Summary: Mrs X complained the Council failed to ensure her mother, Mrs Y, had suitable care at home. The Council was at fault. It was also at fault in how it decided that it would not take action to safeguard Mrs Y’s welfare. The faults caused Mrs X significant distress and uncertainty, for which the Council will apologise and pay her £300. It will also issue a staff reminder to prevent similar fault in future.

The complaint

1. Mrs X complained the Council failed to ensure her mother, Mrs Y, had suitable care from the Council commissioned care provider, Care At Home. Specifically, she says care workers:
• Did not feed Mrs Y properly;
• Did not keep accurate records of the care they provided for Mrs Y;
• Left unkind comments in her care notes;
• Returned to Mrs Y’s home when Mrs X asked them not to; and
• Failed to take a stool sample to Mrs Y’s GP.
2. Mrs X also complained the Council failed to act on her concerns about Mrs Y’s care and that it did not increase Mrs Y’s care package when she wanted it to. Mrs X said this meant Mrs Y experienced neglect and caused her death. Mrs X said this meant she and her daughter experienced significant distress.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
5. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
6. 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)
7. 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

8. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
9. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

Care plans

10. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. This is a needs assessment. If the assessment finds the person has eligible needs and has capital below a certain level, the council must meet their needs.

Care standards

11. 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.
12. Regulation 9 of the Regulations says care and treatment of residents must be appropriate, meet their needs and reflect their preferences.
13. Regulation 10 says people receiving care should be treated with dignity and respect at all times. It also says that care providers must make every reasonable effort to respect a person’s preference about how it delivers their intimate care. This includes a preference to have care workers of particular gender or sex.
14. Regulation 14 states care providers must meet the food and drink needs of people they care for.
15. Regulation 17 sets out that care providers must keep an accurate and complete record of the care and treatment they provide to each person they care for.

Safeguarding

16. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. The main purpose of a safeguarding enquiry is to decide whether or not the council, or another organisation, or person, should do something to help protect the adult from harm or risk of harm.

What happened

17. This section sets out the key events in this case and is not intended to be a detailed chronology.
18. In late August 2023, Mrs Y began receiving a package of care from Care At Home (the Care Provider), commissioned by the Council. The Care Provider prepared a care plan which said Mrs Y would have four visits per day which were at 8-8:45am, 12-12:30, 17-17:30 and 21-21:30. The care plan said Mrs Y needed help:
• Using the toilet. Mrs Y was doubly incontinent and used continence pads;
• Washing herself and putting creams on her skin. This included creams to help keep her from developing sores;
• Taking medication;
• Preparing food and drinks; and
• Keeping her home clean and tidy.
19. The care plan noted each visit would be attended by two care workers and that if one of the care workers was male, Mrs Y would prefer the other person to be female. It also noted Mrs Y sometimes refused food.
20. In mid-September, Mrs Y fell out of her bed and was found by family. Care workers arrived around 11:30 for the morning visit. An ambulance was called which sent a safeguarding referral to the Council. It noted the concerns the family had raised about Mrs Y’s care. These were that care workers:
• Had not moved Mrs X back into bed;
• Were putting Mrs Y to bed at 8pm and not visiting her again until late the next day;
• Were not staying for the entire care visit period or completing all the tasks required. This included that they had not washed Mrs X; and
• Were not giving Mrs X her medication.
21. The Council spoke to the Care Provider which said Mrs Y had only missed one dose of her medication, which had not caused her harm. It said it had reminded care workers to double check they gave Mrs Y her medications. The Care Provider said it had arrived late for the morning visit on the day Mrs Y fell because of an emergency with another client. It said it had reminded care workers to tell Mrs Y’s family if they were going to be late. The Care Provider said it had put a plan in place to address the other concerns the family had raised. It did not provide details of that plan.
22. The Council closed the safeguarding referral on the basis the missed medication was a one-off incident.
23. In early October, Mrs X told the Council she was unhappy with the care Mrs Y was receiving. The Council called Mrs X the same day who said she had spoken to the Care Provider and that the issues she had with the care had been resolved.
24. Mrs Y fell again at the end of the month and cut her leg. An ambulance attended and bandaged Mrs Y’s leg. Care records from later that day note a care worker identified that the bandage of Mrs Y leg was already soaked with blood and told her. Mrs Y said it was fine.
25. Two days later, Mrs Y fell from her bed again. Care workers found her in the morning. They put a duvet around Mrs Y and called an ambulance before leaving her alone to wait for the ambulance. Mrs Y was admitted into hospital for a short period of time.
26. In mid-November 2023, Mrs Y’s sister told the Council the Care Provider was sending two male care workers to support Mrs Y and she was worried that they were not leaving Mrs Y with food to eat after she had her an insulin injection to manage her diabetes.
27. The Council spoke to the Care Provider who said it had spoken to Mrs Y’s family and resolved the issue with the male care workers coming. The Care Provider said it always sent a male care worker with a female one. It accepted it had sent two male care workers a couple of times but said that was unavoidable. It said care workers left snacks near Mrs Y’s bed for her to eat after her injection. The care records do not record that care workers did this. Mrs X says Mrs Y was barely able to lift her arms so she could not have reached the snacks. The Care Provider disputes this.
28. In late December 2023, Mrs Y fell out of her bed again and was found lying face down by care workers. The ambulance came to Mrs Y’s home and made a safeguarding referral to the Council. The referral said care workers had left Mrs Y’s bed raised as high as it could go and had not applied the brakes. It added that Mrs Y’s family were concerned:
• Care workers were not doing what the care plan said they needed to do at each visit. This included that they had allowed the space around Mrs Y’s bed to become dangerously cluttered;
• Care workers had left an extension cord on Mrs Y’s radiator while it was hot; and
• When the care workers had found Mrs Y on the floor they did not do anything to make her more comfortable until the ambulance arrived.
29. The Council spoke to Mrs X in early January 2024. She reiterated what she had said to the ambulance and added that care workers had left broken glass and blood on the floor. Mrs X also said she was concerned Mrs Y would sometimes refuse to eat. The Council said care workers may not have time to sit and encourage Mrs Y to eat when that happened. It said Mrs Y may need longer care visits as a result, so it agreed to reassess Mrs Y’s needs to ensure the care package was suitable.
30. A week later, another of Mrs Y’s relatives told the Council that cameras they had installed in her home showed that a few days previously two care workers who had come to do the evening visit had stayed for no more than 10 minutes instead of the 30 minutes Mrs Y paid for. The relative added that the care workers had claimed they had stayed for the full time they should have been there for in the care records.
31. Mrs X watched the live camera footage and recalls that Mrs Y had been asleep throughout the period the care workers were in her home. Despite that, the care records stated the workers gave Mrs Y food and a drink, which she consumed.
32. In late January, Mrs X told the Council care workers had allowed Mrs Y’s hair to become matted, she had developed sores in her groin and care workers were not engaging with Mrs Y during the visits.
33. Mrs X contacted the Care Provider around the same time to say she was unhappy it had sent the care workers mentioned in paragraph 30 to Mrs Y’s home again. In response to a complaint Mrs X later made, the Care Provider said it had tried to minimise the number of times it sent the care workers Mrs X did not want coming to Mrs Y’s house. It confirmed that since the day complained about, it had not sent those care workers out together. However, it could not stop using the care workers all together without impacting on its ability to deliver Mrs Y’s care package.
34. Mrs Y became unwell and her GP asked for a stool sample. Mrs X repeatedly asked care workers to obtain that sample and take it to the GP. They did not do so. The Care Provider says another of Mrs Y’s relatives had said they would take the sample.
35. Mrs Y was diagnosed with a bacterial infection at the end of January which Mrs X feels was the result of neglect by the Care Provider. In a response to a later complaint from Mrs X, the Council said it did not know why the care workers had not taken the stool sample. The Council said if care workers did not have capacity to take the stool sample to the GP’s practice, they should have said so.
36. The Council spoke to a district nurse who had treated Mrs Y and asked if the sores on her groin were due to neglect. The nurse said the sores were actually moisture lesions and were not necessarily because of neglect. They noted, however, that Mrs Y’s continence pads were always soiled. The nurse prescribed a different barrier cream and referred Mrs Y to the NHS continence team to see if there were other pads she could wear. The Council asked the Care Provider to send a copy of Mrs Y’s daily care records and body maps from January 2024, which logged where Mrs Y had developed lesions.
37. In early February one of Mrs Y’s relatives told the Council the reassessment of Mrs Y’s needs was now urgent and that the Care Provider was missing giving Mrs Y her medication.
38. After considering the Care Provider’s recent records, the Council identified one day when the care workers were late in the morning. It found the care workers were often very early on the bedtime visits. The Council also noted a care worker had recently made an inappropriate comment about Mrs Y in her care records. It spoke to the Care Provider who said it would come later in the day for Mrs Y’s bedtime care visit. It said it would speak to the care worker who had made the comment. The Care Provider later confirmed it had disciplined that member of staff.
39. In mid-February, Mrs Y was taken to hospital. On admission, Mrs Y had a serious pressure sore. Mrs Y later died.

Daily care records

40. The records of Mrs Y’s care show that:
• Between late August and late September 2023, the Care Provider does not have a record of what care it provided to Mrs X, only that care workers carried out the required visits each day. The missing information occurred because of software issues;
• Care workers often arrived late in the morning, sometimes as late as 10am. More frequently, care workers arrived early for Mrs X’s bedtime visit, at times as early as 6:30pm;
• Care workers recorded they had spent the required time at Mrs Y’s home;
• In early October 2023, care workers failed to give Mrs Y her medication three days in a row. In late October a care worker wrote “please give [Mrs Y] her antibiotics for her [infection]!!’. There were other occasions when care workers did not offer Mrs Y her medication;
• Care workers did not offer Mrs Y support to wash every day;
• From late December 2023 onwards, Mrs Y would sometimes decline to eat food care workers offered to her;
• At the same time, Mrs Y began forgetting to take medication care workers had left out for her; and
• Care workers used a barrier cream multiple times a day to help stop Mrs Y developing sores on her groin. Her groin became notably more painful in mid-January 2024. Care workers told the district nurses promptly, who prescribed a different barrier cream for the care workers to use. Mrs Y’s relatives believed care workers did not use the new cream. The care records rarely say what cream the workers used. There was a small number of times when a care worker recorded specifically that they had used the new cream, and a small number of times when they had used the wrong cream.

Action taken by the Care Provider

41. The Care Provider took some action to improve its practice. This includes:
• Reminding staff to try and persuade Mrs Y to accept care;
• Auditing the location of care workers when they were logging in and out of care visits. Where it identified discrepancies, it warned those care workers and monitored them;
• Reminded staff about Mrs Y’s need for support with personal care, drinking, eating and taking her medication; and
• Reminded staff they should not make personal comments about people they care for in the care records.

Findings

Care

42. There were flaws in how the Care Provider supported Mrs Y, which was not in line with regulations 9, 14 and 17, for which the Council is at fault. Those failings were that:
• The Care Provider does not have complete records of the care it provided to Mrs Y;
• The Care Provider failed to include in Mrs Y’s care plan that she needed snacks left near her so she could manage her diabetes;
• Care workers were regularly late for Mrs Y’s morning and significantly early for evening visits;
• Care workers did not stay for the full visit time on at least one occasion, in January 2024, and failed to keep accurate records of when care workers arrived and left Mrs Y during that visit;
• Care workers consistently failed to carry out all the actions set out in Mrs Y’s care plan. This included that they missed giving Mrs Y her medication on several occasions and failed to provide suitable support when Mrs Y began to forget to take the medication care workers left out for her in late December 2023. Care workers did not offer to support Mrs Y to wash every day and did not keep her home neat and tidy. They also failed, on occasion, to use the correct barrier cream prescribed by the district nurses in early 2024. I am also persuaded, on balance, that care workers failed to offer Mrs Y food and drink during the short visit in January 2024;
• Care workers did not record if, and when, they left Mrs Y some snacks;
• Care workers left Mrs Y to wait alone for an ambulance after she fell in late October 2023. Care workers should have ensured someone was with Mrs Y before they left her home;
• The Care Provider did not alert medical professionals such as the district nurses or Mrs Y’s GP when she bled through the bandage on her leg in early December 2023. The Care Provider also failed to tell Mrs X that Mrs Y needed a fresh bandage;
• Care workers did not keep Mrs Y safe. This included leaving Mrs Y’s bed at its highest point and not using the brakes on her bed to secure it. I cannot be sure care workers were responsible for the glass and blood on Mrs Y’s floor, or for putting the extension lead on Mrs Y’s radiator. Nonetheless, those issues were apparent by the time Mrs Y’s family came to her home after care workers found Mrs Y had fallen in late December 2023. Mrs Y’s care plan included that she needed help keeping her home clean and tidy. Therefore, care workers should have addressed the safety hazards before leaving Mrs Y’s home.
• Care workers also failed to make efforts to keep Mrs Y comfortable after she fell in late December 2023. While it was appropriate to not move Mrs Y in case doing so would hurt her, the records do not show the care workers tried to make Mrs Y more comfortable while awaiting the ambulance;
• Care workers failed to respond appropriately to Mrs X’s request to take a stool sample from Mrs Y to her GP. While the Care Provider says another member of Mrs Y’s family had said they would take the sample, the evidence shows Mrs X asked the Care Provider to take the sample several times. If the care workers were unclear who would take the sample, they should have clarified that with Mrs X. If they did not have capacity to take the sample, they should have informed Mrs X; and
• A care worker made an inappropriate comment about Mrs Y in her care records.
43. I am satisfied the Care Provider has taken some suitable action to improve its practice, as set out at paragraph 41. I have made a recommendation below to improve its record keeping.
44. The Council was not at fault for the Care Provider’s refusal to help Mrs Y back into bed after her falls. That was an appropriate action until Mrs Y had been seen by medical staff.
45. The Care Provider acted appropriately in response to Mrs X’s concern that male care workers were coming to support Mrs Y. It confirmed that in accordance with Mrs Y’s care plan, when it sent a male care worker, they came with a female worker too. The Care Provider accepted that was not possible on rare occasions, but I do not consider this amounts to fault. It acted in accordance with regulation 10 of the fundamental standards, in meeting Mrs Y’s preference as far as possible, so the Council was not at fault for the Care Provider’s actions.
46. The Council was also not at fault for the Care Provider sending care workers to Mrs Y’s home which Mrs X did not want it to use. The Care Provider minimised the number of times those care workers attended and did not assign them to work together, but was unable to do so every time, without compromising its ability to do the visits Mrs Y needed.

Safeguarding and care planning

47. The Council was at fault in how it responded to the September 2023 safeguarding referral. It closed the referral on the basis the care provider said Mrs Y had only missed one dose of medication. However, the referral included that care workers were frequently late, had missed giving Mrs Y more than one dose of medication, failed to keep Mrs Y comfortable after her fall and were not keeping Mrs Y clean. The Council failed to consider whether those matters justified further safeguarding action before deciding it was appropriate for the Care Provider to put an improvement plan in place to address them.
48. The Council was not at fault in how it responded to the concerns Mrs X raised in early October because soon after, she confirmed she had resolved the issues with the Care Provider.
49. Following Mrs Y’s fall in December 2023, the Council received a further safeguarding referral which said that Mrs Y was not receiving her full care package, alongside safety concerns. The Council spoke to Mrs X in early January 2024 to explore her concerns, including that Mrs Y could refuse to eat and as a result, might need more encouragement than the existing care package allowed for. Records show that concern was justified, as Mrs Y began to refuse food more often around that time. The Council agreed to reassess Mrs Y’s needs to ensure her care package could meet her needs, which was appropriate. However, it then delayed carrying out that reassessment. It had not begun one by the time Mrs Y went into hospital in mid-February 2024. The delay was fault.
50. The Council also delayed considering whether it should take safeguarding action in response to the referral, alongside the reassessment. Having spoken to Mrs X in early January, the Council did not take any action until the end of the month, when it spoke to Mrs X again, which was fault.
51. During that call, Mrs X added that Mrs Y’s hair was matted, she had developed a sore in her groin and the care workers were not engaging with her. Mrs Y’s relative later added that care workers were not giving Mrs Y her medication. The Council considered whether the sore indicated Mrs Y was being neglected and whether the care workers were coming to the visits on time. It decided it did not need to take action to safeguard Mrs Y. However, in coming to that decision, the Council failed to consider whether the other issues in the safeguarding referral or those raised by Mrs X and Mrs Y’s other relative’s concerns justified a safeguarding response. This was fault.

Injustice

52. I cannot conclude, even on balance of probabilities that the fault I have identified lead to Mrs Y’s death. In addition, Mrs Y has died so it is not possible to remedy her injustice. The faults I have identified caused Mrs X significant distress about how Mrs Y was cared for and leave her with uncertainty over what would have happened had the Care Provider and Council acted as they should have.

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Action

53. Within one month of the date of my final decision, the Council will take the following actions.
1. Apologise to Mrs X for the distress and uncertainty she experienced because of the Council’s, and Care Provider’s faults. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council will consider this guidance in making the apology.
2. Pay Mrs X £300 in recognition of that injustice. Mrs X owes the Council a sum of money to pay for Mrs Y’s care. The Council should pay Mrs X the £300 directly, instead of removing it from the debt.
3. Remind staff involved with safeguarding adults, through guidance or training, that they must consider all relevant facts in a safeguarding referral before deciding whether to take further action.
4. Ask the Care Provider to provide guidance or training for staff on the importance of keeping accurate records of care visits and the care provided.
54. The Council should provide us with evidence it has complied with the above actions.

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Decision

55. I find fault causing injustice. The Council will carry out the actions listed above to remedy injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman