Summary: The care provider cannot evidence it provided the care which Mr A had arranged for ten days for Mrs X. Mrs X was disorientated and suffering from an infection when Mr A returned from holiday. There was also a delay in investigating and responding to his complaint. The care provider has agreed to waive the fees in recognition of the poor standard of care to Mrs X and the anxiety caused to Mr A in consequence.

The complaint

1. Mr A (the complainant), who is his mother’s main carer, complains the care provider did not provide the care he arranged when he went away for 10 days. He says the care provider did not give him a contract or care plan before he went away, has not documented the personal care or medication in its notes and did not take Mrs X for a walk as requested. He says despite being promised continuity of care he found that multiple carers had been involved and Mrs X was disorientated as a result.

Back to top

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))

Back to top

How I considered this complaint

4. I considered the information provided by the care provider and by Mr A. Both parties had the opportunity to comment on an earlier draft of this statement before I reached a final decision.

Back to top

What I found

Relevant law and guidance

5. 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.
6. Regulation 9 says the care and treatment of service-users must meet their needs, be appropriate and reflect their preferences.
7. Regulation 12 says that staff must follow polices and procedures in respect of medication, including administration and recording.
8. 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”.
9. Regulation 17 says care providers must “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.
10. In February 2023 we published guidance for care providers on good record keeping. We said, “We are likely to find a care provider at fault where records are illegible or have clearly been changed after the event, where they are inadequate for their purpose, or where they omit essential information or include misleading information”. We also said, “Care providers compiling accurate records enable us to reach robust findings. However, if there are gaps in recording or a conflict of evidence, we can make findings based on the balance of probabilities”.

What happened

11. Mrs X lives with Mr A who is her prime carer. Mrs X has dementia. Mr A arranged for RochCare to look after Mrs X during a 10-day period while he took a break.
12. Mr A met with the care provider in August 2023 two months before the planned break. He asked the care provider to make three calls a day to administer medication and provide personal care; to visit at consistent times each day (after 9 for the morning call) and use the same carers, to take Mrs X out for a walk every day, and to carry out light household tasks and washing as needed. He says that despite his request the care provider did not provide a care plan or contract before he went away.
13. Mr A says when he returned, he found that his mother had a UTI and was disoriented and distressed. He says the carers had not taken Mrs X walking every day as requested. He says although the care provider had assured him there would be one carer during the week and another at the weekend, there had been several different carers which had confused Mrs X.
14. Mr A has sent me a copy of the daily care notes which were left in the house by the care staff. The notes do not say which carers attended, do not state the times of the calls or whether personal care or medication was given. Mr A says there were seven occasions when medication was not given but no explanation was provided.
15. Mr A says he telephoned the care provider at the end of October and said he wanted to make a formal complaint. He says the manager told him there was a procedure and she would send him a form. He says she did not do so. He says when he contacted the CQC an officer there told him to email the care provider for a complaint form: he says he did so but there was still no reply. He complained to the Ombudsman in November 2023.
16. We wrote to the care provider in December who said she would respond to Mr A within 28 days. Mr A also wrote to the care provider in January 2024 with a description of his complaint. The care provider responded on 1 February and said the investigation findings were that the documentation was incomplete, it was not factual and no call times were recorded. She acknowledged the medication should have been recorded in the daily notes. She said lessons had been learned and an electronic recording system was in place. She said the complaint was now closed.
17. Mr A says he felt totally let down by the care provider. He says he has lost trust in leaving Mrs X with a care agency again.
18. The care provider acknowledges the failure to record times, names of carers, medication and personal care given was an area that required improvement and says it has now introduced electronic monitoring systems.
19. The care provider says it completed MAR charts and a care plan but these were left in Mrs X’s house: it says as it did not at that time keep a copy of the documents it cannot provide evidence now.
20. The care provider acknowledges there was one occasion when Mrs X was found outside the house but staff did not inform Mr A as it should have done.
21. The care provider says when the manager spoke to Mr A by telephone she said she would investigate his complaint if he made it in writing but she did not receive anything until contact from the CQC in November.
22. The records provided by the care provider showing attendance times demonstrate that with one exception the morning calls were all made before 9am. The care provider has also provided two statements from staff indicating that they carried out all tasks as requested except when Mrs A declined.

Analysis

23. The care provider has acknowledged it has no evidence of the care provided. It has now altered its record-keeping system to avoid a recurrence but that is too late for this episode of care. In any event, there was no reason why using paper records should in and of itself have been the reason for failing to keep accurate, comprehensive and contemporaneous records as regulation 17 requires. That was a potential breach of the regulations.
24. There is also a potential breach of regulation 12 in the care provider’s failure to record accurately the medications given.
25. The response to the complaint was late and inadequate and failed to acknowledge any injustice caused to Mr A or Mrs X.

Back to top

Agreed action

26. The care provider has already moved to an electronic recording system so I make no recommendations in that respect, except to reiterate that whatever method of recording is used depends on the accuracy of the input. Electronic systems do not automatically mean records are of a high quality.
27. The care provider has now made a proper written apology to Mr A.
28. The care provider has acknowledged the distress and anxiety caused by its poor service and agree to waive the fees for this ten-day period.
29. The Care Provider has provided us with evidence it has complied with the above actions.

Back to top

Final decision

30. I have completed this investigation on the basis that the actions of the care provider caused injustice to Mrs X and Mr A which completion of the recommendations at paragraphs 27 and 28 above have remedied.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman