Summary: We have found fault in the way the care agency provided care to Mr C, which meant his needs were not always fully met. The Council has agreed to apologise and carry out a service improvement.

The complaint

1. Mrs B complains on behalf of her father, Mr C, who has died. She complains about the care provided by Ornate Healthcare, (the Agency) and says the Agency has failed to meet Mr C’s needs.

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The Ombudsman’s role and powers

2. 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)
3. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:
• their personal representative (if they have one), or
• someone we consider to be suitable.
  (Local Government Act 1974, section 26A(2) and 34C(2), 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. 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)

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How I considered this complaint

6. I have discussed the complaint with Mrs B. I have considered the evidence provided by Mrs B, the Council and the Agency and the relevant law, policy and guidance. Mrs B, the Council and the Agency had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
7.  

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What I found

Law, guidance and policies

Council’s duties

8. The Care Act 2014 and the Care and Support Statutory Guidance 2014 set out the Council’s duties towards adults who require care and support.
9. The Council has a duty to assess adults who have a need for care and support. If the needs assessment identifies eligible needs, the Council will provide a support plan which outlines what services are required to meet the needs.
10. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. The CASS Guidance says councils should review plans at least every 12 months. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.
11. The CASS Guidance also says:
• If there is any information or evidence that suggests that circumstances have changed in a way that may affect the efficacy, appropriateness or content of the plan, then the local authority should immediately conduct a review to ascertain whether the plan requires revision.
• The review should be performed as quickly as is reasonably practicable. As with care and support planning, it is expected that in most cases the revision of the plan should be completed in a timely manner proportionate to the needs to be met. Where there is an urgent need to intervene, local authorities should consider implementing interim packages to urgently meet needs while the plan is revised.

Standards of care

12. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
13. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards. This says that:
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).
• The nutritional and hydration needs of the service user must be met. Where a person is assessed as needing a specific diet, this must be provided in line with that assessment (regulation 14).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The Home must, as far as is reasonably practicable, ensure that service users are able to make decisions about their care or treatment (regulation 11).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)
14. The CQC provides further guidance on the recording of medication. This says
• Care workers should make a record each time they provide medicines support. This must be for each individual medicine on every occasion in line with regulation 17. The record should include the details as outlined by NICE (National Institute for Health and Care Excellence).
• There is no standard format for a medicines record. Care providers should keep a clear record of all support provided for each medicine. Include who administered the medicine and whether it was taken or declined.
• A family member or carer may give medicines support that is usually provided by a care worker. Agree with the person and their family how and who will record this. For example, a family member might administer a ‘when required medicine’ outside the care workers visiting times.
• When the person is fully managing their medicines themselves, the care plan should clearly state this. You do not need to record individual doses taken by the person.

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What happened.

15. Mr C was an older man who lived with his adult son, Mr D. Mr C received a package of care, which he self-funded and which was organised by the Council.
16. Mr C had dementia and needed support with personal care (shower/wash), toileting and providing meals.
17. The Agency started to provide care in May 2023, but its involvement with Mr C decreased from November 2023 onwards as Mrs B had hired a private care worker to provide the care for Mr C. The Agency’s care package eventually reduced to one care visit a week on Sunday.
18. In July 2024 Mrs B contacted the Council as the private care worker was due to retire so the Agency would be required to provide the care package.
19. The Council reviewed the care plan on 17 July 2024 and the care plan was as follows:
• Care workers to attend for 30 minutes in the morning and 30 minutes in the evening.
• Mr C was able to shower and go to the toilet independently but lacked coordination and motivation. He often refused to shower and care workers should encourage him to do so.
• Care workers should prepare breakfast, lunch and dinner. Mr C would often say he was not hungry. Care workers had to ensure that Mr C maintained adequate nutrition. They should prepare the meals and leave them with Mr C, if he did not want to eat.
• Mr C had medication which he had to take four times a day. The medication was on a medication carousel.
20. The Agency contacted the Council on 30 September 2024 as there had been difficulties in providing the care package to Mr C. Mr C was displaying challenging behaviour towards the care workers, he was refusing medication and personal care. Mr C had pressure areas on his legs and redness on his bottom but the care workers were unable to address this because Mr C’s refusal to accept care and his behaviour towards the care workers.
21. The Agency carried out a review assessment of Mr C on 3 October 2024 and Mrs B was present.
22. The concerns raised were:
• Mr C displayed challenging behaviour towards staff.
• Mr C refused to take his medication.
• Mr C refused personal care and he had been scratching his skin which led to skin injuries.
23. Mrs B said she was happy with the support provided by the care workers and said she was fully aware that Mr C had been difficult to manage. She said Mr C was due to be re-assessed by a dementia specialist on 7 November. She thought Mr C may be prescribed a patch for his medication to sedate him. She said the pressure areas on the leg were linked to Mr C not allowing to be washed which meant his legs itched. He would not allow the district nurse to touch him but had allowed Mrs B to apply cream.
24. The Agency said that it may be necessary to employ 2 care workers per visit to ensure their safety. Mrs B said she was willing to try this as she did not want the Agency to stop providing care for Mr C.
25. The Council’s duty worker spoke to the Agency and to Mrs B. Mrs B said Mr C needed a reassessment by the Council and the duty worker said they would request that Mr C was allocated to a social worker for a re-assessment.
26. The duty worker spoke to the Agency on 18 November 2024. The Agency said the problem had been resolved. The Agency had moved the visits to a later date and Mr C’s medication had been changed. Since then, there had been no further challenging behaviour. The duty worker cancelled the request for a review of the care plan and said Mr C’s care plan would be reviewed in June 2025 when he was due his annual review.
27. Mrs B contacted the Council on 17 February 2025 and said the care package was not working. She said Mr C needed to be reassessed. She had been sending the Agency emails up until 9 February 2025 but the Agency had not responded. She sent a video to the Agency on 9 February which showed Mr C hanging off the bed with his trousers around his ankles and the staff did nothing.
28. The Council’s social worker rang the Agency and the Agency said the staff were finding it difficult to provide care for Mr C and Mr C needed to be reassessed. The Agency said Mr C struggled to stand because of pain. The social worker said they would email the GP for a pain review and ask whether covert medication could be considered.
29. The Agency sent an email to the Council on 25 February 2025 saying that it was difficult for care workers to provide care to Mr C because of his behaviour and a full reassessment was needed. Mr C was refusing any personal care and was at risk of skin breakdown.
30. The GP visited Mr C on 26 February 2025 and said Mr C was at the end of his life. Mr C had discoloration to his legs and a pressure sore on his ankle. The GP made a referral to the Council for an assessment of Mr C’s needs for care and support.
31. The community nurse contacted the Council on 27 February 2025 and said Mr C needed two care workers during the two visits a day. One care worker was not sufficient and they were struggling to provide care. The nurse asked whether this could be put in place on the same day as Mr C was at the end of life.
32. The Council contacted the Agency on the same day to organise two carer workers to attend. The case notes showed that two care workers attended from 27 February.
33. Mr C died on 28 February 2025.

Mrs B’s complaint – March 2025

34. Mrs B complained to the Council on 12 March 2025 and said the Agency failed to provide adequate care to the Council.

Council’s response to the complaint

35. The Council responded on 16 May 2025 and upheld Mrs B’s complaint. The Council said ‘poor care support’ had been provided by the Agency and the Council would learn lessons from this. In a later response the Council agreed to pay back all the fees that Mr C had paid since the Agency started providing care in 2023.
36. The Agency also carried out an investigation into the complaint and upheld most of Mrs B’s complaints. I have therefore also relied upon the Agency’s findings in my investigation.

Timekeeping

37. Mrs B said:
• The Agency’s care workers did not spend the allocated time with Mr C during their visits.
• The care log did not always represent the care provided as one of the logs said the care worker had stayed for 2 hours when this was not the case.
38. The Agency checked the visit times from January 2024 to February 2025. They noted that the care workers did not stay for the full 30 minutes on 30 occasions. The times of the visits ranged from 5 minutes to 25 minutes. There were occasions that the family said the care worker could go early, but there were other times when there was no explanation.
39. The Agency upheld the complaint that sometimes the care workers did not stay the allocated time and the Agency offered a refund to the family.
40. I agree there was fault in this respect. Generally speaking, we would not expect care workers to work exactly 30 minutes at each visit. Sometimes the tasks take longer and sometimes shorter but we would expect that, on average, the care workers stayed for 30 minutes.
41. So therefore I am not concerned about visits where the care worker stayed for 25 minutes rather than 30 minutes, particularly as there were visits where the care workers stayed longer than required. However, I uphold the complaint that there were times when the care workers only stayed for a short time and this was particularly concerning when there was no explanation on why this happened. This was fault.
42. In response to the complaint regarding the misrepresentation of the time of the visits, the Agency said that this related to one occasion when the care worker logged out two hours after logging in. The Agency uses a digital recording app for all its record keeping and the app had a built-in alert when the log out time is late. The app asked the care worker why they logged out late and the care worker replied that they had forgotten to log out. So this was picked up immediately and the Agency did not charge Mr C for this visit.
43. The Agency also said that its new recording system does not allow the care worker to log out remotely so it would be even more difficult to put in incorrect information.
44. I uphold the complaint that there had been an occasion when the time was not recorded correctly because of human error. However, overall there was no fault in the way the Agency recorded the time of visits. I note that the Agency’s app had an in-built alert to pick up such mistakes and the mistake was quickly picked up. I also note that the Agency has switched to a different system where it would be even more difficult to put in incorrect start and end times as the new system records where the person is when they log in and out.

Nutritional needs

45. Ms B said the Agency did not meet Mr C’s nutritional needs. She said the Agency failed to meet the meal plan and often offered Mr C poor quality food.
46. The Agency upheld the complaint about the poor quality and presentation of food and said the care workers had been cautioned in that respect.
47. I agree there was fault in terms of nutrition. I have considered the care records about nutrition and the records are poor. The automated record prompts the care worker to ‘leave a note of the observation of what food and drink has been prepared’. However, this rarely happened in the August records I saw. There were only two visits in August 2024 where the care worker specified what food they had prepared. Most of the time the box was simply ticked but there was no explanation. I could not say whether Mr C had been offered a meal but declined or whether he had eaten the meal or what he had eaten. The record keeping was better in February 2025, but still not adequate.
48. I accept that it may well be that, during those visits when the record keeping was poor, that the care workers provided Mr C with a meal and he ate it. However, without good record keeping, nobody can say what happened so I cannot see how the Agency was monitoring whether Mr C was eating adequately.
49. The importance of good record keeping cannot be understated. Either the Agency was not providing adequate care in terms of nutrition or it was not recording its actions properly but either way it was fault.

Incidents of poor care

50. Mrs B complained about incidents she had recorded on video which showed that the care provided to Mr C was poor. The incidents were:
• In August 2024 a care worker offered Mr C his supplement drink while Mr C was on the commode. Mr C refused but the care worker persisted.
• In February 2025, Mr C was seen sitting at the edge of his sofa. The care worker saw this but did not approach or assist Mr C but left him that way.
51. The Agency has upheld both complaints and I agree this was fault.

Medication

52. Mrs B said the care workers failed to properly administer medication to Mr C.
53. The Agency’s care plan said the care workers should administer Mr C’s medication and fill in the Medication Administration Record (MAR) chart in the morning and the evening.
54. I have checked the MAR charts for February 2025. The MAR chart should always be completed either to say that staff had administered the medication or had tried to administer the medication but Mr C refused. I appreciate that Mr C often refused to take his medication, so I expected the MAR chart to reflect that.
55. I noted that there were occasions when the MAR chart was not filled in at all, so it was not possible to say whether the medication had been administered or not administered. This failure to fill in the MAR chart was fault. The importance of filling in the MAR chart cannot be overstated. By not properly filling in the MAR chart, Mr C was at risk of receiving too much or not enough medication.

Personal care

56. Ms B said the care workers failed to provide adequate personal care to Mr C and that they rarely provided him with a shower or wash or continence care.
57. I accept that Mr C often refused personal care. I also accept that care workers could not force Mr C to engage in personal care if he did not want to. Mr C may not have had the mental capacity to make certain decisions but that did not mean care workers could use force.
58. However, I would expect care workers to always offer Mr C a shower or a bath and at least try to engage him in this. I would also expect the care workers to record that they had offered a wash/shower and Mr C refused. Unfortunately, there was no tab in the digital recording system for the care worker to confirm whether personal care has been delivered. Sometimes the care worker would add it to the daily record but frequently they did not.
59. Therefore, it is impossible to say how often personal care was offered or provided. So there was fault in that respect, either in the record keeping or in the lack of care or both.
60. In terms of continence care, there was a tab in the recording system which staff had to fill in so the record keeping in this respect was good. I note, however, that there were a lot of occasions when staff did not provide continence care. For example, during the whole month of February 2024, staff provided continence care 16 times during the morning visit and 9 times during the evening visit. I accept that this may be linked to Mr C’s refusal to accept continence care, but it would mean that a review was urgently required to ensure the Agency could provide appropriate care.

Lack of review

61. Mrs B said the Council failed to review Mr C’s care package, particularly during the last two months when he was no longer mobile and was cared for in bed (‘bedbound’).
62. The Agency alerted the Council on 30 September 2024 that it had difficulties in delivering the care package and that a review was needed. The Agency carried out its own review in October 2024 and involved Mrs B.
63. The Council did not take any action following the Agency’s referral until 18 November 2024 and this delay was fault. However, I note that, by then, the problem had been resolved and both the Agency and Mrs B agreed that a further review by the Council was not needed.
64. There is no evidence that the Agency or Mrs B contacted the Council between 18 November 2024 and 17 February 2025, when Mrs B rang the Council to alert them that a review was needed. Therefore, I cannot say there was fault in the Council’s failure to review the care package during this period as the Council had not been made aware that there were any problems.
65. I do question why the Agency did not contact the Council again to alert them to the problems it had providing care to Mr C. It is difficult to say from the records when matters declined but Mrs B said Mr C declined from January onwards and was cared for in bed so that would normally require a review of the care package and I would have expected the Agency to alert the Council to the problems in administering the care package.
66. The Council did not carry out a review after the request for a review on 17 February 2025, as far as I can see and a review was needed urgently. A review had been requested by Mrs B, the Agency and then later the GP and the district nurse. The failure to carry out the review urgently was fault. I note, however, that, when the district nurse recommended a change in the care plan from 1 carer to 2 carers on 27 February, the Council implemented this immediately.

Language difficulties

67. Mrs B raised the issue that Mr C, whose first language was not English, had reverted to speaking in his first language and Mrs B raised this with the Council in July 2024. The Council upheld the complaint that there had been no follow-up in this respect and apologised for this. I agree this was fault.

Actions taken because of the complaint

68. The Agency said it had taken the following actions as a result of the complaint:
• All staff would be placed on monthly spot checks and two monthly supervisions for 6 months.
• All staff to be retrained on mandatory training.
• Simulation exercises would be carried out to reassess staff’s competence.
• There had been changes in senior management.
• Client feedback and staff feedback would be completed every quarter.
69. The Council said the following actions would be carried out as a result of the complaint investigation:
• The Agency was meeting with the team who provided care to Mr C to address the issues raised and to remind them of the expectations of care staff’s actions.
• The Agency was also meeting the individual care workers who provided care to Mr C to put in place individual plans.
• The Council’s Commissioning team had learned lessons from the poor service provided and would review and monitor the Agency. This would include on-site monitoring.
• Meetings took place between the Agency and the Council and follow-up actions were being monitored.
• A reflective session was held with the Adult Social Care team to discuss the findings of the investigation.
• Work was completed with the teams to remind them to consider finding carers who speak the language of the service user.
• Staff at the Agency would receive safeguarding training.

Injustice and remedy

70. When the Ombudsman finds fault, we consider whether this caused an injustice and, if so, whether this can be remedied. The aim of the Ombudsman’s remedy is to put the complainant in the position they would have been if the fault had not happened.
71. The fault I have found related to the care provided to Mr C. Sadly, the person who suffered greatest injustice as a result of the fault, Mr C, has died and his injustice cannot be remedied.
72. However, I do not underestimate the distress this has caused to Mrs B in witnessing the effect this had on Mr C and her stress trying to resolve the issues.
73. I have explained to Mrs B that the Ombudsman is not a court and we do not provide compensation.
74. Also, when a complainant has died, the Ombudsman does not recommend a remedy to be paid to the complainant’s estate, except if there has been a quantifiable loss.
75. We sometimes recommend a small sum as a symbolic remedy to reflect the distress a relative has suffered. However, I note that the Council has already agreed to repay all the fees that Mr C paid to the Agency (via the Council) from the beginning of the Agency’s contract in 2023 and this has been repaid to Mr C’s estate. Therefore, I do not recommend any further financial remedy.
76. Mrs B said she wanted the Agency to be removed from the list of care providers that the Council commissions. That is not something the Ombudsman can recommend. However, I note the service improvements that both the Agency and the Council have made because of Mrs B’s complaint so I hope she understands that her complaint has made a difference to other families in the future.
77. I have kept service improvements to a minimum as there is little point in recommending a duplicate service improvement. However, I note that the complaint regarding the record keeping was not mentioned in the Council’s response and no service improvement was recommended in this regard so I have made a service improvement regarding the record keeping.
78. I will also share a copy of this decision with the CQC as it is best placed to address any service improvements that may be outstanding.

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Action

79. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. 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 the Agency and make the following recommendations to the Council.
80. The Council has agreed to take the following actions within one month of the final decision. The Council will:
• Apologise to Mrs B for the fault I have identified.
• Ask the Agency to ensure that all relevant staff understand their duty to keep appropriate records. The Council will ask the Agency to provide training or guidance as needed.
81. The Council should provide us with evidence it has complied with the above actions.

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Decision

82. I have found fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman