Summary: Mr X complains Unique Senior Care - Warwickshire failed to give proper notice that his relative’s usual care workers would be away, preventing them from making alternative arrangements, and failed to provide appropriate care until she moved to a care home in November 2023. The care provider is unable to evidence having met all the relative’s needs. This resulted in avoidable distress to her. The care provider needs to apologise to Mr X and make a symbolic payment to his relative.

The complaint

1. The complainant, Mr X, complains Unique Senior Care – Warwickshire failed to give proper notice that his relative’s usual care workers would be away, preventing them from making alternative arrangements, and failed to provide appropriate care until she moved to a care home in November 2023

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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. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

4. I have:
• considered the complaint and the documents provided by Mr X;
• discussed the complaint with Mr 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 Mr X and the care provider, and taken account of the comments received.

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What I found

Key facts

5. Mr X’s relative, Ms Y, has dementia and used to live in her own home. In May 2022 her family arranged for Unique Senior Care – Warwickshire (USCW), which is run by Understanding Care (Warwickshire) Limited (the care provider) to provide live-in carer workers for Ms Y, as she did not want to live in a care home. Mr X has power of attorney for her finances and health and welfare.
6. In May 2023 Ms Y did not respond well when she had a temporary live-in care worker, while one of her main care workers was away. Mr X says this also happened in February 2023. The care provider told Mr X the main care worker would return early, as it was thought to be in Ms Y’s best interest for a short-term care worker to move to another placement. The care provider said it hoped this would help Ms Y to settle. It said it would implement the Herbert protocol – a scheme which involves collating information about a vulnerable person (contact numbers, medication needed, a photograph etc) in case they go missing. It also told Mr X it would continue with two main care workers and noted the issues of the previous week had abated.
7. In June the care provider sent Mr X a copy of the Herbert protocol for the family to sign off.
8. On 21 August Mr X e-mailed the care provider, as he had been told one of the main care workers would be away for several months. The other main care worker was also about to go on leave. Mr X asked about the plans for replacing them and noted the previous experience (in May) had not been good. He said he would be away 10 to 18 September and from 5 to 20 October. There is no record of a response from the care provider.
9. The care workers made records of the support provided for Ms Y between 4 September and 6 November. I refer to the key contents and to other records below.
10. Ms Y was settled until 8 September, which was “a very up and down day”
11. Ms Y was chatty and went for a walk on 9 September.
12. On 10 September Ms Y was agitated in the morning. She was calm after going for a walk, but became agitated again in the evening.
13. On 16 September Ms Y spent a lot of time in her room and refused to go for a walk.
14. Ms Y spent the afternoon with a relative on 17 September.
15. On 18 September Ms Y went for a couple of walks.
16. On 19 September Ms Y went to the shops with the care worker.
17. Ms Y was incontinent twice on 20 September. She was tired, so spent time lying on her bed. There was no clean underwear, so a care worker went to buy some while Ms Y had lunch with another care worker at home.
18. On 21 September Ms Y went shopping with the care worker
19. On 22 September Ms Y was incontinent. The care worker noted Ms Y had been incontinent three times that week. They also noted there was no space to dry bedding, nor a tumble drier, and that the carpets would need professional cleaning. They said Ms Y was “very bad on her feet” when they went out and they would “not do this again”, so shopping would have to be done online.
20. There appear to have been no issues from the care worker’s point of view between 23 September and 8 October, as they either made no records or simply recorded “care was provided successfully”.
21. However, on 7 October Ms Y’s family told the care provider they were concerned about her mental health, as the care worker had been unable get her out to go shopping.
22. On 9 October the care worker noted Ms Y had been “busy” the night before. She had been incontinent on the way to the bathroom and refused to have a shower. In the morning her bed was soiled. Ms Y agreed to be cleaned but refused her medication. The care worker noted Ms Y was often anxious on the day one carer worker was due to handover to another care worker, as was due to happen that day. It appears the new care worker had no problems as they recorded “care was provided successfully”.
23. On 10 October the care worker noted it had been a “rough day” but gave no more information. The care provider told Mr X it had visited Ms Y and a care worker was planning a walk with her. It said Ms Y had deteriorated a great deal. It said the previous care worker had lacked the confidence to take Ms Y out because of a bad experience early in the placement. It said it would be in close contact with their replacement.
24. The care workers made no further entries in the daily logs until 27 October, when one of Ms Y’s long-term care workers returned to work.
25. On 12 October Ms Y was confused and confrontational. She did not respond to attempts to reassure or distract her. Following advice from her emergency contact, the care worker called 999. By the time the emergency services responded, Ms Y had calmed down. They advised contacting Ms Y’s GP, who prescribed antibiotics for a potential urinary tract infection.
26. On 15 October the care worker reported Ms Y being confused and confrontational. They called 999. By the time they responded, Ms Y had calmed down and was resting. The care worker was advised to call the GP in the morning.
27. On 17 October the care worker contacted Ms Y’s GP who advised contacting a dementia nurse.
28. On 18 October the care provider told Mr X it had contacted the community dementia team about Ms Y. It said the care worker had managed to get Ms Y to shower that day, but her home smelt of faeces and she was refusing medication. The care worker contacted Ms Y’s GP. The care provider noted Ms Y had started taking antibiotic for a urinary tract infection the previous week.
29. On 19 October the GP advised contacting the dementia nurse as Ms Y had a urinary tract infection. The care provider left a message for the dementia team, but did not receive a response.
30. On 20 October the care provider sent a statutory notification to the Care Quality Commission (CQC) on the basis Ms Y had been the victim of neglect. The referral outlined events since 12 October. It said Ms Y had refused to take her antibiotics and was refusing to eat or wear continence pads. It said paramedics had said they would organise “hospital at home” as Ms Y needed medication via a syringe.
31. On 23 October Mr X forwarded an e-mail from a sibling to the care provider. This said:
• Ms Y was unkempt, with faeces under her fingernails;
• Paramedics had been called two days ago, as Ms Y had refused to take medication. A paramedic had persuaded her to take the medication;
• The care worker had been unable to get Ms Y to take her medication that day but the relative had supported her to take it;
• The care worker did not feel confident about taking Ms Y out, in case she did not want to return, not even into the garden;
• The home was also untidy;
• A long-term care worker would return on 27 October, but Ms Y’s decline may have gone too far.
32. The care provider agreed Ms Y had declined during the weeks the long-term care workers had been away. She had been difficult for the temporary care workers to manage. It said they would have to see how Ms Y reacted to the return of the long-term care worker. It apologised for the state of Ms Y’s home and said this was unacceptable.
33. When Ms Y’s long-term care worker returned to work on 27 October, they noted Ms Y smelt of urine and faeces, although the previous care worker claimed to have showered her. They noted Ms Y was dishevelled, extremely pale, very frail and had lost a lot of weight. Ms Y had not taken her medication, but the care worker encouraged her to do so.
34. From 28 October until 5 November the care worker made detailed records of the support provided to Ms Y, who continued to have problems with continence, cleanliness and medication. Ms Y was at times angry and confrontational. The care worker managed this by allowing Ms Y time to herself and taking the opportunity of calmer moments to meet her need for support with personal care and medication.
35. On 1 November the care provider noted Ms Y may need to go to a care home as she needed two care workers and there was not enough room in her flat for two of them to stay with her.
36. Later in November Mr X told the care provider they had arranged for Ms Y to live in a care home from 6 November.
37. Mr X complained to the care provider about the problems in March 2024.
38. When the care provider replied to Mr X’s complaint in April, it said:
• It did not discuss alternative care workers as it only employed experienced live-in care workers, with at least one year’s experience in a care setting. The need to provide alternative care workers was beyond its control. It could never guarantee care from only two main care workers. I accepted Ms Y’s dementia symptoms had progressed during the seven weeks alternative care workers supported her. Ms Y’s dementia had been progressing for some time and in May 2023 it had implemented the Herbert protocol because of the risks around Ms Y leaving her home.
• It had liaised with other agencies over the decline in Ms Y’s condition and ways to adapt its service to meet her needs. This includes a dementia nurse, a GP, paramedics, an occupational therapist and a social worker. Ms Y had been able to walk when it stopped supporting her in November 2023.
• Ms Y’s move to a care home had been the best outcome for her and it was pleased to hear she was happy there.
• It had been the paramedics’ decision to contact Mr X after being called out when Ms Y refused to take her medication.
• It had not been able to continue providing live-in care, as Ms Y’s property could not accommodate two care workers. It accepted there were some discrepancies in its information and apologised for any misinformation. It had supported Ms Y until she moved into the care home and did not accept there were grounds to refund money because of the progression of Ms Y’s condition (dementia).
• One of the long-term care workers and the temporary care workers had reported an increase in Ms Y’s needs and challenging behaviour. This related to taking Ms Y out.
• On 12 September the care worker had reported a progression in Ms Y’s dementia and a more dramatic mood swing. It had decided to monito the situation using the same care plan. There had been no need to report this to Mr X. On 10 October it had told Mr X the GP had prescribed antibiotics for a urinary tract infection. On 18 October it had told Mr X about referring Ms Y to the NHS dementia team. On 23 October it had told Mr X the GP would be reviewing Ms Y that day. Ms Y had declined during the time her long-term care workers had been away and, despite best intentions, her needs were progressing.
• There had been some miscommunication about the events on 18 and 20 October. An attempt had been made to contact a social worker on 18 October, but no response had been received. On 20 October a paramedic (not a social worker, as previously advised) had suggested Ms Y needed two care workers.
• It accepted there had been another miscommunication over which company had provided cover for the care workers’ breaks.
• In December it had confirmed it had dealt with Mr X’s concerns as a formal complaint, but had not acknowledged this again when responding in January.
39. Ms Y has settled in the care home.

Did the care provider’s actions cause injustice?

40. There is no dispute over the fact Ms Y’s condition declined significantly during the time temporary care workers supported her.
41. It would have been good practice for the care provider to let Ms Y’s family know it was arranging replacement care workers, rather than let the family find this out form the care workers themselves. However, there is not enough evidence to support the claim that they would have arranged for Mrs Y to stay in a care home if they had been given more notice. Mr X only raised this as a concern after Ms Y went to live in a care home.
42. There are problems with some of the care worker’s records. For instance, the record for 22 September describes Ms Y as a problem, which indicates a lack of person-centred care. The lack of detailed records for 23 September to 8 October is also inadequate. It is clear things were not going well, as the care worker was not taking Ms Y out. But there is no evidence the care provider was addressing the failure to meet Ms Y’s needs or the change in her circumstances.
43. Other records were also inadequate, for instance the record for 10 October which simply referred to a “rough day”. This conflicted with the reassurance the care provider gave Mr X that day.
44. The lack of daily records between 10 and 26 October was also unacceptable. It is clear Ms Y’s needs were not being met, as when her long-term care worker returned to work, they recorded their shock at her appearance. They also questioned the departing care worker’s claim to have washed Ms Y, when she smelt of urine and faeces. The long-term care worker’s records show that with sensitivity and encouragement, it was possible to get Ms Y to accept support, although her presentation remained challenging.
45. By way of mitigation, other records show the care provider took some steps to address the decline in Ms Y’s condition by contacting other agencies. However, it failed to make meaningful contact with the local authority, which could have assessed Ms Y’s needs, despite telling Mr X it had done so, and an assessment recommended the need for two care workers. It later acknowledged there had been no assessment and the recommendation for two care workers had come from a paramedic (who would not have been qualified to make a formal recommendation). The care provider also failed to make meaningful contact with the mental health team, as it took no further action when it did not get a response to the message it left.
46. Ms Y has a progressive illness and there was never any guarantee she would be able to remain in her own home indefinitely. No one can predict the course dementia can take in an individual. Unfortunately Ms Y’s presentation became more challenging, which was neither unusual nor inevitable. Nevertheless, the failure to keep proper records, the lack of person-centred care and the failure to meet all Ms Y’s care needs caused avoidable distress which warrants a remedy.

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Recommended action

47. I recommend the care provider:
• within four weeks of my final decision, writes to Mr X apologising for the failure to meet all Ms Y’s needs and pays her £1,000; and
• within eight weeks of my final decision, identifies the action it is going to take to ensure its care workers keep proper records of the support they provide and understand the meaning of person-centred care.
48. The care provider has confirmed it will take these actions. It should provide us with evidence it has complied with them.
49. 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

50. I have completed my investigation on the basis the care provider’s actions have caused injustice which requires a remedy.

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Investigator's decision on behalf of the Ombudsman