Summary: Ms A complains that the care provider did not provide a good standard of care for her father Mr X, failed to adhere to its pet policy, charged for two care-workers when only one was needed, and failed to keep proper records. There was fault in the actions of the care provider which led to poor care and distress for Mr X. The care provider has waived some fees, reviewed staff training and apologised for its shortcomings. The care provider has also now reimbursed the cost of rehoming Mr X’s dog to remedy the injustice caused.

The complaint

1. Ms A (the complainant) complains about the actions of the care provider during the months it was contracted to provide live-in care for her father Mr X, who has dementia. In particular she complains that the first carer failed to keep proper records, admitted she could not manage Mr X’s needs, and left Mr X alone in the house when she left; that the care provider insisted on a second live-in carer when Mr X’s needs were such that one could not manage; reneged on its agreement to look after Mr X’s dog; sought to terminate the contract abruptly.

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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. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

5. I considered evidence provided by the care provider and Ms A as well as relevant law, policy and guidance.
6. The care provider and Ms A had an opportunity to comment on my decision. I considered their comments and spoke to both parties. Following those interviews I asked for further comments on a revised draft decision and have considered those comments before making this final decision.

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What I found

Relevant 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 the care and treatment of service users must—

(a) be appropriate,

(b) meet their needs, and

(c) reflect their preferences.

9. Regulation 10 says service users must be treated with dignity and respect.
10. Regulation 12 says care must be provided for service users in a safe way.
11. Regulation 17 says care providers must maintain securely an accurate, complete and contemporaneous record 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. The care provider has a policy on pets in clients’ homes: it says, “the care of any pet will remain the full responsibility of the person using the service or other members of their household. It will only take part in the care of any pet only if it has been agreed as part of the service contract and the tasks are clearly stated in the individual care plan. By care of the pet is meant the usual daily tasks involved in feeding, grooming, toileting and exercise.“ The policy also says that this relies on the ability to schedule carers who are willing to care for pets.

What happened

13. Mr X, who has dementia, wanted to continue living in his own home with his dog. Ms A arranged with Understanding Care to provide a live-in carer for him. The service plan which the care provider drew up at the start of care in December 2023 stated that he had ‘memory loss not yet diagnosed’. He needed medication administering by the carer. He required prompting and/or help with personal hygiene and continence needs and his meals prepared.
14. The care provider’s contract for care allowed for the carer to feed, walk and look after Mr X’s dog.
15. Ms A says the care manager missed an appointment without notice or explanation before care began. Ms A says in hindsight this was an example of the poor communication which continued during the contract period. She also says the initial service agreement which the care provider sent to her was for a different client.
16. 0n 16 December the contract began. Ms A says the first carer was unable to manage Mr X’s needs and often messaged her with queries and concerns instead of directing them to her management. She says the carer admitted to leaving Mr X wet and soiled as he refused personal care. She did not look after the dog as had been agreed, failing to document if she had walked him or not. She carried out some tasks inappropriately, such as dragging the wheelie bin through the house and scratching the floor. On the day she left the employment, she left the house before the next carer arrived, leaving Mr X alone in the house and with the entry accessible.

Ms A says the next carer managed to engage with Mr X better, but she personally had to spend considerable time updating her about Mr X’s needs as the first carer had failed to keep proper records or communicate properly. Ms A says she thinks the way in which the first carer had treated Mr A frightened him and made him less compliant.

17. The new carer raised concerns about Mr X’s nighttime activity. Due to his dementia, he often wandered at night in the house and sometimes urinated inappropriately, causing slip hazards. The care manager spoke to Ms A as she was concerned that the carer was unable to sleep properly because of the disturbances. It was agreed that Ms A would provide some extra care over the Christmas period.
18. Two incidents occurred in the first week of January when Mr X entered the carer’s bedroom. During the first incident Mr X got into bed with the carer. She took him back to his room and wedged her door shut to prevent him returning but describes herself as feeling ‘shaken’ by the incident.
19. On 5 January Ms A arranged for a locksmith to fit a lock to the carer’s bedroom door.
20. On 7 January however, Mr X forced the lock on the door on the carer’s bedroom door and broke it. On 8 January an extra carer was introduced and a more robust lock fitted to the door.
21. The local care manager told Ms A on 7 January that the contract would be terminated on 8 January because the carers could not be kept safe from disturbance at night. This did not take place (and was not within the contract terms) but instead an agreement was reached to enable two carers to provide care for Mr X.
22. Ms A says she did not realise when she agreed to this that this would mean two live in carers: she thought there would be additional night-time cover. The care provider says it was not possible for one carer to safely manage Mr A. The manager says she explained fully to Ms A what the policy was and that there would be two carers living in. Ms A disputes this. She said it was not until two carer arrived on 8 January that she realised what was being proposed. She says she had no option but to hand over to them at that point but it was 9 January when the manager emailed her to say both carers would be living at the house.
23. The two carers who now provided the care arrived late on the 8 January. They were reluctant to look after Mr X’s dog, so he had to be rehomed.
24. From 19 February Ms A requested to move back to one carer as she says it had become apparent that both carers were sleeping at night and providing double care during the day. Ms A says the local care manager told her that this would be challenging because of Mr X’s changing needs, and said he was refusing help with dressing or being cleaned up. The care manager says the first pair of two carers were often up in the night supporting Mr X (sometimes both at once). She says later on he settled and it was possible then for the second carer to support the first in persuading him to have personal care during the day. Ms A says although they were paying for two carers it was unclear they were both needed. She says it was not up to the carers to decide unilaterally how the care should be delivered, without consultation.
25. Ms A terminated the contract on 3 March. She says she would have done so sooner had she not needed surgery herself in January. The care provider says it was their intention to move back to one carer but that did not happen before the contract was ended. Ms A says there was never any suggestion from the care provider this would take place.

The complaint

26. Ms A complained to the care provider in April. She said as well as the poor standard of care provided by the first carer, there had been a lack of communication, threat of immediate termination of contract, a carer who smoked, inaccurate charging, she had been forced to accept two live-in carers, she had to rehome her father’s dog, and since the contract ended she had heard from neighbours that the carers had taken Mr X out in pyjamas and slippers. She said the carers had not taken Mr X out to walk daily as stipulated. She said she had been led to believe her father was difficult to look after by one carer but the new live-in carer who was employed was able to care for him without the significant problems previously experienced.
27. The care provider’s live-in care manager replied in May. She apologised for the missed appointment, the data breaches and the actions of the first carer, although she said the first carer had not been briefed about the level of resistance she experienced from Mr X. She added, “It must also be remembered that this was your Dad’s first experience of live-in care and his non-compliance could be a way of demonstrating his non-acceptance of the arrangement.” She noted that the first carer had not kept appropriate records.
28. The manager apologised that Ms A had initially been told the contract would be terminated at a day’s note and accepted this had been “hasty and unhelpful” although the correct approach had then been adopted. She said in the area where Mr X lived the agency only provided live-in care so there was no option other than to engage a second live-in carer. She said there were reports that Mr X’s behaviour was challenging during personal care and it was helpful for a second carer to distract him at those times. She accepted it was unfortunate that neither carer was willing to care for the dog and that he had to be rehomed but said at least this enabled Mr X to continue to live at home. She apologised Ms A had not been given a copy of the pets policy.
29. The manager apologised if Mr A had been taken out inappropriately dressed although she said both carers denied this. She said he had not been taken out daily as agreed but there were occasions when he refused, or when he had had refused personal care and so it was not appropriate to take him out of the house.
30. The manager said Mr X had shown improvement during the time they had cared for him. She said, “Initially he refused food, medication, blood pressure readings and personal care. He was awake a lot at night and involved in potentially risky activities including urinating on the floor and sofa, leaving food items out and laundry on the floor, removing light bulbs and moving furniture. By the time our service ended he was sleeping through the night and being active in the day, he was accepting all food, medication and personal care and he was no longer engaged in risky or unhygienic behaviours”.
31. She accepted there had been some incorrect charges. She said “In recognition of the areas where the service has fallen short of our standards, as a gesture of goodwill, we will deduct the cost of one week’s live-in care from the final invoice. The amount is £1575. We will also deduct £225 for the overcharge on 8th January 2024 and £280 for charging for Caregiver food allowance in error. The total deduction is £2080 “. She added that outstanding invoices still needed to be paid.
32. Ms A was dissatisfied with the response and complained again. She said they had not been provided with the agency’s pet care policy and believed they were engaging carers who would look after Mr X and his dog. She believed the company should reimburse the cost of rehousing the dog which had been £1060. She said she did not believe the family should pay for the additional carer as it was possible (although more difficult) to achieve the necessary care with one carer. She said she did not believe they should pay the outstanding balance of £9660 as the required service had not been delivered.
33. Ms A complained to the Ombudsman.
34. The care provider’s daily notes from the period of care show the first carer experienced significant difficulties with Mr X. Her notes for 20 December, for example, say Mr X was refusing to change his clothes or soiled pad, would not have a shower, took hold of both her arms tightly then bunched his fists and said he would punch her. He repeated that he would punch her later that day.
35. The second carer recorded issues with Mr X’s night-time activity. She recorded that Mr X had moved chairs round the house and screwed up the clean laundry and placed it on the floor. She also noted he had been in all the kitchen drawers without first washing his hands and left an unknown substance on the surfaces and towels. All carers report frequent difficulties persuading Mr X to accept personal hygiene.
36. The care provider says that at the initial assessment with the care manager, Ms A daughter said Mr X’s memory loss caused some anxiety and he required reassurance. She says she spent about two hours with Ms A and Mr X that day during which Mr X personally responded to many questions. She says Ms A was honest that as she did not live nearby, she was unclear about many aspects of his daily routine and she adds “While this provided us with a general understanding of his needs, it did not fully indicate the level of non-compliance or aggression that was later observed”. Ms A does not accept this was a true representation of the meeting. She says she took the lead in the meeting and provided a “detailed, step-by-step explanation of his daily routine”.
37. The care provider says all carers receive comprehensive training in managing dementia and difficult behaviours. She says record-keeping is a core component of the training carers receive.
38. The care manager told me in interview that Mr X had not been taken out in his pyjamas, but Ms A has provided photographic evidence to show that Mr X had been taken out during the day in his pyjamas and slippers, in contradiction to the reports of the carers. The care provider says “Our dementia training, aligned with guidance from Skills for Care and the Alzheimer’s Society, emphasises supporting such [challenging] behaviours in the least restrictive way possible. This means that if a client refuses to change clothes or insists on leaving the home, Caregivers are encouraged to reduce distress by supporting them safely rather than escalating the situation through confrontation.

From the photograph, I can see that (Mr X) was wearing a warm coat and a hat. This indicates that the Caregivers had considered his health and wellbeing, ensuring he was warm and protected in the winter weather. While we cannot assume the exact circumstances behind the image, he appears content and not distressed, which is consistent with the records that suggest he would sometimes insist on walking with purpose.

Our expectation is that Caregivers would always encourage (Mr X) to change into day clothes and discourage him from leaving the home in nightwear. However, if he became resistant and insistent, best practice is to prioritise his wellbeing by accompanying him, engaging him in positive conversation, and then encouraging him to return home; for example, suggesting a warm drink or another familiar routine. This reflects dementia care principles which prioritise reassurance, trust, and dignity, while minimising distress”. The care provider says that carer is no longer employed by the company.

Ms A says these episodes happened during January and February and her father should not have been taken out in cotton pyjamas or material slippers.

39. The care provider says pet care was assessed during the initial care consultation, and the carer agreed to assist in line with the agency policy but there was no separate agreement outside the terms of the pet policy.

Analysis

40. The care provider acknowledges there were some potential breaches of the regulations in terms of failure to provide an appropriate level of care and failure to keep proper records, in respect of the initial carer. That period of care lasted one week and the care provider has agreed a week’s deduction from the charges. In my view that remedies any injustice arising there.
41. The care provider has also deducted the charges which were incorrectly imposed.
42. The care provider accepted it was wrong to say the contract would be abruptly terminated, but in the event that did not happen. Although that caused some distress I am satisfied an apology was sufficient remedy.
43. Ms A agreed to the employment of a second carer and so I do not see the charges for that carer should be waived, although I note her view that the basis of the employment was not made clear to her. The arrangement for the second carer meant there were times when both carers were asleep and both awake but in my view that was an evolving situation and I accept, having seen the records, the assessment of the care provider that it was not safe at that time for one carer to manage Mr X alone. I recognise Ms A has since found a carer who can manage Mr X’s behaviour alone, but the records suggest some significant challenges in his behaviour previously.
44. Apart from the first week of care, where the carer acknowledged she could not manage Mr X’s behaviour, it does not seem to me on the evidence available that the standard of care was such that it should not be paid for as contracted.
45. I am satisfied with the explanation the care provider has given for the actions of the carers in taking Mr X out in pyjamas and slippers, although it is unfortunate this was originally denied.
46. However, if Ms A had been given a copy of the pets policy prior to the contract starting she would have been alerted to the fact that the care of Mr X’s dog was dependent on being able to schedule carers willing to look after him. I can see therefore that the cost of rehoming him was an unexpected expense. I do not see that the inability to find carers willing to look after him was fault by the care provider. The care provider has now reimbursed those costs.

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Decision

47. I have completed this investigation on the basis that I find some evidence of fault causing injustice, which the care provider has remedied.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman