Summary: Mrs X complained about the actions of the care provider. Based on evidence seen, we find the care provider was at fault for failing to turn up to care visits, turning up at care visits late and poor communication between teams. This caused significant distress to Mrs X. To address the injustice caused by fault the care provider has agreed to apologise, make a symbolic payment and issue a refund.

The complaint

1. The complainant, Mrs X, complains:
1. care staff made false allegations about her brother abusing her father and mother;
2. the staff failed to advise her about the alleged abuse and safeguarding;
3. the care provider staff turned up late for visits or failed to turn up at all;
4. the care provider sent male carers to visit when she had told them to no longer send male carers;
5. the care provider sent care staff who had made the abuse allegations against her brother;
6. care staff were insufficiently skilled to provide her mother with care required for her incontinence pads;
7. the care provider brought her father alcohol; and
8. management failed to respond properly to her concerns.
2. Mrs X said this has caused her and her family significant distress.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this report, we 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. We refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
6. 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)

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How I considered this complaint

7. I spoke with Mrs X about her complaint. I considered all the information provided by Mrs X and the care provider.
8. Mrs X and the care provider 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

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
10. Regulation 9 says the care and treatment of service users must be appropriate, meet their needs and reflect their preferences.
11. Regulation 12 aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Care providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks.
12. 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.
13. Regulation 17 says care providers should “maintain securely” records and should have “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”.

Summary of the key events

Care plan and reviews

14. Mrs X’s mother, Mrs Y, lives with her husband Mr Y. She received care from the care provider. The care plan stated this was made up of two care calls per day from two care workers. This care was provided between Monday to Friday.
15. A care review was completed in May 2022. This stated no changes needed to be made to the care. It was also noted Mr Y was satisfied with the current carers.
16. A further care review was completed on 14 December 2022. It stated:
• Mrs Y was bedbound and hoisted by Mr Y and her son;
• the care provider offered to witness transfers to see if it could offer them any support; and
• Mr Y stated he believed Mrs X had lasting power of attorney over Mrs Y’s health and finances. Mr Y agreed for staff to check this.

Care visit notes

17. In January 2022, the notes state care workers attended twice per day and were late to visits five times during the month. This ranged from five minutes late to 15 minutes.
18. On the 12 January 2022, a male care worker was down on the system to visit Mrs Y. The other care worker noted Mr Y did not want male care workers and therefore Mr Y helped the female care worker carry out the care. Throughout the month the care provided to Mrs Y included changing her incontinence pad.
19. In February 2022, care workers attended twice per day and were late by 10 minutes on one day. Throughout the month the care provided to Mrs Y included changing her incontinence pad.
20. In March, April and June 2022, care workers attended twice per day and attended within the arranged times. Throughout the month the care provided to Mrs Y included changing her incontinence pad.
21. In May 2022, care workers attended twice per day and were late four times. This ranged from eight minutes late to 15 minutes. On the 23 May 2022, care workers called Mr Y to let him know they would be late due to traffic. Throughout the month the care provided to Mrs Y included changing her incontinence pad.
22. In July 2022, care workers attended twice per day and were late twice by 13 and 15 minutes. On the 20 July 2022 it was noted Mr Y had rushed care workers to complete the call. Throughout the month the care provided to Mrs Y included changing her incontinence pad.
23. In August 2022 care workers were late once by 10 minutes. The notes state on the 5 August, care workers attended the address once. The notes also state Mr Y had asked care workers not to change Mrs Y’s incontinence pad. This is because he said he and his son, Mr Z would change the pad.
24. In September 2022 care workers attended twice per day and were late three times. This ranged from five to 15 minutes. Care workers made Mr Y aware they were running late on one occasion. Throughout the month the care provided to Mrs Y included changing her incontinence pad.
25. In October 2022 care workers attended twice per day and were late twice by 10 minutes. Throughout the month the care provided to Mrs Y included changing her incontinence pad.
26. In November 2022 care workers were late once by 10 minutes. The notes state on the 26 and 27 November, care workers attended the address once per day. It was noted Mr Y was agitated and said the incontinence pad was on wrong. But care workers stated it was on correct.
27. In December 2022 care workers were late twice by four and eight minutes. The notes state care workers attended the address once on the 25 December. It was noted Mr Y was agitated about the incontinence pad not being on the correct way.
28. On the 19 December, care workers found Mr Y on the floor and tried to arrange for help. Mr Z came in to care for Mrs Y. It was noted he had been manually evacuating Mrs Y’s bowels.
29. On the 22 December, the notes state Mrs Y was extremely upset, and stated Mr Z had manually evacuated her bowels.
30. Towards the end of December there were two days where the care workers stated Mrs Y’s incontinence pad was extremely wet and had not been changed in a while.
31. Mr Z asked a care worker to leave on the 27 December. This was because he did not want to take any risks in allowing someone who had been coughing to care for Mrs Y.
32. In January 2023 the notes state care workers attended the address once per day on the 7, 14 and 15 January. Care workers were late once by five minutes. Mr Z asked care workers to leave on two separate occasions due to them coughing. Mr Z also asked a male care worker to leave as the family had requested no male care workers.

Safeguarding referrals

33. The care provider submitted a safeguarding form in October 2021. It stated care workers had noticed a new dressing on Mrs Y which was saturated in blood. But Mr and Mrs Y were unaware of how this had happened. There were also concerns for Mr Y as care workers had noticed he had been drinking alcohol in the morning and hiding bottles in the oven.
34. The Council’s safeguarding team stated they spoke with Mrs X to see if she had any concerns in regard to Mr Y caring for Mrs Y. This was not upheld.
35. The care provider submitted a safeguarding form on 12 December 2022. It stated:
• there were concerns around Mr Y and Mr Z rushing care workers and not wanting them to complete certain tasks. This included declining Mrs Y’s teeth be brushed as they said it had already been done. But there was no evidence to support this;
• Mr Y would often say he had completed the personal care and rush the care workers;
• Mr Y was always anxious and was often worried care workers would be there when Mr Z arrived;
• on the 6 December, care workers found Mrs Y’s incontinence pad to be very wet due to it being badly applied by Mr Y. Care workers offered to change the bedding and nightie, but Mr Y refused. Care workers insisted and Mr Y did finally agree;
• it had body mapped a cut on Mrs Y’s hand which was caused by a long finger nail;
• care workers ask Mrs Y in the morning if she wants her teeth cleaning and 90% of the time, Mr Y answers and says no;
• it had concerns for Mr Y who seemed stressed and had lost weight. There was always an expectation that care workers attend early and be out of the house; and
• the concerns raised were by several members of staff.
36. The Council’s safeguarding team considered the safeguarding referral and said:
• multiple concerns were raised around Mr Y preventing care workers from completing personal tasks;
• the Council would request a priority review and try and resolve the issue through care management channels; and
• care workers were still providing care to Mrs Y and they would remain the professional lead to monitor ongoing concerns.
37. The care provider submitted a further safeguarding report on 23 December 2022. It was noted that:
• Mrs Y has limited capacity and was under the care of her son, Mr Z;
• Mr Z had been manually evacuating Mrs Y’s bowels;
• care workers witnessed Mrs Y screaming and crying whilst Mr Z was carrying this out and he had told her to ‘calm down and relax’; and
• the nursing team were called who were not aware Mr Z had been doing this. It was noted no training had been provided to him and police were notified.
38. A further safeguarding report was submitted on 28 December 2022. It stated;
• Mrs Y had lots of bruises on her arm;
• police had been contacted due to increasing concerns;
• it was unclear if the marks on Mrs Y were due to Mr Y struggling with manual handling or abusive behaviour. But it was noted Mr Y did not present any aggressive or abusive behaviour on the 23 December;
• the family needed support; and
• Mr Z was in a challenging situation and referrals were made by the police to get them help.

Communication and complaints

39. In January 2022 the care provider spoke with Mr Y who confirmed he was happy with the care workers that attend his property.
40. The care provider spoke with Mr Y in September 2022. Mr Y said care workers always turned up on time. He also said he felt confident the care workers were trained to meet Mrs Y’s care needs.
41. In January 2023, Mrs X spoke with the care provider. She said they did not want any male care workers and confirmed Mr Y was now back at home. The care provider explained it may struggle to provide two female care workers. But Mrs X made it clear the family were happy to assist with the care.
42. In response to Mrs X’s request to cancel the contract with the care provider, it was confirmed the care provider would continue to provide care until the 26 January 2023.
43. Mrs X complained to the care provider in February 2023. She said:
• there had been issues with care workers not turning up on time or sometimes not at all;
• care workers don’t have the skills to tend to her mother’s needs in regard to changing her incontinence pads;
• she first became aware of the safeguarding referrals on 19 December 2022 despite being the main point of contact. She also said she held authority on Mrs Y’s health and medical. But Mrs Y said when she challenged this, care workers said they must have lost her contact details;
• two care workers found Mr Y on the floor and exaggerated stating there was blood on the walls. The care workers also said he had an absent seizure. But the doctor confirmed the collapse was due to fatigue;
• the care provider proceeded to tell Mrs X it believed Mr Z was abusing Mr Y and said it had seen Mr Y with bruises;
• the care provider thought Mr Z was abusing Mrs Y and wanted to seek emergency respite but did not fill in the paperwork correctly;
• she later spoke with the respite team who had now received the correct paperwork. But they said they would close the request as the report filed was so vague;
• the false allegations had a significant impact on the family at a time when they were dealing with two recent deaths;
• Mr Y had a recent scan, showing a bleed on the brain. She said the doctor had confirmed his injuries were consistent with a fall;
• the day of the alleged abuse, Mrs X said Mr Y had arranged for a doctor to visit Mrs Y as she had been stressed. The doctor gave her the all clear and did not raise any concerns;
• staff members had called police about the alleged abuse. But Mrs X spoke with management who were unaware of the issue;
• the police stated there was no evidence of danger or abuse;
• the staff member who had contacted the police turned back up at the house to retract her statement. This caused Mr Z significant distress as they were not aware of reasons why they were there at the time;
• care workers had begun to criticise Mr Z on visits and stated he was not caring for Mrs Y properly;
• the family always had a condition in place due to vulnerabilities that no-one with symptoms of colds would attend the care calls. But care workers attended the address with a cold;
• upon her request on the 6 January 2023, the office confirmed they would not send any further male care workers. But Mrs X said male care workers attended two days later;
• on the 25 January 2023 only one care worker attended in the afternoon;
• over the last month she had been made aware of the findings from a safeguarding referral which referenced concerns around Mr Y's drinking and possible abusive towards Mrs Y. But Mrs X said no one had made her aware of this previously;
• on 27 December 2022, Mr Z asked one of the care workers not to attend as they could be heard coughing and stating ‘there is a lot going around at the moment’. Mrs X said the other care worker refused to enter. But the records show the family were charged for all visits that day;
• on the 28 December 2022, she had a call from a staff member who had tried to emotionally blackmail her into taking back the two care workers she had asked not to attend;
• on the 29 December 2022 the social worker told her they had been sent pictures of bruises to Mrs Y;
• Mrs Y was on blood thinners and bruises easily. She said Mrs Y had weekly visits from nurses who never raised any concerns;
• she called the office in December 2022 and said whilst the investigation as ongoing, she did not want two particular members of staff to attend the address; and
• in 2019, the family all underwent training around hoists, personal care, hygiene and toilet procedures.
44. The care provider responded the following month and said:
• care workers were trained in safeguarding and were taught to recognise signs and to report these concerns;
• one of the safeguarding referrals was raised due to unexplained bruising on both Mr and Mrs Y’s arm and a change in Mr Y’s behaviour which impacted the care that could be provided;
• it now knew that Mr Y had been having falls due to a bleed on the brain which had impacted his behaviour. But it said care workers did not know this at the time and had therefore followed the correct procedure by reporting their concerns. However, said the concerns should have been more adequately investigated by qualified staff before the safeguarding was submitted;
• during the initial safeguarding, Mrs X was contacted by the Council about the concerns around Mr Y’s drinking and unexplained bruising to Mrs Y’s skin. This safeguarding was not upheld or taken any further;
• the lack of communication to Mrs X around the safeguarding was due to the care plan stating there were no Power of Attorneys (POA) in place. The care provider applied for a copy of the POA through the office of the public guardian in January 2023 which returned stating there was not one in place;
• Mr Y was the lead contact and lived with Mrs Y so all communication would have gone through him;
• Mrs Y was very distressed during the manual evacuation carried out by Mr Z. The care provider was not aware Mrs Y required this level of care and it was not raised during the care needs review;
• the district nurse stated there was no record of this in Mrs Y’s medical notes and stated the GP would also raise a safeguarding referral due to the fact Mrs Y’s dementia meant she could not consent to this;
• the staff member who had raised the safeguarding referral was encouraged to ring the police by another organisation believing Mrs Y to be in danger. The staff member later retracted her statement after speaking with Mr Z and understanding more about Mrs Y’s care needs;
• in 2022 Mrs Y’s care package was serviced by a new branch and this led to some communication issues. This is what led to the branch manager being unaware of the alleged abuse. This was because the manager was absent at the time; and
• communications between the branch staff were inadequate and therefore messages were not relayed about the male care workers or about the cancelling of calls and call charges.
45. Mrs X asked for her complaint to be escalated and the care provider considered this under stage two of its complaints process. It said:
• in response to Mrs X stating care workers had brought alcohol for Mr Y, it said as he was not its customer care workers should not be carrying out shopping on his behalf, whether it be alcohol or otherwise. It reiterated this to all care workers;
• the care workers are not medical professionals and should keep to the facts of what happened. All staff are having re-training to ensure this is addressed going forward;
• the safeguarding referrals raised were done with Mrs Y’s welfare being the concern at the time. Staff are trained to recognise potential signs of abuse and raise the issues to the relevant people when they have concerns;
• on the day of the alleged incident, Mrs Y was in significant distress and crying out in pain. It acknowledged that Mrs Y did often get upset, but said on this occasion it was significantly different;
• in regard to the subsequent photographs of bruises, this was done to evidence the fact the care worker had seen a bruise on that day. The care provider had discussed with Mrs X on the phone that Mrs Y was prone to bruising due to her medication. It said it should be monitoring existing bruises and informing the family on whether they were worsening/changing;
• reporting on how and what to report has been briefed to all branch managers and care workers are having refresher communication and training;
• in regard to care workers being refused entry due to having a cough or cold and a care worker refusing to attend, it had passed this information onto its credit control team. It said the team would arrange any refunds due;
• it apologised for the distress this situation has caused the family; and
• staff were being retrained on escalation of concerns to the relevant people. This will include the need to ensure the communication is managed effectively.
46. Mrs X asked for her complaint to be escalated. She said some of her complaint had been glossed over and asked for further investigations. In response, the care provider responded at stage three of its process and said:
• the stage one and stage two complaints were investigated by experienced managers who acted with impartiality and professionalism throughout;
• it reiterated some of the previous responses and said the investigation had found some areas for improvement when dealing with safeguarding and communication to those involved;
• raising safeguarding concerns is a duty it must do. Its important that communications are only made to those who have the legal right, those being the next of kin or those with POA;
• it apologised if the family were made to feel criticised in any way during visits. The intention was to guide and support Mr Z in giving care to Mrs Y;
• it has an absence reporting policy in place and care workers should be informing the branch prior to completing any care calls if they are unwell or are displaying any symptoms of illness. It said on this occasion, it was not informed. But said it has reiterated this to the carer team;
• when care workers are excluded, it revisits with families the reason for exclusion. This should be respectful of families wishes and work with them. But on this occasion said this was not the case. It apologised;
• it works alongside health professionals and shares information as required. The photograph was sent to a social worker as part of an ongoing investigation;
• on the day that one care worker attended, the second care worker was cancelled without charge. But it said they should have been informed. It said the office team have been retrained regarding the process to follow in relation to cancelling customer visits; and
• all staff go through the relevant training and the care provider has a robust recruitment process.

Analysis- was there fault by the care provider causing injustice?

Part a of the complaint

47. The Ombudsman’s role is to review care providers’ adherence to procedure in making decisions. Where a care provider l has followed the correct process, considered all relevant information, and given clear and cogent reasons for its decision, we generally cannot criticise it.
48. The care provider submitted several safeguarding concerns. This was because care workers had serious concerns for Mrs Y. These concerns were also detailed in the visit notes.
49. The care providers safeguarding policy states care workers are to report any safeguarding issues in the correct manner. Therefore, the care provider has a duty to report safeguarding concerns. We could not criticise the care provider for this as it has followed the correct process.

Part b of the complaint

50. Mrs X said staff failed to advise her about the alleged abuse and safeguarding. The care provider told us at the time of the assessment it did not believe there was any issues with capacity. Therefore, in the first instance it would contact the customer directly or their lead contact. In this case, Mr Y lived with Mrs Y, and he was the lead contact.
51. The care provider said it had no record of Mrs Y expressing her wish for Mrs X to be point of contact and said it held no supporting documents to say Mrs X held any legal documents such as the POA. I have reviewed the care plan and Mrs X is not down as the next of kin, nor it is noted that she held POA. I also acknowledge that the care provider applied for a copy of the POA through the office of the public guardian in January 2023 which returned stating there was not one in place.
52. The care provider said as the alleged concerns identified related to a family member of Mrs Y potentially putting her at risk, in line with safeguarding training, it would not disclose concerns directly with family in fear of any potential abuse escalating or being covered up. This is in line with Regulation 12, and we could not criticise the care provider.
53. As the Council is responsible for safeguarding, we would expect it to notify the relevant people. The safeguarding report from 2021 notes the Council spoke with Mrs X as stated in paragraph 34.

Part c of the complaint

54. Between January 2022 and January 2023, the notes evidence care workers were late 22 times. This ranged from between five to 15 minutes. This is fault. During those times, care workers called Mr Y twice to advise they were running late due to traffic.
55. There is evidence of further fault. On the 26 and 27 November 2022, there was once care call each day. There was also only one care call on the 25 and 26 November 2022. But the care plan stated Mrs Y should have received two care calls per day. This meant Mrs Y went without the agreed care. This is not in line with Regulation 9. This also caused significant distress to the family who cared for Mrs Y.

Part d of the complaint

56. Mrs X spoke with the care provider on the 6 January 2023 and asked it to not send any male care workers. She explained that the family were happy to provide the support when needed. The care provider agreed to Mrs X’s request. But the notes state male care workers attended the address two days later. This is fault.
57. The care provider has acknowledged in its complaint’s response that communication was inadequate and said messages were not relayed regarding the male care workers. But this did cause significant stress to the family. This is also not in line with Regulation 17.

Part e of the complaint

58. Mrs X called the care provider on 24 December 2022. She requested that two named care workers did not attend the property. In the correspondence, she referred to them as accusers. I have reviewed the care visit notes from 24 December to the end date of their care contract. I have seen no record to suggest the two named care workers did attend the address. Therefore, I do not find fault. The care provider considered and agreed to Mrs X’s request.
59. The care provider told us its main priority is to the customer and continuity of care. It said in this instance the only people are of who specially raised the concerns would be the care provider and the Council’s safeguarding team. It said there was no identified risk to that care continuing with care visits due to concerns raised.

Part f of the complaint

60. The notes state the care workers changed Mrs Y’s incontinence pads throughout up until August 2022. This was because Mr Y began asking the care workers to not change the pads as he and Mr Z would do it. In December 2022 it was noted Mr Y was getting agitated about the incontinence pad not being on properly.
61. The care provider completed a care review in December 2022 and there were no issues raised in regard to the incontinence pads. In the care providers complaints response it said all staff go through the relevant training during the recruitment stage.
62. We could not say the care workers were insufficiently skills to provide Mrs Y with the care she required for her incontinence pads. This is because there is a lack of evidence to suggest there were any leaks when the care workers changed Mrs Y’s incontinence pads.

Part g of the complaint

63. Mrs X said care workers brought her father alcohol. In the care provider’s complaint’s response, it said as Mr Y was not the customer it should not have been carrying out shopping on his behalf, whether it be alcohol or otherwise. It said it had reiterated this to all carers and advised them that should any requests of this nature be made then they should contact the office team who would deal with the request in the appropriate manner.
64. The care provider has taken the appropriate action, and we cannot achieve another outcome.

Part h of the complaint

65. Mrs X complained to the care provider about nonattendance by care workers, including them being late. In its complaint’s response, it acknowledged the issues raised around care workers being denied entry due to having colds. It has also provided evidence of a refund provided in January 2023. But there is no evidence to suggest the care provider did consider the nonattendance and lateness which is detailed under care visit notes. This is not in line with Regulation 16.
66. I have also seen no evidence to suggest the care provider responded to Mrs X’s complaint regarding the failure to complete the emergency respite paperwork in properly. This is fault. But the injustice is limited as Mrs X did not want Mrs Y to go into emergency respite.

Care providers response to our enquiries

67. The care provider said it understands how stressful this situation would have been for the family. It recognised its own shortcomings where it did not live up to the high standards expected which was acknowledged in the complaint’s response. It has offered a payment of £250 to acknowledge any distress caused. This is in line with our guidance on remedies.

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Agreed action

68. To address the injustice caused by fault, within one month of my final decision, the care provider has agreed to:
• apologise to Mrs X for the fault identified in this statement;
• review the late visits and nonattendance and provide a refund; and
• pay Mrs X £250 to acknowledge the distress caused to her by the fault identified in this statement.
69. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

70. There was fault by the care provider. The actions the care provider has agreed to take remedy the injustice caused. I have completed my investigation.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman