Summary: Mrs X complains the Council’s care provider, Alcedo Care Blackpool, failed to meet her mother’s needs properly during 2022, resulting in medication errors, failing to provide her with hot meals and causing avoidable distress. There were four medication errors. The Council needs to apologise and work with Alcedo Care Blackpool to ensure this does not happen again.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council’s care provider, Alcedo Care Blackpool (ACB), failed to meet her mother’s needs properly during 2022, resulting in medication errors, failing to provide her with hot meals and causing avoidable distress.

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The Ombudsman’s role and powers

2. 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)
3. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)
4. 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)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• invited comments on a draft of this statement from Mrs X, ACB and the Council, for me to consider before making my final decision.

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What I found

What happened

6. Mrs X’s mother, Mrs Y, has dementia. She lives on her own with support arranged by the Council. The Council commissioned ACB to visit twice a day from 08:00 to 08:30 and 18.00 to 18.30. Mrs X has power of attorney for her mother’s health and welfare.
7. ACB produced a care plan which said Mrs Y needed help with:
• continence care;
• maintaining emotional and psychological health by talking to her, as the care worker may be the only person she saw all day;
• maintaining adequate dietary and fluid intake, as she often forgot to eat, and so she could enjoy a varied diet;
• administering medication;
• managing dementia related behaviour;
• housekeeping tasks;
• promoting her health, independence, choice, safety and comfort.
8. The care plan said to:
• encourage a shower every morning;
• make a drink on every visit and not to take “no” as an answer, otherwise she would not have a drink;
• help make a meal (a small bowl of cornflakes with a little sugar for breakfast);
• leave snacks for her to eat during the day;
• put laundry in the washing machine, when washed put it in the drier and when dry leave in piles on the bed;
• remove out of date food from the fridge;
• dispose of rubbish in Mrs Y’s bin;
• help her to make a hot meal, based on what was in the fringe, ensuring a balanced diet – “don’t ask me if I want anything, just make it”.
9. The minimum call length commissioned by the Council is 30 minutes. Each call provides for up to 10 mins of travelling time within the 30 minutes, so could last no more than 20 minutes. The average weekly call length during 2022 was 19 minutes and 40 seconds. This does not include the weekly calls when the care workers delivered Mrs Y’s medication, as most of their time was spent outside her home and was not therefore recorded. These calls stopped in October as Mrs X started collecting her mother’s medication.
10. ACB’s records of the care provided for Mrs Y show she did not always accept the support on offer. In particular, she often did not need any laundry doing or did not accept help with personal care, either because she had already done it for herself or wanted to do it later.

Meals

11. ACB says Mrs Y often declined hot meals. It accepts some care workers were more familiar with her and more persuasive in encouraging a hot meal. Its records show Mrs Y did not have a particularly varied diet. She often had toasted sandwiches. She sometimes had more substantial meals (e.g. spaghetti carbonara or sweet and sour chicken with rice). Sometimes she would turn down the food offered, saying she had already eaten, would eat later or did not want anything substantial. Mrs Y did not always have hot food, sometimes just a sandwich or other unheated food. ACB’s records of its visits show Mrs Y could express her preferences and would not eat anything she did not want to eat. They show the care workers left Mrs Y with snacks, so she had something to eat when they were not there.

Medication

12. ACB says the medication errors were minimal in terms of the harm caused to Mrs Y and it managed them properly. The Council received two safeguarding alerts from ACB about medication errors. One was in January 2022 but this did not meet the threshold for safeguarding enquiries, as there had been no harm to Mrs Y. Mrs X says the morning care worker gave her mother her evening medication.
13. The second safeguarding alert was in November 2022 and resulted in the Council making recommendations to prevent a reoccurrence of the error. In the morning of 26 November, the care worker gave Mrs Y her evening medication. That evening ACB advised the care worker not to give her any medication.
14. In the morning of 28 November, the care worker noted Mrs Y was abusive and shouted at them for “babying her”. Mrs Y said she could take her own medication and food, and said “I hope not” when the care worker said “see you again soon”. The care worker noted this was not her normal behaviour. Mrs X believes this may be linked to the medication error.
15. Mrs X has identified other medication issues. But most of them relate to times when Mrs Y was not in when a care worker visited and therefore either missed her medication or received it when a care worker returned later.
16. However, on Wednesday 7 September there are records of two morning visits by different care workers, one from 10.08 to 10.34 and the other from 10.43‑10.58. Each care worker recorded giving Mrs Y her morning medication, including Dabigatran Etexilate. In the evening the care worker did not give Mrs Y Dabigatran Etexilate, as she had received two doses in the morning.
17. ACB’s incident log says the first care worker gave Mrs Y Monday morning’s medication from the blister pack. The second care worker, who was meant to be picking up and delivering medication from the pharmacy, assumed Mrs Y had not had her morning medication as Wednesday’s medication was still in the blister pack and gave it to her. The pharmacy said not to give Mrs Y Dabigatran Etexilate at teatime and not to give her Thursday morning’s medication until after 10.30. ACB says the pharmacy said there was no direct harm to Mrs Y, so the incident did not meet the threshold for reporting as a safeguarding concern. ACB advised the care worker to discard any extra medication noted not to put the two Wednesday morning visits so close together in future, to prevent a recurrence of the problem.
18. The Council’s guidance on when to consider raising a safeguarding concern following a medication error says:
• “For the purposes of making a decision about the need for a safeguarding concern then, if a medication error as defined above has occurred and in addition there is evidence of significant impact upon or significant harm to the individual subject of the error than a safeguarding concern should be raised. Otherwise the error should be reported and recorded in accordance with medication and management of incidents policies and procedures.”
19. In the morning of 17 October, the care worker noted Mrs Y’s morning medication was missing. Mrs Y said she had had no other visitors that morning and the care worker found no evidence of medication errors by other care workers. ACB says it moved from one electronic recording system to another on 17 October. It says a supervisor contacted the care worker who confirmed they had given Mrs Y her medication. The care worker said they had not been able to find the right button to record giving medication on the new system. There is no written record of this.
20. On 10 November ACB told Mrs X there had been no medication error on 17 October, just a documentation error. It said the care worker had been struggling with the new system. It said other care workers who visited Mrs Y regularly had confirmed no medication was missing.
21. Mrs X complained to ACB in November about the short visits and the failure to follow her mother’s care plan. They exchanged e-mails about the length of her mother’s calls and the failure to give her a hot meal each day. ACB agreed to monitor the calls and to remind the care workers of the need to follow Mrs Y’s care plan.
22. Mrs Y is now receiving support from another care provider.

Is there evidence of fault by the Council which caused injustice?

23. ACB’s care plan for Mrs Y was unhelpfully worded in suggesting the care workers should just make a hot meal for her without taking account of her preferences. ACB does not dispute this. It raised expectations about their ability to ensure Mrs Y had a hot meal each day and a balanced diet. The care workers could not make Mrs Y eat food she did not want to eat. It would have been helpful if ACB had reviewed Mrs Y’s care plan to make it more realistic. While there is evidence of fault by ACB, there is not enough evidence to say this caused injustice to Mrs Y which would warrant a remedy.
24. ACB’s calls were, on average, just under 20 minutes. However, given that Mrs Y did not always need all the support on offer, that did not amount to fault.
25. ACB decision not to report all the medication errors to the Council appears to have been in line with the Council’s policy. However, the action taken to prevent a recurrence of the problem on 7 September did not address its cause, which was the first care worker giving Mrs Y medication assigned for another day rather than the proximity of the two called. This resulted in the second care worker thinking Mrs Y had not received her morning medication.
26. ACB’s records for 17 October 2022 indicate there was a medication error. There is nothing in them to confirm Mrs Y received her medication that morning. Even if Mrs Y did receive her medication, the failure to record it properly was, in itself, a medication error. Four medication errors in under a year is significant. The medication errors put Mrs Y at risk of harm. That is fault for which the Council is accountable (see paragraph 4 above).

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Agreed action

27. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the ACB, I have made recommendations to the Council.
28. I recommended the Council:
• Within four weeks, writes to Mrs X apologising for the medication errors and ACB’s failure to deal with them all properly.
• Within eight weeks, work with ACB to identify the action it is going to take to ensure it deals with medication errors properly in future.
29. The Council has agreed to do this. It should provide us with evidence it has complied with the above actions.
30. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of my final decision.

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Final decision

31. I have completed my investigation on the basis there has been fault causing injustice which warrants an apology.

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Investigator's decision on behalf of the Ombudsman