Summary: Mrs X complained the Care Provider failed to provide her mother (Y) with an adequate standard of care between October and November 2023. The Care Provider was at fault for poor record keeping and not carrying out care visits in line with when Y needed her medication. It was also at fault for how it administered Y’s care contract. However, it was not at fault for failing to stay for the full duration of Y’s care visits. The Care Provider has agreed to apologise and make a symbolic payment to Y to remedy the injustice caused.

The complaint

1. Mrs X complained the Care Provider failed to provide her mother (Y) with an adequate standard of care between October and November 2023. Mrs X says the Care Provider:
1. failed to ensure care visits were spaced appropriately in line with medication administration;
2. failed to stay for the full duration of Y’s care visits;
3. failed to give clear information about the care contract terms.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. 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.
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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)
6. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

7. I have considered information Mrs X has provided.
8. I considered information from the Care Provider.
9. I considered the relevant law and guidance.
10. Mrs X and the Care Provider had an opportunity to comment on this draft decision. I considered comments before making a final decision.

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What I found

11. 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. The standards include:
• Providers must make sure that they provide care and treatment in a way that ensures people's dignity and treats them with respect at all times (regulation 10).
• Providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe (regulation 12).
• Providers must securely maintain accurate, complete and detailed records in respect of each person using the service (regulation 17).
• Providers must make written information available about any fees, contracts and terms and conditions, where people are paying either in full or in part for the cost of their care, treatment and support (regulation 19).

What happened

12. The information below is not a comprehensive overview of everything that happened. It is a summary of key information.
13. Y is partially blind and lives in a self-contained flat which is part of an extra care housing scheme meaning she has access to some support to maintain living independently. Y has capacity to make decisions about her own care and treatment. In October 2023 Y contracted an illness which required her to have eye drops and to be cared for in bed for several weeks. Mrs X arranged for the Care Provider to go into Y’s home to provide personal care and administer the eye drops for her. Mrs X informed the Care Provider the carers must visit Y between 9:30am and 9pm which is a 11.5 hour window.
14. In Mid-October 2023, a doctor prescribed Y an initial seven day course of eye drops to be taken five times a day. The administration advice was to try and space the doses evenly throughout the day. The case records show Y only refused her eye drops twice during this period.
15. Following this seven-day course, a doctor prescribed Y more eye drops which needed administering four times a day every four hours. Records show over this three-week course, Y refused eye drops approximately 20 times. Some of the care records do not say why she refused them. However, on the records that do give a reason, it is mostly due to the carers not administering these four hours apart. Mrs X says this has damaged Y’s eyesight as a result.
16. In November 2023, a nurse who worked at the extra care housing scheme visited Y in the morning and found her in bed in soiled bedding and clothing. The nurse reported this to Mrs X who went round to visit Y that night and she was still in the same soiled bedding and clothing. The Care Provider visited Y four times that day and none of the case notes have a record of this incident.
17. Following this, Mrs X cancelled the Care Provider’s services and made a complaint the same month regarding the standard of care Y had received. This included carers not giving Y eye drops at the correct times, staff not staying for the full duration of the visit and carers leaving Y in soiled clothing. Mrs X also complained the Care Provider never gave her a copy of the care contract. As a result, she says she was not aware of the increased cost of care visits on a weekend or the two week notice period to cancel care until she received an invoice at the end of October. Mrs X asked for the invoices to be amended accordingly.
18. The Care Provider responded to Mrs X’s complaint in December 2023 and January 2024. In summary, the Care Provider said:
• Y often refused care and asked carers to leave which it communicated to Mrs X. As a result, the carers were limited with what they could achieve.
• There was a contract available which outlined charges and cancellation notices. Therefore, it would not be amending any invoices.
• It accepted records of care visits were sometimes lacking detail.
19. The care records show Y often refused aspects of care and on occasion asked carers to leave. Therefore, the records show carers did not stay for the full duration of the visit.
20. In reply to the Care Provider’s response, Mrs X says she does not accept that Y frequently refused care. She says the carers asked Y if they could leave.
21. In December 2023, the Council undertook a safeguarding enquiry and said on the balance of probabilities Y experienced neglect from the Care Provider. The recommended actions that came out of the enquiry were as follows:
• When a service user has capacity and wishes to change their care, the Care Provider should conduct a review directly with the person and changes should be made in line with their views and wishes. The Care Provider should ensure they are involving the service users directly in their care arrangements where possible and where the person has the capacity to understand. 
• Conduct spot checks in terms of ensuring visits are being completed in their full call duration. Where care workers are regularly/consistently identified to not be staying the full length of their visits, supervision would be required to discuss this.
22. Mrs X remained dissatisfied with the Care Provider’s handling of the matter and complained to us.

Care Provider’s response to our enquiries

Administering eye drops

23. In relation to the second course of prescribed eye drops, the Care Provider says it was not possible for it to administer these every four hours, four times a day because the Care Provider only had an 11.5 hour time window to visit Y in.

Care contract

24. The Care Provider says all communication was with Mrs X when setting up the package of care as she had Legal Power of Attorney (LPA) for finances. The Care Provider put a physical copy of the contract in a cupboard in Y’s flat which it says Mrs X was aware of. The Care Provider says it did not provide a contract in a suitable format for Y who is partially blind. Following this situation, the Care Provider now emails contracts to clients and next of kin to ensure they have the information available to them.

Case recordings

25. The Care Provider says it was not aware Y was in soiled bedding and clothing until the nurse went to see her at approximately 09:40am that day. Y had three care calls after this. It says the carers did not realise what had happened as Y had refused personal care that day, so they did not include it in their notes.
26. With regards to the carers leaving early, the Care Provider says if a client asks them to leave they have to respect this. It says Y would often refuse care and support. The Care Provider accepts that the case recordings of this are poor and will address this with the carers by providing further training.

My findings

Administering eye drops

27. The second course of eye drops Y was prescribed should have been administered four times a day, four hours apart. The case records show this did not happen with visits being as little as 90 minutes apart on occasion. The Care Provider failed to ensure care visits were spaced out appropriately in line with the eye drop administration which was fault. I cannot say this caused damage to Y’s eyesight. However, it caused Y distress, frustration and uncertainty about the standard of care she was receiving during the four-week period. The Care Provider said from the instructions and the times that it could visit the client it was not possible for the eye drops to be administered every four hours. When the Care Provider realised this, it should have informed Mrs X immediately so she could make other arrangements.

Duration of care calls

28. Mrs X says carers were not staying for the full duration of the care calls. The case records show for most of the care calls Y refused at least one aspect of her care whether this be food and drink, personal care, medication or domestic tasks. There were also occasions where Y told the carers to leave. This has undoubtedly impacted on the length of care calls. Y has capacity and carers must respect her wishes. Therefore, the Care Provider was not at fault in relation to the length of the care calls.

Care contract

29. The Care Provider says all communication was with Mrs X when setting up the package of care as she had Legal Power of Attorney (LPA) for finances. However, it then issued Y with a physical copy of the contract which she could not review as she was blind. This was fault. The Care Provider should have sent Mrs X a copy of the contract as it arranged the care with her and she had LPA. This caused uncertainty about the cost of care prices. However, Y required an urgent package of care and these are typical fees incurred with care providers. Therefore, on the balance of probabilities it is likely Mrs X would have still accepted the care package had she been aware of this.
30. Following this situation, the Care Provider now emails contracts to clients and next of kin to ensure they have the information available to them. Therefore, it is not necessary for us to make a further service improvement.

Case recordings

31. In November 2023, Y was left in soiled bedding and clothing all day despite having four care calls. The Care Provider says it was not aware of the incident until the nurse from the care home went to visit Y at 09:40 am that day. The purpose of the nurse’s visit to Y was a check-up following a fall. The case records show one of the care calls coincided with the nurse’s visit and three care calls took place after. The Care Provider says none of the carers’ visit records reflect this as Y had refused personal care all day so they were not aware she had an accident. However, the nurse did not carry out personal care either and was aware of what had happened. Therefore, on the balance of probabilities, in at least one of the four care visits a carer would have known Y had an accident. Y has capacity to refuse personal care. However, the carers should have recorded this in their care notes and reported it so that Mrs X was aware of the situation. Not doing so was fault. The poor record keeping leaves uncertainty about whether the correct care was given and meant Y was left in soiled bedding and clothing for longer than she should have been.

Agreed action

32. Within one month of the final decision the Care Provider has agreed to take the following action:
1. Apologise to Mrs X and Y to recognise the distress, frustration and uncertainty caused to them. 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 I have recommended.
2. Pay Y £200 to acknowledge the distress, frustration and uncertainty caused by its poor record keeping, not completing care calls in line with medication times and how it administered the care contract.
3. Provide us with evidence of the training completed to improve the record keeping of staff.
33. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

34. I have completed this investigation. I found fault causing injustice and the Care Provider agreed to my recommendations to remedy the injustice caused.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman