Summary: Mrs X complains the care provider provided inadequate care to her father between April and July 2021. She also complains about the actions of a particular carer following an incident where paramedics were called. She says the carer provided incorrect information to the paramedics. We find some fault with the care provider for not always providing care in line with the care plan. We have made some recommendations for the care provider to remedy the injustice caused.

The complaint

1. Mrs X complains the care provider provided inadequate care to her father between April and July 2021. The care issues complained about include:
• Moving and handling and the use of specialist equipment.
• Not helping her father to eat which put him at risk of choking.
• Failure to give medication.
• Causing pressure sores.
• Failure to lock a door.

Mrs X also complains about the actions of a particular carer following an incident in July 2021 where paramedics were called. She says the carer provided incorrect information to the paramedics. Mrs X says the care provider’s actions have caused her and her family distress.

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The Ombudsman’s role and powers

2. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3A covers complaints about care bought directly from a care provider by the person who needs it or by a representative, and includes care funded privately or with direct payments under a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. If we are satisfied with a care provider’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

7. I spoke with Mrs X and considered the information she provided.
8. I made enquiries with the care provider and considered the information it provided.
9. I sent two draft decisions to Mrs X and the care provider and considered their comments.

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What I found

Legislation and guidance

10. 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 Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall
11. Regulation 9 highlights providers must ensure a person received appropriate person-centred care and treatment that is based on an assessment of their needs and preferences. Providers must make sure they take into account people’s capacity and ability to consent and that they, or a person lawfully acting on their behalf, must be involved in the planning, management and review of their care and treatment.
12. Regulation 17 highlights providers must securely maintain accurate, complete, and detailed records in respect of each person using the service.

What happened

13. In April 2021, Mrs X commissioned a care package for Mr V. The initial care package was for a morning and afternoon call every day, to be completed by a single carer. This was reduced to one morning call in May 2021.
14. Mr V’s care plan outlined the tasks for the carer to complete each call, including:
• Assist to mobilise to the bathroom and chair.
• Assist with personal care routine.
• Making breakfast and lunch. The plan did not specify for carers to help Mr V to eat his food.
• Prompt Mr V to take his medication in the morning and afternoon.
15. Mrs X also left care instructions out for carers. The instructions detailed the care the family wanted to be provided to Mr V. In response to our draft decision, the care provider confirmed it had agreed to the instructions and was happy the requests fell within the scope of its service.
16. Mr V also had a moving and handling plan created by an Occupational Therapist (OT). The plan noted using specialist equipment, including:
• A Sara Stedy. The plan noted the equipment should only be used at the end of the day or if the client has an infection and is unable to walk with the wheeled walking frame.
• Use of satin sheets for bed transfers. The plan noted this equipment could be used by one carer.
17. The care provider’s care notes highlighted the times the carers used the Sara Stedy. Between April and July 2021, carers recorded using the equipment 14 times. The records showed the equipment was used more often in the morning, used when Mr V’s mobility was recorded as being poor, and once used even though Mr V’s mobility was recorded as being average.
18. In May 2021, there was also record of the OT reminding the care provider the Sara Stedy was only to be used in an emergency, towards the end of the day, or if Mr V had an infection.
19. In July 2021, Mrs X increased Mr V’s care package to three calls every day as she was going on holiday. Mr V’s care plan noted the following tasks for the evening call:
• Preparing tea for Mr V.
• Prompt Mr V to take his evening medication.
• Help to mobilise to bed.
20. The care notes showed inconsistent recording of carers prompting Mr V to take his medication (morning, afternoon, and evening) between April and July 2021.
21. On 14 July 2021, the carer attended the evening call and found Mr V had slid down his chair. The carer called for help as she felt it was unsafe to move Mr V on her own. A supervisor from the care provider attended, Supervisor 1. Supervisor 1 decided to call an ambulance for help as they felt they could not move Mr V safely.
22. Paramedics attended and helped move Mr V. The paramedics spoke with Supervisor 1 and with Mrs X over the phone. Following the incident, the paramedics made a safeguarding referral to the Council due to concerns about neglect.
23. The ambulance service referral form noted the following:
• Family had arranged single carer only to visit Mr V and they could not aid Mr V properly. Two people were needed to mobilise, wash and dress Mr V.
• Family only willing to pay for short visits when on holiday. Family refused to pay for increased visits or double carer visits.
• Mr V’s grandson had stayed but did not help with meals or care. Also, that granddaughter supposed to help care staff every afternoon visits but only seen twice in a week.
24. The Council considered the referral as part of its safeguarding process. The Council’s records showed it spoke with Mrs X about the safeguarding concerns before it decided on the next steps. The Council’s records also noted it spoke with the paramedic who attended on 14 July. The paramedic confirmed the carer present had alleged Mrs X did not want to pay the extra cost for increasing the carers.
25. Mrs X ended the care package on 19 July 2021 and raised a complaint with the care provider in August 2021.
26. In response to our enquiries, the care provider provided further information about its moving and handling training. It confirmed the training was provided by an external training provider which was accredited

Analysis

Care plan

27. Mrs X told us she never agreed to the care plan created by the care provider. In response to our further enquiries, the care provider confirmed the care plan document contained all the details that were already provided by the family. The care provider did not provide any evidence it had provided a copy of the care plan for the family to review.
28. In line with Regulation 9, the care provider should have involved Mrs X in the care planning. Therefore, it should have provided Mrs X with a copy of the care plan to review and input into. This is fault.
29. However, we do not consider the fault identified caused any injustice. This is because Mrs X was able to leave detailed care instructions out for the carers and the care provider followed the instructions provided. This meant Mr V received care in line with Mrs X wishes.

Information provided to paramedics

30. Mrs X told us she was unhappy with the information contained within the referral form. Mrs X highlighted her view the information could only have come from Supervisor 1 because the paramedics could not have known about it otherwise.
31. The evidence available suggests it is likely the information contained within the referral form came from, or was influenced by, the carers.
32. However, we do not consider it is for the Ombudsman to decide whether this amounts to fault or not. This matter is not a procedural issue or failure to provide a service. Instead, the matter is about the conduct of an employee and whether they provided wrong or inaccurate information to a third party. Therefore, we consider this is a personnel issue as it is for the care provider, as the employer, to decide whether the conduct of the employee was appropriate or not.
33. Further, it also worth noting that while we accept it is likely the carers did provide the information to the paramedics, the referral report was ultimately written by the paramedics. Therefore, there is uncertainty about whether the content of the referral is a verbatim record of what the carers told the paramedics.

Moving, handling, use of specialist equipment, and pressure sores

34. Mr V’s moving and handling plan noted carers should only use the Sara Stedy at the end of the day or if the client has an infection and is unable to walk with the wheeled walking frame. The OT also contacted the care provider to confirm the limited circumstances for when the carers should use the Sara Stedy.
35. There is evidence the carers used the Sara Stedy in circumstances outside of those listed in Mr V’s moving and handling plan. There are several occasions where the equipment was used early in the morning. There was also one occasion where the carer used the equipment even though Mr V’s mobility was recorded as being average. This would not suggest Mr V was unable to walk or that it was an emergency.
36. Therefore, this suggests the care provider failed to use the Sara Stedy in line with Mr V’s moving and handling plan, this is fault.
37. Further, we note Mrs X only wanted the equipment to be used in emergencies. It is important to highlight that what constitutes an emergency is subjective and can depend on the individual. For this reason, we are satisfied it was a matter for the carers to exercise their professional judgment as to whether they considered a matter to be an emergency.
38. That being said, carers should clearly record their rationale for why they have decided a matter constitutes an emergency and why it was necessary to use the Sara Stedy. The care logs only note Mr V’s mobility was poor but does not expand on this. Given the limited set of circumstances the Sara Stedy was to be used, it would have been good practice for the carers to provide a clear and detailed rationale for their decision to use the Sara Stedy. The carers failed to do this, and this is fault. We consider the fault identified has caused Mrs X some distress.
39. We note Mrs X is concerned about the level of training the carers received. She feels the carers did not understand how to use all the equipment needed to safely move and handle Mr V. In response to our further enquiries, the care provider has confirmed its moving and handling training is provided by an external training provider, and the course is accredited.
40. Therefore, we are satisfied, on balance, the care provider has provided appropriate training for moving and handling as it is likely the course covered how to safely use the most common equipment for moving and handling.

Not helping Mr V to eat

41. Mr V’s care plan does not set out that carers need to help him to eat. It only sets out that carers should prepare breakfast, lunch, and dinner for him. The only assistance that is outlined is where there are large pieces of food, these should be cut up for him.
42. Therefore, we do not consider there was any fault with the care provider as the records showed it managed Mr V’s meals in line with his care plan.

Failure to give medication

43. Mr V’s care plan outlines carers should prompt him to take his medication on each visit. Therefore, we would expect accurate records to be kept noting when this was completed by carers.
44. The care notes showed inconsistent recording of carers prompting Mr V to take his medication between April and July 2021. At worst, this suggests the carers did not always prompt Mr V, in line with his care plan. At best, this shows poor record keeping by the carers. In either case, this is fault.
45. There is no evidence to suggest Mr V was adversely affected by the fault. However, we consider the fault identified caused Mrs X some distress.

Failure to lock a door

46. We do not consider we can make any findings on this element of Mrs X’s complaint. This is because there is a conflict in evidence and there is no way to make a finding, even on the balance of probabilities.

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Agreed action

47. To remedy the injustice caused by the fault identified, the care provider has agreed to complete the following:
• Apologise to Mrs X for the distress caused by the failure to use Mr V’s equipment in line with his moving and handling plan, and for failing to always prompt Mr V’s medication in line with his care plan.
• Pay Mrs X £300 to acknowledge the distress caused.
• Remind staff of the importance of always recording actions taken, especially when the action is required by a service user’s care plan. All records should accurately reflect the action, rationale, and results.
48. The care provider should complete the above within four weeks of the final decision.

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Final decision

49. I find fault with the care provider for failing to always prompt Mr V on his medication and for failing to use Mr V’s equipment in line with his moving and handling plan. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman