Summary: Mr X complained about the quality of live in care provided to his late mother Mrs Y. The care provider was at fault for delay in signing Mrs Y’s contract, an argument between carers, poor record keeping, gaps with monitoring Mrs Y’s fluid intake, and not complying with its out of hours policy. The care provider has already apologised and refunded two weeks payment of Mrs Y’s care to acknowledge the impact of the faults on Mrs Y. However, the faults also caused Mr X avoidable frustration and time and trouble. The care provider will pay Mr X £200 to recognise the frustration, time and trouble caused and reviews its procedures for when accidents occur. The care provider has already reviewed its procedures to prevent a reoccurrence of some faults.

The complaint

1. Mr X complained about the quality of the live in care provided to his late mother Mrs Y. He complained the care provider:
• failed to provide an acceptable choice or continuity of carers for Mrs Y;
• allowed Mrs Y to fall due to poor training of carers;
• had poor practices over medication reporting, record keeping and not updating Mrs Y’s care plan;
• failed to follow its out of hours policy;
• blocked his use of the care notes’ system; and
• the Manager was aggressive towards him and other family members and threatened to withdraw care.

Mr X says it has caused him distress, sleep loss, time and trouble and Mrs Y was unhappy and it affected her mentally and physically. Mr X wants processes changed so other families do not go through the same issues.

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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 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)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.
5. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
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 have considered:
• the information Mr X provided and discussed the complaint with him on the telephone;
• the care provider’s comments about the complaint and the supporting documents including records from the care provider in response to my enquiries; and
• relevant law and guidance.
8. Mr X and the care provider had the opportunity to comment on the draft decision. We considered their comments before making a final decision.

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What I found

Relevant law and guidance

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 provide fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
• Regulation 12 states care and treatment must be provided in a safe way and prevent avoidable harm or risks. It states the care provider must assess health and safety risks and do all they can to mitigate any risks. This also includes management of medicines.
• Regulation 14 sets out people must have acceptable nutrition and hydration to aid good health. It states people must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition.
• Regulation 16 states complaints to a provider must be investigated thoroughly and any necessary action taken where failures have been identified.
• Regulation 17 states providers must securely maintain accurate, complete and detailed records about each person using their service.

What happened

10. In 2021, Mrs Y lived in her own home with her husband. She received daily support from her children and carers called 4 times a day. Mrs Y required extra care and a live in care provider was contacted.

Continuity of carers

11. In early October 2021 a manager with the care provider, Ms Z, filled in a care needs and pre-assessment questionnaire with Mrs Y and her family.
12. The pre-assessment recorded Mrs Y:
• had mobility problems and a high falls risk;
• used a rise and recliner, Mo-lift (a transfer aid) and wheelchair for independence;
• needed help with all personal care;
• had reoccurring UTI’s causing delirium;
• needed to be reminded to drink fluids;
• medication needs to be administered by a carer;
• wore continence pads at night and used toilet during the day but needed full support to manage continence;
• had high levels of anxiety;
• had dementia symptoms; and
• needed carers to speak clearly when communicating.
13. Mrs Y’s son, Mr X said in the first assessment:
• the need for continuity of carers was made clear because of Mrs Y’s high anxiety; and
• he asked about vetting of carers and the care provider told him ‘all carers were vetted and matched to clients’ and he would ‘receive a comprehensive introduction to the carer before a carer was put in place’.
14. In mid-October 2021, Mrs Y started to receive care from the care provider in her own home.
15. The care provider had arranged for Carer 1 to provide care for Mrs Y. However, Carer 1 was unwell and could not start the placement. So the care provider arranged for Carer 2 to support Mrs Y. In early November 2021, Mr X asked the care provider to replace Carer 2 because Mrs Y did not get along with her and Mrs Y had difficulty in understanding Carer 2’s accent.
16. The care provider sourced Carer 3. At the change over between Carer 2 and Carer 3 the carers spoke in their native language and Carer 3 refused to stay. A supervisor from the care provider and Mrs Y were present at the exchange, which Mr X says caused Mrs Y increased anxiety. The care provider said the supervisor overseeing the exchange was spoken to by the care provider management, to ensure in future carers were stopped immediately from talking in their native language in front of clients.
17. In mid-November 2021 Mrs Y’s contract was signed by Mrs Y’s other son, Mr Z.
18. In mid-November 2021 the care provider arranged for Carer 4 to provide care for Mrs Y. Carer 4 cared for Mrs Y until the end of January 2022. Mr X said Mrs Y and Carer 4 got on well. The care records show that from Christmas Eve to the end of January 2022 Mrs Y was anxious most evenings and throughout January 2022 Mrs Y woke Carer 4 on eight nights. Carer 4 did not return after a break. Carer 4 told the care provider she was not returning because of the ‘package of care’. Carer 4 told Mr X she was not returning because of health concerns. The care provider sourced Carer 5.
19. Carer 5 provided care to Mrs Y between the end of January 2022 and mid February 2022. Mrs Y’s condition deteriorated in mid-February 2022 and Mrs Y was cared for in bed for four days. Mr X asked the care provider to replace Carer 5 because she did not get on with Mrs Y and Mrs Y found Carer 5’s accent difficult to understand. The same day Carer 6 started to care for Mrs Y. Mr X said Mrs Y and Carer 6 got on well. Carer 6 cared for Mrs Y for ten days until Mr X ended the care provider’s contract.
20. In early March 2022 Mr X complained to the care provider, he said:
• the care provider was made aware in the first assessment of the need for long term carers;
• Mrs Y’s contract with the care provider was not signed until a month after care started;
• carers were not vetted and he was not given information about the carers in advance; and
• he was unhappy Mrs Y had five different carers in a four month period.
21. In late March 2022 the care provider responded to the complaint, it said:
• it strived to provide long term carers but it was made clear to Mr X not all carers’ personalities matched with new clients;
• carers were all vetted but it did not offer a comprehensive introduction to carers before care commenced and a profile would be sent if possible but profiles were not sent in advance for Mrs Y;
• following feedback a new carer profile would be used including previous experience and training;
• it apologised for the delay in the contract being signed;
• it had a new checklist in place to ensure all new clients had the contract signed during the first day of care;
• the change over of carers speaking in their native language was unacceptable; and
• it did not charge Mrs Y for a week’s care because of ‘issues when Mrs Y’s care first started’.

My Findings

22. There is no evidence of fault in the way the care provider sought to ensure continuity of care for Mrs Y. The care provider sourced carers to care for Mrs Y continuously between mid-October 2021 and late February 2022. Carer 1 could not start due to illness and Mrs Y did not get on with Carer 2 and Carer 5 and found their accents difficult to understand. This was not the care provider’s fault. It accepts Mrs Y and her family were not always shown new carers’ profiles before carers started. However, I cannot say with any certainty this would have made a difference as the profiles could not account for carers’ personalities. Mrs Y did get on well with Carer 4 and Carer 6. The care provider has put a new service improvement in place to ensure carers profiles include more information. This is appropriate.
23. Mrs Y’s contract with the care provider was not signed for a month; this was fault but it did not cause Mrs Y an injustice as care was provided in line with the contract. The care provider has already put a service improvement in place to ensure all contracts are signed at the start of the care package. This is appropriate to prevent reoccurrence of the fault.
24. There was fault at the changeover between Carer 2 and Carer 3. Carer 2 and Carer 3 had a disagreement in front of Mrs Y in their native language which caused Mrs Y increased anxiety. The care provider acknowledged there were issues with the start up of the care package and refunded £1100 in the November invoice. This remedied the injustice caused to Mrs Y.

Mrs Y’s Accident

25. Mrs Y’s care plan said she was at ‘high risk of falls’.
26. In early November 2021 Mrs Y had an accident with her commode. Carer 2 recorded this on Mrs Y’s daily care record as ‘[Mrs Y] slipped from the commode, I stand she back to commode, she help me, no have any risk situation’.
27. Mr X said after the accident Mrs Y hurt her shoulder and she was afraid to use the Mo-lift to use the commode. Mr X said this fall led to Mrs Y’s decline due to her inactivity after the fall and Mrs Y’s reliance on the electric lift.
28. The daily care records show in November 2021 both before and after the accident Mrs Y was helped to use the commode by carers and there were no accidents in Mrs Y’s first two weeks of care.
29. The care provider’s records show Carer 2 had manual handling training in 2020 and attended an induction training refresher course in manual handling in July 2021. The care provider said Carer 2 had a handover from Mrs Y’s previous care agency to train her on how to use Mrs Y’s equipment.
30. In response to my enquiries the care provider said it has changed its practices including:
• any falls or slips recorded on daily care notes will be viewed by a manager on their daily audit within 24 hours. The management team will address them immediately; and
• supervisors have been trained to conduct client specific competencies when carers start with a client using clients specific equipment.

My findings

31. The daily care records showed that no accidents happened in the first 2 weeks with Carer 2 and the care provider’s records show Carer 2 was trained appropriately. There is no evidence to show the accident was caused by lack of training.
32. The records show Mrs Y still used the commode with assistance from her carer after the fall and there is no evidence Mrs Y stopped using the Mo-lift after the accident. The records show Mrs Y’s condition did deteriorate over time but I cannot say this was as a result of Mrs Y’s fall.
33. The daily care records make no reference to Mrs Y being injured or hurt by the fall. However, the care provider did not record the incident on an accident form. A full body map was not produced to record any injuries and the care provider did not consider updating Mrs Y’s care plan. This did not meet CQC Regulation 17 which states providers must securely maintain accurate, complete and detailed records about each person using their service. This was fault and caused Mr X uncertainty about the effect on Mrs Y.
34. The care provider has put two new service improvements in place. However it is unclear what action it has taken to ensure accidents are appropriately recorded.

Record Keeping

35. Between mid-October and early November 2021, Mr X said he was not given access to Mrs Y’s daily care records portal.
36. The care provider said it takes time to set up the daily records application and it waited for documentation about lasting Power of Attorney to allow Mr X access to Mrs Y’s records.
37. Between early to mid-February 2022, Mr X said he told the care provider he had concerns about Carer 5. He said Carer 5 did not record Mrs Y’s fluid intake on the daily record application and hydration was not encouraged.
38. The daily care records showed Carer 5 logged fluids between 1 February to 14 February 2022. On one morning in early February 2022 Mrs Y’s fluids were not logged.
39. The daily care records showed for two consecutive days in early February 2022 Mrs Y drank 445ml fluid and 575ml fluid respectively. Each day Mrs Y was offered 1350ml fluid.
40. The daily care records show a comment from Ms Z at 8:55pm in early February 2022 stating ‘No updates since 15:49 today. Rang carers phone to ask why. Rang landline spoke to carer and explained the importance of keeping the daily records application up-to-date. Told it’s a legal requirement’.
41. In mid-late February 2022, in Mrs Y’s final week with the care provider Mr X complained in he was ‘locked out’ of Mrs Y’s daily records portal.
42. The care provider said it had not locked Mr X from the daily record application deliberately and other clients had reported an issue with the application. The care provider also said it provided Mr X with Mrs Y’s daily care records for her final week of care.
43. In response to my enquiries the care provider said it now has a running total of daily fluid intake for all its clients. All clients have a fluid target of 1500ml. The care provider says it now undertakes a morning audit and if a client does not meet the 1500ml target on two consecutive days a supervisor will be given actions to discuss it with the relevant carer.

My findings

44. The care provider provided copies of Mrs Y’s daily care notes. The daily care notes for early February 2022 show Carer 5 filled in the fluid amounts but a manager comment shows the amounts on one day were filled in retrospectively. Also Carer 5 did not check Mrs Y was drinking enough fluid. This did not meet CQC Regulation 14 which states people must have acceptable hydration to aid good health. This was fault and meant Mrs Y was not drinking enough and no action was taken to try and address this. The care provider has introduced a new service improvement to address this. This is an appropriate remedy to prevent reoccurrences of the fault.
45. The care provider was not at fault for the delay in providing daily care records between mid-October and early November 2021 because it required legal documentation to ensure Mr X could review Mrs Y’s care notes. The care provider said it did not block Mr X from viewing Mrs Y’s daily care records in her final week with the care provider. It has since provided Mr X with Mrs Y’s daily care records so this did not cause an injustice.

Out of Hours Policy

46. The care provider’s Out of Hour policy states: ‘The out of hours’ duty is a requirement within the service specification for social services contracts and is linked to the care and welfare of people who use services, in that it provides a mechanism to ensure that while staff are at work, there is a safe and tried method of contact between the staff and Elite Live In Care’. The care provider’s policy includes the out of hours’ phone number which is available Monday to Friday 5.30pm to 11:00pm and 7am to 9am, and weekends from 7am till 10:30pm Saturday and Sunday.
47. In mid-February 2022 Mr X said Carer 5 called his sister, Ms W at 10:00pm because Mrs Y could not get off the commode and into bed. Mr X said he and Ms W ‘rushed’ to Mrs Y’s home to help get her into bed.
48. The Carer recorded the incident in Mrs Y’s daily care notes. These stated ‘At 9-45 when I transferred Mrs Y from the recliner chair on the commode very hard she managed to get up and stay stand up. Then when she had to go in bed she didn't was able to stand up. I called her daughter and she came with her brother and they helped me to put her in bed’.
49. In response to my enquiries the care provider said it has retrained its staff on the out of hours procedure.

My findings

50. Carer 5 did not follow the out of hours policy. Carer 5 should not have contacted Mrs Y’s family to help get her into bed. This was fault which caused Mr X and Ms W time and trouble. The care provider has retrained its staff on the out of hours policy. This was appropriate and will prevent a recurrence of the fault.

Medication

51. In late December 2021 Mrs Y was prescribed antibiotics for a urine infection and the family collected the prescription and gave it to Mrs Y’s live-in carer to administer. Mr X complained about the care provider’s unclear policy about who should tell the care provider about medication changes. Mr X said he told the live-in carer about a change in medication for Mrs Y for a urine infection and the change was on advice from Mrs Y’s doctor. Mr X said it was not in the contract that he also had to tell a manager of the medication change.
52. In March 2022 the care provider responded to Mr X’s complaint regarding medication and said carers were asked to report any changes in client medication to the care provider’s office so clients’ medical charts could be immediately updated. The care provider said the family bringing in the medication led to confusion as to whether the carer told the care provider’s office.
53. The care provider said it had introduced a new client contract so clients, next of kin and carers report any change in medication to its office to ensure any changes are not missed.

My findings

54. There was a lack of clarity over who should advise the head office of medication changes. Mr X told the carer of the change in medication for Mrs Y who failed to report this to their manager.
55. This was fault and caused Mr X confusion. The care provider has since taken action to prevent recurrence of the fault. There was no evidence this caused Mrs Y an injustice because the records show Mrs Y received her medication.

Manager Behaviour

56. In mid-February 2022 Mr X complained about Ms Z’s behaviour on a telephone call. Mr X said Ms Z was aggressive on the telephone to Ms W who then handed the telephone to Mr X to continue the conversation. Mr X said Ms Z told him ‘I am so close to emailing you to give you two weeks notice of our withdrawal’. Mr X said there were also two other occasions when Ms Z verbally threatened the family to give 14 days notice to finish Mrs Y’s package of care. Mr X said during a final telephone call with Ms Z she threatened to pull the care provider’s care immediately.
57. In its complaint response to Mr X the care provider said:
• it apologised if Mr X felt at any time the way in which Ms Z spoke was inappropriate;
• another manager was present during one telephone call and said Ms Z was not ‘threatening or vitriolic’; and
• if Ms Z did not think the care provider could provide the care needed for Mrs Y she did have a right to advise it could give 14 days notice to stop the care package.
58. In response to my enquiries the care provider said it did not record the telephone conversations between Ms Z and Mr X and Ms W. Ms Z said Ms W was not listening and Ms W passed the telephone to Mr X and it was mutually agreed the care package could not continue for Mrs Y. It said the notice period was also discussed.

My findings

59. There was a difference of opinion about the telephone calls between Ms Z and Mr X and Ms W. The care provider does not have a record of the conversations. I cannot resolve the conflict of what was said between Mr X and the care provider. So I cannot, even on the balance of probabilities, make a finding on what happened. In any case the care provider has already apologised which is a sufficient remedy for any injustice caused to Mr X.

Summary

60. In response to our enquiries the care provider advised it now uses an external agency to audit it against CQC expectations to ensure it is effective, safe, responsive, caring and well-led. It has had two mock inspections so far. It also advised it offered a further one week’s discount of £1100 on Mrs Y’s last invoice to acknowledge the experience was not of the expected quality.
61. The care provider has already taken action and carried out service improvements to prevent a recurrence of the faults identified. This was appropriate.
62. Where we find fault leading to injustice we may recommend a small symbolic payment to acknowledge the impact of the faults. The care provider has already refunded two weeks of care to Mrs Y which remedies any injustice caused to Mrs Y.
63. However, Mr X was also caused frustration and time and trouble by the care provider’s actions. I have therefore recommended a small payment to acknowledge the impact upon him.

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Agreed action

64. Within one month of the final decision the care provider has agreed to make a symbolic payment to Mr X of £200 to recognise the frustration and time and trouble he was put to by the care provider’s faults.
65. Within two months of the final decision the care provider has agreed to:
• review its processes after an accident to ensure it is recorded on an accident form, a body map of any injury is completed and care and support plans are updated; and
• provide evidence to demonstrate it has retrained staff on the out of hours procedure.

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Final decision

66. I have completed my investigation. I have found fault by the care provider causing injustice, some of which has already been remedied. The care provider has agreed to take action to remedy the injustice and prevent reoccurrence of the fault.

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Investigator's decision on behalf of the Ombudsman