Summary: Mrs X complained on behalf of her late brother about care provided to him at his home by a Council commissioned care provider. We found fault causing an injustice and the Council has agreed to provide an apology and financial remedy to Mrs X.

The complaint

1. Mrs X complained on behalf of her late brother, Mr Y, about care provided to him at his home by a council commissioned care provider. Mrs X complained:
1. Carers did not always visit at the correct time, missed scheduled visits and did not stay for the required period of time;
2. Carers did not always carry out appropriate catheter care when visiting, and
3. Carers did not always apply topical medication as required.
2. Mrs X says the actions of the care provider caused her considerable distress as she considers Mr Y did not receive the care he required. She would like the Council to take steps to ensure the same does not happen to anyone else, and to ensure it acts promptly on concerns about care when they are reported.

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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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. 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)

5. 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)
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 discussed the complaint with Mrs X and considered the information she provided.
8. I made enquiries to the Council and considered the information it provided.
9. Mrs X and the Council have had the opportunity to comment on a draft of this decision. I considered their comments before making a final decision.
10. Under our information sharing agreement, we will share our final decision with the Care Quality Commission (CQC).

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What I found

Care Act 2014

11. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
12. 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. 
13. We can investigate complaints about actions by adult social care providers that can be regulated by the Care Quality Commission. Such activities include giving personal care or other practical support in the place where the person lives.
14. The law defines ‘personal care and other practical support’ as ‘physical assistance (or prompting and assistance) given to a person in connection with:

• eating or drinking;
• toileting;
• washing or bathing;
• dressing;
• oral care; or
• the care of skin, hair and nails (except for nail care provided by a chiropodist or podiatrist)’.

(Health and Social Care Act 2008 (Regulated Activities) Regulations 2010)

Fundamental Standards of Care

15. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
16. The CQC is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

Safeguarding

17. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

18. This chronology includes key events in this case and does not cover everything that happened.
19. Mr Y had several medical conditions and reduced mobility. In June 2022, the Council carried out a care and support needs assessment to see if Mr Y required care and support while he was living at home.
20. The needs assessment identified Mr Y required some assistance, including help with the preparation of food, getting dressed and undressed and the maintenance of a catheter.
21. In mid-2022, Home Sweet Home Care, (the care provider commissioned by the Council), began providing home care to Mr Y.
22. Home Sweet Home Care carried out its own assessment regarding Mr Y’s care. It produced a care plan which set out the actions to be carried out by the carers visiting Mr Y. This included the monitoring of Mr Y’s skin integrity, mobility and medication. The care plan also specified Home Sweet Home Care would visit Mr Y three times per day, for 30 minutes each visit, to provide support. This included administering catheter care and assistance in applying topical medication, (cream for Mr Y’s skin). Mrs X says the family did not receive a copy of Home Sweet Home Care’s care plan.
23. Mr Y was admitted to hospital about a month later.

Mrs X’s complaint

24. In August 2022, Mrs X complained to the Council on behalf of Mr Y. She says she arranged for a hand-delivered letter to be taken to the Council and a copy was sent by Recorded Delivery. The letter asked the Council to cancel the care package with immediate effect and said Mr Y was being treated in hospital. Mrs X complained about the service from Home Sweet Home Care; she said the carers rushed their visits and occasionally did not turn up at all, did not accurately record their visit times and did not ensure Mr Y had eaten and stayed hydrated. Mrs X also complained that carers had sometimes intended to leave Mr Y without properly attaching the catheter equipment. Mrs X said a District Nurse had told her this could have endangered Mr Y’s health. Mrs X also complained that on one occasion a carer was unable to attach a night bag to the catheter, resulting in a loss of sleep for Mr Y.
25. Mrs X says she did not receive a response to her complaint and subsequently contacted a manager at the Council in October 2022. Mrs X says the manager asked her to send the letter again by email.
26. Mrs X told the Council she wanted to make a formal complaint. She complained she had called Mr Y’s social worker about her concerns, but her messages were not passed on or were ignored. Mrs X said carer’s visits were unreliable, did not always take place at the allocated times and did not always last for the required 30 minutes. She said carers did not always apply the necessary cream to Mr Y’s skin and maintained that on one occasion, a carer was going to leave without properly attaching the catheter equipment. Mrs X said her family felt Mr Y would not have had further medical complications if Home Sweet Home Care had provided him with adequate and appropriate care.
27. Mr Y was discharged from hospital but died in November 2022.

Complaint response

28. In February 2023, Mrs X received a response to her complaint from Home Sweet Home Care. It said its staff visited Mr Y to deliver personal care, including to provide catheter care and ensure wellbeing. Home Sweet Home Care said it did not have the care records so could not state what care was delivered on each visit; Home Sweet Home Care said it was usual practice to collect the records from the service user’s property, but as Mr Y was taken into hospital, this did not happen. It said its carers are trained in catheter care and said the application of cream to Mr Y’s skin was part of the personal care routine; it said this should have been completed but it was unable to confirm the carer’s actions because it did not have the care records.
29. Mrs X replied to Home Sweet Home Care as she was dissatisfied with the response. In April 2023, Home Sweet Home Care provided a further complaint response. Regarding the visit times, Home Sweet Home Care said it could not fully investigate without knowing which carer Mrs X’s complaint was referring to. It acknowledged the service user or family should be contacted if the carer was going to visit much earlier than the agreed time and apologised that this did not always happen. Home Sweet Home Care said its carers were competent and were trained in catheter care, but it acknowledged it should have tried to collect the care records from Mr Y’s address when someone was available.
30. Mrs X replied to Home Sweet Home Care and said it had had five weeks to collect Mr Y’s care records but had not done so. She also said there were some dates where the care records only showed a single entry, and some dates for which there was no paperwork at all. Mrs X said that although Home Sweet Home Care acknowledged the application of cream to Mr Y’s skin was part of his care routine, the carers did not always do this.
31. Mrs X says she did not receive a response to the above letter. In May 2023, she brought her complaint to us.

Analysis – visit times

32. Mrs X complained Home Sweet Home Care did not always visit at the correct time, missed scheduled visits, and did not stay for the required amount of time. To clarify the visit times, I asked the Council to provide copies of the care provider’s records to show the arrival and departure times for the carers.
33. The Council said Home Sweet Home Care had experienced difficulties with its electronic time recording system, and as a result, it had manually logged carer’s times. The Council provided a list of the visit times to Mr Y. In addition, Mrs X provided a copy of the care records that were retrieved from Mr Y’s home.
34. The care records do not always demonstrate the duration of the visits as some entries do not record a departure time. Although the list of manually recorded visit times shows start and end times, they show carers did not always stay at Mr Y’s address for the 30 minutes specified in the care plan. For example, on one date, the records show a carer arrived at 8:18 am and left at 08:22 am. In addition, some dates do not show arrival or departure times for some scheduled visits, indicating either a failure to attend, or a failure to record the visit times.
35. The National Institute for Health and Care Excellence (NICE) guidance on home care says contracts should allow home care workers to provide a good quality service without being rushed or compromising the dignity or wellbeing of the person. It also says calls should be no less than half an hour unless:
• The home care worker is known to the person; and
• The visit is part of a wider package of support; and
• It allows enough time to complete specific, time limited tasks or to check if someone is safe and well.
36. The record of visit times demonstrates there were occasions when carers attended for less than half an hour, and potentially, occasions when no visit took place.
37. Mr Y’s care plan specified the level of care and support he required at each visit. In the case of the visit referred to in paragraph 34, it is more likely than not the visit duration was insufficient for the carer to carry out the care routine specified in the care plan. As a result, there were occasions when the actions of Home Sweet Home Care were not in line with the NICE guidance specified above. This is fault.

Care provided to Mr Y

38. Mrs X complained Home Sweet Home Care did not always carry out appropriate catheter care and did not always apply cream to Mr Y’s skin. The care records provided by Mrs X show occasions where the carers recorded that they did apply cream as required. However, this is not recorded for every visit. Similarly, the care records show occasions where catheter care is referred to, and some dates where it is not.
39. Catheter care and the application of cream to Mr Y’s skin was specified in the care plan. In addition, Home Sweet Home Care acknowledged in its response to Mrs X that these measures formed part of the personal care routine which should have been completed at each visit.
40. Regulation 17 of the Fundamental Standards of Care states that care providers must securely maintain accurate, complete and detailed records in respect of each person using the service. This includes a record of the care and treatment provided to the service user.
41. As the care records do not provide details regarding the application of cream to Mr Y’s skin and/or catheter care for each visit, this indicates either a failure to provide the care as specified in the care plan, or a failure to accurately record the care administered. I am unable to make a finding as to whether Home Sweet Home Care carried out appropriate catheter care and/or applied cream to Mr Y’s skin as required. This is because the care records do not provide an accurate, complete and detailed record of each visit and do not consistently specify the nature of the care provided. However, whilst I cannot make a finding regarding this aspect of the complaint, Home Sweet Home Care’s record keeping is not in line with the fundamental standards of care. This is fault.

Safeguarding

42. The Council says it received Mrs X’s letter expressing her concerns but did not communicate this to other professionals. The Council says it has no evidence to show that the letter was escalated, and acknowledges it was late in uploading the letter onto its system. The Council says on further analysis, it identified that Mr Y’s family had reported their concerns about the care agency to the CQC. In addition, the Council says it acted swiftly to ensure care provided to Mr Y following his discharge from hospital was provided by another care provider. The Council says as a result, there were no safeguarding concerns.
43. The Care Act 2014 requires local authorities to make enquiries, or ensure others do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. Also, the Care and Support statutory guidance says local authority’s duties apply when an adult:
• Has needs for care and support
• Is experiencing, or is at risk of abuse or neglect
• As a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
44. I acknowledge Mr Y was in hospital at the time Mrs X raised her concerns in August 2022. However, the Care Act 2014 required the Council to make enquiries or ensure others did so if it believed Mr Y was experiencing, or was at risk of, abuse or neglect. I have seen no evidence to demonstrate the Council made such enquiries.
45. It is positive the Council acknowledges it was late in uploading Mrs X’s letter. However, this delay and the subsequent lack of enquiries by the Council following the concerns raised is fault.
46. Mrs X says she considers the actions of Home Sweet Home Care may have contributed towards Mr Y’s deterioration in health. Mrs X also says the matter has also caused her a significant amount of distress.
47. 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

48. To address the injustice identified, the Council has agreed to take the following actions:
1. Provide an apology to Mrs X regarding the fault identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology;
2. Make a symbolic payment of £300 to Mrs X in recognition of the distress and uncertainty identified;
3. Remind Home Sweet Home Care about the importance of completing care records in line with the requirements of the fundamental standards of care and statutory guidance;
4. Consider whether any refresher training on the completion of care records is needed;
5. Review its monitoring arrangements regarding services commissioned by providers on its behalf, and
6. Remind adult social care staff of the importance of considering safeguarding issues when concerns about care provision are received.
49. The Council should provide us with evidence it has complied with the above actions within one month of the final decision.

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Final decision

50. I have found fault by the Council and the Council has agreed to take the above actions to address the injustice identified. I have therefore concluded my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman