Summary: There were some faults by the care provider in the delivery of Mrs X’s care. The family has been reimbursed some costs for late or short calls but in my view the care provider should go further. Some aspects of poor care caused particular distress and failed to respect Mrs X’s dignity, and the care provider should also offer a sum which recognises that.

The complaint

1. Ms A (as I shall call her) complains about the standard of care provided to her mother by Lotus Home Care. In particular she complains of short and late calls and says she carried out many care tasks herself when carers failed to do so. She says her mother’s dignity was not always respected by carers. She says the care provider failed to respond properly to her complaints.

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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 injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

4. I considered the information provided by Ms A and by Lotus Home Care. I spoke to Ms A. Both Ms A and the care provider had an opportunity to comment on and earlier draft of this statement and I considered their comments before I reached a final decision.
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Relevant law and guidance

6. 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.
7. Regulation 9 says care and treatment of service users must be appropriate and meet their needs.
8. Regulation 10 says service users must be treated with dignity and respect.
9. Regulation 13 says care must not be carried out in a way that is degrading for service users, including failing to attend to their toileting needs.
10. Regulation 16 says “Any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation.”

What happened

11. Mrs X lives with her husband. She has a number of conditions which require care and is doubly incontinent. Her daughter Ms A arranged care from Lotus Home Care which consisted of 30-minute care visits with two carers 4 times a day, 7 days a week. The contract with Lotus Care allowed for a 30-minute ‘tolerance’ period outside the agreed times for carers’ arrival.
12. Mrs X’s care plan noted she required assistance with all personal care, and required hoisting. The procedure required Mrs X to be hoisted onto a commode then transferred to her bedroom for privacy and dignity. Her care plans stated she must be assisted into her bedroom for continence care without exception, and continence pads should be changed at every visit. A note on the care plan states, “No excuses will be taken into account from Lotus office regarding how this is done”.
13. Ms A says it was impossible to keep to a proper routine as they did not know when carers would arrive. She says Mrs X needed meals, medications and personal care needs attended to at the regular times stated in the contract but sometimes carers would arrive at 10.00 for an 08.15 call.
14. Ms A says she complained to the care provider many times about late or short calls. She says over the 16 months the contract was in place, she and her daughter undertook a considerable amount of the care tasks herself (she says 22%) or did work the carers had failed to do during their calls. She kept a note of the phone calls she made to the office about late or short calls and says there were 653 over the period the contract was in place.
15. In July 2022 there was an incident when carers began to hoist Mrs X onto her commode but were unable to complete the transfer before Mrs X opened her bowels and bladder. They did not clean up properly. Ms A says this was not an isolated incident as the care provider said, but carers frequently hoisted Mrs X onto the commode in the living room when visitors were present.
16. Ms A says her mother developed a cyst or pressure sore. She says she asked the carers if she could check it but the affected area was obscured by faecal matter which Ms A says called into question the risk of infection as well as the level of personal care.

The safeguarding alert

17. Ms A raised a safeguarding alert with the local council. She gave notice on the contract with Lotus from 5 February 2023.
18. The council safeguarding planning team met in May 2023 with Ms A and representatives of Lotus Home Care. Ms A told the meeting -

• There were examples of care calls lasting as little as 6 minutes;
• Some care calls were over an hour late and no courtesy call had been made to explain;
• There were many occasions on which carers had assisted Mrs X with personal toileting needs in her living room even though this was specifically prohibited on her care plan;
• Ms A had complained to the care provider about the state of Mrs X’s cyst but not received a response;
• Ms A believed there were documents on which her signature had been forged.

19. In response Lotus Home care said carers were still getting used to a new time- monitoring system which might explain the drop in some call times. It apologised if courtesy calls had not been made to explain a late call, but said calls over an hour late were not chargeable, and Ms A had been reimbursed where this had happened. Lotus said it had apologised directly to Mrs X for the incident in her living room and would remind all staff to be aware of directions in the care plans.
20. The outcome of the meeting was that Lotus would investigate the outstanding matters and provide evidence to the safeguarding team.

The complaint

21. Lotus also investigated Ms A’s complaint and responded on 28 July 2023. It said a review of the care calls in the last 6 weeks of the contract showed 24/168 calls lasted 25 minutes or less, but that all tasks had been completed in that time and permission had been given to leave. It also said there were calls which lasted longer than 30 minutes. It did not uphold the complaint.
22. Lotus said in the last 6 weeks, there were 13 calls which were later than the 30-minute tolerance period (some of which were over an hour late) and Ms A had been reimbursed £380 for those episodes. It apologised for the late calls and for the failure to make courtesy phone contact.
23. Lotus said it had investigated the allegation that Ms A’s signature had been forged on a care document but said that it could not see how this had technically been achieved in the way Ms A believed, and did not uphold this aspect of the complaint.
24. In respect of the incident in Mrs X’s living room Lotus said this had already been upheld, no charge had been made for the call and the carer had been moved off the rota for Mrs X. It added that the manager had visited Mrs X personally to apologise.
25. Lotus said there was no evidence Mrs X had suffered from pressure sores but had a moisture lesion which was cared for appropriately.
26. The care provider concluded by saying if Ms A remained unhappy she should appeal within 5 days of the response letter.
27. Ms A wrote back to the care provider on 4 August with a comprehensive rebuttal of the contents of the complaint response and asking for additional information. The care provider did not respond other than to acknowledge her letter.
28. Ms A complained to the Ombudsman. She said the actions of the care provider had caused her personally considerable stress and taken up valuable time in contacting it about late care calls as well as undertaking her mother’s care herself. She said some of the care was poor and she does not believe carers were changing incontinence pads as frequently as they should (she says she counted them) or properly attending Mrs X’s needs. She says even though she wrote back to the care provider shortly after receiving its response to her complaint, she has not heard anything since.
29. The care provider says the feedback from Ms A and Mrs X about its services had often been positive. It says it reimbursed where appropriate for late calls and has provided a snapshot of reimbursed calls and their reasons between January 2022 and January 2023.
30. The care provider says that following the safeguarding meeting in May 2023, “the induction process was upgraded back to 4 days face to face induction training (these had initially been reduced during COVID-19) to ensure that we provided a comprehensive level of training to new care staff, to react in emergency situations and not panic.” It says no further action was take by the local safeguarding team after Lotus had submitted the required evidence of training improvements.
31. The care provider says it thought from Ms A’s response that she intended to pursue the matter with the council and as she did not say she was appealing its response, it took no further action.
32. In response to my draft decision the care provider says “our carers were faced with an entirely unexpected and challenging situation when (Mrs X) involuntarily opened her bowels at the start of a transfer. The carers acted swiftly to manage the situation, ensuring (Mrs X’s) dignity and comfort as much as possible under the circumstances. It is important to recognise that such unforeseen incidents can occur despite the best planning and care standards. We are not clear about what alternative actions would the Ombudsman have expected us to take in this specific scenario that we did not already perform?”.
33. However, Ms A points out that “mum was to be hoisted onto the wheeled commode cushion and then wheeled into her bedroom where she was then hoisted up to remove underwear and pad, so carers shouldn’t have known if mum was urinating while in the living room as she would still have underwear and pad on”.

Analysis

34. There was a high level of contact between Ms A and the care provider about Mrs X’s care calls. There were clearly instances of late and very short calls, which was poor service and led Ms A to believe care was not being provided for her mother in accordance with the care plan. Often she carried out care tasks herself when care staff were late.
35. In addition there were training concerns about some members of staff who failed to read and act on the instructions in the care plan. That caused a significant loss of dignity for Mrs X and was a potential breach of the regulations.
36. The care provider should have taken further action on Ms A’s reply to its complaint response but instead it chose to consider the matter closed. It would have been good practice, and in accordance with the regulations, to respond to her requests for information.

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Agreed and recommended action

37. I recommended that within one month of my final decision the care provider should provide evidence of the way it monitors adherence to time schedules and care plan instructions; The care provider agreed and says it has implemented a robust time-monitoring system to ensure adherence to scheduled call times and care plan instructions. This includes regular audits and feedback mechanisms to promptly address any deviations.
38. I recommended that within one month of my final decision the care provider should clarify for me its position where staff have been given permission to leave very early by the service user and how it ensures all tasks are completed in that time; the care provider agreed and says all tasks must be completed and if a service-user gives permission for early departure the carer will document that permission and note that all tasks were completed first.
39. I recommended that within one month of my final decision the care provider should offer £500 to Mrs X and an additional £500 to Ms A in recognition of poor care provided to Mrs X and the consequent distress and anxiety caused to Ms A. The care provider says in its view, the credits and refunds already given should be adequate to address the distress and inconvenience caused. That is not my view: the credits and refunds were to redress late or short calls, not to recognise the distress caused by a particular failure to comply with the care plan as noted in paragraphs 15, 32 and 33.
40. The Care Provider should therefore provide us with evidence it has complied with the actions at paragraph 39.

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Final decision

41. I have completed this investigation and find the actions of the care provider caused injustice to Mrs X and Ms A, which the completion of the recommendations at paragraph 39 will remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman