Summary: Mr X complains the Council did not carry out his mother, Mrs Y’s, Care Plan correctly. Mr X says this caused himself and Mrs Y distress. We have found fault in the Council’s actions for failing to attend one call or attend for full call times, correctly follow its procedure for keeping records and ensure staff acted professionally. The Council has agreed to write to Mr X to apologise for the distress caused to him.

The complaint

1. Mr X complains the Council did not carry out his mother, Mrs Y’s, Care Plan correctly.
2. Mr X says this caused himself and Mrs Y distress.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), 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. 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)
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(1), 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 Mr X and the Council as well as relevant law, policy and guidance.
9. Mr X and the Council were invited to comment on my draft decision. I have considered any comments before making a final decision.

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What I found

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.

What happened

11. The Council instructed Cera Care Operations Limited (the care provider) to provide domiciliary care for Mrs Y on its behalf. Mrs Y’s care and support plan said Mrs Y required four half an hour visits per day for support with personal care, continence care, medication administration and meal and drink preparation throughout the day.
12. Mr X complained to the care provider in late December 2024 and said Mrs Y’s friend had found her on the floor following a fall. He also said a carer noted the back door had been left open and the house was freezing but no one had told him. Mr X also said he had received reports that carers were taking medication meant for clients and a carer had taken a selfie with Mrs Y without his permission. Mr X also complained carers had not bathed Mrs Y and had left cook from frozen meals out to defrost.
13. Mr X also raised a complaint with the Care Quality Commission (CQC) and said carers had not stayed the full call time, carers left bedsheets dirty, and carers missed calls. He also said heated food had been left in the fridge and food and drinks had not been encouraged by carers.
14. Mr X also contacted his MP to raise his concerns.
15. The care provider responded to Mr X’s complaint in late January 2025 and said carers had not been correctly logging items on its system which meant any areas of concern had not been flagged with the office. The Care provider said it would send a memo to staff to remind them to correctly log items on the system. The care provider said it was not appropriate for a carer to take selfies with clients and that it would remind carers to remain professional. The care provider also said it had reviewed the care notes and carers did not bathe Mrs Y as they felt it was unsafe to do so. The care provider said it would not make carers complete actions when they felt it was unsafe. The care provider also said it would address the issue with frozen meals and reheated meals with carers.
16. The care provider went on to address the issues Mr X complained to the CQC about and said there had been occasions where a full visit had not been used but all tasks had been completed. It said this should not happen and it would remind staff of this. The care provider also said Mrs Y’s sheets were not changed after she spilt tea on them as she refused but the carers should have done this.
17. The care provider said it had not missed calls but on one occasion a carer had not attended work or advised they were not doing so and therefore a morning call was missed. The care provider said this should not have happened and apologised for Mrs Y missing her medication which should have been administered in that call. The care provider said there was no evidence of food or drink not being provided.
18. The care provider issued a memo to carers the following day explaining the issues found in this complaint and reminding them of the correct process.

Analysis

19. The care providers care records show the carers carried out the tasks set out in the care plan and on the care records on most visits. Carers also made notes when Mrs Y declined medication or food.
20. However, as noted by the care provider there was one occasion where a call did not take place. It also noted carers were not correctly logging items on its system to flag up concerns. This is fault. However, the care provider has since put procedures in place to ensure calls are not missed and staff are aware of how to correctly log issues on its system.
21. Mr X complained the care provider did not bathe Mrs Y. The care providers care records show carers did not provide Mrs Y with a bath but did not do so as they felt it was unsafe. I cannot criticise the care provider for this approach.
22. Mr X said carers did not change Mrs Y’s sheets. The care provider has said this was due to Mrs Y refusing to have the sheets changed after spilling her tea, but the carers should have done so. This is fault. However, the care provider apologised for this.
23. Mr X said not all calls were for the full time detailed in Mrs Y’s care and support plan. This is fault. The care provider accepted this but did note that carers completed all tasks and that some calls were longer than the specified time. However, the care provider has addressed this issue with its staff and reminded carers to ensure they remain for the whole call time.
24. Mr X said carers left out cook from frozen meals to defrost and placed reheated food in the fridge. The care provider said it believed this may be down to an oversight by one member of staff. The care provider has reminded staff about cook from frozen meals.
25. Mr X said the care provider failed to encourage Mrs Y to eat and drink. The care providers notes record carers did offer or provide food and drinks to Mrs Y during calls. If Mrs Y declined food or drinks the care provider has recorded this. I cannot see the care provider failed to encourage Mrs Y to eat or drink.
26. Mr X said a carer took a selfie with Mrs Y without his permission. The care provider had accepted this and has reminded carers to always act with professionalism.
27. Whilst I welcome the action the care provider has taken in relation to the faults it identified, I cannot see it apologised to Mr X and Mrs Y for the distress caused by each of the areas it found fault.

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Action

28. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of Cera Care Operations Limited and make the following recommendations to the Council.
29. Within one month of a final decision, the Council should:

• Write to Mr X to apologise for the distress caused by the faults identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.

30. The Council should provide us with evidence it has complied with the above actions.

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Decision

31. I find fault causing injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman