Summary: Mr X complained, on behalf of his grandfather Mr Y, about the Care Provider’s Broadoak Manor Nursing Home. The Care Provider delayed sending required information about fees to Mr Y’s family and failed to keep accurate and complete records about Mr Y’s care. This contributed to a delay in Mr Y moving to a new care home and caused avoidable uncertainty to Mr X. The Care Provider agreed to further reduce Mr Y’s care fees, apologise to Mr X and pay him a financial remedy. It also agreed to review how it records the care it provides.

The complaint

1. Mr X complains, on behalf of his grandfather Mr Y, about the Care Provider’s Broadoak Manor Nursing Home. He says that during Mr Y’s stay the Care Provider failed to:
• send them a contract for Mr Y’s stay until shortly before he left the care home;
• provide adequate personal care;
• ensure Mr Y received the medication he needed; and
• check on Mr Y regularly after several falls.
2. As a result, Mr X says Mr Y went without adequate care, his health deteriorated and was charged more for his care than he expected. Mr X wants the Care Provider to properly apologise and provide a greater discount on Mr Y’s outstanding fees than it has already offered.

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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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
4. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
5. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
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 considered:
• the information Mr X provided and discussed the complaint with him;
• the Care Provider’s comments on the complaint and the supporting information it provided; and
• relevant law and guidance.
8. Mr X and the Care Provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

Information about private care fees

10. Where someone is responsible for paying some or all of the costs of their care, their care provider must give them, or the adult representing them, a written statement of the terms and conditions of their care, including the amount of their care fees. As far as possible, that information should be provided before the care provider starts providing services. (Care Quality Commission (Registration) Regulations 2009, Regulation 19)

Fundamental standards of care

11. 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.
12. Regulation 9 says care providers must provide care that is appropriate, meets the needs of the person receiving care and, reflects that person’s preferences. To do this, care providers must involve the person receiving care in planning the care they need, help the person make decisions where they can and involve the person in their own care as much as possible.
13. Regulation 11 requires care providers to seek the consent of the person receiving care before it provides care for them. This applies each time care is provided and this will often be many times a day for someone in a care home. If someone lacks the ability to agree to receive personal care, a care provider cannot force someone to receive care unless it decides it is in the person’s best interest to do so and there are no other reasonable alternatives.
14. Regulation 12 says care providers must provide care in a safe way. This includes assessing the risks to those receiving care, doing what it reasonably can to mitigate those risks and properly managing any medication.
15. Regulation 17 requires care providers to keep accurate, complete and contemporaneous records of the care it provides and the decisions it makes about that care.

Background

16. Mr Y has care and support needs related to a diagnosis of Alzheimer’s disease. He also has problems with circulation and his skin. When Mr Y moved to the Care Provider’s Broadoak Manor Nursing Home (the Care Home) it noted that Mr Y:
• had a history of falls, including a recent admission to hospital;
• needed support from two carers for most tasks, including personal care and moving around;
• needed to use a walking frame when moving around;
• needed a ‘crash mat’ when sleeping to reduce the risk of injury if Mr Y got out of bed in the night;
• needed help repositioning himself to reduce the risk of developing skin problems.
17. Mr X is Mr Y’s grandson and has lasting power of attorney for Mr X. I am satisfied that due to Mr Y’s illness he is unable to authorise Mr X to complain for him and that Mr X is a suitable person to bring the complaint on behalf of Mr Y.
18. Mr Y started his stay in the Care Home in late July 2021. His local council arranged the care home placement, at first, on a temporary basis while it assessed Mr Y’s finances to decide if he qualified for council help with his care costs.
19. In December 2021, the Care Provider contacted Mr Y’s local council as it had not received any payments for Mr X’s care since late August 2021. The council told the Care Provider it had wrongly stopped the payments and reinstated these in January 2022. However, the Care Provider later discovered the council had decided Mr Y did not qualify for council help with his care costs, apart from NHS Funded Nursing Care payments, and therefore the council considered him to be a self-funding resident from late August 2021. The council confirmed this in early February 2022.
20. Around a month after this, the Care Provider sent Mr X, as Mr Y’s representative, an invoice for Mr Y’s care fees between late August 2021 and the end of February 2022. It also says it sent Mr X a contract for Mr Y’s care home placement. Mr X says he did not receive a copy of the contract from the Care Provider at that time.
21. Shortly after receiving the invoice, Mr X contacted the local council about Mr Y’s care home funding and told the Care Provider that Mr Y could not afford the fees it had charged. Mr Y’s family arranged for Mr X to move into a different care home from early April 2022.
22. Mr X complained to the Care Provider in September 2022 and raised further concerns about Mr Y’s time at the Care Home in March 2023.
23. The Care Provider sent its final response to Mr X’s complaint in mid-March 2023. It accepted that:
• Mr Y had several falls while at the Care Home and, in some cases, care staff had failed to properly complete all the post-fall checks on Mr Y;
• care staff had sometimes failed to record when they had helped Mr Y to change position;
• the Care Home had lost some of Mr Y’s personal belongings and these were not returned to him when he left the Care Home; and
• the dosage of some of Mr Y’s medication had not been increased at the right time, but this was because his doctor had not told the Care Home about the increased prescription. The Care Provider apologised that it had previously told Mr X that the delay in increasing Mr Y’s medication was shorter than it was.
24. The Care Provider paid Mr Y £500 Mr Y to cover the costs of the belongings Mr X said were missing and reduced Mr Y’s fees by £2,400 in recognition of the delays with increasing Mr Y’s medication.
25. Mr X was not satisfied with the Care Provider’s response, so he complained to the Ombudsman in

Information about Mr Y’s care fees

26. Care home was first notified by the council about the change to Mr Y’s funding arrangements in early February 2022. Before that point, it had no reason to believe Mr Y would be funding his own care. Therefore, before then it had no duty to send Mr Y or his family details about the fees.
27. Once the Care Provider became aware in February 2022, it should have sent Mr Y of his family the required information about the terms, conditions and fees as soon as possible. However, it did not do this until a month later and has not provided a good reason for that delay.
28. Although Mr X said he did not receive a copy of the contract from the Care Provider, he did receive the invoice it sent around the same time. Therefore, I am satisfied that Mr X knew how much Mr Y’s fees were in early March 2022. He contacted the local council about this shortly afterwards.
29. Mr Y’s family moved him to a different care home very quickly after they knew how much the fees would be. Although Mr Y’s needs had also increased, I am satisfied that if they had known this sooner, they would likely have arranged a different care home for Mr Y sooner.
30. Allowing a reasonable period for the Care Provider to send the required information about fees, my view is there was a delay of three weeks in providing the required information to Mr X. Had that delay not happened, Mr Y would likely have moved three weeks sooner. Therefore, the delay caused an injustice to Mr Y so was fault. The Care Provider should deduct three weeks’ worth of care fees from Mr Y’s outstanding balance.

Care provided to Mr Y

31. In its response to my enquiries, the Care Provider was only able to provide care records for the early part of Mr Y’s stay. These records showed:
• the Care Provider took into account both Mr Y’s individual needs and the preferences he was able to share when planning his care. It also says it based this care plan on one provided by Mr Y’s local council which set out his care needs in detail;
• the Care Provider appropriately sought Mr Y’s consent to receive care. There is evidence that Mr Y sometimes declined support with aspects of his personal hygiene. In those cases, carers asked again on a latter occasion and Mr Y accepted the help offered;
• no evidence that Mr Y’s personal hygiene was significantly neglected or that carers did not offer help to Mr Y on a regular basis; and
• the Care Provider took steps to manage Mr Y’s risk of falling, including using ‘crash mats’ in his bedroom when Mr Y was sleeping.
32. However, there were also gaps in the records detailing:
• when Mr Y was helped to reposition himself as regularly as his care plan said he should; and
• some of the checks which should have happened after Mr Y fell.
33. The Care Provider accepted these failures in its response to Mr X’s complaint.
34. Mr X says there were occasions when Mr Y’s personal hygiene should have been better, particularly his fingernails, that Mr X had several falls while at the Care Home and that Mr Y sometimes had pressure sores. However:
• there is evidence Mr Y declined some help with his personal care on occasions, which care staff must respect;
• when moving to the home Mr Y was already frail, had a history of falls and his Alzheimer's disease got worse during his stay at the care home;
• Mr Y had ongoing skin problems from the start of his stay at the Care Home. The Care Home had several wound care plans for Mr Y which were monitored and reviewed regularly where necessary. The Care Home arranged input from both district nursing teams and specialist NHS services in late 2021; and
• there is no evidence Mr X or other family members raised these concerns with the Care Provider or the local council during Mr Y’s stay at the Care Home.
35. Because of gaps in the records and that some of these records are now missing, I cannot say whether the care Mr Y received was fully appropriate to his needs or that this met the Fundamental Standards throughout his stay. However, on the balance of probabilities, my view is the care Mr Y received from the Care Home did not cause him any harm, risk of harm or a deterioration in his health or wellbeing.
36. The Care Provider’s failure to keep accurate and complete records about Mr Y’s care did not meet the requirements of Regulation 17 and this was fault. Although there is no evidence Mr Y’s health or wellbeing was affected, there is still a remaining uncertainty about this for Mr X, who is very close to Mr Y.

Mr Y’s medication

37. One of Mr Y’s medications should have been increased after Mr Y was seen by the local memory clinic in late 2021. The local council’s safeguarding investigation established that Mr Y’s GP did not change Mr Y’s prescription until January 2022.
38. The memory clinic said they called the Care Home to check whether Mr Y was tolerating the increases in dosage in November and December 2021 and were told by nursing staff at the Care Home that Mr Y was fine.
39. The Care Provider says its staff believed the memory clinic were asking whether Mr Y was tolerating the medication in general, rather than any changes to his dosage. They did not know that Mr Y’s dosage should have been increased as his GP had not issued a new prescription at the time of those phone calls.
40. I cannot say what was said during the conversations between the memory clinic and Care Home, as I was not there. On the balance of probabilities, I am satisfied that since the Care Home had not been told about the increase in prescription at the time of the calls, it could reasonably have understood the question to be about the medication in general, rather than the new dosage. Mr Y’s GP was responsible for updating the prescription. The Care Home increased Mr Y’s medication as soon as it received the updated prescription.
41. Although Mr Y received a lower dose of his medication than he should have done between November 2021 and January 2022, I am satisfied this was not due to a failure on the part of the Care Provider.

Monitoring Mr Y after falls

42. Mr Y fell 11 times during his stay at the Care Home and most of these falls happened when Mr Y tried to move by himself, without the assistance of staff. In each case care staff assessed Mr Y for injuries and monitored him following his fall. Later in Mr Y’s stay the Care Home also referred Mr Y to the local specialist falls team for advice.
43. Mr Y had a history of falls when he moved to the Care Home and, because of his Alzheimer’s disease had limited understand of the risks of moving unaided. The evidence shows the Care Home took appropriate immediate action in response to each fall and that Mr Y did not suffer any significant injuries. There is no evidence to suggest that, given his health conditions, Mr Y’s falls could have been prevented. Towards the end of Mr Y’s stay in the Care Home, it told the local council that because of the deterioration in Mr Y’s dementia he needed a more specialist placement.
44. The Care Provider accepted in its complaint responses that there were some occasions where not all the checks which should have happened following Mr Y’s falls were carried out. There is no evidence Mr Y suffered any significant injuries following his falls while at the Care Home or that any missed checks caused any harm or risk of harm to Mr Y. However, this could have caused harm in different circumstances so was fault.

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Agreed action

45. Within one month of my final decision the Care Provider will:
• apologise to Mr X for the uncertainty caused by the lack of accurate and complete records for Mr Y’s care;
• pay Mr X £250 to recognise that uncertainty; and
• reduce Mr X’s outstanding care fees by:
1. the £2,900 it has already offered for lost belongings and medication/care issues; and
2. the equivalent of three weeks fees to recognise the delay in providing the required information about terms, conditions and fees.
46. Within three months of my final decision the Care Provider will review its approach to record keeping and retention, particularly at its Broadoak Manor Nursing Home. It should decide whether it needs to make any changes to its policies and whether it needs to arrange additional training for care staff. If so, it should arrange or provide that training.
47. The Care Provider should provide us with evidence it has complied with the above actions.
48. Since Mr X made his complaint, the Care Provider has taken steps to improve its practices based on the findings of its own investigation. I am satisfied these actions were proportionate so I do not need to make further service improvement recommendations.

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Final decision

49. I have completed my investigation. The Care Provider delayed sending required information about fees to Mr Y’s family and failed to keep accurate and complete records about Mr Y’s care. This contributed to a delay in Mr Y moving to a new care home and caused avoidable uncertainty to Mr X. The Care Provider agreed to further reduce Mr Y’s care fees, apologise to Mr X and pay him a financial remedy. It also agreed to review how it records the care it provides.

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Investigator's decision on behalf of the Ombudsman