Summary: Mrs F complained about the quality of home care from 2M Health & Home Care Services, arranged by the Council, for her late husband. We found fault as the care provider failed to monitor Mr F’s health, or to record or report any concerns and failed to seek medical attention for him. This caused significant distress to Mrs F and also uncertainty about whether the faults led to Mr F’s death. The Council will ensure 2M’s staff are trained and report back the outcome of its quality monitoring. It also agreed to apologise and make a payment but Mrs F said she did not want this.

The complaint

1. Mrs F complained about the quality of home care arranged by the Council that her late husband received from 2M Health & Home Care Services. In particular, she complained carers did not seek medical attention for pressures sores and a urinary tract infection, left him unkempt in dirty sheets and there was poor record keeping.
2. Mrs F says this led to the deterioration of her husband’s health and his death from sepsis in December 2022.

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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. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. We normally name care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. 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)

7. The Care Quality Commission (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. We normally expect someone to notify the CQC about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
8. 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)
9. Under our information sharing agreement, we will share this decision with the CQC.

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How I considered this complaint

10. I spoke to Mrs F about her complaint and considered the information she sent and the Council’s response to my enquiries.
11. Mrs F 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

Relevant law and guidance

Care and support

12. The Care Act 2014 requires local authorities to carry out an assessment for any adult with an appearance of need for care and support. The assessment determines what the person's needs are and whether the person has any needs which are eligible for support from the council. Where councils have determined that a person has any eligible needs, they must meet those needs. The person's needs and how they will be met must be set out in a care and support plan.

Fundamental Standards of Care

13. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the Regulations”) set out the fundamental standards those registered to provide care services must achieve. The CQC has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:
• Dignity and respect (Regulation 10): Service users must be treated with dignity and respect and in a caring and compassionate way.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Safeguarding from abuse (Regulation 13): Service users must be protected from abuse and improper treatment, this includes neglect.
• Food and drink (Regulation 14): Service users must have enough to eat and drink to keep them in good health while they receive care and treatment.
• Complaints (Regulation 16): The provider must have a system in place to handle and respond to complaints.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.

What happened

14. Mr F was in his 80s and in generally good health. He lived at home with Mrs F. In 2022 Mr F was injured in a fall. He spent some time in hospital and a care home before being discharged home to continue his recovery. Mr F was unable to stand, walk or use a chair, so he had to be cared for in bed and had a catheter. He had a leg ulcer which was being cared for by a district nurse.
15. The Council assessed Mr F’s care and support needs on 27 September 2022. It found he required two carers to visit him at home four times a day to provide personal and catheter care. The carers were also to check Mr F’s skin to prevent pressure sores, and ensure he had enough fluids and had taken medication.
16. The Council commissioned 2M Health and Home Care (“the care provider”) which started to provide care on 17 October 2022. The care provider’s care plan says it would provide Mr F with a daily full body wash and clothes change, catheter care and would inspect pressure areas. The risk assessment says if red areas or warm patches are found on Mr F’s skin, a barrier cream should be applied and Mrs F and managers should be informed. Breaks in the skin should be reported immediately to the district nurses, Mrs F, and managers.
17. In November 2022, Mrs F fell and needed care at home which she received from a different care provider. She was therefore unable to provide support to Mr F.
18. Mrs F raised a number of concerns with the care provider, but says no action was taken. These were:
• Mr F having difficulty eating or drinking but no action being taken.
• Providing him with inedible, incorrect, or out of date food and milk and undiluted cordial.
• Not changing his clothes.
• One instance of leaving Mr F in a hoist sling in his chair for three hours causing marks to form on his legs.
• One instance of leaving Mr F on his back where he could not reach his food, with no sheet and the curtains drawn. Mrs F says the carers came back after she complained but did not offer fresh food.
• Blocking the toilet with wipes causing a flood. The care provider replaced the carpet three weeks later, but the roll of carpet was left in the lounge where Mr F was staying, causing problems for caring.
• Using her towels on Mr F when she had COVID-19.
• A male carer walking in on her without knocking when she was being washed.
• Giving her grapefruit instead of Fortysip one time.
19. I have reviewed Mr F’s daily care records for December. They show carers would empty and clean the catheter bags and bottles, give Mr F food and drink and full body washes, apply creams to his skin and change the sheets.
20. But the records are not detailed or comprehensive, so there are only two records of carers checking Mr F’s skin on 5 and 7 December. These noted his back and bottom were “turning continuously red every day”. There is no record of this being reported to Mrs F, a supervisor or the district nurse. No records were kept of Mr F’s fluid intake and output.
21. The records show that Mr F was given full body washes each day from 10 to 17 December. On 14 December he had chosen to stay in his T shirt and his bed sheet was changed on 15 December, but there is no record either were changed after that.
22. On 13 December Mr F had vomited, was not feeling well and refused to eat. There is no record this was reported. On 18 December he was struggling with his speech and declined food. The care provider says the manager visited that day to discuss replacing the carpet. The manager said no concerns were raised with him about Mr F’s health. Mrs F says that evening the carers told her Mr F was not feeling well. She said she would call the GP the next day. Mrs F slept on the sofa in the lounge that night as Mr F was unwell.
23. When Mrs F’s carer arrived on the morning of 19 December, she gave Mr F some water as there was only a small amount of urine in the catheter bag. Mrs F called the district nurse to check the catheter in case it was blocked. When Mr F’s carers arrived, they were advised to seek medical attention for him as he possibly had a urinary tract infection.
24. The care provider’s daily record says carers arrived at 8am and Mr F “was not fine on arrival. Exchanged the greetings. Assisted with a face wash as per his choice. Emptied the urine bag. Made sure he is comfy. Made a cup of tea and cornflakes. Put clothes in a dryer. Assisted with a glass of water. Mr F was finding it hard to eat and speak. We left Mr F safe.”
25. Mrs F says when she went in to see Mr F that morning his sheets were blood stained from open pressure sores, with dead skin and perspiration stains. The ambulance crew requested clean sheets to prevent cross infection. There was juice on his face, he had not been shaved, was dirty and smelt. Mrs F has found this significantly distressing and upsetting.
26. The district nurse arrived. She found Mr F confused with slurred speech, dehydrated and with very low blood pressure. There were extensive skin abrasions in his pressure areas. After speaking to Mr F’s GP she called an ambulance. The hospital record says Mr F had hypothermia, extensive lesions and impaired kidney function. Mr F sadly died the next day from sepsis as a result of a urinary tract infection.

Safeguarding enquiry and Mrs F’s complaint

27. The hospital made a safeguarding referral to the Council and Mrs F contacted the CQC. The care provider’s investigation report said it had not received any warnings about Mr F’s health and that if he had been ill on 18 December, Mrs F would have phoned an ambulance.
28. The safeguarding allegations were substantiated. It was found that the care provider had not sought timely medical intervention for Mr F. The Council met with Mrs F in April 2023 to discuss the outcome.
29. Mrs F made a formal complaint to the Council on 25 April 2023. She said the care provider’s inability to monitor, record and report changes to Mr F’s health had put him at risk. She was also concerned that it had failed to provide records when requested by the safeguarding enquiry.
30. The Council responded on 3 May. It said the care provider had no records. The safeguarding allegation had been substantiated and the Council had recommended improvements for the care provider to make, which it would monitor.
31. The CQC inspected the care provider and found breaches of the Regulations in relation to consent, safe care and treatment, and governance. It rated the service as inadequate and the care provider is currently under special measures.
32. In response to my enquiries, the Council said training had since been delivered to the care provider’s staff on catheter care and the care provider was using new care plan and daily care records templates, including a new risk assessment for catheter care and recording re-positioning for pressure care. The Council was monitoring the care provider.
33. In response to my draft decision statement, the care provider said:
• All carers were undertaking record-keeping update training.
• Monitoring charts have been put in place for all service users who are at risk.
• It had introduced spot checks, regular staff supervisions and audits to ensure compliance.
• It was improving communication between management, care staff, service users, and relatives to ensure information is not lost.
• Service users had been encouraged to make complaints if they are not happy about anything. Concerns raised must be recorded and reported to ensure actions are taken in a timely manner.

My findings

34. The lack of detailed records about Mr F’s care causes uncertainty about whether adequate care was given. Poor record keeping is fault and a possible breach of the Regulations.
35. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
36. On the evidence I have seen, and taking into account that Mr F was admitted to hospital with a urinary tract infection and extensive pressure sores and the safeguarding allegation was substantiated, my view is that on the balance of probability the provider failed to properly check, notice, record, monitor and report concerns about Mr F’s health and skin. This is fault and a possible breach of the fundamental standards of care.
37. On 19 December there is evidence that the care provider failed to seek medical assistance and that Mr F was left unkempt. This is fault and a possible breach of the Regulations.
38. Mrs F raised a number of concerns about Mr F’s care with the care provider during the autumn of 2022. I have seen no evidence that the care provider responded to these or dealt with them. This is fault and a possible breach of Regulation 16.
39. Mrs F has asked how and why the Council commissioned the care provider to provide her husband’s care, when it appeared that staff had not been trained in catheter care, pressure care or hoisting. She noted that CQC had found no records around catheter care management or evidence of training. The Council said the care provider was compliant with its contract in August 2022. It is for CQC as regulator, rather than the Ombudsman, to consider whether staff are sufficiently trained.
40. Sadly, we cannot now remedy the injustice caused to Mr F by these faults. But Mrs F has been caused significant distress. She also has the uncertainty of not knowing whether Mr F’s health would have deteriorated if concerns had been reported sooner. Whilst I cannot say that Mr F would not have died if the care provider had noticed his deterioration, this uncertainty and distress is a significant injustice to her.
41. When we have evidence of fault causing injustice, we will seek a remedy for that injustice which aims to put the complainant back in the position they would have been in if nothing had gone wrong. When this is not possible, we will normally consider asking for a symbolic payment to acknowledge the avoidable distress caused. But our remedies are not intended to be punitive, and we do not award compensation in the way that a court might. Our guidance says a moderate, symbolic payment is appropriate to remedy distress and uncertainty caused by fault. This is not intended to be compensation to Mrs F for the loss of her husband.
42. 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 have found fault with the actions of the care provider, I have made recommendations to the Council.

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Agreed action

43. Within a month of my final decision, the Council has agreed to ensure the care provider’s staff are trained in record keeping, pressure area care, and identification and escalation of health concerns.
44. The Council should provide us with evidence it has complied with the above action. It should also report back the outcome of its monitoring of the care provider.
45. In my draft decision statement, I recommended the Council apologise to Mrs F and pay her £300 as a symbolic remedy for the distress caused by fault. The Council agreed to these recommendations. However, Mrs F said she did not want an apology or payment from the Council. I have therefore removed them.

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Final decision

46. There was fault by the Council. The actions the Council has agreed to take remedy the injustice caused. I have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman