Summary: Miss X complains the Council was at fault in the way it provided domiciliary care to her mother Mrs X as she was admitted to hospital because her pressure sores deteriorated causing distress. We have found no evidence of fault in the way the Council considered these matters. So we have completed our investigation.

The complaint

1. I have called the complainant Miss X. She complains for her mother Mrs X there were failings in the way a Council commissioned care provider gave domiciliary care to Mrs X. Miss X says this resulted in Mrs X’s admission to hospital because of deteriorating pressure sores causing distress to Mrs X and Miss X.
2. Miss X complains the carers did not stay with Mrs X for the allotted time, so Mrs X was contributing towards care she did not receive. And the carers did not follow the care plan causing further distress.

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The Ombudsman’s role and powers

3. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• there is not enough evidence of fault to justify investigating, or
• any fault has not caused injustice to the person who complained, or
• any injustice is not significant enough to justify our involvement, or
• we could not add to any previous investigation by a Council, or
• further investigation would not lead to a different outcome, or
• we cannot achieve the outcome someone wants.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

4. 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, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

5. I considered the information provided by Miss X and discussed the complaint with her. I made enquiries of the Council and considered its response along with the relevant law and guidance.
6. Miss X and the Council 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

Care plan

7. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.

What happened in this case

8. This section sets out the key events in this case and is not intended to be a detailed chronology.
9. Miss X and Mrs X live at the same property. Mrs X received daily care at home from a council commissioned care provider from October 2021. The Council assessed Mrs X as being able to contribute towards her care fees. The Council drew up a care plan for Mrs X’s care for the care provider to follow. This was for two carers to attend Mrs X four times a day. The timings were for 45 minutes in the morning, 30 minutes at lunch, 30 minutes teatime, with 45 minutes in the evening to help Mrs X to bed.
10. The care provider noted Mrs X’s mobility was variable, and she had grade 2 pressure sores being monitored by the district nursing service run by the relevant hospital trust.
11. Mrs X’s care plan for ‘managing and maintaining good skin integrity’ says for the carers to apply creams if prescribed to maintain good skin integrity and reduce risk of breakdowns. Carers were to discuss any concerns about infection, damage, or skin damage with Mrs X and to report immediately to the main office or correct if possible following policies, procedure, and training.
12. In December 2021 the carers reported Mrs X’s pressure sores looked worse. They obtained and applied new cream to her skin from the district nurses who attend Mrs X. Documents report Mrs X’s mobility declined in January 2022, so the Council made a referral to the Occupational Therapy (OT) team. An OT visited in March 2022 and discussed the pressure sore damage to Mrs X. The OT recommended an air mattress and pressure relieving seating, but this was declined by Miss X.
13. The Council arranged respite care for Mrs X in May 2022 for two weeks at Miss X’s request. The carers reported the pressure sores returned to grade 2 in June 2022 and the district nurses attended to Mrs X. The carers reported the pressure sores reopening in September 2022 and advised Miss X to contact the district nurses.
14. In October 2022 the carers provided ‘on bed’ care to Mrs X due to her lack of mobility. Miss X request a further respite break for Mrs X. The carers reported Mrs X had an open pressure sore on a buttock and asked the district nurses to attend. The district nurses gave the carers instructions for Mrs X’s pressure sores, ordered a new mattress for Mrs X, and advised she have bedrest.
15. The district nurses visited Mrs X again in October and the carers advised Mrs X had declined to have bedrest. The carers made further reports about Mrs X’s pressure sores and the district nurses visited again.
16. The Council offered Mrs X respite care at a care home for a minimum of three weeks. The care provider said it could not hold the placement open for that time so would hand it back to the Council if Mrs X went for respite. Miss X declined the respite care.
17. At the end of October 2022, the care provider requested an urgent OT referral as Mrs X developed another pressure sore and contacted Mrs X’s GP. The Council says this was the start of significant conflict between the care provider and Miss X.
18. The OT suspected the pressure sore was due to Mrs X’s decreased mobility as she tended to shuffle when in bed and her chair. This caused ‘shearing’ and increased pressure sores. The care notes record the district nurses treated and dressed the pressure sores.
19. The care notes record Mrs X refused bedrest when the carers attended and refused the cream for the pressure sores. The carers reported Mrs X’s pressure sores looked worse to the district nurses, and she was refusing bed rest. The district nurses visited and gave advice. Mrs X’s GP attended and prescribed antibiotics. The care notes record the bed sores were now grade 4 and being regularly dressed by the district nurses and Miss X.
20. In November 2022 Mrs X’s social worker asked the support team to look at replacing the care provider who reported Miss X was being verbally abusive to the carers. The social worker noted Mrs X and Miss X were resisting bedrest for Mrs X which was not helping Mrs X’s pressure sores.
21. The carers reported Mrs X had two new pressure sores and the wounds were deteriorating. Following contact with Mrs X’s GP Mrs X and Miss X agreed Mrs X needed to be admitted to hospital because of the pressure sores. Mrs X was admitted to hospital a few days later.
22. Miss X complained to the Council there had been neglect by the care provider causing harm to Mrs X. The Council investigated and social care and district nurses reported no indication of neglect by the care provider. Mrs X was discharged to a care home in December 2022 where she remains living.

Miss X’s complaints to the Council

23. Miss X made further complaints to the Council about the carer provider and Mrs X’s care. These included Miss X’s concerns the carers failed to monitor Mrs X’s pressure sores, did not stick to the care plan, or carry out the items on the care plan. Miss X said the carers did not stay for the allotted time and used their time to fill in records. Miss X complained she was wrongly told not to be a third carer for Mrs X and Mrs X was provide with a lower standard of care as she was mainly funded by the Council. Miss X also raised concerns about the lack of respite care given to her and Mrs X.

My assessment

Failure to monitor Mrs X’s pressure sores and standard of care

24. The Council says Mrs X had several pressure sores when the care provider started providing her with care. And the carers worked with the district nurses to manage the pressure damage by following the advice given. When a carer could not carry out a task the reason was documented.
25. This action is supported by the documents provided which show the carers were following the instructions given by the district nurses. The care records about the skin integrity were marked as completed. The documents show the carers kept raising concerns about the pressure sores as required and discussed them with Mrs X, Miss X, GP’s, and district nurses. The care notes record Mrs X and Miss X were not always willing to follow the advice about bedrest and Mrs X refused the cream on occasions. There is no evidence of fault by the Council and the care provider regarding Mrs X’s pressure sore care.
26. The Council says care staff are not made aware of how a person’s care is funded. So, it would expect the carers to provide the same level of care and quality for any person.
27. There is no evidence in the documents I have seen to show the carers did not treat Mrs X with respect. The care records note the carers would have pleasant chats with Mrs X while dealing with Mrs X’s care needs and she seemed well on the visits. If there were any issues, then the carers reported this for action to be taken.

Carers failed to stay for the allotted time and filled in records on visits

28. The Council confirms the carers need to complete the records during each visit at the time to ensure the actions carried out are as accurate as possible. I consider it would be reasonable for the carers to do so. This would ensure Mrs X was being provided with the appropriate care and so any issues could be raised when necessary.
29. The Council accepts that some care visits were not for the full time allotted and finished early. But the care needs on those visits were completed. The care visits tended to be shorter when the carers were providing care to Mrs X on the bed rather than needing to transfer her from the bed to a chair.
30. However, the documents show the carers stayed for the allotted time and on occasions the carers stayed longer than the allocated time to deal with Mrs X’s care needs. As the care records show that the Mrs X’s care needs were completed on visits, I do not consider I can achieve a different outcome through further investigation.

Miss X told not to be a third carer

31. The Council noted Mrs X’s mobility was declining from October 2022 and she struggled to follow instructions. The carers reported it was difficult for them as Mrs X would call out for Miss X to help. The carers asked Miss X not to help as they may be doing tasks differently from how Miss X would do them. The Council confirmed it would expect the carers to do the task according to policy to maintain the safety of the person being helped and themselves.
32. I accept it would be difficult for Miss X when Mrs X was asking for her help when the carers were present. However, the carers need to ensure they complete tasks safely and according to policy and training. The care plan refers to the care being provided by the carers and so would not include Miss X in the tasks while the carers were present.

Respite care

33. The Council says Miss X requested respite care in April 2022. The respite was sourced and arranged for two weeks in May 2022 which Mrs X attended. Miss X requested further respite in October 2022 and the Council offered a placement for a minimum of three weeks. The care provider advised it would not be able to keep the package of care open for that length of time and would hand it back to the Council to be re-sourced after the respite. However, Miss X declined the respite, but asked the Council to consider respite during Spring 2023. Before this could be arranged Mrs X was admitted to hospital in November 2022 and discharged back to a care home. So, the issue of respite was no longer needed.
34. The documents show the Council arranged respite when Miss X requested it. Miss X chose to not go ahead with respite in October 2022 as it would require the Council having to source a different care provider afterwards. I do not consider there has been any fault by the Council in responding to Miss X’s respite care requests.

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Final decision

35. I have completed my investigation. There is no evidence of fault by the Council in the way it provided domiciliary care to Mrs X.

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Investigator's decision on behalf of the Ombudsman