Summary: Ms Y complained about the standard of care Landmark Care Ltd, trading as Home Instead, provided to Mrs W. We have found fault by Landmark Care Ltd in failing to properly assess Mrs W’s care needs, engage a care worker with appropriate skills and provide an adequate standard of care, causing injustice. Landmark Care Ltd has agreed to remedy its faults by apologising and making a payment to reflect Ms Y’s distress, time and trouble.

The complaint

1. The complainant, who I am calling Ms Y, complains about the standard of care provided to her late mother, who I am calling Mrs W, by Landmark Care Ltd, trading as Home Instead (the Care Provider).

2. Ms Y is unhappy about the way the Care Provider assessed, arranged and provided Mrs W’s care. She says it failed to:

• adequately assess Mrs W’s complex needs and the risks to her safety;
• assign a care worker with adequate training, experience, aptitude and skills to keep Mrs W safe;
• monitor the care provided for Mrs W and take immediate action when she was left progressively and precariously dehydrated, hungry, soiled, unwashed and without regular medication; and
• notify the family of the situation.

3. Ms Y says, because of these failings, a care worker without appropriate skills and experience was allowed to look after Mrs W, a vulnerable person, affecting her health and wellbeing. She wants the Care Provider’s management team to take responsibility for their failings, review and change their procedures to ensure this situation does not happen again.

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The Ombudsman’s role and powers

4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. 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

7. I have spoken to Ms Y, made enquiries of the Care Provider and read the information Ms Y and the Care Provider have provided about the complaint.
8. I invited Ms Y and the Care Provider to comment on a draft version of this decision. I considered their responses before making a final decision.
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

What should have happened

Fundamental care standards

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards registered care providers must achieve. The CQC, as the statutory regulator of care services, has issued guidance on how to meet these standards below which care must never fall.
11. It is not our role to decide whether any failings in care or treatment by a care provider are breaches of the fundamental standards. These are matters for the CQC with which we share our decisions.
12. But we will consider the 2014 Regulations when deciding complaints about poor standards of care. Regulations, relevant to this complaint, require care providers to:

• provide appropriate and person-centred care and treatment based on an assessment of the person’s needs and preferences. (regulation 9)
• assess the risk to people’s health and safety during any care or treatment (regulation 12)
• ensure a person has enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. Nutrition and hydration intake should be monitored and recorded to prevent unnecessary dehydration, weight loss or gain (regulation 14)
• keep accurate, complete and contemporaneous records of care and treatment (regulation 17)
• deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times and other regulatory requirements (regulation 18)

What happened

Background

13. I have set out a summary of the key events below. It is not meant to show everything that happened.
14. Mrs W had dementia and a number of other medical conditions. She was living on her own at home, with family support.
15. Mrs W’s family had become concerned about a deterioration in her health and ability to look after herself safely. After discussing their concerns with Mrs W’s GP and the local council’s Adult Social Care team, it was decided it would be in Mrs W’s best interests to stay in her own home supported with a care package or a live-in care worker.

Ms Y’s contact with the Care Provider

16. Ms Y contacted the Care Provider in September 2021 about support for Mrs W. Ms Y sent the Care Provider information referring to Mrs W’s:

• level of self-neglect and distress on being left alone
• moderate to severe dementia, becoming increasingly anxious and at times, paranoid, and experiencing auditory hallucinations.
• lack of insight into her care and support needs and risk of neglect and malnourishment. She would not eat or drink sufficiently without frequent support from family. Her fluid intake would be extremely limited which could lead to multiple health concerns
• not attending to her own personal care. Her skin integrity could be at risk without support with her personal care.
• lack of insight into her reduced cognitive abilities. She found understanding the need for formal care support challenging and did not have the capacity to understand her care and support needs.

17. One of the Care Provider’s managers visited Ms Y and Mrs W on 1 October to assess Mrs W’s care needs. Ms Y says they discussed safeguarding issues referred to in the information sent to the manager before the meeting.
18. The manager assessed a live-in care worker would provide the appropriate support for Mrs W. The Care Provider accepted Ms Y’s request to provide this support for Mrs W.

The Care Plan

19. The Care Provider completed a written assessment and plan setting out Mrs W’s care needs, identified risks and support. It did not send the plan to Ms Y.
20. The plan included an assessment of the following risks:

• Memory: Mrs W had dementia and needed support with memory and cognition. She experienced hallucinations which could be quite distressing. The risk was assessed as low.

Decision making: Mrs W was able to make basic decisions but needed to be assisted with more complex decisions. The care giver would provide support for Mrs W to complete all daily activities and meal choices and drinks. The risk was assessed as low.

• Personal hygiene: Mrs W was not able to effectively complete her own personal care. The care giver would assist and encourage daily washes and use gentle persuasion. There was a risk of personal neglect and poor hygiene which could lead to ill health. This was assessed as low.
• Skin condition:There were no major concerns with Mrs W’s skin. There was a risk of skin getting dry and irritation. This was assessed as low.

21. The following risks set out in the plan were not assessed.

• Hydration
• Nutrition
• Washing

22. The support to be provided for Mrs W included:

• Encouraging Mrs W to have meals and fluids. The care giver should prompt fluids throughout the day and ensure a drink was always available.
• Supporting Mrs W with her medical conditions and administering medication. Reference was made to monitoring her sores, which were about to burst, and reporting any concerns
• Supporting Mrs W with more major decisions. She had dementia and had been assessed by her GP as having no mental capacity. The care giver should use all training gained about dealing with dementia.
• Assistance with all personal care, encouraging regular washes to maintain healthy skin and no sores, and providing regular washes as required to ensure good personal hygiene.

The engagement of the live-in care worker

23. Following the meeting and assessment of Mrs W’s needs on 1 October, the Care Provider agreed to provide a live-in care worker to support Mrs W from 9 October.
24. It used a recruitment agency to find a care worker to provide this support. The agency submitted an applicant’s details on 6 October. In her application form the applicant confirmed:

• she had completed the Care Certificate England
• she had been employed as a live-in care worker for three care providers from March 2019 to September 2021, and a private employer from September to October 2021. She gave her employers’ details for references.

25. The agency sent copies of certificates confirming the applicant had attended a one- day induction training course and a one- day refresher training course run by another care provider. The certificates listed the areas covered in the one- day course, including dementia, safeguarding adults, the importance of care and support plans, food and nutrition and 16 other areas.
26. The Care Provider has told us it had an informal phone call with the applicant to briefly explain Mrs W’s situation and discuss whether the applicant had previously provided care to clients living with dementia. It did not make a record of this call.
27. The Care Provider engaged the applicant as a live-in care worker to provide Mrs W’s support. It says its manager collected the care worker from the station on 9 October, explained Mrs W’s needs in detail and talked through the care plan before introducing her to Mrs W and her family.

The monitoring, and standard, of care

28. The Care Provider has sent us records of its monitoring of the care provided to Mrs W. These records show the care worker told it on:

• 10 October: Mrs W was suffering with a very bad mental health condition but eating and drinking well
• 11 October: all was well
• 14 October: she was happy with how things were going and had no concerns
• 15 October: all was well

29. A manager visited Mrs W’s home on 16 October to collect the daily logs completed by the care worker recording the care provided to Mrs W. These logs do not include any details of the amount of food or fluids Mrs W ate or drank each day. The care worker told the manager all was going very well, but she was struggling with medication, Mrs W was not drinking a lot and only had a small appetite.
30. Ms Y called the Care Provider the same day with concerns about the standard of care and Mrs W’s wellbeing. Ms Y and her sister had visited Mrs W a few days after the care worker had started. They were worried the care worker was out of her depth and unable to provide the specialised care Mrs W needed, as someone with advanced dementia. They felt she was not able to ensure Mrs W was eating and drinking enough and maintaining personal hygiene.
31. The Care Provider’s manager visited Mrs W’s home on 17 October to discuss the concerns with Ms Y and the care worker. The manager accepted the standard of care was not adequate. Ms Y asked to end the live-in care arrangement and it was agreed the care worker would leave immediately.

The complaint to the Care provider

32. Ms Y complained on 8 November the Care Provider had failed to:

• adequately assess Mrs W’s complex needs and the risks to her safety;
• assign a care worker with adequate training, experience and skills to keep Mrs W safe;
• monitor Mrs W’s care and take immediate action as she was left progressively and dangerously dehydrated, hungry, soiled, unwashed and without regular medication; and
• notify the family of the situation

The Care Provider’s response

33. Ms Y was not satisfied with the Care Provider’s initial response of 12 November. In its further response in January 2022, the Care Provider said:

• It did not accept there had been a failure to adequately assess Mrs W’s needs and risks to her safety.
• It accepted it had failed to assign a care worker with adequate training, experience and skills to keep Mrs W safe.
• It accepted it had failed to monitor Mrs W’s care and take the action required because of the inadequate care.
• It did not accept it had failed to notify the family of the situation.
• As with other care providers, it was experiencing recruitment challenges. Clients requiring support at short notice presented a challenge to maintaining high standards because this required time and personnel to do so.

My findings – was there fault by the Care Provider causing injustice?

The assessment of Mrs W’s needs and risks to her safety

34. The care plan included some detail about Mrs W’s needs, but a number of important risks were not assessed or highlighted. In particular:

• Ms Y told the Care Provider at the outset about concerns Mrs W was not eating or drinking enough. The hydration and nutrition sections of the plan were not completed. There was no assessment of the risk to Mrs W of not eating and drinking enough and no reference to nutrition and fluid monitoring.
• The risk to Mrs W’s skin condition risk was assessed as low and there was no reference to the particular issue detailed in the health and medication section.

35. My view is the failure to properly complete important parts of the care plan was fault. I consider these were significant omissions with potentially serious implications for Mrs W’s health and wellbeing. There was no plan for recording and monitoring how much Mrs W was eating and drinking or the action needed if she became dehydrated or malnourished.
36. I have considered the impact of this fault on Mrs W and her family in my conclusion.

