff to return normal working practices and times and would hold regular meetings with its staff.
35. The Council completed a further review of Mrs R’s care in March 2022.
36. Mr V remained unhappy with the Council’s response. He reiterated his earlier complaint but added:

• Mrs R’s assessment had been completed by a moving and handling officer and not an occupational therapist.
• The Council was still not taking Mrs R’s views into account about the use of the static commode. He said Mrs R was refusing to use this.
• Food was always dated and sealed in airtight containers.
• He had reported the safeguarding issues to the safeguarding social worker.

37. The Council reinvestigated Mr V’s complaint and replied in March 2022. It said:

• It had addressed Mr V’s concerns about short care call times but would not uphold his further complaint as staff had now been told to remain for the full duration of the call.
• It had decided not to uphold Mr V’s complaint about the hoist and the commode.

• It was satisfied Mrs R had been assessed by the care provider’s occupational therapist as well as the moving and handling team, along with support from the social work team.
• An OT referral had been made about the mobile commode.

38. Mr V remained dissatisfied and complained to the Ombudsman in late March 2022.
39. The Council completed a further moving and handling assessment with Mrs R in May 2022. During this visit the Council demonstrated the correct use of the new commode. It also said it had considered compromising by using the moveable commode to take Mrs R to the privacy of the hallway. It said Mr V was pleased with this.
40. Mrs R sadly passed away in June 2022.
41. In response to my enquires the Council said it had re-examined Mr V’s concerns about short care call times and accepted calls were not delivered within 30 minutes of the agreed time. It also acknowledged that morning and bedtime calls were consistently delivered outside of the planned times. However, it said it was content that all tasks had been completed appropriately.
42. However, it did not accept that it failed in its duty to correctly assess Mrs R or consider her views and needs. It also did not accept it failed to deliver appropriate care as specified in Mrs R’s care plan. It said:

• It had reviewed Mrs R’s support plan with the care provider, Mr V and Mrs R and sought their views.
• It was satisfied that its moving and handling team were suitably trained and had the relevant expertise to make recommendations.
• It had trialled the hoist and slings and had offered alternatives when Mr V raised concerns.
• The Care Provider ensured Mrs R’s dignity was always upheld and it was content staff had the appropriate training.
• It had addressed the minor care quality issues raised by Mr V.
• Mrs R had indicated she was satisfied with the Care Provider.
• All assessments and support plans were completed appropriately and with the oversight of nursing staff.
• Appropriate equipment had been implemented and installed to support Mrs R’s assessed needs.
• It had spoken with the Care Provider about Mr V’s safeguarding allegation, however, there was no evidence to further its investigation.
• It would work closely and raise issues with the Care Provider to improve care call times.

Analysis

43. At the heart of this complaint is Mr V’s belief the Council did not assess Mrs R’s needs correctly when it completed its moving and handling assessments. This resulted in Mrs R being temporarily bedbound while the Council assessed and purchased a new hoist and static commode. The Council holds a different opinion. It concluded that following assessment, the old hoist, and mobile commode were no longer suitable and posed a safety risk to Mrs R.
44. The Council’s notes show its moving and handling team assessed Mrs R three times during this complaint. It also asked advice from an occupational therapist and Mrs R’s district nursing team. Its notes also show it considered and discussed Mrs R’s concerns and held several meetings with Mrs R and Mr V explaining the reason for the changes and demonstrating how to correctly use the new hoist. It considered alternatives when Mr V explained he believed the new hoist was affecting his mother’s health. Therefore, I am satisfied the Council took account of all the relevant information and took reasonable steps to satisfy itself Mrs R received the appropriate equipment to meet her assessed needs. Its decision was based on the professional judgement of its officers. This was a decision the Council was entitled to make. We can only question the Council’s decision if there is fault. Therefore, I cannot question the outcome.
45. However, when reviewing the Council’s notes, it is clear the Care Provider told the Council of its concerns about the safety of the hoist in April 2021. I have seen no evidence the Council acted upon these concerns until it received a second referral in September 2021. This was fault. The Council allowed this referral to drift without considering it or taking action. However, I am now unable to determine the injustice to Mrs R as she has sadly passed away. I have made a recommendation for a service improvement to address this fault.
46. The Council has recognised the Care Provider did not always provide calls lasting the full duration of the time allotted. The Council has investigated the records of care visits between September 2021 and March 2022. The Council said Mrs R was always provided with appropriate care. I have reviewed the Council notes and I am satisfied it delivered Mrs R’s care in line with her care plan. However, there is evidence that overall carers were not staying for the agreed time and that calls were consistently outside of the planned times. This was fault. This caused uncertainty for Mr V leading him to question whether Mrs R was receiving the appropriate care as specified in her care plan. It also put him to the time and trouble of complaining.
47. Mr V complained the Care Provider gave false information about his actions concerning out of date foods. I am aware a safeguarding concern was raised due to out-of-date foods and the risk this posed to Mrs R. I am satisfied the Council investigated this. It considered all relevant information and updated Mrs R’s care plan to include instructions to label defrosted food and ensure food was suitable for consumption. Therefore, I am satisfied this was a judgement the Council was entitled to make, and I have no grounds to criticise it.
48. Mr V also complained about an incident where recreational drugs were found in his home. Mr V believed a care worker left them there. The Council spoke with the Care Provider, and it said it had spoken to staff members on duty at the time. However, it decided there was no evidence to support the allegations made. Mr V reported this to the Police. Therefore, I do not intend to investigate this matter further.
49. Mr V also said he told and emailed a social worker about his concerns that Mrs R was frightened of a care worker and that she had called out in pain on a few occasions when being hoisted. The Council looked into this matter, but said there was no recorded evidence, no safeguarding referral and the social worker concerned had now left its employment. In the absence of written evidence confirming either version, I cannot reach a safe conclusion about precisely what happened.
50. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.

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Agreed action

51. By 16 January 2023 the Council has agreed to:

• Apologise to Mr V for the uncertainty caused by short and inconsistent calls.
• Pay Mr V £100 for causing uncertainty and putting him to the time and trouble of complaining.
• Share this decision with staff to highlight the need to address any concerns raised without delay.

52. The Council should provide us with evidence it has complied with the above actions.

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Final decision

53. The Council was at fault for completing short hours and for delay in investigating concerns raised. However, I do not find the Council at fault for how it delivered care as specified in Mrs R’s care plan. I also find no fault in how the Council assessed and considered Mrs R’s needs and views when completing its moving and handling assessments.

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Investigator's decision on behalf of the Ombudsman