Summary: Mrs X complains, on behalf of her father, Mr Y, Barchester Healthcare Homes Limited mishandled the pre-admission process and failed to ask relevant questions before her father moved into in the home. She says the Care Provider failed to engage with her or social services to complete a re-assessment. Mrs X also complained the Care Provider took a long time to respond to the complaint and provided inaccurate information. Mrs X says the complaint procedure was not completed in accordance with the policy. Mrs X feels both she and her father have been caused distress. We have found fault with the Care Provider’s complaint handling and recommend it pay a small financial remedy.

The complaint

1. Mrs X says the Care Provider:

• mishandled the pre-admission process and failed to ask relevant questions before her father moved into the home,
• failed to engage with her or social services to complete a re-assessment, and
• took a long time to respond to her complaint, provided inaccurate information and the complaint investigation was not completed in accordance with its policy.

2. Mrs X says the Care Provider has caused both her and her father distress.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

6. I have considered all the information Mrs X provided and discussed the complaint with her. I have also asked the Care Provider questions and requested information, and in turn have considered the care providers response.
7. Mrs X and the Care Provider have provided comments on the draft decision which have been considered before a final decision was issued.

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What I found

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. Regulation 9 requires person centred care. Regulation 10 requires care providers to treat people with dignity and respect. Regulation 12 requires the care provider to provide safe care and treatment.
9. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. The CQC’s guidance says care providers should carry out, collaboratively with the relevant person, an assessment of the needs and preferences for care and treatment of the service user 9(3)(a).
10. The Care Provider’s admissions policy says a Regional Director should authorise admittance of residents if one of several criteria were met which would cause concern.

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What happened

11. Mrs X arranged a placement for her father, Mr Y, at the Care Providers property in early May 2023.
12. The Care Provider completed a pre-admission assessment with Mrs X and Mr Y at their home address on 5 May 2023. Based on this assessment, as neither Mrs X or the Care Provider had identified Mr Y had complex needs or any needs which required Regional Director authorisation, the Care Provider felt that it could deliver the care that Mr Y needed.
13. Mr Y moved in on 11 May 2023.
14. Mrs X had to collect Mr Y the next day following an incident where Mr Y tried to leave the property.
15. The Care Provided found Mr Y a place in a different unit at the home and moved back in on 16 May 2023. Mrs X was told she could not put-up pictures she had brought with her for her father’s room. The Care Provider said this needed to be done with specific equipment and the maintenance team would need do this.
16. An incident took place on 18 May 2023 where staff found Mr Y inappropriately presented in the dining room with another resident. The Care Provider contacted Mrs X and told her of this. At this point, Mrs X told the Care Provider that Mr Y had acted inappropriately with her and a carer previously.
17. Following a risk assessment, the Care Provider put a sensor in Mr Y’s room which would alert staff if he tried to leave the room. The Care Provider says it also increased visual checks.
18. Mr Y was involved in a serious incident in the morning of 20 May 2023. The Care Provider notified the Local Authority safeguarding team, community mental health team and Mrs X. Mrs X says the Care Provider told her to collect her father.
19. The mental health team and Mrs X then agreed the most appropriate step was for Mr Y to have one-to-one care within the home until a setting better suited to his needs was found. This was arranged by the Local Authority in agreement with the Care Provider and Mrs X. Mrs X was to pay for this.
20. Mr Y had one-to-one care until he went into hospital six weeks later. After being in hospital Mr X moved to another care setting. The Care Provider says one-to-one care remained due to the nature of the incident until Mr X went into hospital.
21. Mrs X raised concerns with the Care Provider in June 2023. Mrs X then raised a complaint in July 2023 and the Care Provider said it would issue a response within 20 days.
22. The Care Provider and Mrs X had a meeting in August 2023 and a final response was issued to the complaint in October 2023 in which it apologised for some areas of fault.
23. The Care Providers website says it deals with complaint in a two-stage process and a full response is issued within 20 days.
24. Mrs X chased the Care Provider in the period between raising the complaint and receiving the response and asked them to clarify what stage the complaint was at. Mrs X says she was told the complaint was being dealt with at stage two. However, the Care Provider says this wasn’t the case and apologised if it had provided misleading information.

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Analysis

Pre-admission assessment and one to one care

25. The Care Provider did a pre-admission assessment with Mrs X and Mr Y in early May to find out if it could meet Mr Y’s needs. This assessment included questions about behaviours that might cause concern. The assessment records the answer to this question as no.
26. The terms and conditions of the Care Provider’s contract with Mr Y and Mrs X set out that if it had reason to believe Mr Y had complex needs, including behaviour causing concern, admission would need to be further considered and authorised by the Regional Director of the provider. As the pre-admission assessment did not note anything in relation to this, the Care Provider agreed it could meet Mr Y’s needs and it did not need further consideration to admit Mr Y.
27. After the Care Provider found Mr Y in the dining room, Mrs X told the Care Providers that Mr Y had behaved inappropriately previously. I cannot see any record to show the Care Provider was told this information before the incident.
28. I am satisfied the Care Provider took appropriate action to gather information about Mr Y before deciding whether it could meet his needs and based its early care on the information it had received. The admission document had clear sections to records these needs. The Care Provider also had a process and policy in place to ensure that those identified with complex needs had further consideration as to whether their needs could be met. Whilst the Care Provider was responsible for gathering information to assess Mr Y’s needs, responsibility was also with Mr Y and his representatives to ensure information shared with the provider was reflective of his needs. I do not find the Care Provider to be at fault on this point.
29. Mrs X says the Care Provider did not engage with her or social services to reassess Mr Y after one-to-one care started. However, I am satisfied there were discussions between Mrs X, the Care Provider and the Local Authority about one-to-one care and the reasons for this. The Care Provider has explained Mr Y needed one-to-one care in its view due to the nature of the incident. The Care Provider also has a duty to safeguard both staff and residents and made the decision for one-to-one care as part of a multi-agency agreement to keep everyone safe. I do not find the Care Provider to be at fault on this point.

Personal belongings

30. The Care Provider says in its complaint response it did not hang the pictures as the incidents took place relatively shortly after Mr Y moved in. It says the maintenance team had not had time to hang the pictures before it was decided a new setting would be found for Mr Y. It also explained it locked away items for safekeeping after staff found them in other spaces. The Care Provider apologised for any distress this caused.
31. I accept the Care Provider could have hung the pictures which Mrs X brought with her and kept returning any of Mr Y’s belongings to his room to aid him in the onboarding process. However, the reasons explained by the Care Provider are reasonable given the short time between Mr Y moving into the property and the incidents taking place. The Care Provider has also apologised for any distress caused which is a reasonable remedy.
32. I cannot say that had the Care Provider taken any other action the incidents would not have occurred.

Complaint handling

33. I cannot see the Care Provider followed its complaint process. Mrs X emailed the Care Provider to ask about the stage the complaint was at and had to chase the Care Provider for clarification and a response. This is fault as the Care Provider should have been clear with Mrs X about how it was dealing with her complaint. This has caused Mrs X both confusion and distress.
34. The Care Provider has said the complaint did not complete its complaint process. However, it had enough time to review the complaint before Mrs X brought to the Ombudsman. The Care Provider had not issued responses in line with its complaint procedure.

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Agreed action

35. Within one month of my final decision the Care Provider should:

• Apologise to Mrs X for the confusion caused about what stage the complaint was at and for failing to respond within the timescales it outlined.
• Pay Mrs X £100 to recognise the upset and confusion caused to her.

36. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

37. I have found fault in the Care Providers complaint handling. I have not found fault with the Care Provider for its handling of the admissions process and care decisions for Mr Y.

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Investigator's decision on behalf of the Ombudsman