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Sheffield City Council (18 016 372)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 29 Oct 2019

The Ombudsman's final decision:

Summary: the Council was responsible for failing to provide a proper standard of care and treatment to Mr and Mrs X. The care provider it commissioned failed to order medication, left the medication within reach of vulnerable elderly adults, and on one occasion omitted essential medication, causing actual harm to Mr X.

The complaint

  1. Ms A (as I shall call the complainant) complains about the poor care and treatment of her late parents by the care agency Inspire Care UK which was commissioned by the Council to provide care for her elderly parents.

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The Ombudsman’s role and powers

  1. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word ‘fault’ to refer to these. If we are satisfied with a council’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)
  2. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves, or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)

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How I considered this complaint

  1. I considered all the information provided by the Council and Ms A. We spoke to Ms A. Both the Council and Ms A had the opportunity to comment on an earlier version of this statement and I took their comments into consideration before I reached a final decision.

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What I found

Relevant law and guidance

  1. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)
  2. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
  3. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The CQC has issued guidance on how to meet the fundamental standards below which care must never fall.
  4. Regulation 12 says sufficient amount of medications should be ensured to meet the needs of service users. Regulation 12 also says care providers are responsible for the proper and safe management of medicines.
  5. The Council operates a risk management/escalation process for service provision jointly with the local health body. “Low or no risk” is categorised green; “low/moderate risk” is categorised amber; “high risk/concern” is classed as a serious incident and categorised red. A provider in the amber category is visited every 4-6 weeks to monitor its action plan for improvement. A provider in the red category is visited every 2-4 weeks to monitor its improvement plan.

What happened

  1. Mr and Mrs X were an elderly couple. Mr X had significant care needs. Mrs X had dementia. Their daughter Ms A supported them with shopping, laundry and other tasks but they were assessed by the Council as requiring 4 care calls a day. Mr X’s care plan included a stipulation for carers to administer medication. The administration of one of his drugs was time-critical.
  2. In January 2018 the Council allocated the provision of care services to Mr and Mrs X to the care agency Inspire. In addition to the care plan, the Council also sent a service amendment form which said, “Once a month practical call 20mins to order and collect medication. ‘Carers to re-order medication for the month from GP Surgery. This needs to re-order at least 48hours before medication runs out so it can be processed”.
  3. Within a day of the agency starting the care calls for Mr and Mrs X on 20 January, Ms A raised concerns about the carers’ ability to look after Mr X properly. She said she had to order the medication herself as she discovered the carer had not ordered it and it was close to running out. The carers were supposed to check the weekly Warfarin dose with the hospital and administer appropriately but Ms A had concerns they did not do so. Carers did not always sign the Warfarin chart (which Ms A says she provided anyway). On occasions medication was left out where either Mr and Mrs X could have taken it: On other occasions the previous day’s tablets were unused, although Ms A says the carers wrote in the logbook the medication had been taken. Mr X was supposed to take Warfarin at 6pm but sometimes the care calls were later than 7.30pm.
  4. Ms A also said her father was sometimes left soiled and wet. Urine bottles were left unemptied; soiled pads were left on the floor, and the dishes were left unwashed. Ms A said on 4 February she went to their home to find excrement all over the bathroom and bedroom.
  5. Ms A says she raised concerns first of all with the Council on the second day the carers were in post. She raised concerns in writing on 27 January

The safeguarding investigations

  1. On 12 February Ms A raised a safeguarding alert about the poor care. She sent photographic evidence to the Council of the poor conditions in the flat and the medication left out. She said there were many different carers who attended; they did not know on their first call what medication was supposed to be administered; they wrote “all well” in their notes when they left even if the flat was not clean, Mr A was left soiled or no medications had been administered. Carers did not assist Mrs X to wash or dress. Ms A said she was looking for a different provider. The Council agreed the matter warranted a safeguarding enquiry.
  2. Then on 23 February Mr X’s GP raised a further safeguarding concern. The Council’s safeguarding form notes, “Patient required emergency '999' hospital admission on 21/02/18 as care staff from Inspire (UK) care agency omitted or failed to give patient bumetanide 3mg once daily over weekend - resulting in severe heart failure and cardiac arrest….Care staff also failed to administer correct WARFARIN dose over weekend - was advised to omit dose ….- but care staff tried to administer - increased risk to patient.”
  3. The Council’s records note a discussion on 21 February with a manager from the care agency who said Ms A wanted a change of care provider. The manager said the situation had been difficult because of the hostile environment created by Ms A who staff found intimidating.
  4. In March Mr X’s social worker met with Mrs X, Ms A, and the team manager. Ms A said when Inspire started the care package, the problems with medication and poor care were such that she started visiting on a daily basis. She said as well as the concerns already reported, carers had failed to check and monitor the pressure sores on Mr X’s legs. As a result of the discussion in the meeting, the Council agreed to continue the safeguarding process.
  5. A new care agency took over the care contract from Inspire.
  6. Mr X died on 4 March.
  7. In June the Council held a safeguarding planning meeting which Ms A attended. The manager of Inspire as well as a contracts monitoring officer were also present. The Inspire manager acknowledged there were some points where carers had clearly failed but said there were other matters she needed to investigate further. The team manager said she had spoken to the senior carer after the medication error had resulted in Mr X’s hospital admission and he said he had put an action plan in place to withdraw the two carers, carry out spot checks and put a new MAR chart in place. She asked if that had been done. Ms A said the two carers returned the following day so the action plan had not been implemented. The Inspire manager accused Ms A of intimidating the carers and said they were not given time to process any information. A further meeting was planned when the Inspire manager would have gathered more information.
  8. Ms A says she had to wait two months for the safeguarding meeting. She says two of the carers she was accused of intimidating were large men, of whom her father was frightened.
  9. The social worker carried out a detailed investigation of Ms A’s concerns. In respect of the failure to order medication she noted Inspire said they had never received the email with the service amendment form. She found evidence however to show the form had been received. She found evidence that carers had not been consistent with completion of the MAR charts or the Warfarin record. The care agency had not contacted the hospital as stipulated to find out the dosage for the week. On one occasion Ms A had to stop a carer giving her father medication he should not have had. The social worker noted the agency’s acknowledgement that the wrong dosage of Warfarin had been given and another tablet had been wrongly administered. Overall the social worker found that neglect had occurred.
  10. The social worker also considered the hygiene complaints. She said it was difficult to establish whether the carers had failed to clean up the flat on 4 February or whether the incident had occurred after they had left. She said there were concerns about the standards of personal care and Inspire acknowledged staff had not liaised properly with District Nurses about Mr X’s skin integrity.
  11. The social worker concluded there had been a breakdown of communication between Inspire and Ms A.
  12. The next safeguarding meeting was held in July. The contracts monitoring officer said the Council had held weekly meetings with Inspire between June 2017 and February 2018 but they were stopped as improvements were made. The meeting concluded there were serious concerns about medication handling by Inspire. It agreed however there was insufficient evidence to link the incidents described in paragraph 13 above to Inspire.
  13. Mrs X also sadly died.

The complaint

  1. Ms A complained to the Council in September 2018. She complained about Inspire and said their contract should be terminated. She complained about the Council's monitoring of the agency. She expressed concerns about the training provided to carers. She said the Council should ask service users about their experience of care. She complained about the delay in sending her the minutes of the safeguarding meetings.
  2. The Council’s head of commissioning responded in October. She upheld the complaint about the poor-quality service given to Mr and Mrs X. She apologised for the length of time it had taken to conclude the safeguarding process. She explained the Council’s risk escalation process and said that Inspire had been given an ‘amber’ status in July 2018 because of the concerns raised. She said the contracts monitoring officer was working closely with them and had visited 18 times between February and October. She said the contracts monitoring officer was currently visiting on a fortnightly basis to ensure the agency complied with its action plan for improvement. She detailed the areas of training required by the Council.
  3. Ms A remained dissatisfied and continued to complain. She said she presumed (given the description of the escalation procedure) that Inspire had been placed in the “red” category. She said “the carers could not read MAR charts or understand how to administer Warfarin, did not order the medication and did not answer the phone in the office. They put my father’s life at risk from day 1”.
  4. Ms A complained to the Ombudsman. She said the Council had not taken her concerns seriously.
  5. Mr X’s social worker says “There were clearly some failings from Inspire UK in regards to administration of medication and overall standards of care, however Inspire UK staff also felt intimidated by (Ms A). This made it difficult for (Ms A) and Inspire UK to effectively communicate about the care and the arising issues.”


  1. The care agency (acting on behalf of the Council) failed to provide safe care for Mr and Mrs X. Carers’ failure to administer medication properly and abide by the stipulated dosage caused actual harm to Mr X. That was fault for which the Council remains responsible, and which caused significant injustice to Mr X as well as to Ms A.
  2. There is evidence that carers also failed to provide proper care and treatment to Mrs X, leaving medication within reach and failing to ensure she was always washed and dressed.
  3. The carers failed to report sores on Mr X’s legs and a sore in his groin which Ms A says was clearly visible to anyone who carried out personal care. That failure also caused injustice.
  4. The contracts monitoring officer was visiting the care agency on a two-weekly basis; there had been a serious incident with medication, but the Council did not escalate the status of the care provider to “red”. The Council should clarify the way in which it complied with its procedure here. If there was an incorrect category that has implications for the viability of the contract.
  5. It is unfair for the Council to criticize Ms A for a breakdown in communication when it was the actions of the care provider which caused harm to Mr X.

Agreed action

  1. Within one month of my final decision, the Council should let me know the outcome of its review of the way in which it ensures the competency of medication handling and administration by care providers;
  2. Within one month of my final decision the Council should let me know the outcome of its review of its compliance with its risk management/escalation process in this instance in particular;
  3. The Council agrees to offer the sum of £2000 to Ms A within one month of my final decision, in recognition of the considerable anxiety and distress caused by its actions.

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Final decision

  1. There was fault which caused injustice to Mr and Mrs X and Ms A.

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Investigator's decision on behalf of the Ombudsman

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