Summary: There was fault in the way the Agency provided care to Mrs D and in its record keeping. The Council has agreed to apologise, provide a financial remedy and carry out a service improvement.

The complaint

1. Mr B complains on behalf of his mother, Mrs D. He complains about the care provided by AMG Nursing and Care Services (the Agency) and the Council’s safeguarding enquiry into the concerns the family raised about the Agency’s care.

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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 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).
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 have spoken to Mr B and I have considered the evidence he and the Council have sent as well as the relevant, law, policies and guidance.

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What I found

6. The Care Act 2014, the Care and Support Statutory Guidance 2014 set out the Council’s duties towards adults who require care and support.

Assessment, care plan and personal budget

7. 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.

Safeguarding

8. Section 42 of the Care Act 2014 says that, if a local authority has reasonable cause to suspect that an adult in its area:
• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
9. The local authority must make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken.
10. The aims of safeguarding include, among other things:
• prevent harm and reduce the risk of abuse or neglect to adults with care and support needs
• stop abuse or neglect wherever possible
• address what has caused the abuse or neglect
11. The objectives of a safeguarding enquiry include, among other things:
• establish facts.
• ascertain the adult’s views and wishes.
12. The Care and Support Statutory Guidance emphasises the importance of putting the adult at risk of abuse at the centre of the enquiry. ‘Making safeguarding personal’ means safeguarding should be person-led and outcome-focused.
13. The Guidance says the adult should always be involved from the beginning of the enquiry. The enquiry lead should ask the adult at risk what they would like the enquiry to achieve and how they would like to be involved. What happens as a result of an enquiry should reflect the adult‘s wishes wherever possible, as stated by them or by their representative or advocate.

Care Quality Commission

14. 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.
15. 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. The guidance says:
• 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 provider must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)
16. Regulation 9 says:
• Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences.

• Assessments should be reviewed regularly and whenever needed throughout the person's care and treatment.  Reviews should make sure that people's goals or plans are being met and are still relevant.
2. 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. You 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.

What happened

18. Mrs D is an older woman who lives at home. Mrs D had a fall in April 2024 and was admitted to hospital and later to a care home.

Council’s assessment of needs – 17 May 2024

19. The Council's social worker assessed Mrs D's needs for care and support on 17 May 2024 and said Mrs D would require a package of support when she returned to live at home.
20. The social worker’s assessment noted that Mrs D was incontinent of urine, had mobility problems and mild difficulties with memory. In terms of medication, the assessment said Mrs D would be at risk of forgetting to take medication, if support was not provided. Mrs D therefore required ‘prompting and supervision’ when taking medication.
21. The social worker recommended 4 visits a day and said the Agency should (among other things):
• Assist to get up.
• Change and wash bedding if required.
• Shower/wash and dress.
• Prepare meals and drinks.
• Monitor medication and prompt to take as necessary.

The complaint

22. The Agency provided support from 30 May 2024 to 17 June 2024 (18 days). Mrs D’s daughter, Mrs C complained to the Council and the Agency about the care provided in the early days when the Agency started to provide care. She said the Agency failed to change Mrs D’s continence pad, failed to change the bed when it was wet, did not give Mrs D a shower or full body wash and there were problems with the administration of medication.

Meeting – 6 June 2024

23. There was a meeting between Mrs C, the Council and the Agency on 6 June 2024 to resolve the complaints that Mrs C had been making and a care plan was agreed at the meeting.
24. The Council sent an email confirming what had been agreed at the meeting. In terms of medication the email said: ‘Thank you [name of Agency manager] for agreeing to the prompt of antibiotics.’ The email concluded that:
• ‘Carers will now administer medications as required to ensure compliance’.
25. It was agreed at the meeting that the family would be given access to the Agency’s online care records so that they could see what care had been provided.

Care plan – 6 June 2024

26. The Agency wrote Mrs D’s care plan on 6 June 2024. The care plan said:
• During the morning visit care workers should provide Mrs D with a wash or shower. If Mrs D said she had already washed, care workers should check for evidence that this had been done.
• Staff should check all the rooms for dirty incontinent pads as Mrs D sometimes left them around the house.
• Staff should administer cream under Mrs D’s breast.
• Staff should make sure that the bedding was clean and dry. Staff should wash any wet clothing and wet bedding. There were spare waterproof sheets for the beds and spare bedding available. Staff should document that they had washed and hung out the wet bedding to dry.
• Staff should ‘administer Mrs D’s medication and see these are taken.’
• ‘Medications to be administered by staff.’
• During the lunch visit and evening visit staff should prompt Mrs D to use the toilet and to change the incontinence part. They should document that they had offered this and whether it had been refused. Staff should check the bed again to make sure that was dry and document this. Staff should again check the house for dirty incontinence pads and remove these and document that they had done so.
27. The care plan noted 6 medications that Mrs D had to take daily and also Paracetamol for pain relief which was to be given ‘as and when’ Mrs D needed it.

Start of safeguarding enquiry – 10 June 2024

28. Mrs C called the Council on 10 June 2024 as said there had been further problems with the medication and that the Agency had not administered Mrs D’s antibiotics on some days.
29. The Council started a safeguarding enquiry into the concerns Mrs C had raised on the same day and asked the Agency to respond to the allegations.

Complaint – 30 July 2024

30. Mrs C made a formal complaint to the Agency on 30 July 2024. I have summarised the complaints. Mrs C said:
• There was no initial assessment by the Agency to decide how to meet Mrs D’s needs and formulate the care plan. The Agency told her that a meeting would be arranged withing 24 hours of starting, but this never happened. Mrs C said that, especially during the first week, she had to tell the care workers what Mrs D's needs were and what they should do on almost daily basis.
• On 31 May 2024, Mrs C visited Mrs D in the morning and found Mrs D in a wet bed with a wet incontinence pad and underwear. Staff had not administered Mrs D’s medication.
• On 1 June 2024, Mrs D was found in a wet bed again. Wet incontinence pads and underwear were left in the shower cubicle.
• On 2 June 2024, the bed was wet again when Mrs C visited. Mrs C said that Mrs D’s towels, the soap and the toothpaste had not been used since the Agency started. There was no evidence that Mrs D had had a wash since the Agency started.
• On 3 June 2024, Mrs D was again found in a wet bed. There was still no evidence that a wash or shower had been administered.
• While Mrs C assisted Mrs D with a shower on 3 June 2024, she noticed the red sore under Mrs D's left breast was now weeping. Mrs D already had a sore when she left the care home but Mrs C suspected that the sore had deteriorated because the Agency staff had not been administering the cream they should put under Mrs D’s breast.
• On 4 June 2024, Mrs D was again found in a wet bed. Medication had still not been administered.
• There were ongoing problems with the administration of medication. Mrs D had been prescribed antibiotics because of the deterioration of the red sore. Mrs D was not given her antibiotics medication on the evening of 6 June and the mornings of 7 and 9 June.

The Agency’s response to the complaint

31. The Agency denied all the allegations that had been made. I have summarised the responses the Agency made to the Council and the CQC. The Agency said:
• ‘After reviewing the care logs, I can clearly see that care staff were providing [Mrs D] with full body washes daily’ (from the Agency’s response to the CQC dated 9 July 2024).
• Staff changed Mrs D's bed if it was wet but it could be that the family visited between care calls and found the bed wet. The Agency could not be held responsible for this. The Agency said there was not enough bedding in the property to change the bed so the carers had to clean the bed and leave it to dry.
• Mrs D often removed her incontinence pads and dropped them around the house. This is why the family would find incontinence pads when they visited in between care calls.
• There had been no missed medication and staff had documented all the medication administered.
• On 9 June 2024, Mrs C gave Mrs D her antibiotic medication even though the Agency care worker had already administered this. The Agency told Mrs C that ‘care staff have been instructed to have responsibility for the medication so the family did not have any dealings with this.’ The care worker contacted 111 advice service and they had said that the additional dose would not have caused any harm to Mrs D.

The Council’s safeguarding enquiry – 9 October 2024

32. The Council completed its safeguarding enquiry and made the following findings:
• ‘A thorough review took place on 6 June 2024 ensuring that all concerns were addressed and integrated into the care plan, although [Mrs C] remains dissatisfied.’
• There was not enough space in the shower for Mrs D to be supported safely with the shower. The care document showed that Mrs D was offered body washes regularly although she did not always accept those.
• Mrs D would often remove her incontinence pads and leave them around.
• The care plan was clear on the need to change the wet bedding and to pick up discarded incontinence pads. The case notes evidenced that this was being done at each visit. It may be that the family visited between visits and Mrs D had removed her incontinence pad again and had possibly wet her bedding again.
• On 9 June 2024 Mrs C administered Mrs D’s antibiotic medication and this led to a double dose. The staff followed the correct medication error process following this incident.
• On balance, the evidence did not substantiate the concerns and no harm was caused.
33. The safeguarding enquiry section called ‘making safeguarding personal’ which records the views of the complainant and their representative was left blank as ‘not answered.’ There is a note which says ‘Mrs C has been invited to call me if she wishes to discuss the outcomes further.’

The evidence the Ombudsman has considered

34. The Agency has sent Mrs D’s daily records to the Ombudsman. The Agency uses electronic daily records which contain two sections:
• A list of tasks, copied from the care plan, which the care worker ticks to indicate they have completed the task and the task then turns from red to green.
• A section where the care worker writes, in their own words, what tasks they have completed.
35. I have focussed on those tasks which Mrs C complained about. I have firstly focussed on the first 7 days (from 30 May to 5 June 2024) when the Agency started to provide care as these days were the focus of Mrs C’s complaint.
36. I noted that there was no list of tasks for the care worker to complete between 30 May and 3 June 2025 (5 days). Most days the care workers would note this on the daily record and say: ‘No tasks available, no task list to complete’ or something to that effect. Tasks were uploaded on 3 June 2024 and additional tasks were uploaded on 6 June 2024 after the Agency had completed its care plan.
37. From the records, I noted that:
• The Agency staff changed the bedding on 31 May as it was wet, but left the soiled bedding by the washing machine as Mrs D said Mrs C would wash it. The staff changed the bottom sheet of the bed on 1 June and changed and washed the bedding on 4 June.
• Mrs D had a ‘full body strip’ on 2 June 2024.
• On 2 June 2024, during the evening visit, the care worker wrote: ‘No task list. Asked [Mrs D] if she had any medication to take. She said she didn’t know and also didn’t know if she had taken any this morning. Looked on notes to see. It says [Mrs D] has taken them but she’s not sure what she took and it doesn’t say. Found discharge letter. Should have a calcium tablet at tea time but [Mrs D] said she didn’t know if she had taken it already or not (just says take one a day on box but says tea time on discharge letter) so [Mrs D] said best to start from tomorrow.’
• There was a change after 3 June 2024 as the task had been uploaded so care workers could tick the completed tasks. A task was set for care workers to say whether medication was prompted. There was no task set to tell the care workers that they had to change the bedding if Mrs D’s bed was wet.
• On 3 June, during the evening visit the care worker wrote: ‘Meds put on to dosette box by family. No meds for night time.’
• In terms of the application of the cream under Mrs D’s breast, this was applied once on 30 May, once on 2 June, twice on 3 June and four times on 4 June.
• On 4 June, the care worker said Mrs D was already washed and dressed during the morning visit when the care worker arrived. The care worker said: ‘washed, dried and applied cream under left bust as very red and sore.’ The care worker ‘prompted’ the medication. The bed was stripped as it was wet. The washing machine was on.
• On 5 June, Mrs D was prescribed antibiotics because of the sore under her breast. Mrs D had a full body wash on 5 June 2024.
• The electronic checklist was updated and new tasks were added on 6 June. Staff now had to ensure they checked Mrs D’s bed at each visit and document what they found. Staff had to check Mrs D’s incontinence pad at each visit and check each room to make sure there was no incontinence pad lying there and document this. I noted that, from that day, these tasks were always ticked.
• The daily record for 6 June also listed 3 medications Mrs D had to take during the morning visit. It was noted that: ‘Antibiotic prompted from dosette box with permission from [manager] who is present until they have gone from dosette box, then move onto original box.’
• At the morning visit on 9 June, The care worker listed (on the daily record) the 4 medications which they administered which included the antibiotic. The lunchtime record on 9 June noted that Mrs C had given Mrs D the antibiotic medication as she thought it had not been administered. The note said: ‘It was in her dosette box.’
• On 12 June the record said the care worker asked Mrs D to take her medication and noted: ‘[Mrs D] replied. I hope you know what I take because I don’t know. Sat at the table. I asked [Mrs D] if any of the boxes looked familiar. She picked up her turmeric box (no prescription label) and said this was the only one she recognised. The care worker then ensured Mrs D took her other medication. The record said: ‘Seems like [Mrs D] doesn’t remember what she has to take and also what she has taken.’

Further information

38. The Council and the Agency have provided the following information in response to the Ombudsman’s investigation. In response to the complaint about a lack of communication during the safeguarding enquiry, the Council said the safeguarding officer tried to contact Mrs C but there was no response. This was not recorded but there was a reference to it in the safeguarding enquiry document. The Council’s manager has requested that the officers should, from now on, record the reason why they were unable to provide a summary of the outcome.
39. I asked the Agency to send me Mrs D’s medication administration record (MAR) charts. The Agency sent me a MAR chart starting from 12 June. The Agency said:
• ‘[Mrs D] was originally prompt with medication, this was also the support requested from the original assessment sent by social worker, on the original care plan.
• ‘We then started to take over the administration of medication on 11 June.’
• Care staff have documented prior to the EMAR (electronic MAR chart) that medication had been prompted, within their daily logs.

Analysis

40. On the evidence we have seen, there was fault in the way the Agency provided care to Mrs D, particularly during the first week. In my view, a lot of the problems related to the fact that the Agency failed to properly assess Mrs D’s needs for care before or as soon as it started to provide the care, nor did the Agency provide Mrs D with a care plan.
41. I accept that the Council had assessed Mrs D’s needs and written a care plan. However, a local authority’s care plan, generally speaking is more aimed at setting out a person’s eligibility for local authority funded care under the Care Act, rather than formulating the detailed care plan that a care agency uses to provide the day-to-day care. Care agencies then carry out their own assessment of a person’s needs and write their own care plan which provides the staff with the detail they need to provide the care the person requires.
42. The Agency told Mrs C that it would assess Mrs D within 24 hours of starting and it should have done so and should have written a detailed care plan. The failure to do so was fault and was linked to a lot of the problems encountered during the first week (before 6 June).
43. Matters were made worse during the early days (before 3 June 2024) because the tasks had not been uploaded yet to the Agency’s online care recording system. Therefore, the staff did not have any tasks set to complete and staff did not always record what tasks they had carried out in the narrative section of the electronic record, so it is impossible to say whether the care was carried out properly. It is also difficult to say whether the staff knew which tasks they had to complete.
44. I accept, of course, that care may have been provided but not recorded in the first week, so the issue may be one of poor record keeping, but either way there was fault. The importance of good record keeping cannot be stressed enough. If the staff do not record that something happened, then it is impossible to say whether a task has been carried out or not.
45. In its response to the CQC, the Agency said the records showed that staff gave Mrs D a full wash every day. I have not seen evidence of that in the first week. There was evidence that Mrs D was given a wash on 5 June and there was mention of a ‘full body strip’ on 2 June and I accept this may be a full body strip wash. However there was no evidence on the other days, before 6 June 2024 that Mrs D was given a full wash or was offered a full wash.
46. In terms of the administration of the cream to be administered under Mrs D’s breast, I have set out in paragraph 37 how frequently this happened before 4 June 2024. It is not clear from the records whether the cream should have been administered at every visit, but clearly it should have administered more than it was.
47. In terms of changing the bedding, again, it is difficult to say what happened during the first week as staff did not always record this. Staff were meant to check the bed and change it if was wet (that had been included in the Council’s care plan), but the staff did not always record that they had checked the bed or changed the bed so again there was fault.
48. In terms of changing the incontinence pad, there were records to show that this had been done on several occasions before 6 June, but again, there was no record to say, certainly before 3 June that the incontinence pad was checked at each visit, but again it may be poor record keeping as staff did not have a task to tick.
49. I note a significant improvement in the tasks carried out and the record keeping after 6 June 2024, when the Agency, the Council and Mrs C had a meeting and the Agency then wrote Mrs D’s care plan and uploaded the full task list that staff had to complete. So the fault I found relates mainly to the care provided and the record keeping before 6 June.
50. There was also fault in the way the Agency administered Mrs D’s medication. I do not agree with the Agency's position that the staff did not have to keep a record of what medication had been administered as they were only ‘prompting’ Mrs D to take her medication rather than ‘administering’ it until 12 June 2024.
51. Firstly, the guidance on medication on record keeping says that, if a person is not able to take medication independently, then staff should record what and how much medication the person took and the timing of the medication. It is only when a person is independent in taking medication that it is not necessary to provide that detail.
52. And, in any event, the records are clear that staff were expected to administer medication from 6 June 2024. The minutes of the meeting on 6 June 2024 clearly say that staff will administer the medication and so does the care plan that the Agency wrote following that meeting.
53. And even before 6 June 2024 I would argue that it was clear that the Agency’s failure to record was causing problems and the Agency should have acted. The incident that was recorded on 3 June 2024 clearly shows that Mrs D could not be relied upon to remember what medication she had taken or had to take. And as there was no record of what she had taken, and when she had taken it, the care worker did not know what Mrs D needed. This put Mrs D at risk of receiving too much or not enough medication which is why record keeping in medication is so important. And, in my view, this incident should have triggered an immediate revision of the care plan to make sure that the staff were properly recording the medication.
54. I also think that this caused the problem on 9 June 2024 when the Agency says Mrs D was given antibiotics twice. I accept that, on 9 June 2024, the care worker had actually noted the medication taken in the daily record (one of the few dates where this happened), but the family did not have access to the online records (despite the Agency’s promise to allow access at the meeting on 6 June 2024) so there was no record in the house which the family could check.
55. I have also considered the Council's safeguarding enquiry.
56. Firstly, I should stress that the aim of a safeguarding enquiry is different from the aim of a complaint investigation. The aim of the complaint investigation is to decide whether to uphold the complaint or not. The emphasis in a safeguarding enquiry is to manage risk. If the risk is managed or there is no longer a risk, then the Council has achieved its aim. However, one of the objectives of a safeguarding enquiry is to establish facts and this should not be overlooked.
57. I note that Mrs C’s detailed complaint dated 30 July 2024 was sent to the Agency, not the Council so the Council presumably did not have this information when it carried out its enquiry.
58. I note the Council has focused its safeguarding enquiry on the care provided overall and mostly on the time after the care plan was put in place by the Agency - 6 June 2024. And I agree that, in terms of record keeping and care provided, the Agency’s performance had improved as a lot of the concerns that Mrs C had raised had been addressed in the meeting on 6 June 2024.
59. So I accept that, from a risk management point of view, a lot of the risk in the care provision had been addressed by the time the Council carried out its enquiry. However, it would have been helpful, if the enquiry report had been clearer about the facts and the difference in the care provided and record keeping before and after 6 June.
60. In terms of the medication, the Council focussed on the incident on 9 June 2024 where an additional dose of antibiotics was given to Mrs D and I agree that the Agency staff took the correct action after the incident happened. However, the Council did not really investigate why the incident occurred or whether the Agency’s medication record keeping was in line with the policies and guidance. I am surprised that the Council did not comment on the fact that the Agency did not keep a proper record of the medication until 12 June 2024.
61. In terms of the communication, Mr B says neither he nor Mrs C were contacted during the safeguarding enquiry.
62. The safeguarding enquiry report has details of a conversation between the investigating officer and Mrs C at the start of the enquiry so there is evidence that the officer spoke to Mrs C. I could not find evidence that there were any further conversations with the family during the enquiry and I am of the view it would have been good practice to do so if the Council wanted to keep Mrs C and Mrs D at the centre of the safeguarding enquiry. I do accept the Council’s evidence that the investigating officer tried to ring Mrs C to inform her of the outcome, but was unable to speak to her.
63. I also understand the family’s frustration as they felt that their complaint had not been addressed. It is not unusual for a safeguarding enquiry report to be treated as a complaint response and that, in itself, is not fault. However, I think in this case, the Council investigated Mrs C’s initial complaint from June 2024 but never saw her detailed complaint dated 30 July 2024 which then left the family feeling that their complaint had not been properly considered.

Injustice

64. The poor care caused an injustice to Mrs D and the poor medication record keeping put her at risk of not receiving enough or too much medication. I also accept this would have been stressful to Mrs D’s family who would have had to provide the care that was not provided and who felt they were not listened to by the Council.
65. I note that Mrs D’s contribution to the costs of the care package which is £367.86. has not been paid. I recommend the Council reduces this invoice by 50%. That would be a fair remedy for the faults I have identified and the distress it caused to Mrs D and her family.
66. I also recommend the Council asks the Agency to remind staff of the regulations and policies for good record keeping in care provision and medication to ensure similar problems do not occur again.
67. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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Action

68. 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.
69. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise to Mrs D and Mr B (who represents the family).
• Reduce Mrs D’s invoice of £367.86 by 50%.
• Ask the Agency to remind staff of the regulations and policies regarding record keeping in care provision and medication.

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Decision

70. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman