Summary: Mr X complained the care provider did not provide a breakdown of its costs and carers did not attend for their allotted visit times. He also complained about the standard of care provided to his mother. We have found the actions of the care provider caused injustice. The care provider agreed to apologise, make payments for the distress and uncertainty caused and carry out a service improvement.

The complaint

1. Mr X complains on behalf of Mrs Y about the action of the care provider Westcountry Home Care Ltd. Mr X complains Westcountry Home Care Ltd:
1. Did not provide a breakdown of its care costs until after the family received an invoice.
2. Carers did not attend for their allotted visit times and as a result the family have been charged too much.
3. Provided a poor standard of care to Mrs Y, namely:
1. Her incontinence pads were not being put on properly.
2. Carers did not tell Mrs Y’s husband when her catheter was leaking.
3. Carers removed a soiled bedsheet and replaced this with a towel.
4. Carers kept positioning Mrs Y’s legs incorrectly on an inflated cushion.
5. The care provider did not send staff rota sheets out the week beginning 29 December 2023.
6. Carers initially failed to carry out domestic household chores despite this being on the care package.
7. Carers were rough with their handling of Mrs Y.
8. Carers did not tell Mrs Y’s husband they found blood spots.

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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 injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

5. As part of this investigation I considered the information provided by Mr X and the care provider. I made enquiries with the care provider and considered the information received in response.
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Law and guidance

7. 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.
8. Regulation 9 says, “people using services and those lawfully acting on their behalf must be given relevant information in the most suitable way for them and in a way that they can understand. This includes information that describes costs/fees/tariffs associated with care and treatment.”
9. Regulation 10 says people using care services should be treated with dignity and respect.
10. Regulation 13 says care providers must, “take all reasonable steps to make sure that people who use services are not subjected to any form of degradation or treated in a manner that may reasonably be viewed as degrading”.
11. Regulation 17 says care providers must “maintain securely an accurate, complete and contemporaneous records in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.
12. In February 2023 we published guidance for care providers on good record keeping. We said, “We are likely to find a care provider at fault where records are illegible or have clearly been changed after the event, where they are inadequate for their purpose, or where they omit essential information or include misleading information”. We also said, “Care providers compiling accurate records enable us to reach robust findings. However, if there are gaps in recording or a conflict of evidence, we can make findings based on the balance of probabilities”.

What happened

13. In late November 2023, Mrs Y was discharged from hospital with a funded care package from the National Health Service (NHS) for four to six weeks. The care package was provided by Westcountry Home Care Ltd and was made up of four visits per day to Mrs Y’s home by carers.
14. Carers were due to visit Mrs Y for 45 minutes in the morning, then three further 30 minute visits at lunch, afternoon, and evening. At each visit, two carers were supposed to be present.
15. The care package started on 29 November 2023. In early December 2023, the care provider completed a needs assessment for Mrs Y and produced a care plan. The care plan set out the care Mrs Y needed and included:
• Dressing and undressing.
• Washing.
• Changing incontinence pads.
• Helping with her catheter.
• Applying cream.
• Repositioning Mrs Y.
• Helping to keep Mrs Y’s home clean and tidy.
16. On 12 December 2023, the care provider started charging Mrs Y for its care service as the NHS funded care ended. At this stage the care provider had not told Mrs Y’s family what its charges were for care.
17. On 11 January 2024, Mr X telephoned the care provider to raise concerns about a carer who did not want to wash dishes during their visit.
18. On 15 January 2024, Mr X telephoned the care provider to discuss Mrs Y’s care. Mr X asked the care provider for a reduction in visit times and reported he did not know what the care provider’s fees were. The care provider told Mr X the charges for the weekday rate and agreed to confirm full details of its charges with him. From 16 January 2024, carers lunch, afternoon and evening visits were reduced to 20 minutes per visit.
19. On 17 January 2024, Mr X telephoned the care provider and asked to cancel Mrs Y’s package of care.
20. Mr X made a formal complaint to the care provider on 29 January 2024. Mr X complained:
• The care provider had never provided him with details of how much Mrs Y’s care would cost and he has now received an invoice for charges.
• Carers did not attend for their allotted visit times and almost always left early.
• He should not have to pay the full care costs as carers did not stay for their allotted visit times.
• The standard of care provided to Mrs Y was poor, namely:
1. Her incontinence pads were not being put on properly.
2. Carers did not tell Mrs Y’s husband when her catheter was leaking.
3. Carers removed a soiled bedsheet and replaced this with a towel.
4. Carers kept positioning Mrs Y’s legs incorrectly on an inflated cushion.
5. The care provider did not send staff rota sheets out the week beginning 29 December 2023.
6. Carers initially failed to carry out domestic household chores despite this being on the care package.
7. Carers were rough with their handling of Mrs Y.
8. Carers did not tell Mrs Y’s husband they found blood spots.
21. In mid-February 2024, the care provider responded to Mr X’s complaint. The care provider gave Mr X details of its care costs. The care provider told him the average time carers would attend was for 20 minutes and carers needed time to get to know Mrs Y and her needs so it scheduled 30 minute visits in the first instance. The care provider said it has an app with a built in geographical locator so was aware where a carer was after they had checked out.
22. Mr X respond to the care provider a few days later. Mr X said he disputed carer visit times. Mr X said carer visits were short so did not believe he should have to pay for the full 30 minutes. Mrs X said the care provider had not addressed the points he made about Mrs Y’s standard of care.
23. The care provider provided its final response in early March to Mr X’s complaint. The care provider said it had carried out its own investigation and was satisfied the care outcomes for Mrs Y were good. The care provider said it did not bill clients minute by minute and had to allow enough time for any variances.
24. Mr X remained dissatisfied and complained to the Ombudsman.
25. In response to my enquiries the care provider sent us copies of Mrs Y’s care logs, carer visit records and its responses to the allegations about the standard of Mrs Y’s care. I have outlined the details in the ‘Findings’ section of this statement.

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Findings

26. Mr X has made several complaints, alongside concerns about the standard of care Mrs Y received. I have separated my findings into each individual item.

Breakdown of Mrs Y’s care costs

27. Mrs Y signed a contract with the care provider detailing how it would bill her for care, however this document contained no information about the amount she would have to pay for her care.
28. The records showed the care provider did not provide full details about the cost of Mrs Y’s care until it responded to Mr X’s complaint on 15 February 2024. This was fault. The care provider had a responsibility, as detailed in the regulations, to ensure it specified the fees payable and the terms and conditions of Mrs Y’s placement.
29. There is a record of a telephone conversation between Mr X and the care provider, on 15 January 2024, where the care provider told him its weekday care costs. The notes from this telephone call showed the care provider was due to follow up with the full details of Mrs Y’s care costs. I have seen no evidence that it did.
30. Mr X did not know how much he would have to pay for Mrs Y’s care costs and had to wait over two months from when Mrs Y’s care started to find out. Had the care provider told him the costs from the outset he may have decided to look at other providers.

Carers attendance times

31. There were 23 occasions when carers stayed for over their allotted visit times. There were also 18 times when carers stayed for less than 50% of their visit times. These were mainly for lunch and afternoon visits where there were slightly less tasks in Mrs Y’s care plan to complete.
32. There is one visit which only lasted for two minutes. The care logs for this visit said Mrs Y had her continence pad changed and was repositioned. There are other visits which only lasted 11 minutes where Mrs Y had her pad changed, cream applied and was repositioned. There are also other visits where only these tasks are recorded and which lasted longer than this.
33. While the daily care logs suggest care workers largely completed tasks in line with Mrs Y’s care plan, it is difficult to see how, on the short visits, care workers could have accomplished all of the tasks set out in in the care plan while ensuring Mrs Y was treated with dignity and care. This is particularly the case for the two minute, and eleven minute visits and will cause uncertainty about the standard of care Mrs Y received. This was fault.
34. A short care visit does not automatically cause an individual an injustice. For that reason, the Ombudsman does not normally recommend care providers reduce a person’s care fees to reflect each minute a care visit is short by. However I think a payment for uncertainty about the standard of care for the short visits is warranted.

The standard of care Mrs Y received

Her incontinence pads were not being put on properly

35. Mrs Y’s care plan said carers were to change her incontinence pads at each visit. Mr X alleged carers were lying Mrs Y onto incontinence pads.
36. The care provider’s position was that the nets which held the pads in place were causing Mrs Y’s skin to breakdown leaving lesions and without using the nets the pads were leaking. The care provider said because of this its carers would place pads flat either side of Mrs Y so all of the urine was caught and did not leak onto the bedding.
37. On balance I am satisfied carers were not using the pads correctly. This was fault. I cannot see anything in the care logs where carers raised concerns about the nets holding the pads in place or where this was discussed with Mrs Y’s family. The care provider could have mentioned this to the family and discussed the possibility of using alternative pads which would not cause Mrs Y to leak. As a result, Mrs Y was left in pads which would not stop urine from leaking.

Carers did not tell Mrs Y’s husband when her catheter was leaking

38. The care logs showed carers reported issues with the catheter on 12, 17 and 18 December 2023 and on 18 December 2023 Mrs Y’s husband told carers he would contact the district nurse. I have not found the care provider at fault.

Carers removed a soiled bedsheet and replaced this with a towel

39. This is alleged to have taken place on 18 December 2023. The care provider said the bedding was changed twice on this day.
40. The care logs from 18 December 2023, show carers changed the bedding in the morning and evening visits. There are no records about a towel being placed underneath Mrs Y or complaints from the family at the time. I have not found the care provider at fault.

Carers positioning Mrs Y’s legs incorrectly on an inflated cushion

41. Mr X said carers were placing Mrs Y’s legs incorrectly on the pressure cushion she used. There are no details in Mrs Y’s care plan about how her legs have to be positioned except to say she cannot be in a sitting position as she will lean forwards or sideways which is detrimental to her bone condition.
42. The care logs mention the positioning of Mrs Y’s legs on 15 December 2023 when a district nurse asked for Mrs Y’s feet to be elevated but there is no mention about carers not positioning Mrs Y correctly. I am satisfied the care provider was not at fault here.

The care provider did not send staff a rota out the week beginning 29 December 2023

43. The care provider has acknowledged it did not send out a staff rota for this week. While this will have been inconvenient for Mr X as he may not have known which staff were visiting that week, I do not consider it caused any injustice, nor that Mrs Y missed out on any care as a result.

Carers initially failed to carry out domestic household chores despite this being on the care package

44. Mr X alleges carers never asked if Mrs Y’s husband needed help with domestic chores. When this was raised with a carer on 11 January 2024 Mr X said the carer told them they did not do domestic chores.
45. The care provider said its staff asked whether the family wanted them to do anything else such as household chores but Mrs Y’s husband would often decline this.
46. Before Mr X raised the issues of carers carrying out household chores, the care logs do reference carers washing dishes on 6, 8, 9 and 10 January 2024 and on 16 December 2023 the care logs say there were no dishes to be done.
47. Without further evidence I cannot say the care provider was at fault. The care records back up the care providers position that carers regularly asked if anything else was needed.

Carers were rough with their handling of Mrs Y

48. The care records do not mention this or mention any reports from the family about how Mrs Y was being handled by carers. There also appears to be no evidence that the family raised this with the care provider before the formal complaint after the care stopped. I have not found the care provider at fault.

Carers did not tell Mrs Y’s husband they found blood spots

49. Mr X said carers should have reported blood spots to Mrs Y’s husband instead of calling him to report they would call the district nurse. Mr X said the family would have been able to explain the blood spots were caused by the removal of a morphine patch. Mr X said the lack of communication caused stress.
50. The care logs showed carers told Mrs Y’s husband about blood spots on 8 January 2024. I do not consider the care provider was at fault. Even if carers did not initially communicate this with Mrs Y’s husband, I do not see that this caused any significant injustice.

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Agreed action

51. Within one month of my final decision the care provider agreed to carry out the following:
• Apologise to Mr X for the faults identified.
• Pay Mr X £150 to recognise the distress caused for not providing details about care costs and missed opportunity to consider other providers.
• Pay Mr X £300 to recognise the uncertainty caused about the standard of care Mrs Y received.
52. Within two months of my final decision the care provider should carry out the following:
• Look at its procedures and take steps to ensure there is a system in place where customers are provided with information about care costs when they sign a contract with the care provider.
53. The care provider should provide us with evidence it has complied with the above actions.

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Final decision

54. I have completed my investigation and found that the actions of the care provider caused injustice. The care provider agreed to the above actions 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