• The complaint
• The Ombudsman’s role and powers
• How I considered this complaint
• What I found
• Agreed action
• Final decision

The Ombudsman's final decision:

Summary: Mr X complained the Care Provider failed to provide suitable care in line with Mrs Y’s care plan and adhere to the financial spending limits it had in place for client money. We found the Care Provider failed to keep sufficient records to document the care it provided and failed to update care plans. This caused uncertainty for Mrs Y and her family. The Care Provider has agreed to apologise, make payment to recognise the uncertainty caused and take action to prevent reoccurrence.

The complaint

1. Mr X complained the Care Provider had failed to provide suitable care in line with Mrs Y’s care plan. He said it had:

• Failed to provide the correct medication.
• Failed to ensure staff adhered to the financial spending limits in place.
• Failed to provide exercise, companionship and stimulation.
• Not ensured that food was safe to eat and Mrs Y received sufficient hydration and nutrients.
• Taken extended breaks over and above the agreed two hours.

2. He says this has affected his mother’s quality of life and her health and it has caused her a financial loss. He says it has caused him and his family distress and frustration.

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The Ombudsman’s role and powers

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. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
5. 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)
6. 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

7. I have considered:
   • The information provided by Mr X and discussed the complaint with him;
   • The Care Provider’s comments on the complaint and the supporting information it provided; and
   • Relevant law and guidance.
8. Mr X and the organisation had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Law and guidance

9. 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 below which care must never fall. The standards include:
   • Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Assessments should be reviewed regularly and whenever needed throughout the person’s care and treatment.
   • Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
   • Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user. This includes systems to assess, monitor and mitigate risk relating to health, safety and welfare of service users.
   • Duty to notify (Regulation 18) Care Providers must notify the CQC of all incidents that affect the health, safety and welfare of people who use services.

The Care Provider’s money handling policy

10. The policy’s objectives are to ensure it supports customers to keep their independence. It seeks to provide financial support on an open, honest and transparent basis.
11. Where a client requires financial support the Care Provider will ensure there is a care plan in place for this which sets out the task covered. The care plan should include details of amounts, frequency and a recording mechanism.
12. Before any financial support is provided a senior member of staff will carry out an assessment. If financial support is agreed risk assessments should be carried out.

Key events

13. Mrs Y has dementia and significant mobility difficulties. Her family arranged for a live-in care worker to help her with daily tasks in October 2021. At first the care was overseen by Mrs Y’s husband with support from their children. When he passed away the children started overseeing Mrs Y’s care.
14. Mrs Y’s care plan stated that she needed help with:
    • Housekeeping tasks - washing up, cleaning the bathroom after use and once a week, dusting and hoovering
    • Laundry
    • Cooking – assistance with meal preparation, ensuring regular fluids, and checking use by dates
    • Medication, and
    • Personal care – dressing, washing and helping with toileting.
15. The Care Provider’s terms and conditions attached to the care plan state that live-in care workers must be provided either full board or an amount in cash each week for their dietary requirements. This agreement should be set out in the confirmation of instructions. It also states care workers are to be given a minimum two hour break each working day.
16. The care assessment paperwork outlined that care workers are allowed a two-hour break per day and that staff can use their bedroom when not needed to provide support. It also noted that Mrs Y would like meals to be taken with the care worker. It also stated the parties agreed Mrs Y would pay a food allowance of £40 to the Care Provider who would pay the staff member.
17. In early 2022 Mr X raised concerns with the Care Provider about the care Mrs Y was receiving and the care worker was charging Mr Y for joining in meals cooked for Mrs Y. In the correspondence following this Mr X explained that his mother needed regular mobilisation as recommended by the physiotherapist, mental stimulation, and social interaction. The Care Provider agreed to look into this, but did not update the care plan to reflect this agreement.
18. In December 2022 a new care worker began working with Mrs Y. The new care worker helped Mrs Y with personal care in the morning and evening and toileting care. They made her breakfast, lunch, and dinner unless Mrs Y was out visiting family and carried out housekeeping tasks. According to the care records Mrs Y was provided with a newspaper each morning, spent afternoons watching television – often with the care worker - and would read a book of an evening. In February 2023, after Mr X raised concerns about mobility, the care worker began walking round the house with Mrs Y.
19. The care worker also carried out online shopping for Mrs Y. The online shopping orders included food for Mrs Y and food for the care worker. No record was made of the food intended to be for the care worker.
20. Mr X became concerned about the online shopping bills and raised concerns to the Care Provider in late April. Mr X supplied one receipt for December 2022, three receipts for February 2023, two receipts for March and one receipt for April. He explained that he did not believe his mother would have eaten several of the items bought. He was also concerned the care worker bought seldom used items, such as mayonnaise, regularly and there were large amounts of milk being purchased.
21. The Care Provider looked into Mr X claims. It reviewed the care notes for Mrs Y from January to April to decide what food had been made for Mrs Y. It used this information to decide what items were legitimate purchases or likely to be a legitimate purchase. It calculated the cost of those items not linked to the care notes to see if spending was above the £40 allowable.
22. It first spoke with the care worker who said that Mrs Y chose some items to be bought and said that she froze some food items. She said she had to do large amounts of cleaning and washing which meant she had to buy cleaning supplies regularly. However, the care worker did not attend a hearing about this. The Care Provider has explained that she was an agency staff member and they were unable to reach her.
23. In conclusion it noted the care plan had not been updated to reflect the care worker buying food for Mrs Y and the arrangements made, especially about the £40 allowance. It noted the milk was reasonably explained by the care notes and explanation given by the care worker as were the cleaning materials and some other food items. It decided the items not linked to food recorded as being given to Mrs Y was likely to be less than the £40 per week allowance.
24. Following its review, the Care Provider introduced a new system for handling client purchases. It signed up to a financial service which provides a shopping and expense card allowing a set amount to be uploaded each week or month. The Care Provider also proposed to make a number of changes to how it managed supervision, spending agreements, care plan reviews and annual leave requests.

Medication

25. From December 2022 to March 2023 Mrs Y had several changes in medication. On each occasion Mr X would tell the care worker of the change and they would provide Mrs Y with the medication as directed. The Care Provider did not change Mrs Y’s care plan to reflect the new medication she was receiving. The care worker did not communicate the new medication requests with the main office.
26. In early May Mrs Y’s GP diagnosed her with a urinary tract infection and prescribed a course of antibiotics. Mr X says his brother contacted the staff member acting as Mrs Y’s live-in care worker and explained the situation. They agreed to ensure Mrs Y took her course of antibiotics.
27. Mrs Y’s condition did not improve. When Mr X looked into it, he says the staff member acknowledged that she had been providing one tablet per day not two as prescribed. In late May he raised a complaint to the Care Provider about this. The Care Provider noted it had not been asked to provide medication and had not updated the care plan accordingly to support the care worker in administering the medication.

Findings

Financial spending

28. I can see no clear record of when the care staff began placing online food orders for Mrs Y. The earliest receipt is from December 2022 and both parties appear to agree it started around this time. I have seen no evidence the care worker reported this to Care Provider, that the care plan was updated or that the money handling policy was considered.
29. As a result of the care plan not being updated and no detailed conversations occurring there was no discussion about the amounts of money to be spent on shopping, the frequency, or the recording mechanism.
30. When carrying out its review the Care Provider included a £40 allowance for the care worker within the spending. Whilst I appreciate the care worker had a weekly allowance, the care assessment indicated this money was to be paid to the Care Provider. There should be evidence that there was a clear agreement this arrangement had changed.
31. This has left Mr X questioning the amount spent and whether the purchases were necessary and for Mrs Y. The Care Provider’s failure to ensure the financial agreement was documented has caused Mr X an injustice.
32. I appreciate that Mr X is concerned the care worker has purchased items for themselves above the spending limit agreed. The Care Provider under its policy should have carried out a risk assessment before the care worker was able to start purchasing online shopping. There is no evidence this happened.
33. The Care Provider has reviewed the spending comparing bills to the food detailed in the care notes. The notes detailed some items eaten by Mrs Y or likely to have been eaten as an ingredient of a named dish. It does leave several items unaccounted for. While some of these may be attributed to Mrs Y the Care Provider can only guess, therefore a true picture of the care worker’s own spending cannot be determined. Had the Care Provider ensured it’s staff followed it’s policy for spending customer money the remaining doubt Mr X has following the investigation would have been avoided. This doubt is an injustice.

Provision of medication

34. The care notes for Mrs Y show that she did have changes in medication when her GP issued new prescriptions. On each occasion the discussion on providing these medications was had between only Mr X and the care worker. There is no evidence the care worker communicated these changes to the Care Provider nor that it updated Mrs Y’s care plan.
35. Mrs Y care notes confirm the care worker gave her medication in the morning and evening. However, there are no details to confirm what medication it gave her.
36. In relation to this Mrs Y’s urine infection in May 2023 there is no evidence of Mrs Y’s family asking the care worker to provide medication around this time. However, I am satisfied, on balance, they asked the care worker given the care notes record Mrs Y needing to provide a urine sample for the doctors in mid-May and they helped with this.
37. The Care Provider has failed to ensure it has a system in place which recorded the medication care workers were providing or how it will deal with new medications. In doing so it has not ensured that it has a system in place that mitigated the risk to Mrs Y’s health, safety and welfare.
38. I cannot say whether Mrs Y received the correct medication as prescribed by her doctor’s based on the evidence available. However, the lack of recording system has left Mr X concerned the medication was not provided as prescribed and that his mother suffered for longer than necessary. This is an injustice.

Care plan provision

39. Mr X believes the Care Provider failed to provide Mrs Y with regular exercise. Mrs Y’s care plan from October 2021 makes no reference to the need for regular exercise. If this was not an identified need, I would consider it reasonable the Care Provider did not help Mrs Y in such activities.
40. However, in February 2022 Mr X brought this need to the attention of the Care Provider. He explained that a physiotherapist had recommended his mother receive regular mobilisation. The Care Provider agreed to arrange a visit with Mrs Y. Following this visit it did not create a new care plan to reflect Mrs Y’s changing needs.
41. I am satisfied it accepted Mrs Y needed help with exercising as in April 2022 the Care Provider discussed needing to continue to maintain Mrs Y’s mobility. It should have updated Mrs Y’s care plan at this time and provided mobility support.
42. The Care Provider has not provided any notes for 2022. The notes for 2023 show the care worker provided mobility support in mid-February 2023 but it is not directly referenced in the care notes for January, March or April. As such I cannot be satisfied the care worker provided the care Mrs Y needed during this time. The lack of care notes detailing whether Mrs Y received mobility support has left Mr X believing that his mother did not receive this. He is worried how this may have affected her health. This is an injustice.
43. Similarly, Mrs Y’s care plan did not detail any need to provide mental stimulation. Mr X raised this as a concern in April 2022. The Care Provider responded agreeing it would need to think about regulated activities and a routine. It asked for more details about Mrs Y’s interests. No changes were made to Mrs Y’s care plan following this conversation.
44. I can understand why Mr X expected the care worker to provide mental stimulation following this conversation, even though it was not specifically agreed. We expect care providers to be open in their correspondence. The Care Provider should have explained whether it could or could not provide mental stimulation for Mrs Y and not have left this request partly considered. As a result of this conversation Mr X believed this had been agreed to and would be provided to Mrs Y. He therefore did not take action to pursue this further or ensure it was provided elsewhere.
45. Mr X believes the Care Provider did not arrange for staff to spend time with Mrs Y when they were not providing her with support. I appreciate that when he or other family members came to the house the care worker often remained in their room. I am not persuaded these times are representative of how the care worker spent their time. There are references within the care notes of the care worker watching TV and spending time reading with Mrs Y. For instance, on 14 January 2023 the care worker watched a documentary with her. The following day it’s noted the care worker watched the news and a series episode with Mrs Y.
46. Mr X says that food was left to go past its use-by date and go off in the fridge. He is concerned the care worker gave his mother out of date food. The care notes regularly record the care worker placing meals in the freezer and taking them out later for Mrs Y. I appreciate that this may have looked like expired food had been left in the fridge. Given the care worker regularly froze food I cannot be satisfied the food Mr X found past its sell by date was inappropriate to have in the fridge.
47. I appreciate Mr X is concerned about the nutrient value of the food served as well. I am satisfied that Mrs Y received a balanced diet. The care worker gave Mrs Y vegetables, protein and carbohydrates for lunch and dinner such as rice, vegetables and fish. While on occasions Mrs Y did have a less well-balanced meals this was not common and was generally after she asked for a specific meal.
48. The care notes show that between January and March 2023 the care worker regularly provided Mrs Y with cups of tea and juice throughout the day. Although at times she may not have had a drink by her side I am persuade she regularly had drinks. I am not satisfied there is sufficient evidence to conclude that her hydration was insufficient in 2022 despite the lack of notes given the regular drinks detailed in the notes available.

Staff breaks

49. Mr X says that care workers regularly left Mrs Y’s house for hours at a time and did not stick to the two-hour breaks agreed. The Care Provider kept no records to record how often or long staff breaks were. This has left Mr X uncertain that Mrs Y received the care she was entitled to.

Injustice

50. The Care Provider’s failure to keep accurate records of the care provided to Mrs Y and update her care plan when needed has left Mr X with a lot of uncertainty. He is unsure whether Mrs Y received the care she needed in terms of medication, exercise, and stimulation. He also has been left worrying that she was regularly left for longer periods than agreed without the support and care she needed while staff took breaks away from the home.
51. Further, Mr X has been confused and frustrated, worried by the lack of discussion prior to taking on Mrs Y’s weekly shopping. He is concerns about the amount of money spent on Mrs Y’s shopping. The Care Provider should take action to recognise these injustices.

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Agreed action

52. Within one month of the final decision the Care Provider has agreed to:
    • Apologise to Mr X and Mrs Y for the confusion and uncertainty caused by its failure to record the care provided and keep updated care plans for Mrs Y.
    • Pay Mr X £400 for the distress caused by the lack of care records about Mrs Y medication, exercise and stimulation offered.
    • Pay Mr X £300 in recognition of the distress and anger caused by the Care Provider’s failure to follow its policy before carrying out shopping duties for Mrs Y.
53. Within three months of the final decision the Care Provider has agreed to:
    • Remind staff of the importance of updating care plans to reflect any change of need or medication.
    • Ensure it has a system in place to ensure care plans are reviewed regularly.
    • Remind staff of the importance of keeping accurate records of the care being provided.
    • Ensure it has a process in place for agree a spending limit for weekly shopping. This process should include discussions around what items are to be purchased prior to agreeing to take on the care in line with the policy. The new process should be shared with all staff.
    • Ensure it has a process in place to make a clear agreement as to how the care worker can claim their weekly budget and all parties are aware of this.
54. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

55. I have completed my investigation and uphold Mr X’s complaint. I have made recommendations the organisation has agreed to carry out.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman

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