Summary: Mrs X complains Habitat Care Limited failed to provide care workers who were able to meet her father’s needs as he approached the end of his life, leaving his family having to cover for them. The care provider accepts its services did not meet the required standard and has apologised. It needs to take action to improve its records keeping and make its quality checks more meaningful.

The complaint

1. The complainant, Mrs X, complains Habitat Care Limited failed to provider care workers who were able to meet her father’s needs as he approached the end of his life, leaving his family having to cover for them.

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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. If they have caused a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)

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How I considered this complaint

3. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the care provider has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Mrs X and the care provider, and taken account of the comments received.

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What I found

Key facts

4. In July 2023 Mrs X’s father, Mr Y, was diagnosed with a terminal illness. He wanted to be cared for at home, so he returned to be with his wife on 20 July. His family met all his needs until 24 July, when NHS funded care workers started visiting four times a day for one hour.
5. Mr Y’s family also arranged for Habitat Care (the care provider), which trades as Home Instead, to provide a live-in carer to support Mr Y. They did this so the family could spend quality time with Mr Y before he died. They were reassured by this statement on the care provider’s website: “Our palliative care service benefits individuals with terminal illnesses who want to remain in their own homes, surrounded by the people that are important to them”.
6. Live in carer A arrived on 24 July.
7. Home Instead produced a care plan for Mr Y. This said the aim was for him to maintain his daily routine as much as possible. It said the live-in carer should:
• offer to help Mrs Y prepare Mr Y’s meals, but she may not accept the help
• assist the NHS funded care workers when required
• apply creams to Mr Y’s skin when another family member, who would normally do this, was not visiting
• prompt Mr Y to make day-to-day decisions
• clean Mr Y’s dentures each day
• help Mr Y get out of bed and ensure a sensor mat was by the bed or his armchair
• be close by when Mr Y was walking with his frame or stick, in case he needed help
• collect a newspaper each day and do any other additional shopping which may be necessary
• take the rubbish and recycling out
• help Mr Y to bed
8. Mr Y’s family produced their own care plan, to supplement Home Instead’s care plan.
9. Home Instead provided additional care workers who visited for two hours each day to give the live-in carer a break from their work. The family later increased this to four hours, when Mr Y needed more support during the night.
10. Home Instead contacted the family on 26 July to check how things were going with live-in carer A. The form does not say who they spoke to (Home Instead later said it was Mrs Y), but recorded them saying everything was going well and live-in carer A was “very kind”.
11. Mrs X says live in-carer A:
• spent most of their time away from her father, either on her phone or writing notes
• would only help Mr Y with personal care when the NHS funded care workers were there
• would not sit and talk to her father and refused to walk him down the garden, saying they could only guide him with one hand on his back and another on his shoulder
• refused to take Mr Y out in his wheelchair, so his family had to do this
• would wake Mr Y up so the NHS funded care workers could do his morning routine for him, despite having been asked to let him sleep.
12. Live-in carer A left without giving any notice on 31 July, after the family told Home Instead they were not happy with their work. Mr Y’s family had to step in to help look after him.
13. Live-in carer B started on 3 August. The next day Home Instead contacted the family to check how things were going. According to its records, everyone was getting on and live-in carer B was “very chatty”.
14. Mrs X says live-in carer B:
• wanted the NHS funded care workers to do all Mr Y’s personal care;
• refused to take advice from the other professionals involved in Mr Y’s care and often disagreed with requests from his family;
• refused to change Mr Y’s clothes, when he spilt a drink on himself;
• agreed they had not complied with manual handling guidance, after this was pointed out by an occupational therapist;
• often failed to wake up when Mr Y needed help getting to the bathroom at night, or encouraged him to support himself on the furniture rather than use his walking frame;
• told other people involved in Mr Y’s care that he was constipated, when he was having multiple bowel movements a day;
• made errors with Mr Y’s medication, which meant the family had to monitor this closely.
15. On 11 August live-in carer B recorded Mr Y falling on the floor, having been in bed. Live-in carer B found Mr Y trying to get up. They told him to get on his knees first. They checked Mr Y for fractures and head injuries, but found none. Mr Y supported himself to get up and sat on the commode, which live-in carer B had placed behind him. Although Mr Y did not look confused, he was unable to answer live-in carer B’s questions about pain. Live-in carer B settled Mr Y back into bed at around 06.30, and decided to observe him further during the day.
16. Home Instead visited the home that day and spoke to someone who said live-in carer B was “very caring”. They also said live-in carer B had “some very funny ideas and ways, but we get on well”. They said things were “better than last time”.
17. Live-in carer B left on 14 August, as planned, and live-in carer C started. Mrs X says by this time Mr Y’s needs had increased. She says live-in carer C:
• Refused to help Mr Y with intimate personal care;
• Mr Y had no creams applied from 20 August until he died eight days later;
• Failed to prevent Mr Y from falling out of bed, despite checking on him 15 minutes before this happened, and screamed for Mrs Y to help (who could not hear as she did not have her hearing aids in) and failed to call an ambulance, which only happened after the NHS funded care workers arrived, so Mr Y was left on the floor for over an hour;
• Did not always take her breaks (despite agreeing to increase them to four hours a day, as she was often woken by Mr Y at night) but spent time chatting/distracting the respite care workers, and often asked the family to do her shopping for her;
• Had an argument with one of the respite care workers, which continued the following day, causing unnecessary tension;
• Had to be prompted to give Mr Y mouth care and had little experience of palliative care, resulting in them asking a hospice for more support;
• Was reluctant to ring the district nurses, instead calling Mrs X at 04.00;
• Started manhandling Mr Y after he died, rather than allow the family time to process his death.
18. Mrs X said she had to stay in her father’s home for 10 days leading up to his death. She said all the live-in carers complained about Home Instead and being underpaid, which was inappropriate. The live-in carers only made paper records, despite being told they would use an app so all members of the family could see what was going on.
19. On 23 August live-in carer C told Home Instead Mrs X had been interfering in Mr Y’s care (Mrs X disputes this) and had not wanted them to call the district nurse when Mr Y became agitated during the night. Live-in carer C reported an incident to Home Instead. The report said Mr Y had been breathing heavily. When live-in carer C went to him, he was half on the bed with his feet on the crash mat. They called an ambulance and the district nurse. Paramedics arrived at 08.00 and helped Mr Y back to bed. They also helped clean Mr Y and applied his creams. Mrs X says live-in carer C failed to call an ambulance until after the NHS funded carer worker arrived. She says the live-in care workers had the authority to call for medical help (GP, district nurse, ambulance) but always deferred to others before doing so.
20. Mr Y died on 28 August.
21. Mrs X complained to Home Instead on 5 September about the support provided for her father. When the care provider replied on 11 October, it said:
• Some documents had been missing from the information provided to the family, but this had now been rectified.
• All its care workers had to complete care certificate training, and were given 12 weeks to complete this. All the live-in carers had completed mandatory training before starting work, which included: manual handling; medication; basic life training; and specialist training. One live-in carer had completed the care certificate training during their breaks, but this did not affect the support provided.
• End-of-life care was not the same as palliative care. Home Instead did not provide palliative care.
• It had hired staff on the basis they had experience of providing 24-hour care, either in a care home, a nursing home, a hospital or as a private care worker, and they needed experience of end-of-life care. None of them had domiciliary care experience, as that was not enough to support someone who needed 24‑hour care.
• It denied the claim that any of the live-in carers were unhappy with Home Instead management. It said one of them had an argument with one of the NHS funded care workers.
• During the first week the live-in carer provided all the personal care, as the NHS funded care worker did not turn up. The live -in carer decided to stay close to Mr Y’s bedroom, rather than in their own room,
• It was unfortunate that one of the live-in carers could not take the pressure and decided to leave before they could get a replacement.
• It had done a service review with Mrs Y.
• The live-in carers had problems accessing the app for making notes, so had to make paper records.
• It apologised for the experience the family had with the live-in carers and its management
22. Mrs X was not satisfied with the care provider’s response, so she complained again.
23. When the care provider replied in January 2024, it said:
• It apologised for any distress caused by missing documentation while the app was not accessible.
• It apologised for the inconvenience and uncertainty caused by live-in carer A leaving after seven days.
• All the live in carers had completed their mandatory training before starting work. It said Mrs Y had good support from the live-in carers but apologised for the fact Mrs X did not have a good experience with them.
• It thanked Mrs X for bringing manual handling and medication issues to their attention and apologised for her experience. It said it had taken action to address the issues via its training materials and training sessions.
• It apologised the distress caused by the incidents of conflict Mrs X had witnessed between its employees.
• It apologised for its workers not using the allocated bedrooms.
• It apologised for the distress caused by the live-in carer’s decision about the administration of pain relief medication. It said they should have sought advice when there was a difference of opinion.
• Following the complaint about force feeding Mr Y, it had decided to retrain live‑in carers. It would raise the issue as a safeguarding concern if it happened again.
24. Home Instead has few records of the care its live-in carers provided for Mr Y. It has handwritten records for:
• 25 July – Mrs X slept over and met Mr Y’s needs when he got up four times during the night. Live-in carer A did Mr Y’s personal care in the morning as the NHS funded care worker did not turn up. Mr Y would not use his sensory mat or commode and needed prompts to use his walking frame.
• 26 July – Mr Y was steady on his feet when he got up during the night. The NHS funded care worker did not turn up in the morning.
• 28 July – Mr Y was unsteady on his feet after going out with friends the previous day. He got up three times during the night. Mr Y was still not using the commode.
• 4 August – Mr Y got up once during the night. He slept in his hospital bed.
• 7 August – NHS 111 was called as Mr Y had chest pain late the previous evening, but it turned out to be indigestion. The palliative nurse would speak to Mr Y’s GP about reducing the swelling in his legs. Paramedics prescribed medication. A steroid cream would be prescribed for Mr Y’s legs. Mr Y only woke once during the night. Live-in carer B had not applied any cream as no one had mentioned it to them.
• 10 August – Mr Y had been tossing and turning and had got up four times during the night. Live-in carer B had been unable to sleep in case Mr Y got out of bed. Mr Y was more unsteady on his feet. He was sometimes rushing to get to the commode, which put him at risk of harm.
25. Home Instead also has electronic records from 10 to 28 August. Most of them were made by the respite care workers, but some appear in the name of live-in carer C. They all appear to relate to the respite breaks, but they have been completed inconsistently and are difficult to follow.

Did the care provider’s actions cause injustice?

26. When responding to Mrs X’s second complaint, the care provider accepted her experience of its live-in carers had not been acceptable. It apologised for various failings. This included:
• A live-in carer leaving with no notice
• Incomplete records
• Problems with manual handling and medication
• Inappropriate comments and disputes between those sent to look after Mr Y
• Force feeding Mr Y
27. These failings caused avoidable distress to Mrs X, and prevented her from spending time with her father without having to worry about his care needs. The care provider has apologised for its failings.
28. The care provider was right to say its workers could not provide palliative care. That is a specialist service, which is beyond the scope of a registered domiciliary care provider. The care provider therefore needs to remove the misleading statement on its website about providing a “palliative care service” (see paragraph 5 above).
29. There was nothing unusual about the fact that the live-in carers had not previously worked for the care provider. Care providers often have to recruit live-in carers specifically for individual clients. This reflects the fact that given the nature of the work, they will not always have people on hand.
30. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. Regulation 10 requires care providers to treat people with dignity and respect. Regulation 17 requires care providers to maintain an accurate, complete and contemporaneous record of the care provided for each service user.
31. The care provider’s records are incomplete. It does not have records covering all the days its workers supported Mr Y. The records it has are superficial and give a patchy account of what went on. The lack of proper records is a potential breach of the fundamental standards. The care provider needs to improve its record keeping.
32. It would have been good practice to review Mr Y’s support plan on a regular basis. Given that he was approaching the end of his life it was inevitable that his needs would change more quickly than might otherwise be the case. Had it done this, everyone would have been clear about what needed doing. It would also have provided an opportunity to resolve any issues which had arisen.
33. It is also good practice to identify who has been spoken to when contacting the family. The contact with the family was also superficial. Given that issues had been raised in the first week, the care provider should have been looking to ensure that they had been resolved and whether there was any scope for further improvement. The care provider needs to review the way it does such quality checks, to make sure they are meaningful.

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Recommended action

34. I recommend the care provider within six weeks:
• Removes the misleading claim to provide a palliative care service from its website;
• Identifies all the action it has taken to address the issues raised by this complaint, including the action taken to ensure:
1. care plans for people receiving end-of-life care are reviewed regularly;
2. accurate and complete records are kept in future;
3. it carries out meaningful quality checks, aimed at identifying the scope for any improvements.
35. The care provider should provide us with evidence it has complied with the above actions.
36. Under the terms of our Memorandum of Understanding and information sharing agreement with CQC, I will send it a copy of my final decision statement.

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Final decision

37. I have completed my investigation on the basis the care provider’s actions have caused injustice.

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Investigator's decision on behalf of the Ombudsman