An independent provider in the Blackpool area

6. Ms N complains about the care her mother, Mrs C, received from the Provider in 2024. Ms N says the Provider:

•often did not attend at the appointed hours •did not ensure her mother took her medication before a Medicine Administration Record (MAR) chart was instituted in November 2024 •did not attend to her mother’s hygiene needs •repeatedly sent a carer who was rude and antagonistic to her father, Mr C, in July 2024, despite requests they be changed.

7. Ms N says the experience has caused significant stress, distress and anxiety to her and her father. She says this meant he had to seek support from his GP and sometimes felt suicidal.

8. Ms N is seeking an apology, service improvements and financial remedy.

9. Ms N’s mother, Mrs C, had a complex medical history, including dementia, cerebral atrophy, osteoporosis and diabetes.

10. In April 2024, the Provider was contracted under an NHS Continuing Health Care (CHC) package to provide care. This initially funded seven hours per day on Tuesday, Wednesday, Friday and Saturday. In June, this increased to include an hour in the evenings every night of the week, including the days already funded. An additional seven hours of care was also funded on Sundays. In November, a 15-minute medication visit was instituted at 9.30am and 1.30pm and the seven-hour visits were split into two separate visits, one each in the morning and afternoon.

11. Ms N and Mr C raised concerns about the Provider’s care via phone and email in May and July. In November, Ms N made a written complaint and the Provider instituted changes to the medication care plan in response. Ms N made a further complaint in December 2024 and The Provider responded in January 2025. On 9 January 2025, Mrs C sadly died. We offer Ms N and Mr C our condolences for their loss.

The Provider often did not attend at the appointed hours in the evenings

15. Ms N says the Provider often attended its evening appointments with Mrs C outside of the appointed hours.

16. The package of care states the contracted time for evening visits was between 9.30pm and 10.30pm.

17. The visit records show carers generally attended Mrs C between 8pm and 9.30pm.

18. The NHS Standard Contract between the Integrated Care Board (ICB – the local commissioner of NHS services) and the Provider says the care provider should ensure calls are delivered at the agreed time. It says as an exception, the care provider can deliver the call within 30 minutes of the agreed time and should have systems in place to inform the service user of any delay.

19. The visit records do not generally document any issues raised by Mr C regarding the timing of the evening appointment. They show Mr C first queried the timing of an evening visit in June, when the carer arrived at 10pm. Mr C is documented as saying this was too late for a night visit.

20. In September, when the carer arrived at 7pm, Mr C is documented as saying he did not want it so early, and requested 8.30pm. In October, Mr C cancelled visits twice on the grounds it was too late. On these occasions, the carer arrived at 9.30pm and 9.22pm.

21. The records show a carer was scheduled to attend for Mrs C’s evening appointment between 7.30pm and 8.30pm on 101 occasions. On these occasions, the actual time of attendance was generally within 30 minutes of the scheduled time.

22. The records show a carer was scheduled to attend for Mrs C’s evening appointment at Mr C’s requested time of 8.30pm on 23 occasions. On these occasions, the actual time of attendance was generally within 30 minutes of the requested time of 8.30pm. There were three occasions where carers attended outside of 30 minutes from the requested time of 8.30pm.

23. The records show a carer was scheduled to attend Mrs C at the contracted time of 9.30pm on 19 occasions. Of these, they attended at Mr C’s preferred time of approximately 8.30pm on ten occasions. On other occasions, the records show the actual time of attendance was generally within 30 minutes of the contracted time.

24. The records show a carer was scheduled to attend Mrs C between 10pm and 11pm on four occasions. Of these, a carer attended earlier on three occasions.

25. Having reviewed the records, they show significant variation in the time the Provider attended Mrs C in the evening. The contracted hours were between 9.30pm and 10.30pm, but Ms N and Mr C appeared to believe the contracted hours were between 8.30pm and 9.30pm. There is no record of the Provider explaining this to them. There is some record of the Provider making efforts to attend at Mr C’s requested time of 8.30pm.

26. The records show the Provider generally scheduled carers to attend Mrs C between 7.30pm and 8.30pm. This is two hours earlier than the contracted time of 9.30pm and one hour earlier than Mr C’s requested time of 8.30pm. There is no evidence this was requested by Mr C or Ms N.

27. On the balance of probabilities, we consider the Provider generally attended Mrs C’s evening appointment significantly outside of the contractually agreed times. Although it appears the Provider did make some efforts to attend at Mr C’s requested time of 8.30pm, there is no evidence it explained the contracted hours to Mr C. This variation in the time of attendance is indicative of a failing on the part of the Provider, and would have caused distress and frustration for Mr C and Ms N.

28. We use our Severity of Injustice (SOI) scale to calculate appropriate financial remedy where failings are identified. Our SOI scale defines a level two injustice as distress or inconvenience which had a relatively low impact on the person affected. In these cases, we consider an apology is not suitable by itself. We have concluded the variation in the timing of the Provider’s evening appointment, which was generally considerably outside of contracted hours, would have caused a degree of distress and inconvenience to Ms N and Mr C. This places it in level two of our SOI.

29. Based on this and previous similar cases, we believe an appropriate level of financial remedy would be £300.

30. We contacted the Provider to discuss this. Following our contact, the Provider agreed to pay Ms N and Mr C financial remedy of £300 and make a further apology to Ms N and Mr C for the identified failings, explaining what actions will be taken to ensure these failings are not replicated in the future.

31. We consider this sufficient to resolve this part of the complaint. We will therefore not be looking at this part of the complaint further.

The Provider did not ensure Mrs C took her medication before a Medicine Administration Record (MAR) chart was implemented in November 2024

32. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications something has gone wrong.

33. Ms N complains the Provider failed to ensure her mother took her medication in the period April to November 2024. In November 2024, an MAR chart was implemented. Ms N says this should have been in place from the start of her mother’s care.

34. The Provider said that between July and November 2024, it did not have authority to give medication, as it was being given from a family filled pill box. It said while medication was recorded as taken on visit records, staff would not have prompted Mrs C to take it as they did not have authority to do so. The Provider said once it became aware of the issue in November and confirmed no other providers were giving Mrs C medication, it implemented an MAR, added Mrs C’s medication to its app and administered medication from that date onward.

35. The Provider started Mrs C’s care in April 2024. The NHS contract for this care included prompting medication administration. In November 2024, the contract was updated to include assisting Mrs C with her medication, as described in her Needs Assessment.

36. NMC guidance says nurses should give families, as far as the law allows, the information they want or need to know about their loved one’s health, care and ongoing treatment sensitively and in a way they can understand.

37. Our adviser said prompting should have included encouraging and reminding Mrs C to take her medication, but not administering the medication. They said if Mrs C refused her medication, carers should have highlighted this to her husband. They said the records showed carers did prompt Mrs C to take her medication. When Mrs C declined to take her medication, the records show carers informed Mr C. Our adviser said this was in line with NMC guidance.

38. The records show Mr C sometimes asked carers to administer Mrs C’s medication and there was variation in how carers responded. On some occasions, carers administered Mrs C’s medication. On others, carers waited for Mr C to administer it. At other times, carers documented they were not able to administer Mrs C’s medication and made Mr C aware.

39. In summary, carers consistently prompted Mrs C to take her medication prior to November 2024 and informed her husband when she refused. Administering medication was outside of the contracted service provision prior to November 2024.

40. We recognise Ms N’s concern that the Provider did not ensure Mrs C took her medication. Having reviewed the evidence we are satisfied the Provider consistently prompted Mrs C to take her medication and informed Mr C when she refused, which is line with relevant guidance. We will therefore not be looking at this part of the complaint further.

The Provider did not attend to Mrs C’s hygiene needs

41. The records show carers generally recorded some details of Mrs C’s hygiene needs in their visit notes.

42. NMC guidance section 1.1 says nurses should treat people with kindness, respect and compassion. Section 2.5 says nurses should respect, support and document a person’s right to accept or refuse care and treatment.

43. Our adviser said carers did attend to Mrs C’s hygiene needs. The records show carers changed Mrs C’s underwear and hygiene products, washed her and changed her clothes. This is in line with NMC guidance.

44. The records show there were occasions when Mrs C refused care. On these occasions, carers prompted and encouraged Mrs C and informed Mr C if they were not successful. Our adviser said this was in line with NMC guidance.

45. In summary, carers attended to Mrs C’s hygiene needs in line with her care plan and documented any refusals in line with nursing standards.

46. We recognise Ms N’s concern that the Provider did not attend to Mrs C’s hygiene needs. Having reviewed the evidence, we are satisfied the Provider cared for Mrs C’s hygiene needs in line with relevant guidance and Mrs C’s care plan. We will therefore not be looking at this part of the complaint further.

The Provider repeatedly sent a carer who was rude and antagonistic to Mr C in July 2024

47. Ms N says the Provider repeatedly sent a carer who was rude and antagonistic to her father, Mr C, in July 2024, despite requests it not send her. She says she made this request on several occasions by phone.

48. The Provider told us that when a client requests a specific staff member not to attend, it does not usually remove them from the visit unless there is an immediate danger, to ensure a fair process for its staff. It said it required time to assess why a client did not want a specific staff member to attend and sought to resolve any issues in the first instance. It said it was unable to immediately action Ms N’s request due to Mrs C’s requirement for female only staff.

49. We requested the recordings of the calls from Ms N and Mr C to the Provider concerning this issue. The Provider informed us the recordings were not available.

50. The written records show the issue with this specific carer first arose in late July. The following day, the records show the carer in question was aware of the issue and the office was informed. The next day, the carer was refused entry by Mr C and the visit records document the office was aware. There is no incident report concerning this issue. Two days later, the carer was refused entry by Mr C. The following day, the carer was refused entry by Mr C upon identifying herself. The records show the carer did not attend again after this date.

51. The Provider’s complaint file documented the carer in question left the company at the end of July. It said the slow speed of internal action was due to an administrative error.

52. We recognise Ms N’s concern that the Provider repeatedly sent a carer whom she and Mr C had objected to. Having reviewed the evidence, we are satisfied the Provider dealt with this issue in line with its internal processes which does not require immediate removal of a carer. We will therefore not be looking at this part of the complaint further.

53. We thank Ms N for taking the time and effort to bring her complaint to our attention. We recognise how distressing this experience has been for her and Mr C. We hope our explanation and the further apology from the Provider provides some reassurance about the care and treatment Mrs C received. We wish Ms N and Mr C the best for the future.

1. We have carefully considered Ms N’s complaint about the care the Provider gave her mother, Mrs C, in 2024.

2. We were very sorry to hear Ms N’s experience caused her and her father, Mr C, distress and anxiety.

3. We have looked at the Provider’s care and treatment of Mrs C over this period. We consider the Provider prompted Mrs C to take her medication and attended to Mrs C’s hygiene needs in line with guidance. We consider the Provider handled concerns over the suitability of a specific carer in line with its internal policies. On the balance of probabilities, we consider the Provider generally attended Mrs C’s evening appointment significantly outside of the contractually agreed times and this likely caused distress and frustration for Mr C and Ms N.

4. We contacted the Provider to discuss this complaint. Following our contact, the Provider agreed to pay Ms N £300 and to make a further apology for the distress caused, explaining what actions will be taken to ensure these failings are not replicated in the future. We consider this sufficient to resolve this complaint. We explain this in more detail below.

5. We hope our explanation and resolution provides reassurance for Ms N about the care and treatment her mother received.