Summary: Mrs X complains about the care provided to her late mother by the Council commissioned care provider, Guild healthcare Ltd. We find the Council was at fault. This caused significant distress to Mrs X. The Council has agreed to make several recommendations to address the injustice caused by fault.

The complaint

1. The complainant, Mrs X, complains about the care provided to her late mother by the Council commissioned care provider, Guild healthcare Ltd. She said:
1. the care was inadequate, and the care provider did not act quickly to prevent pressure sores;
2. her mother’s home was in a very poor state with numerous hazards and the home was not adequately heated;
3. the care provider has incorrectly invoiced her mother for private care that was already provided under the Council commissioned care;
4. the care provider took two days to act after it noted her mother was confused and hallucinating; and
5. there was no handover process when the care contract was terminated. The care provider removed all the care notes, plans and do not attempt resuscitation (DNAR) documents on leaving the property.

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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. 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)
4. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
5. We normally name care homes and other care providers in our reports. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
7. 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

8. I spoke with Mrs X about her complaint. I considered all the information provided by Mrs X and the Council.
9. Mrs X and the Council had an opportunity to comment on my revised draft decision. I considered their comments before making a final decision.

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What I found

10. 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.
11. 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

12. Mrs X’s, mother, Mrs Y, received domiciliary care from the care provider. In March 2021, it was noted by the Council that Mrs Y’s care calls consisted of 4 x 30 minutes calls per day. This is noted as being provided in the morning, lunch, tea and evening. There were an additional 2 x 1-hour calls per week.
13. A review of the care was completed in April 2021 by the Council. It was noted the care provider said they had made changes to the hours of care to add an additional 30 minutes to the lunch time care call. This was so Mrs Y could have a full home cooked meal each day. It was noted Mrs Y had chosen to fund this herself.
14. Mrs Y’s council commissioned care and support plan stated:
• she had a DNAR in place;
• she required assistance with preparing and serving food and drinks;
• she required support with housekeeping and similar tasks;
• she could wash and dress independently and was able to tell staff when she needed support with personal care in relation to washing;
• care workers were to ensure her home was set to a reasonable temperature and no hazards. Care workers were to report any concerns;
• Mrs X was Mrs Y’s next of kin;
• care workers were to report any concerns or refusal to eat or drink to the GP;
• Mrs Y needed assistance with incontinence care. Care workers were to notify the office when she declined personal care;
• care workers were to monitor Mrs Y’s health and report any concerns;
• Mrs Y funds the morning care visit privately; and
• the remaining council funded care visits consisted of lunch, tea and bed with an additional 2 x 1 hour visits for cleaning and putting shopping away.
15. Mrs Y’s private care plan stated visits were provided in the morning between 10:15 and 10:45am. It was noted she required support with:
• personal care;
• laundry;
• social interaction;
• incontinence care;
• housekeeping/cleaning; and
• being provided enough nutrition and hydration.
16. The Council completed an annual review of Mrs Y’s care and support needs in September 2023. It was noted that:
• the Council confirmed the current package of care consisted of 4 x 30-minute calls a day (AM, lunch, tea and bed), plus an additional 2 x 1 hour weekly visits for shopping and housework;
• Mrs Y provided an invoice she had received from the care provider. This showed she was being charged for 30 minutes every morning. The Council agreed to look into this;
• Mrs Y said she could change her pad herself. But said she required carers to dispose of them. She also said she could reposition herself;
• Mrs Y confirmed she did not have any pressure sores.
17. The Council spoke with the care provider shortly after. The care provider confirmed:
• the extra 30-minute visit was something Mrs Y had requested. This was to support Mrs Y with drink preparation, laundry if required and other things that Mrs Y requested. It said no personal care was provided as Mrs Y was independent;
• it confirmed it attended for 1 hour at lunch. This was to support with meal and drink preparation, take the bins out if needed and other light jobs that Mrs Y requested. It was also noted Mrs Y liked the support of care workers to go through/organise her things; and
• the extra 30 minutes of private care was not necessary to meet Mrs Y’s care and support needs.
18. The Council called Mrs Y. It explained the private 30 minutes was combined with her lunch time call making it an hour. It confirmed this additional half an hour was to assist Mrs Y with going through her things and any other light jobs she had. It said that it would not be able to add this care to her care and support plan. It provided her with details of voluntary services who could offer this support and help Mrs Y to organise her home. But Mrs Y declined. The Council also suggested a fire home safety check. But Mrs Y declined.
19. It was noted the care provider had made the Council aware that when care workers attempt to move things out the way in Mrs Y’s property to prevent trip hazards, Mrs Y would accuse them of stealing her things. They said Mrs Y will tell care workers what she wants them to do at each visit and will not accept anything else.
20. Care workers visited Mrs Y in December 2023. She was given a full strip wash and care workers noticed pressure sores. This was referred to the district nurse. Care workers also made a referral to the occupational therapist as Mrs Y’s legs were stiff. The care workers asked the Council if it could assist with providing a double care crew. They also asked for a review to be completed as it was noted Mrs Y’s needs were changing.
21. Shortly after, it was noted that pressure relieving equipment had been provided to Mrs Y. A safeguarding enquiry was raised by the care provider.
22. A request was also made by the care provider for an increase to the package of care. As the current care provider did not capacity, a new agency was sourced to start on the 13 December 2023.
23. The Council investigated the safeguarding enquiry in February 2024. It was noted that concerns had been raised around the level of care provided to Mrs Y. Mrs Y had been declining support and as a result, developed several pressure sores. Mrs X raised concerns about the state of the home and the extra charges Mrs Y was paying. The investigation noted:
• the daily notes document Mrs Y was visited four times per day which is in line with the care and support plan. There is consistent evidence Mrs Y was offered support with continence which was often declined;
• there was no daily recording that Mrs Y was offered personal care. This was only recorded once;
• despite declining support with continence multiple times a day, there was no evidence to suggest the care provider had taken any steps to address this;
• no concerns were raised until the pressure sore was found in December 2023. But it was clear Mrs Y had been declining support for a significant period of time before this;
• the records show the care workers recorded that they completed housekeeping and laundry every visit. But evidence from photographs taken of the property evidence it was not in a fit state and extremely unkempt;
• the photographs show large amounts of soiled and unclean clothing in the property. But no concerns had been raised about the property by the care workers;
• the care provider had provided evidence they had provided and charged Mrs Y for an extra 30 minutes per day to support with a freshly cooked meal. But the Council said there was no evidence that this had been provided. The daily records consistently shows as declined or provided with fruits and trifles; and
• the concerns were substantiated. The care provider confirmed they were looking at additional training around accurate recording and looking at when to escalate concerns around self-neglect.

Complaint to the Council

24. As part of Mrs X’s complaint to the Council, she said:
• in April 2021, the care provider put a private contract in place, as well as the contract Mrs Y had with the Council. This was discussed with the Council at the time who did not question it, despite this care already being provided within her care plan;
• in 2022, Mrs Y began to struggle to pay for this additional cost but the Council still did not question it;
• at the September 2023 review, the Council failed to adequately investigate Mrs Y’s concerns around why she was paying an additional cost;
• the Council was made aware in December 2023 that Mrs Y had been found with several pressure sores, but no safeguarding action was initiated;
• Mrs Y passed away on the 13 December 2023 after being left alone by the care provider hallucinating and extremely confused;
• she requested a safeguarding enquiry on the 14 December 2023 which has now been concluded.
25. Mrs X requested:
• all the money paid to the care provider under the private contract be reimbursed as the enquiry found no evidence to prove a meal was being provided;
• all contributions made to the Council to be reimbursed as the enquiry highlighted that care provided was neglectful and substandard; and
• compensation due to having to raise these issues over a long period of time during a difficult time.
26. In response, the Council said:
• the concerns raised were considered as part of the safeguarding. It was recognised that there were issues with the recording of information, particularly around Mrs Y having history of declined support with personal care;
• the issues raised have been addressed with the care provider. The care provider has taken this on board as part of their action plan;
• it was in discussions with the care provider to see if they would refund the charges from the private contract; and
• a refund of all the contributions Mrs Y paid was not deemed appropriate as she had received care for a number of years prior to concerns being raised.
27. Mrs X raised concerns around the potential offer to backdate payments made to the care provider. She said this was due to the safeguarding enquiry finding the care to be inadequate.
28. But the Council stated:
• despite there being some areas of concern, the care provider did complete the care visits that they had charged for;
• Mrs Y had the ability and right to set up the private agreement;
• on reflection, when the care provider advised the Council of the private agreement, the Council should have gathered more information around what these additional calls were for;
• it has now considered that the additional calls should have been considered under the commission contract as they related to the outcome outlined in the care act. The Council said if it had explored this further, its likely it would have included these calls within the commissioned care; and
• as Mrs Y was liable for contribution towards the care, the Council would apply a retrospective contract to the care provider to cover the private contract.
29. In October 2024, the Council confirmed it should have commissioned the care and said it had had backdated the contracts between February 2021 and December 2023. It said the care provider would then issue a refund to the estate. It said Mrs Y’s contribution was £5746 which remained outstanding. It also offered Mrs Y a payment of £150 in acknowledgement of the time it had taken.

Complaint to the care provider

30. Mrs X raised similar concerns directly to the care provider in May 2024. She also asked why it took the care provider two days to seek help following reports of Mrs Y hallucinating and being extremely confused. She said the DNAR paperwork was also removed from the property.
31. In response the care provider said:
• on the 6 April 2021, Mrs Y requested an additional private care visit which was put in place;
• if any of the care staff moved anything in the property or tried to clean, Mrs Y would restrict their ability to attend. Several team members were not allowed to attend the address following these calls;
• Mrs Y preferred the heating to be set at a lower temperature. They would frequently persuade Mrs Y to turn the heating up to find out she had contacted neighbours to turn it down;
• over the seven years they supported Mrs Y, she would repeatedly refuse support with personal care;
• they became aware of the pressure sores in December 2023 and made the relevant referrals;
• the GP communicated with Mrs X and Mrs Y only as the care provider did not support with medication. The social worker visited Mrs Y on the 8 December 2023, and it was evidenced Mrs Y was not taking her prescribed medication. This was reported to the GP;
• on the 11 December 2023, after the teatime care visit, the care worker reported Mrs Y was confused and possibly hallucinating. The GP was contacted online as they were closed. Mrs Y had previously said she did not want an ambulance or to attend hospital. But it was noted this was not relayed back to Mrs Y. The care provider said the care worker has been directed to complete communication, recording and refresher training and undertake further on-call training;
• during the last visit on the 12 December 2023, the care worker picked up the folder not realising the DNACPR was in there. This led to Mrs X enduring CPR which was not her wish. The care provider said the care worker has been directed to complete communication, recording and reporting refresher training. They also said they have taken them through the disciplinary process.

Analysis- was there fault by the Council causing injustice?

Part a of the complaint

32. The Council’s safeguarding enquiry found there were no daily recordings to suggest Mrs Y was offered personal care. It found that no concerns were raised until pressure sores were found in December 2023 and action was taken. But noted Mrs Y had been declining support for a significant period of time before this.
33. The care plan stated care workers were to notify the office when Mrs Y declined personal care. But as noted above, no concerns had been raised prior to December 2023, despite Mrs Y declining support. This is fault. This caused significant distress to Mrs Y and uncertainty to Mrs X as to whether the correct care was always provided. The failure to record is also not in line with regulation 17 of the CQC guidance.
34. A pressure sore risk assessment was completed in November 2023. This was rated as medium, which Mrs X said was inaccurate. In my view there were some inaccuracies in the assessment which is fault. The assessment noted Mrs Y as being continent, despite the care plan stating staff were to remove her incontinent pads. Mrs Y was taking several medications including steroids, but the assessment noted there were no medication factors to consider. The assessment also noted Mrs Y as having an average build. But it was also noted that Mrs Y was extremely thin.
35. The pressure sores were identified by care staff in December 2023. A referral was made to the district nurse and occupational therapist. Pressure relieving equipment was also provided. On balance, had the assessment been completed accurately, its likely Mrs Y would have been provided with this equipment sooner.

Part b of the complaint

36. The Council’s safeguarding enquiry found that although care workers were recording that they had completed housekeeping and laundry every visit, there was evidence the property was not in a fit state and extremely unkempt. No concerns had been raised about the property by the care workers.
37. From the evidence seen, the care provider did previously make the Council aware that Mrs Y would not allow them to move things. They said if they were to move things, Mrs Y would accuse them of stealing and would refuse to have that care worker back. Whilst I acknowledge this would have restricted care workers from carrying out certain tasks, given that there were photographs of large amounts of soiled and unclean clothing in the property, we would have expected the care workers to have raised concerns to the relevant services. This is fault which caused significant distress to Mrs X.
38. Following the outcome of the safeguarding enquiry, the care provider confirmed they were looking at additional training around when to escalate concerns around self-neglect. In my view this is an appropriate remedy.
39. Mrs X said the house was not adequately heated. In the care providers complaint response, it said Mrs Y preferred the heating to be set at a lower temperature. They would frequently persuade Mrs Y to turn the heating up to find out she had contacted neighbours to turn it down. We have two differing accounts, and I therefore cannot take a view on this.

Part c of the complaint

40. In March 2021 the Council noted the care provided as being 4 x 30-minute calls per day which consisted of morning, lunch, tea and evening. There was an additional 2 x 1hour calls per week. I have also seen an email from the Council to Mrs X in July 2024 which confirmed the care package the Council had in place consisted of 4 calls per day, including the morning visit. Within the email, the Council said Mrs Y’s contribution to her care should have been paid to the Council, rather than the care provider.
41. At the April 2021 review, it was noted care provider had added an additional 30 minutes to the lunch time call to provide Mrs Y with a hot meal. They said Mrs Y was funding this privately. The Council’s safeguarding investigation found there to be no evidence to support that Mrs Y was provided with a freshly cooked meal every day. The records consistently show as declined or provided with fruits and trifles.
42. Whilst I acknowledge the care provider did attend Mrs Y’s property, it is unclear whether this care was in addition to the council commissioned care. This is because both care plans as stated in paragraphs 14 and 15, state Mrs Y was to be provided with nutrition support. The Council commissioned care plan also noted Mrs Y would like a hot meal at lunch and tea/dinner.
43. The care provider has provided evidence of the quotation forms for the care calls which were signed by Mrs Y in April 2021. Mrs Y was charged £12.11 for 30 minutes. This was at the night rate which is payable until 9am. But as noted above, in April 2021, the care provider stated it had agreed an additional 30 minutes at lunch time. Therefore, the day rates of £10.89 which were payable between 9am and 6pm should have applied. This is fault. In January 2022, Mrs Y signed a further quotation form which arose from her wanting different times for the visits to reduce the costs to the day rates.
44. The Council carried out a review in September 2023. Mrs Y said she was being invoiced for a morning call privately. This is detailed in paragraph 16. The Council confirmed with the care provider what the additional private care call consisted of. This is detailed in paragraph 17. This is different to what the care provider said was agreed in April 2021 and there is no evidence to support when this agreement was changed, other than a quotation form signed by Mrs Y in January 2022. But this does not explain what care was agreed. The Council told Mrs Y it could not add this to her care and support plan and made her aware of voluntary services which Mrs Y declined.
45. Mrs X has provided us with copies of invoices from the care provider from 2022 and 2023. These evidence the care provider was invoicing Mrs Y for 30 minutes in the morning. Therefore, this is evidence of further fault as it is noted the additional 30 minutes was added to the lunch time call.
46. As stated in paragraph 29, the Council has now considered that the additional calls should have been considered under the commission contract as they related to the outcomes outlined in the care act assessment. It has agreed to commission the care by backdating the contracts. I have seen evidence to support the care provider sent its invoice to the Council in September 2024. But the Council has delayed in actioning this which is fault.
47. I acknowledge that Mrs Y had capacity, chose to seek a private agreement and signed forms to confirm this. But in my view, based on the evidence seen, there is uncertainty around what care was provided and what Mrs Y was charged for. This is fault. There also appears to be some discrepancy over what the care provider is saying is owed to them. The Council has agreed to backdate the contracts, but the care provider remains of the view that Mrs Y owes them money in addition. The care provider said there are outstanding invoices.
48. The Council told us the backdating of the contracts has now been approved. It said the funds will be sent to the care provider who will then send payment to Mrs X. In my view, as a result of the fault, the Council should arrange for Mrs X to receive this payment. It should also liaise with the care provider to complete an audit of what care was provided and what Mrs Y was charged for between April 2021 and December 2023. If the audit identifies that Mrs Y has been overcharged for care, the costs should be reimbursed to Mrs X.

Part d of the complaint

49. In the care providers complaints response, it said Mrs Y’s GP communicated with Mrs Y and Mrs X only as the care provider did not support with medication. The care plan stated if staff have concerns, they were to seek medical advice and/or help from the GP.
50. The care worker who attended the teatime visit on the 11 December confirmed on the notes that all was ok on leaving. But the care providers complaints response states after the teatime visit, the care worker reported Mrs Y was confused and possibly hallucinating. It said the GP was contacted online as they were closed. An online referral was made to the GP the following morning. The care provider said it also called the GP. But the care provider noted this was not relayed back to Mrs Y.
51. Mrs X provided us with GP records. This states a non-urgent request was received from the care provider on the 12 December 2023 at 10:32am which stated Mrs Y had been experiencing hallucinations and extreme confusion for two days. A GP visit was requested.
52. I have reviewed the daily notes from December 2023. The notes stated Mrs Y was ok and chatted through the visits. It did sometimes note she was very tired and noted on the 11 December 2023 she had pain in her stomach and felt sick. But there were no significant concerns noted. Other professionals also saw Mrs Y between the 10 and 11 December 2023 and raised no concerns. In my view the care provider was at fault for not updating Mrs Y and for failing to keep proper records. In its complaints response it said care worker has been directed to complete communication, recording and refresher training and undertake further on-call training. This is an appropriate remedy.

Part e of the complaint

53. Mrs X said there was no handover process when the care contract was terminated on the 12 December 2023. She said the care workers removed all care notes, plans and DNAR documents on leaving the property. When the new care agency attended Mrs Y’s property on the 13 December 2023 and found her unresponsive, they were not aware she had a DNAR in place.
54. The care provider told us it contacted the new care provider prior to ending the contract. But it said the other provider declined a handover meeting prior to the 13 December 2023. In the care providers complaints response, it said during the last visit the care worker picked up the folder not realising the DNAR was in there. This led to Mrs X enduring CPR which was not her wish. The care provider said the care worker has been directed to complete communication, recording and reporting refresher training. They also said they have taken them through the disciplinary process. Whilst the care provider has taken action, this did cause Mrs X significant distress.
55. The Council said the new care provider would have completed their own care planning, including a conversation regarding the DNAR in due course. This would have taken place on the day the new care provider attended Mrs Y’s property. However, Mrs Y sadly died on the day the new care provider attended her property.
56. The care provider has acknowledged it was at fault for removing the DNAR from the property. We acknowledge the action it has taken. But this did cause significant distress to Mrs X as this led to Mrs Y’s wishes not being followed.

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Agreed action

57. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Care Provider, I have made recommendations to the Council.
58. Sadly, it is no longer possible to remedy the injustice to Mrs Y as she has died. To remedy the injustice to Mrs X caused by fault, within one month of the date of my final decision the Council has agreed to:
• write to Mrs X with an apology that takes account of our published guidance on remedies and accepts the findings of this investigation;
• liaise with the care provider to complete an audit of what care was provided and what Mrs Y was charged for between April 2021 and December 2023. If Mrs Y was overcharged for any care (council commissioned care or private care), this should either be disregarded if charges are considered to be outstanding or reimbursed to Mrs X if the payment had already been made;
• arrange for Mrs Y to receive the backdated payment from the care provider; and
• pay Mrs X £300 to acknowledge the distress and uncertainty caused to her by the fault identified in this statement.
59. The Council should provide us with evidence it has complied with the above actions.

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Final decision

60. There was fault by the Council. The actions the Council has agreed to 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