Summary: Mr B complained about the care provided by a care agency, the Council’s and the agency’s communications with him and the agency’s records. We have not found fault with the care provided by the agency or the Council’s and the agency’s communication with Mr B. However, there was some fault in the agency’s record keeping. The Council has agreed to apologise and to remind the agency of the importance of good record keeping.

The complaint

1. Mr B complains about the actions of the Care Signature Christian Homecare Services (the Agency) in Leeds. He also complains about the Council. The complaints relate partly to the care provided by the Agency to Mr B’s mother, Mrs C. Mr B also complains about the Agency’s and the Council’s communications with him, the Agency’s records and the calculation of the invoices by the Council.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
4. We normally expect someone to refer the matter to the Information Commissioner if they have a complaint about data protection. However, we may decide to investigate if we think there are good reasons. (Local Government Act 1974, section 24A(6), 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)

Back to top

How I considered this complaint

6. I have considered the information provided by Mr B, the Council and the Agency, the relevant law, guidance and policies and both sides’ comments on the draft decision.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

What I found

Law, guidance and policies

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards which says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

What happened

10. Mrs C was an older woman who lived at home and received a package of care funded by the Council. Mr B is the executor of Mrs C’s estate.
11. Following Mrs C’s death, Mr B complained to the Agency on 1 August 2023 and said:
• Mrs C’s care plan said care workers should let themselves in via the side door using the key in the keysafe, but care workers failed to do so. Instead, they knocked on the front door, which was distressing to Mrs C, particularly after dark.
• There had been ‘numerous occasions’ when the care workers had asked Mrs C for money. Mrs C had contacted her bank to obtain a new bank card as she was worried that care workers were stealing from her.
• The care workers failed to properly administer Mrs C’s medication and sometimes gave the medication at the wrong time of the day.
• The care workers sometimes only stayed for a few minutes instead of the full allowance of 30 minutes.
• The care plan contained mistakes. Two thirds of the plan related to another person.
• When the care workers found Mrs C dead on the sofa, they failed to inform him. Instead a friend of Mrs C called him to inform him of the news.
12. The Agency spoke to Mr B and explained to him that it would have to seek advice in how to respond to the complaint as it was restricted in the information it could disclose.
13. On 24 August 2023 Mr B complained to the Council about the Agency. He asked the Council to send him its contract with the Agency and the time records of the Agency’s visits to Mrs C. He chased the Council for a response on 14 September 2023.
14. The Council wrote two letters to Mr B on 20 September 2023. The first letter related to his complaints about the care Mrs C received and said:
• It had passed his complaint to its Adult Safeguarding Team.
• The Safeguarding Team would consider the complaints about Mrs C being frightened of the care workers, care workers asking for money and stealing money and medication not being given as prescribed.
• The Safeguarding Team could not carry out a formal safeguarding enquiry in relation to a person who was deceased but could look at the concerns.
• It hoped that this would give Mr B reassurance and that he was satisfied with this response.
15. The second letter contained a breakdown of the outstanding invoices that had to be paid. The Council said Mrs C’s account was on hold as Mr B was applying for probate.
16. Mr B wrote to the Council on 11 October 2023. He said he would not pay the outstanding invoices relating to Mrs C’s care until the Council provided him with a detailed breakdown and explanation of the attendance of the Agency. He said he did not have records of the visits as the Agency had refused to disclose them to him.
17. The Council responded on 14 November 2023 and said:
• The Council had an ongoing duty of confidentiality regarding Mrs C’s information. Therefore, it was only able to provide him with the information he needed as executor of Mrs C’s estate.
• His complaint that the care plan he had seen in Mrs C’s flat related partly to another person had been reported to the Agency as a data breach.
• The Council could not send him a copy of Mrs C’s care plan because of the duty of confidentiality towards Mrs C.
• The Council sent him a copy of the electronic record providing details of the Agency’s care visits to Mrs C and the length of call time attended.
• The Council enclosed a list of the invoices and an excel spreadsheet detailing the calculations the invoices were based on.

Analysis

Scope of the investigation

18. The scope of my investigation has been limited for the following reasons.
19. Mrs C told the Agency that she did not want Mr B involved in her care. Mr B was not named as the next of kin on the Agency’s care plan.
20. Mrs C told the Council in January 2023 that she did not want the Council to provide information about her care to Mr B. However, she changed her position in February 2023 and said the Council could speak to Mr B and give him some information.
21. I note that Mrs C had mental capacity to make complaints while she was alive and she did not make any complaints about the Agency.
22. Mrs C then died and Mr B complained to the Agency and then the Council after her death.
23. Mr B is the executor of Mrs C’s estate so he is entitled to information which he needs to fulfil his duties as an executor. Mr B was entitled to check that the appropriate care was provided by the Agency, as he had a duty to pay outstanding invoices for the care provided from Mrs C’s estate.
24. Mr B could also raise concerns about the care, in his own right, from his own observations. However, any response would always be limited as the Agency, the Council and now the Ombudsman had a continuing duty to respect Mrs C’s wishes about what information could be disclosed to Mr B, even after she died.
25. Finally, some of Mr B’s complaints related to his own interactions with the Agency and the Council and those could be investigated fully.

Care records

26. I have no concerns, from the records that I saw, about the length of the visits and find no fault in that respect. Attendance times were electronically recorded and matched the times set out in the care plan, except on a few days.

Using the key safe

27. The records showed that the care workers entered the flat using the key safe, as set out in the care plan. This was recorded most days. I therefore do not find fault in that respect.

Medication administration records (MAR) charts

28. The MAR charts were filled in and showed that Mrs C was given her medication in line with the prescription, in the morning or in the evening. However, the actual time was not always properly recorded when it should have been.
29. Mrs C did not suffer any injustice as the medication was provided in line with the prescription.

Money

30. I have not found evidence that Mrs C raised concerns about misuse of her finances by the Agency. I have not found fault in this respect.

Communication

31. When Mrs C died, the Agency contacted Mrs C’s next of kin, as specified in the care plan so I do not find fault in that respect.
32. I appreciate that both the Agency and the Council were restricted in what information they could disclose about Mrs C. I find no fault in that respect.

Care plan /communication

33. In terms of the care plan, the main concern was that Mr B said he found Mrs C’s care plan at her home and said there were inaccuracies in the care plan and sections of the plan related to a different person. He also said that this care plan had his name as next of kin, but the Agency failed to contact him when Mrs C died. He has sent a copy of the care plan to the Ombudsman.
34. The Agency has sent its copy of Mrs C’s care plan to the Ombudsman which is detailed, correct and only relates to Mrs C. It is different from the plan that Mr B has sent. Mr B is not named in that care plan as next of kin.
35. The Agency has said that the plan that Mr B has sent is in the format of the agency. It cannot confirm the content of the plan as it does not match the paperwork that they have for Mrs C. It was not the plan that was used by the staff.
36. I accept that the Agency’s staff were using the correct care plan, so Mrs C did not suffer any injustice from the existence of the incorrect care plan.
37. However, an incorrect plan should not have been left at Mrs C’s house so there was some fault in that. And I accept that the plan may have caused some distress to Mr B, as he was worried that it contained incorrect information. It also led to his expectation that the Agency should have rung him when Mrs C died as he was named as next of kin in the document that he found but not in the care plan that the Agency used.

Back to top

Agreed action

38. The Council has agreed to take the following actions within one month of the decision. It will
• Apologise to Mr B as he has suffered distress as a result of the incorrect information that he read in the care plan.
• Remind the Agency of the importance of good record keeping.

Back to top

Final decision

39. I have completed my investigation. I have not found fault with the care that was provided to Mrs C or the communications with Mr B. There was some fault in relation to the records and the Council has agreed the remedy to address the injustice.

Investigator’s final decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman