Summary: Mr A complained that the care provider failed to keep his mother Mrs X safe in her home. In particular he complains that the live-in carer was unaware Mrs X had left the house alone in the night, or had put liquid soap in her own food. The evidence shows the care provider took appropriate action to address the incidents but the family chose to terminate the contract.

The complaint

1. Mr A (as I shall call him) complains that the care provider did not take appropriate measures to prevent the incidents which occurred. He says he was able to access the house through the front door which was supposed to be locked after his mother had left the house. He says when he visited there was no soap in the downstairs WC. As a result the family did not feel Mrs X would be safe if the care provider continued.

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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)

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How I considered this complaint

3. I considered evidence provided by the care provider and by Mr A as well as relevant law, policy and guidance.
4. Promedica24 and Mr A had an opportunity to comment on my draft decision before I reached a final decision.

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What I found

Relevant law and guidance

5. 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.
6. Regulation 12 says that care must be provided in a safe way for service users. It says care providers should ensure that the premises used are safe to use for their intended purpose and are used in a safe way. It also says Assessments, planning and delivery of care and treatment should:

• Be based on risk assessments that balance the needs and safety of people using the service with their rights and preferences.
• Include arrangements to respond appropriately and in good time to people’s changing needs.
• Be carried out in accordance with the Mental Capacity Act 2005. This includes best interest decision making; lawful restraint; and, where required, application for authorisation for deprivation of liberty through the Mental Capacity Act 2005 Deprivation of Liberty Safeguards or the Court of Protection.

7. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
8. The Mental Capacity Act 2005 introduced the “Lasting Power of Attorney (LPA)”. This replaced the Enduring Power of Attorney (EPA). An LPA is a legal document, which allows a person (‘the donor’) to choose one or more persons to make decisions for them, when they become unable to do so themselves. The 'attorney' or ‘donee’ is the person chosen to make a decision on the donor’s behalf. Any decision has to be in the donor’s best interests.

There are two types of LPA.

• Property and Finance LPA – this gives the attorney(s) the power to make decisions about the person's financial and property matters, such as selling a house or managing a bank account. Unless the donor says otherwise, the attorney may make all decisions about the donor’s property and finance even when the donor still has capacity to make those decisions.
• Health and Welfare LPA – this gives the attorney(s) the power to make decisions about the person's health and personal welfare, such as day-to-day care, medical treatment, or where they should live.

What happened

9. Mrs X (now aged 90) lives in her own home. In 2022 her family approached Promedica24 to provide live-in care for Mrs X. The pre-contract assessment notes that Mrs X had some short- and long-term memory loss. She sometimes needed prompting with personal hygiene or appropriate dressing and required assistance with medicine administration. The care provider’s scoring chart described her as of ‘medium’ dependency.
10. The care plan said that Mrs X should not be allowed out of the house on her own except into the garden. It said she did not have capacity to make ‘big’ decisions but could make daily decisions about her care. Mr A has power of attorney for health, welfare and finances.
11. Shortly after care commenced there was an incident when the then carer left Mrs X on her own while out of the house – at a bus-stop and in a café – and was dismissed immediately.
12. On 7 June 2024 Mrs X managed to leave the house alone in the night, dressed in her night clothes. The carer had locked the Yale lock but not the mortice locks. A passer-by alerted a neighbour who telephoned Mr A’s brother and the matter was resolved. Mr A says the carer was reminded that she must use all 3 locks. He says however that when he visited a week later the front door was unlocked and he was able to enter the house without keys.
13. Mr A complained to the care provider later that month. In addition to the complaint that Mrs X had been able to wander alone at night and the doors were not properly locked, he raised other matters of concern. He said when he had recently visited the house there had been no soap in the downstairs WC, the one his mother usually used during the day. He said his mother had fallen and cut and bruised her knees when out walking with the carer but no dressings had been applied. Finally he said that several times his sister had stayed overnight and gone downstairs in the morning to find Mrs X was already up, but the carer was still asleep in bed.
14. The care provider responded. In respect of the nighttime incident, they said the care worker had worked all day and was asleep as there was no provision for nighttime care. They said “This was the first incident of this kind with (Mrs X), the care worker and the care manager were unaware of any further risks at this moment in time and it was seen as an isolated incident”. The care manager had told the care worker to monitor the situation and alert her if there were any further incidents.
15. The care provider apologised that the door had been unlocked when Mr A visited again. They said the carer had left it unlocked because she knew of Mr A’s planned visit.
16. The care provider said there was no soap in the WC because Mrs X had taken it and used it on her food the previous evening, so the carer had to buy a new botte.
17. The care provider said Mrs X had not fallen while out but had tried to use her walker while the carer was out of the room, and slid to the floor.
18. The care provider said the carer had never known Mrs X get up before her unless there was a visitor in the house. The carer had her alarm set for before Mrs X’s usual waking time.
19. Mr A disputed the care provider’s findings. The family terminated the contract on the day of the complaint.
20. The care provider says care needs are reviewed every 4-6 weeks by a care manager at a visit and plans updated accordingly. In respect of the two principal complaints, the care provider says, “The incident that occurred on the 7th of June where (Mrs X) left the property was the first incident of its kind. The plan was to monitor moving forward and double lock the front door as agreed with the family and then potentially implement other strategies which were least restrictive, which may have been door sensors to start with. The incident with the soap again was the first incident that we had been made aware of and the day we were made aware they gave notice, so we were unable to put any steps in place”.
21. The care provider says although Mrs X had poor short-term memory, she was able to make her own daily decisions and would also participate in reviews of her care.
22. The care provider says it took reasonable steps to ensure Mrs X’s safety. It says prior to the incident on 7 June the door was locked but with accessible keys to Mrs X: after the incident it was agreed with the family to double lock the door but place the keys somewhere where they would be easily reached in an emergency. It goes on, “This was the reasonable next step. We would have reviewed the situation with the family if we had continued with the care provision”.

Analysis

23. The care provider had looked after Mrs X without incident (barring an early complaint in April 2022) for two years. It was of course worrying for her family that she was able to exit the house at night alone but there had been no previous attempts by her to do so. The care provider put in place a plan going forwards to prevent a recurrence.
24. The family disputed the care provider’s explanation why there was no liquid soap in the downstairs WC as being implausible, but I have no evidence to suggest it was untrue.
25. Mr A and his family took the decision to terminate the contract at that point, which was their prerogative to do. However, I have not seen evidence that significant injustice was caused to Mrs X by any fault of the care provider and so no reason to pursue the complaint further.

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Final Decision

I have completed this investigation as I have not found evidence of fault causing injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman