Summary: We upheld a complaint about the late Mrs Y’s home care. The Care Provider acting for the Council failed to ensure Mrs Y received emergency medical help when she became unwell and failed to keep an accurate records. It also failed to take action when Mrs Y did not take her medication. The Council which is responsible for Mrs Y's care, will apologise and take action described in this statement.

The complaint

1. Mrs X complained about Deltacare (the Care Provider), commissioned by Sefton Metropolitan Borough Council (the Council) to provide home care for her late mother Ms Y. Mrs X complained her mother did not receive her medication and staff did not identify Mrs Y was unwell and needed urgent health care.
2. Mrs X said this caused her avoidable distress and she wants to ensure the same thing does not happen to other vulnerable adults.

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The Ombudsman’s role and powers

3. 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)
4. The Council commissioned the Care Provider to provide care and support for the late Mrs Y to fulfil the Council’s legal obligations under the Care Act 2014. We can investigate the Care Provider.
5. 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)
6. 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)

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How I considered this complaint

7. I considered Mrs X’s complaint, the Care Provider’s response and some case records. I discussed the complaint with Mrs X.
8. Mrs X, the Council 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

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
10. Regulation 10 of the 2014 Regulations says people using care services should be treated with dignity and respect.
11. Regulation 17 of the 2015 Regulations says there should be an accurate, contemporaneous and complete record of care.
12. Regulation 12 of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents. Guidance explains medicines should be given accurately and in line with the prescriber’s instructions and at suitable times to ensure the person is not placed at risk. Staff must follow policies and procedures about managing medicines and these should address supply and ordering, storage, preparation and dispensing, administration, disposal and recording.

What happened

13. Mrs Y was in her nineties and lived in sheltered housing. She received care and support from the Care Provider for assistance with personal care and administering medication.
14. A care worker’s note of the morning call to Mrs Y on 8 August 2022 says they ‘arrived at 08:30, Mrs Y found on phone agitated. She declined any breakfast or tea. Flopped back onto her bed and her eyes were fluttering and snorting. Phoned the office and was advised…. to document her playing up and left’
15. Mrs Y’s other daughter logged on to the Care Provider’s electronic records to check whether the care worker had visited her mother, read the above entry and went to Mrs Y’s flat, as she was concerned for her mother’s well-being. She called an ambulance on arrival as Mrs Y appeared confused and unwell and had been incontinent of urine. Mrs Y was admitted to hospital and died a few days later.
16. Mrs X and her sister found their mother’s medication box when clearing out the flat. They noticed the last three doses had not been taken. They complained to the Care Provider about the issues I am investigating and other issues.
17. Senior staff of the Care Provider met with Mrs X and her sister. The Care Provider’s response to the complaint said:
• The care worker who attended Mrs Y on 8 August did not tell the care co-ordinator she spoke to at the office Mrs Y was unwell; she made it sound as if Mrs Y was ‘being difficult’
• The care co-ordinator told the care worker to leave the room for a few minutes then go back and try again and to call the office again if Mrs Y continued to refuse care. The care worker did not call back and so the care co-ordinator assumed all had been resolved. A manager however, overheard the discussion in the office and asked the care co-ordinator to contact the care worker to check again as the record suggested Mrs Y was unwell. Meantime Mrs Y’s daughter contacted the office to say paramedics were with Mrs Y.
• A manager carried out a supervision with the care co-ordinator and the care worker. The care worker said she felt Mrs Y was unhappy because the call was late. The care worker should have called an ambulance for Mrs Y. The care co-ordinator should have called the care worker back to check whether Mrs Y had had her morning routine. The care co-ordinator should not have assumed all was ok. The care worker was put on a performance improvement plan and had some re-training. She had since left the company.
• The three calls where medication was not taken were assigned to the care co-ordinator who attended but did not complete the medication records for the visits. The care co-ordinator did not work for the Care Provider anymore.

Findings

18. There was fault. The Care Provider’s documentation was inappropriate. The record should not have said Mrs Y was ‘playing up’. This was not a respectful or dignified way of referring to Mrs Y. It is not in line with Regulation 10 or Regulation 17. The record is a value judgment and not an objective account of what happened. If Mrs Y was refusing care and the care worker thought she was unhappy because the care worker was late, then this should have been recorded as such. If the care worker was late, she should have apologised to Mrs Y at the time and documented the apology in the records.
19. The Care Provider accepts Mrs Y did not receive her medication as prescribed. No action was taken as a result. It is unclear whether Mrs Y was offered her medication and refused it or if it simply was given because the care co-ordinator forgot or had not read Mrs Y’s care plan. Either way this is fault. Care was not in line with Regulation 12.
20. The Care Provider accepts its staff should have called an ambulance for Mrs Y. The failure to do so means her care was not in line with Regulation 12. Fortunately, Mrs Y’s daughter checked her and called an ambulance so the injustice to Mrs Y is limited.
21. However, Mrs X was caused avoidable distress by the Care Provider’s poor care and by the inappropriate recording. There is avoidable uncertainty about what the outcome might have been had Mrs Y received adequate care. This is a form of injustice.

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Agreed action

22. 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 care provider, I have made recommendations to the Council, which it has agreed to do.
23. The Council will apologise to Mrs X for the avoidable distress identified in paragraph 21.
24. The Council will ensure the Care Provider:
• arranges training for all its staff on record keeping and administering medication, including the importance of reporting concerns to the person’s GP and acting on advice from the GP when a person has refused or missed their medication.
• makes all care workers and care co-ordinators read its medication policy to ensure staff are clear about what action they must take when a person declines to take their medication.
25. The Council should provide us with evidence it has complied with the above actions. The apology should be within one month of my final decision and the training and reading of the medication policy should be within three months. I note the Care Provider is part way through medication and record keeping training for staff and that some of its staff have read the medication policy. The Council has agreed to ensure the training and reading programme is completed within the next three months.

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Final decision

26. We upheld a complaint about the late Mrs Y’s home care. The Care Provider acting for the Council failed to ensure Mrs Y received emergency medical help when she became unwell and failed to keep accurate or complete records. It also failed to take action when Mrs Y did not take her medication. The Council which is responsible for Mrs Y's care will apologise and take action described in this statement.
27. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman