Summary: Mr B complains, on behalf of his father Mr C, that the Care Provider did not properly provide care for Mr C. The Care Provider took too long to reply to Mr B’s complaint and did not follow its complaints process properly. This did not cause Mr C any injustice.

The complaint

1. The complainant, whom I shall refer to as Mr B, complains that St Judes Care Ltd did not provide proper adult social care for his father because it:
1. failed to provide proper care when it did not call the district nurse after his father removed his catheter;
2. failed to handle his complaint properly as responses were not provided by the nominated person or within necessary timescales; and
3. failed to provide training and employment information about a carer.
2. Mr B says that Mr C was subsequently admitted to hospital and passed away as a result of the failure of care. He also suffered distress because he believes the failure of care has not been investigated properly.

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What I have investigated

3. I have investigated that part of Mr B’s complaint about care provided to his father, Mr C, and the handling of his complaint by the Care Provider. The final section of this statement contains my reasons for not investigating the rest of the complaint.

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The Ombudsman’s role and powers

4. 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)
5. 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)
6. We investigate complaints about adult social care providers. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• the action has not caused injustice to the person who complained, or
• the injustice is not significant enough to justify our involvement, or
• it is unlikely we could add to any previous investigation by the care provider, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants, or
• there is another body better placed to consider this complaint.

(Local Government Act 1974, sections 34B(8) and (9))

7. 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

8. I spoke to Mr B about his complaint and considered documents he provided. I made enquiries of the Care Provider and considered its response and the supporting documents it provided.
9. Mr B and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Law, guidance and policies

Definition of an Adult Social Care Provider (the Care Provider)

10. An adult social care provider within our jurisdiction is one which carries out ‘regulated activities’ relating to providing adult social care. The activities include personal care or other practical support provided in the place where the person lives.

Care Quality Commission (CQC)

11. 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.

What happened?

12. This is a brief chronology of key events. It does not contain everything I reviewed during my investigation.
13. Mr C was receiving domiciliary care from the Care Provider paid for by direct payments from the Council to Mr C.
14. Mr C had a catheter fitted. Mr C removed his catheter.
15. The district nurse was not called until the following day.

St Judes Care Ltd Complaints Policy

16. When a written complaint is received an acknowledgement will be sent to the complainant within three working days.
17. The complainant will be provided with a leaflet detailing the complaints procedure.
18. An investigation will be completed and a full explanation provided to the complainant within 28 days, in writing or by arranging a meeting. The complainant will be informed of any delays.

Analysis

Provision of care to Mr C

19. I have reviewed the evidence from Mr B, the Care Provider and the Council’s later safeguarding enquiry to ascertain what happened.
20. The different accounts agree and support that:
1. Mr C removed his catheter and Mr B was informed of this by the carer
2. The district nurse was not called that day;
3. Mr B called the district nurse the following morning;
4. Mr C had been passing urine overnight; and
5. Mr C’s GP was consulted and agreed that Mr C’s catheter should not be replaced.
21. The different accounts do not agree and support any conclusion about what was said between Mr B and the carer about calling the district nurse. There is no further evidence to show whose account is correct. I am therefore unable to determine which account is correct.
22. Mr B’s initial complaint acknowledged that, “nothing serious happened to dad, being without a catheter for over 24 hours. I would just like to add that other than this incident....that her level of care for dad was good.”
23. No information was contained in Mr C’s care plan regarding actions to be taken in respect of catheter removal.
24. The Care Provider says they, “are a nurse led agency and have registered nurses within our office. Those nurses go out and provide 1-1 training on catheter care.” I have seen a file note from the Care Provider which supports this.
25. There is no evidence to show that Mr C’s subsequent hospitalisation and death was caused by the complained about incident involving his catheter. This is not fault by the Care Provider.

Complaint handling

26. The Care Provider acknowledged the complaint made by Mr B within three days. It provided a response to his complaint after more than 28 days. The Care Provider did not advise Mr B of any delay. The Care Provider accepts that it did not follow its complaints process properly. This is fault by the Care Provider. Mr B did not suffer any injustice because there is no evidence the substance of the complaint response was affected by this fault.

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Final decision

27. I have found fault by the Care Provider, which did not cause injustice to Mr B or Mr C. I have now completed my investigation.

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Parts of the complaint that I did not investigate

28. I have not investigated that part of Mr B’s complaint about the provision of information about a carer as this would be more appropriate for the Information Commissioner, there is insufficient evidence of injustice to warrant an investigation and it is unlikely to result in a different outcome.

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Investigator's decision on behalf of the Ombudsman