Summary: Ms X complains about poor personal care provided to her mother Mrs Y by the Care Provider. There was fault by the Care Provider. However, it has already provided an appropriate remedy.

The complaint

1. Ms X complains on behalf of her mother Mrs Y that the private home Care Provider she employed failed to provide the personal care and support set out in Mrs Y’s care plan. Ms X says on one occasion her mother was left in wet (soiled) clothes for up to 36 hours.
2. Ms X says due to poor personal care, Mrs Y contracted a urinary tract infection.
3. Ms X also complains the Care Provider failed to carry out household duties such as cleaning, putting away laundry properly and food management.

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The Ombudsman’s role and powers

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

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What I have and have not investigated

6. Our role is to consider complaints where the person bringing the complaint has suffered significant personal injustice as a direct result of the actions or inactions of the organisation. This means we will normally only investigate a complaint where the complainant has suffered serious loss, harm, or distress as a direct result of faults or failures.
7. I have investigated Ms X’s complaint that the Care Provider failed to provide the personal care and support set out in Mrs Y’s care plan.
8. I have not investigated Ms X’s complaint regarding carers not completing household tasks, and food management because I do not consider Mrs Y suffered serious loss, harm or distress as a result of the claimed faults or failures.

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How I considered this complaint

9. I have discussed the complaint with Ms X and considered the information she provided. I considered the information the Care Provider provided. Ms X and the organisation now have an opportunity to comment on my draft decision. I will consider their comments before making a final decision.

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What I found

Relevant Law and Guidance

Fundamental Standards of Care

10. 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.
11. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their personal preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences. Guidance explains there may be times when a person’s needs and preferences cannot be met. If so, providers must explain the impact and explore alternatives.

What happened

12. This is a summary of key events. It does not detail everything that happened.
13. Mrs Y has dementia and lives at home on her own. Her daughters, Ms X and Ms W, arranged care for Mrs Y from October 2023. The Care Provider assessed Mrs Y at home and separately discussed her needs with Ms X and Ms W. It set out her care needs in a care plan.
14. The Care Provider initially visited Mrs Y once a day at lunchtime for four days a week. This increased to five days. The care plan stated carers were to:
• Encourage and support Mrs Y have a bath at least twice a week and to wash each day. It noted she could be reluctant to have a bath.
• Ensure Mrs Y got dressed in clean clothes
15. The Care Provider started providing its service in mid October.
16. After two weeks the Care Provider carried out a review of the provision for Mrs Y. A supervisor spoke to Ms X and Ms W who raised some concerns. They said that:
• communication was poor because their messages were not passed to carers
• Care should be more person centred
17. The Care Provider said it would place a communication book in the house so Mrs Y’s representatives could pass on messages to carers. The Care Provider noted in its review it was early days and the family said Mrs Y did not adjust well to too many new people visiting the house. It also said it would look at different approaches. It did not make any changes to the care plan.
18. On 7 November Ms X contacted the Care Provider as she was expecting feedback. A supervisor was due to observe carers, but they had not heard back. She set out where carers did not provide the care or service in the care plan:
• Carers did not ensure Mrs Y wore clean day clothes.
• Carers were not providing personal care twice a week as the Care Provider proposed in the agreed plan because Mrs Y had not had a bath. Ms X and Ms W supported her with a bath once a week, but they wanted her to bathe more frequently. They hoped over time carers would be able to do this as carers developed a relationship with Mrs Y.
• Ms X also raised issues regarding cleaning, tidying and food management.
19. The Care Provider’s manager contacted Ms X the next day summarising her contact and stating it would treat this as a formal complaint.
20. Ms X said she did not want to make a formal complaint, but did want carers to do what was set out in the care plan.
21. The Care Provider supervisor carried out a monitoring visit. She confirmed carers had a daily task list and she advised carers regarding person centred recording in daily notes. Carers had raised the subject of having a bath to Mrs Y.
22. Ms X and Ms Y confirmed some things improved over the next few weeks. But Mrs X was still wearing clothes from two days earlier. Carers were recording they offered Mrs Y a bath but she refused. Ms W said carers would not succeed if they just offered Mrs Y a bath as a yes/no question. She hoped this may improve over time.
23. In December Ms X and Ms W met with the Care Provider and agreed that carers would discuss how they provided support. Ms X and Ms W said the Care Provider manager also agreed to shadow carers. However, there is no note by the Care Provider confirming shadowing.
24. In January 2024 Ms W said carers were doing a good job and asked if the Care Provider could increase its hours to support with more cleaning of the house. The Care Provider said it did not have capacity to do this.
25. In late January Ms X contacted the Care Provider to advise that one of its carers had succeeded in giving Mrs Y a bath. She gave more information about how the family encouraged Mrs Y to have a bath.
26. In early March Ms X and Ms W discussed Mrs Y’s care with the Care Provider’s manager and director. The Care Provider agreed to carry out shadowing visits in order to better understand how to support Mrs Y with personal care.
27. On 14 March Ms W left a note for the carer that Mrs Y needed to be supported to change into clean clothes when they visited the next day. This was because when Ms W left at around 5.30pm it was probable Mrs Y had been urinary incontinent.
28. On 15 March in the morning Ms W also emailed the Care Provider to explain she had had to leave at a certain time the previous evening but was pretty sure that Mrs Y was wet. Ms W said she and Ms X had discussed a continence assessment with Mrs Y’s GP. The Care Provider passed this information on to the carer due to visit Mrs Y at lunch time that day.
29. The carer’s notes of her visit show that she asked Mrs Y to change into clean clothes which were set out for her. However, Mrs Y did not change into clean clothes. The carer later asked if Mrs Y would change into clean clothes. She noted she then “tried to insist” and “tried not to give her an option” but Mrs Y said she would change later. The carer noted she did not want to be too pushy or offend Mrs Y. The carer said Mrs Y was not wet when she visited.
30. However, that evening Ms W emailed to say she said she was very disappointed because the Care Provider’s online notes showed the carer had not ensured Mrs Y changed into clean clothes. This meant she had likely been left in wet and dirty clothes for more than 24 hours. And she would remain in the same clothes until Ms X visited the next morning.
31. On 16 March Ms X told the Care Provider that when she visited Mrs Y that morning she found her in wet clothes which she had been in since 14 March. She was upset to find her in such a horrible state. She said they could not continue when only one out of the three carers seemed to have the necessary skills to address obvious personal care needs.
32. On 17 March the Care Provider’s director replied to Ms X and Ms Y. He said the Care Provider had arranged dementia training for one of the carers and she was due to shadow a more experienced carer. However, it concerned him that as a Care Provider it was continually disappointing Ms X and Ms W. In his view the Care Provider was not the right organisation for them. He attached a letter giving Mrs Y 14 days notice that it would end its service.
33. The Care Provider director later discussed the termination notice with Ms W. She asked the provider to allow time for shadowing to succeed. However, after considering whether to continue the service, he decided that it should end.
34. The carer shadowing took place in the notice period. The Care Provider also extended the notice period for a further week, to enable Mrs Y’s representatives to arrange a new provider
35. Ms X complained to the Care Provider in April 2024. She said she expected a settling in period, but did not expect a continued series of support failures.
36. Ms X said the care plan stated carers would assist Mrs Y to have a bath twice a week. However, carers only managed this once. She had met with the Care Provider in early March and agreed a carer would shadow a more experienced carer. Then despite their requests the Care Provider had left Mrs Y in wet clothes for a day and a half.
37. In her view the Care Provider treated Mrs Y’s representatives as nuisances. Then it sent an abrupt and unprofessional termination notice in March after they complained. Ms X said the issues were the same throughout and were not satisfactorily addressed. Shadowing had resulted in some improvements with dressing in clean clothes and washing, but not bathing.
38. The Care Provider responded in April 2024. It said it met with Ms X and Ms W before it started the service. The agreed approach was for carers to be progressively introduced as “friends”.
39. The Care Provider said when clients were reluctant to receive care it could take time to develop trust. This was compounded by carers being positioned as “friends”. It said carers offered Mrs Y support changing into clean clothes many times, but she refused despite carers trying different techniques. Carers had more success recently with dressing, but the Care Provider acknowledged this had not been to the level Ms X wanted, for which it apologised.
40. The Care Provider said when the carer visited on 15 March she made every effort to assist Mrs Y to change but was unsuccessful. The Care Provider said that the carer did not believe that Mrs Y was wet when she visited.
41. With regard to bathing, the Care Provider agreed this was a required service. But it proved challenging as Mrs Y refused offers of support. The Care Provider had discussed this with carers a number of times to try and improve things but had only been successful in supporting with bathing once. The Care Provider apologised it had been unable to meet their expectations despite its best efforts.
42. The Care Provider apologised for some faults in cleaning, tidying and food management.
43. As a result of Ms X’s complaint, the Care Provider said it would:
• Review its assessment procedures to ensure the positioning of its service meets the clients’ needs and representatives’ requirements.
• Review its assessment procedures to ensure that client representatives were provided with information at the outset about limitations to service provision where a client does not consent,
• seek confirmation that carers have read and understood instructions sent.
• provide carers with refresher dementia awareness training.
44. Ms X complained further that
• the Care Provider itself suggested carers presented as friends. It was never intended to be permanent. And in any case Mrs Y knew that they were carers.
• The Care Provider said it could take time to develop trust, but six months was excessive. Mrs Y’s new Care Provider was able to provide personal care from the start.
• The Care Provider’s failure to make progress showed that at least some of its carers did not have adequate levels of skill. It was wrong for the Care Provider to say Mrs Y’s refusal was the reason for the failure to provide personal care.
• Support with washing and dressing was not just a preference but was fundamental to Mrs Y’s health and wellbeing.
• It took too long to train carers and put shadowing in place. It started in March during the notice period and showed signs of improvement. But it was too late.
• On 15 March the carer did not ensure Mrs Y changed into clean clothes and this led to Mrs Y contracting a urinary tract infection. This raised concerns about safeguarding.
45. The Care Provider replied it could not add more to its original response regarding washing and dressing. It repeated its apology that it was unable to progress things as quickly as it would have liked.
46. It noted Ms X said washing and dressing were fundamental for her wellbeing. But it did not consider Mrs Y’s health was put at risk. If it had, it would have referred this to the Council’s safeguarding team. Towards the end of the period it cared for Mrs Y her circumstances were changing, and it was able to support her more in the areas of washing and dressing.
47. The Care Provider said
• All carers received training for their roles but it could still take time for clients to feel comfortable in consenting to some tasks.
• It communicated with carers via email and telephone and spent time with them individually and as a group, discussing approaches and trying to learn lessons.
• It suggested shadowing when it met with Ms X on 8 March. This took place in March. The success of this did not influence its decision to end the service.
48. It considered Ms X’s request for compensation and offered to reduce its final invoice by 50% as a gesture of goodwill. This amounted to £276.
49. Ms X remained dissatisfied and brought her complaint to the Ombudsman.
50. In its response to our enquiries the Care Provider said:
• Providing care to a person with dementia who resists support is a delicate process. The Provider seeks to give the client dignity, respect their choices and develop a strong relationship. But the Provider must also ensure daily living activities are maintained so the client is not exposed to an unacceptable risk. This sometimes cannot be achieved over a defined period of time.
• Client consent is key to the provision of the service and the client is free to accept or decline the service at any time. However, the Care Provider addressed the issues by meeting with the family, listening to their concerns and putting forward its own perspective an experience. The Provider discussed the issues with carers, the manager shadowed carers and experienced carers shadowed less experienced carers.
• It noted Mrs Y struggled towards the end of the period and was more accepting of care such as assistance to dress and to wash using warm flannels.
• It said it did not find Mrs Y in a soiled state. Therefore, it did not consider she was at risk or have concerns for her safety.
• It made the decision to end the service because it did not consider it could work together with Mrs Y’s representatives.
• It accepted it had sent an incomplete stage one response by email and the posted response had insufficient postage. This delayed delivery and Ms X and Ms W had to pay postage. It apologised for this and had offered them £25.

Analysis

51. The Care Provider did not meet Ms X and Ms W’s expectations about Mrs Y’s personal care. It apologised for this and for minor issues regarding cleaning and tidying. However, it did not consider that it failed to take appropriate action when Mrs Y refused personal care.
52. The Care Provider’s complaint response is supported by the care notes and its records which show that Mrs Y refused a bath whenever carers offered to support her to do this. Regulation 9 says a person’s care should be in line with their preferences. Carers could not force Mrs Y to have a bath.
53. I consider the Care Provider took appropriate action to address the issue and tried various approaches. These were not successful, but it continued to try to assist and was more successful over time. I consider the evidence shows the Care Provider treated Mrs Y with dignity and respect.
54. The carer tried to assist Mrs Y to change on 15 March but was unsuccessful. She did not believe that she was wet. There is insufficient evidence Mrs Y had been incontinent at that time. I do not consider the Care Provider was at fault here.
55. The Care Provider has apologised to Ms X and Ms W because it did not meet their expectations. It also accepted it was at fault in the way it sent its stage one response due to lack of postage causing delay. It offered a financial remedy. It has also made service improvements.
56. I consider this is an appropriate response and remedy for the faults identified. Taking account of all the circumstances I do not consider a further remedy is warranted.

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Final decision

57. I find fault causing injustice. The Care Provider has already taken action to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman