Decision Date: 18 December 2024
Summary
Unique Senior Care – Warwickshire failed to give proper notice that Ms Y’s long-term care workers would be away. Mr X claimed that this prevented him and Ms Y’s other relatives from making alternative arrangements. Mr X also claimed that the care provider failed to provide appropriate care for Ms Y, until she moved to a care home in November 2023.
What happened
Mr X’s relative, Ms Y, had dementia.
In May 2022 Ms Y’s family arranged for a company (USCW) which was run by Understanding Care (Warwickshire) Limited (the care provider) to provide live-in care for Ms Y under a power of attorney which he held for her.
[The pattern was likely to have been the conventional two or four weeks of live-in care from a given person, followed by a break covered by another one, with short breaks being provided by a temporary worker. Here, there is a brief mention of some other company providing cover for breaks – and it is unclear whether short daily breaks are what is meant, in that regard, or breaks for a week or longer period. You can read more about this model here: https://www.thegoodcaregroup.com/live-in-care/what-is-live-in-care/]
In February and May 2023 Ms Y did not respond well, when she had a temporary replacement live-in care worker.
In August 2023 Mr X was told that both Ms Y’s main care workers would be away for a considerable period (months rather than weeks, in the case of one of them).
On 21 August Mr X emailed the care provider. Mr X asked about plans to replace them and noted the previous experience of temporary care workers. There was no record of a response from the care provider.
Between 23 September and 8 October the care workers either made no records or simply recorded “care was provided successfully”. However, on 7 October Ms Y’s family told the care provider they were concerned about Ms Y’s mental health as the care worker had been unable to get her out shopping.
On 9 October there was a handover from one care worker to another. On 10 October the care worker recorded that it had been a “rough day” but provided no more information. On 10 October, the care provider told Mr X it had visited Ms Y. It said Ms Y had deteriorated a great deal and that the previous care worker had not taken her out.
On 12 and 15 October Ms Y was confused and confrontational. The care worker called 999 on both occasions. On 12 October the care worker contacted Ms Y’s GP on the advice of the emergency services. The GP prescribed antibiotics for a potential urinary tract infection. On 17 October, the care worker contacted Ms Y’s GP again who recommended contacting a dementia nurse.
On 18 October the care provider told Mr X that it had contacted the community dementia team about Ms Y. It said that Ms Y’s home smelt of faeces and she was refusing medication.
On 20 October the care provider sent a statutory notification to the Care Quality Commission (CQC) on the basis Ms Y had been the victim of neglect. The referral outlined events since 12 October. It said Ms Y refused to take her antibiotics and was refusing to eat or wear continence pads. It said paramedics had said they would organise “hospital at home” as Ms Y needed medication via a syringe.
On 23 October Mr X forwarded an e-mail from a sibling to the care provider which noted Ms Y had required persuasion from paramedics or relatives to take medication and that the care worker was not taking Ms Y out even to the garden. It also raised concerns about cleanliness and tidiness.
In response to Mr X’s e-mail, the care provider agreed that Ms Y had declined during the weeks during which the long-term carer had been away. It also said that Ms Y had been difficult for the temporary care workers to manage. It apologised for the state of Ms Y’s home and said it was unacceptable.
On 27 October Ms Y’s long-term care worker returned to work. She noted Ms Y’s uncleanliness, frailty and poor health. Ms Y had not taken her medication but the care worker encouraged her to do so.
From 28 October until 5 November the care worker made detailed records of the support provided to Ms Y, who continued to have problems with continence, cleanliness and medication. Ms Y was at times angry and confrontational.
On 1 November the care provider noted Ms Y may need to go to a care home as she needed two care workers and there was not enough room in her flat for two of them to stay with her.
Mr X told the care provider the family had arranged for Ms Y to live in a care home from 6 November.
In March 2024, Mr X complained to the care provider about the problems with Ms Y’s care.
In April 2024, the care provider replied to Mr X’s complaint it said:
· It only employed experienced live-in care workers, with at least one year’s experience in a care setting. The need to provide alternative care workers was beyond its control. It could never guarantee care from only two main care workers. [It may be that this is the context for the report stating that the company said it “did not discuss alternative care workers. We can’t tell whether the report means to convey that this had not been discussed at the point of making the contract, or whether it was saying that it would not discuss the matter of alternatives in the ordinary course of delivering the service, because it was inevitable that people have to be replaced.]
· It had liaised with other agencies including a dementia nurse, a GP, paramedics, an occupational therapist and a social worker. The company did not accept there were grounds to refund money because of the progression of Ms Y’s condition [even though it had reported itself for neglect.]
· On 12 September the care worker reported a progression in Ms Y’s dementia and a more dramatic mood swing. There had been no need to report this to Mr X. It had told Mr X about the antibiotics prescription and contacting the NHS dementia Team.
Ms Y was settled in the care home.
What was found
It would have been good practice for the care provider to let Ms Y’s family know it was arranging replacement care workers. However, there was not enough evidence that they would have arranged for Mrs Y to stay in a care home, even if the family had been given more notice.
There were problems with the care worker’s records. The record for 22 September described Ms Y as a problem which indicated a lack of person-centred care. The lack of detailed records during certain periods was also unacceptable given that things were clearly not going well. There was no evidence the care provider was addressing the failure to meet Ms Y’s needs or the change in her circumstances.
It was clear Ms Y’s needs were not being met. Her long-term carer recorded shock at her appearance. She questioned the departing care worker’s claim to have washed Ms Y. The long term worker also recorded that it was possible to get Ms Y to accept support with sensitivity and encouragement.
The care provider did take some steps to address the decline in Ms Y’s condition by contacting other agencies. However, it completely failed to make meaningful contact with the local authority which could have assessed Ms Y’s needs. It falsely told Mr X that it had contacted the local authority which had recommended two care workers. It later acknowledged that this recommendation had come from a paramedic (who would not have been qualified to make a formal recommendation). The care provider also failed to make meaningful contact with the mental health team, as it took no further action when it did not get a response to the message it left.
It was recognized that Ms Y had a progressive illness. Nevertheless, the ombudsman found failure to keep proper records, the lack of person-centred care and the failure to meet all Ms Y’s care needs caused avoidable distress which warranted a remedy.
The LGSCO recommended that the care provider write to Mr X apologising for the failure to meet all Ms Y’s needs and pay her £1000. They also recommended that the care provider identify the action it would take to ensure its care workers keep proper records and understand the meaning of person-centred care.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The lack of meaningful contact with the Council or CMHT to access services to which all members of the public are entitled is only touched on here, but it is key in our view to the incompetence of this particular provider’s management. In reporting itself for neglect of the client to the CQC whilst asserting in a complaint that despite its best intentions no money was due back because the problem was all down to the client’s deterioration ought to be ringing bells with the Ombudsman – as the two stances are not consistent.
It is unclear to what extent the client in this situation had been assessed for mental capacity and this should be something that any provider of care at home undertakes to do, because it will be key to instructing staff as to the approach to take to essential care – the whole point of the MCA is to ensure that benign hands-on or interventionist care can in fact be safely provided regardless of consent. This is an essential part of the business of providing care, after all, and not all intervention can be done by way of mere persuasion. It requires firmness, and this is part of what is being paid for.
Mere intransigence – even articulate intransigence is not the determinant of capacity – hence the need for a proper decision to have been made. It is not unusual for family members to have no awareness of the MCA legal framework even when they have got a power of attorney for health or welfare (here there was both).
Section 5.49 of the Mental Capacity Act Code of Practice states that there is a duty on the decision-maker to consult other people close to the person who lacks capacity on decisions affecting the person and what might be in the person’s best interests.
The provider failed to equip itself with the necessary information and views from Mr X or Ms Y’s other relatives regarding the replacement of her main care workers – in our view that is a basic pre-requisite for determining what level of skill or experience must be sourced for a competent system of replacement on this kind of rota. However, it should also be noted that when an attorney makes this kind of arrangement they too are bound by best interests principles (and should surely have understood the basic pattern of what they were choosing to fund with Ms Y’s money?)
It was not unreasonable of the provider to say that it could not guarantee care from only two main care workers because the rules relating to Working Time etc make it unlawful to do that. It is however a straightforward breach of contract in terms of supply of services to fail to provide competent temporary cover.
The replacement care worker lacked the confidence to take Ms Y out. The family had noted the impact this had on Ms Y’s mental health. Therefore, had there been more communication with the provider its management would have likely understood the type and skill level of care worker from whom Ms Y would have benefited.
Mr X also contended that the failure to inform him of the temporary absence of the main care workers prevented him and Ms Y’s other relatives from considering alternative arrangements. The Ombudsman found that there was insufficient evidence that Mr X would have arranged alternative arrangements as he only raised this point after Ms Y was already in a care home. However, on the 21 August 2023 Mr X emailed the care provider asking for information about the replacement care workers. The fact that he was concerned about this means that he may have considered alternative arrangements such as a care home.
The Ombudsman’s report noted that the characterisation of Ms Y as a “problem” indicated a lack of person-centred care. Potentially, the Ombudsman could have been more critical of the care provider’s attitude to Ms Y’s care as being uninformed by the Mental Capacity Act.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Understanding Care (Warwickshire) Limited (23 020 187) report.
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