The engagement of the live-in care worker

37. The Care Provider has accepted, and I agree, it failed to engage a care worker with the necessary training, experience and skills to provide the support Mrs W needed and keep her safe.
38. I note the application confirmed the care worker had completed an induction course, provided by another care provider, repeated a year later as a refresher course, which covered 20 important areas during the course of one day. I find it difficult to see how these one- day courses, on their own, could have provided in-depth training in these areas.
39. There was no detail on the application form about the type of work the applicant had done as a live-in care worker or her experience of caring for clients with advanced dementia. There is no record of the references the agency obtained to confirm her employment history or details of any discussions with the applicant about her training and experience.
40. The Care Provider has referred to the challenge of providing support at short notice because of industry wide recruitment issues. I note the Care Provider agreed on 1 October to provide live-in care support for Mrs W from 9 October. It did not have to agree to provide this support at short notice, it was its decision to do so.
41. My view is the Care Provider failed to carry out proper checks or assessment of the care worker’s experience, training and skills before engaging her to support Mrs W. This was fault. I have considered the impact of this fault on Mrs W and her family in my conclusion.

Monitoring Mrs W’s care

42. The Care Provider has accepted, and I agree, it failed to monitor and take appropriate action in response to the inadequate care provided for Mrs W. I consider this is confirmed by the records I have seen.
43. The Care Provider did not provide the care worker with nutrition and fluid charts to record and monitor Mrs W’s food and drink.
44. Although the care worker had not been employed by the Care Provider before, its managers relied only on her assurances all was well. The daily logs were not collected until a week after the care worker had started. There is no record of any other checks by the Care Provider on the adequacy of the care and support being provided.
45. The failure to monitor Mrs W’s care and take the action needed because of its inadequacy was fault. I have considered its impact on Mrs W and her family in my conclusion.

Informing Mrs W’s family

46. Had the Care Provider monitored Mrs W’s care, as it should have done, it would have known of, and told the family, about the issues with the standard of care. In my view its failure to do so was fault.
47. And had the family not visited Mrs W and raised their concerns with the Care Provider, the effect of the care failings on Mrs W’s health and wellbeing would have been even more serious.

Conclusion

48. In my view, the faults identified above affected Mrs W’s health and wellbeing. She was left increasingly hungry and dehydrated, not having had all her medication and with compromised personal hygiene for over a week., causing her upset and distress. Mrs W has passed away and we are unable to put this right for her now.
49. But I consider these faults also affected Mrs W’s family. Ms Y and the family were caused significant distress and worry about the impact of the care failings on Mrs W’s health and wellbeing. Ms Y has had to spend time and trouble raising her concerns.

Service Improvements

50. In addition to the impact on Mrs W and her family, I consider the faults identified above, if not addressed by the Care Provider and its management team could affect other vulnerable clients and their families.
51. The Care Provider confirmed, before we started our investigation, it would make a number of service improvements to ensure its failures were not repeated. These improvements included:

• Where a client lacked capacity to decide the level of support needed, it would provide the family with the care plan
• It would undertake discussions with its recruitment agency about their training processes and validation of care certificates. If it is accepted these do not include an observational component it will closely monitor care workers to assess their competence.
• It will treat all agency supplied care workers as new employees and follow its own induction procedures, including an interview, and records of assessment of suitability.
• Food and fluid recording charts should be used in all situations where it is assessed clients have issues with eating a balanced diet.
• Managers need to read daily notes and follow up any shortfalls in information provided and compare the notes against the care plan.

Further action

52. In addition to the service improvements the Care Provider said it had already made I recommended in my draft decision it should also:

• provide us with a report confirming the service improvements put in place in response to Ms Y complaint, together with a review of their effectiveness; and
• consider whether any further changes should be made in light of the findings in this decision.
• provide us with evidence it has done this.

53. In its response to the draft decision, the Care Provider told us it has ceased providing care services and is no longer registered with the CQC to do so.
54. On this basis it is not now appropriate to require the Care Provider to complete service improvements to a service it no longer provides.
55. But we would expect the Care Provider’s directors and management team to take the learning and service improvements from this decision and ensure these are implemented in any care services they provide through another entity registered with the CQC.

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Agreed action

56. To remedy the injustice caused by the above faults, and within four weeks from the date of our final decision, the Care Provider has agreed to:

• apologise to Ms Y and her family for the distress caused to them, and Mrs W, by its failure to provide Mrs W with adequate care because of the faults identified above; and
• pay Ms Y £300 to acknowledge the distress, and £150 to acknowledge the time and trouble these failures caused her and her family (making a total payment of £450).

57. This figure is a symbolic amount based on the Ombudsman’s published Guidance on Remedies. This Guidance indicates a usual range of between £100 and £300 for distress, and also for time and trouble.

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Final decision

58. I have found fault by the Care Provider causing injustice. I have completed my investigation in the basis the Care Provider will carry out the above actions as a suitable way to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman