Summary: Mr X complains that Collingswood Care provided inadequate care to Mr Y. The Care Provider is at fault as it did not properly record the administration of medicines to Mr Y which resulted in him not being given medication on one occasion. Collingswood Care’s handling of Mr X’s complaint was poor which caused frustration to him. Collingswood Care should remedy the injustice to Mr X by sending an apology to him. It should also carry out the recommended service improvements.

The complaint

1. Mr X complains on behalf of Mr Y. Mr X complains that the Care Provider provided inadequate care to Mr Y which he considers contributed to Mr Y’s admission to hospital in late 2022. Mr X is seeking a refund of Mr Y’s care fees.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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)
5. 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

6. I have:

• Considered the complaint and the information provided by Mr X;
• Discussed the issues with Mr X;
• Made enquiries of the Care Provider and considered its response;
• Invited Mr X and the Care Provider to comment on the draft decision. I considered any comments received before making a final decision.

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What I found

Law and guidance

7. 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.

Care provider’s procedures

8. The Care Provider’s procedures for a client awaiting medical help are for the carer to stay with the client until next of kin arrive to replace the carer. Office staff will replace a carer if the next of kin cannot be contacted.

Complaint procedure

9. The Care Provider’s complaints procedure provides that a client will receive a response within 24 hours of a complaint being made and a final response within 28 days.

What happened

10. The following is a summary of the key events relevant to the consideration of the complaint. It does not include everything that happened.
11. Mr Y had a number of health conditions and restricted mobility. Mr Y’s wife also had a number of health conditions. In Autumn 2022, Mr Y commissioned the Care Provider to provide support with personal care, giving medication and meal preparation.
12. Mr Y signed a service agreement with the Care Provider which set out the terms of its service. The Care Provider produced a care plan for Mr Y setting out the care he required. This noted Mr Y would be bed bound until a tissue viability nurse had visited him to assess whether he could transfer to a chair. The care plan noted Mr Y had mental capacity. The Care Provider also completed risk assessments including one for moving and handling as Mr Y required assistance with transfers.
13. Carers recorded the care provided to Mr Y in care records. The care records set out the tasks required to be undertaken. In response to my enquiries, the Care Provider said that the carer should tick the relevant boxes to record that the tasks have been completed. If a task is not completed, the carer should record the reasons.
14. Some care records note Mr Y declined food and personal care on occasions.
15. The care records show that in late October 2022 Mr Y became unwell. The records note that Mr Y declined carers initial offer to call NHS 111. In early November 2022, Mr Y’s symptoms worsened. The care records note that the carers called an ambulance for Mr Y. The notes also record that the Care Provider advised the carers to move on to their next client while Mr Y was waiting for the ambulance. The records of the later visits in the day record that Mr Y’s GP may visit but also show the Care Provider called an ambulance for Mr Y as he was still unwell.
16. The record from 1 November 2022 shows a carer noted they were unable to give Mr Y his medication as there was no record of what medication had been given on earlier visits.
17. The care records note Mr Y became unwell again a few days later. The records note Mr Y’s wife said she would call NHS 111 if his condition deteriorated. Carers visited again some hours later and found Mr Y had been admitted to hospital.
18. I understand Mr Y cancelled the care package and moved into residential care. Mr Y sadly passed away in 2023.

Complaint

19. Mr X contacted the Care Provider shortly before Mr Y was admitted to hospital. Mr X said that Mr Y had raised concerns with him about the standard of care provided by carers. This included his meals being cold and that carers left him lying on his back. The Care Provider advised it would refer the concerns to a manager to put right. There is no evidence to show the Care Provider dealt with the concerns.
20. Following Mr Y’s admission to hospital, Mr X made a complaint about the care provided to Mr Y which he considered could have contributed to his hospital admission. The complaints included carers had not provided warm meals and had not transferred Mr Y from his bed to his chair. Mr X has said he did not receive a response to these complaints. The Care Provider sent copies of statements from carers regarding their concerns about Mr Y. The Care Provider has not provided evidence to show if or how it investigated Mr X’s specific complaints about the standard of care.
21. Mr X made a freedom of information request for Mr Y’s care records. When responding to Mr X’s request, the Care Provider said Mr Y did not engage with the carers and declined care. The Care Provider also said Mr Y’s wife had been abusive to the carers. The Care Provider invited Mr X to ask further questions when he’d had the opportunity to read the care records.
22. Mr X raised a number of further concerns with the Care Provider regarding the content of the care records. These included concerns about carers noting Mr Y had been rude and the action taken when Mr Y was unwell. There is no evidence to show the Care Provider responded to Mr X’s specific concerns.
23. The Care Provider has provided copies of invoices to Mr Y for his care. These show the Care Provider did not charge Mr Y for the period he was in hospital. I understand Mr X has paid the care charges.

Analysis

Contract

24. Mr X has said the contract signed by Mr Y for the provision of his care is unethical and questionable. There is no evidence of fault as the contract clearly sets out the terms of the care provision. So, I am satisfied Mr Y would have been aware of the terms of the contract when signing it.

Standard of care

25. The Care Provider’s 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 noted when Mr Y had declined care or meals. So, I am satisfied appropriate care was provided to Mr Y on most visits.
26. However, there are a small number of records where the carers did not properly complete the care records to show the care delivered. This includes recording what medication was given and when. Some records note in the summary that medication was given but do not record what that medication was. The care record of the evening call from 1 November 2022 notes the carer could not administer Mr Y’s medication as the Medical Administration Records (MAR) had not been completed to show what medication had been given that day. I therefore consider the failure to consistently and properly record the medication given to Mr Y is fault and is poor care. As a result, Mr Y did not receive medication on one occasion. The failure to properly record the administration of medication is also potentially a breach of the fundamental standard to provide safe care.
27. Mr X is seeking a refund of Mr Y’s care fees. It is not appropriate or proportionate to recommend the Care Provider refunds Mr Y’s care fees for the one occasion he did not receive medication. The care records show Mr Y received care on that and the other care visits. There are no other appropriate ways to remedy Mr Y’s injustice as he has passed away. But I make recommendations at the end of this statement for the Care Provider to improve the recording of the administration of medicines.
28. Mr X raised with the Care Provider that carers did not transfer Mr Y from his bed to his chair. Mr Y’s care plan noted he would be bed bound until assessed by the tissue viability nurse in October 2022. There is no information to show if the Care Provider reviewed Mr Y’s care plan and moving and handling assessment following the tissue viability assessment. But it is not proportionate to investigate the matter further. Any injustice would have been to Mr Y and that now cannot be remedied as he has passed away.
29. Mr X has said some of Mr Y’s meals were cold. I cannot know from the care records if meals were inadequately cooked. Further investigation will not establish if this was the case.
30. Mr X has raised concerns about carers noting Mr Y and his wife were rude. I have not investigated this matter as I cannot know if Mr Y and his wife were rude to carers. I have no means of establishing if this was the case.
31. Mr X also raised concerns with the Care Provider about the care provided when Mr Y became unwell. On balance, I consider the Care Provider took appropriate action. The care records show carers offered to call for medical help when Mr Y became unwell which he declined. The records also show the Care Provider called an ambulance on two occasions. Carers did not stay with Mr Y while he waited for the ambulance. But this was in accordance with the Care Provider’s procedures as Mr Y’s wife was present so he was not alone. I am there satisfied there is no evidence of fault.

Complaint handing

32. The Care Provider’s handling of Mr X’s complaints was poor and was not in accordance with its complaints procedure. There is no evidence to show the Care Provider investigated Mr X’s concerns which he raised in early November 2022 or respond to him. The Care Provider’s response of early 2023 did not address Mr X’s specific concerns about the standard of care provided to Mr Y. The Care Provider invited Mr X to submit further questions when it sent the care records to him but there is no evidence to show it addressed those questions. This is fault which will have caused frustration to Mr X. The Care Provider should remedy this injustice.

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Recommended action

33. That the Care Provider:
1. Sends a written apology to Mr X for the frustration caused by the failure to address his specific complaints about Mr Y’s care. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Care Provider should consider this guidance in making the apology I have recommended in my findings.
2. By training or other means, reminds staff of the importance of recording the care delivered to clients and the Care Provider’s expectations for recording the delivery of care.
3. Reviews its procedures for recording the administration of medicines to ensure medicines are managed safely and are appropriately administered. The Care Provider should also remind staff by training or other means of the importance of properly recording the administration of medicines. This is to ensure the Care Provider complies with the fundamental standard for providing safe care.
34. The Care Provider should take the action at a) within one month of my final decision and the actions at b) and c) within six weeks of my final decision. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

35. I have ended my investigation and partially uphold Mr X’s complaint. Fault causing injustice. I have made recommendations to remedy the injustice and for service improvements. The Care Provider has not yet agreed to carry out these recommendations.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman