Summary: the care provider did not provide an admission agreement or clarify the way in which Funded Nursing Care awards were applied (although there was no fault in the way FNC was applied). During its handling of Mrs X’s complaint, it suggested it would backdate an increased fee to the start of the placement. The care provider should apologise to Mrs X and confirm it will not pursue a backdated increase in fees between October 2022 (the start of the placement) and April 2023.

The complaint

1. Mrs X (as I shall call her) complains about the way the care provider applied the Funded Nursing Care (FNC) award to her mother’s care home fees.

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The Ombudsman’s role and powers

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

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How I considered this complaint

4. I have considered the information provided by Mrs X and by the care provider. I spoke to Mrs X. Both Mrs X and the care provider had the opportunity to comment on earlier draft statements and I considered their comments before I reached this final
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Relevant law and guidance

6. 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.
7. Guidance produced by the CQC on the regulations says (Regulation 19), “Providers must give people information about the terms and conditions of their care, treatment or support, including the expected costs and the requirement to pay for their care, treatment and support. This applies to people who pay the provider in full or partially.” It also says People must be given a written copy of the terms and conditions that they must agree to before their care, treatment or support begins. Providers must give people using the service information about the costs, terms, and conditions of the service, so that they can make decisions about their care, treatment or support.”
8. NHS-Funded Nursing Care (FNC) is the funding provided by the NHS to care homes providing nursing, to support the cost of nursing care delivered by registered nurses. If a person does not qualify for NHS Continuing Healthcare, the need for care from a registered nurse must be determined. If the person has such a need and it is determined their overall needs would be most appropriately met in a care home providing nursing care, then this would lead to eligibility for NHS-Funded Nursing Care.
9. In 2018 we issued guidance for care providers on FNC payments. The guidance says “Our starting point with FNC complaints is to look at the contract and any standard information given to the resident or their representative before they moved in. We interpret contracts on an ordinary reading. If a contract does not make sense to us, then we may view it as a failure by the care provider. We are likely to find fault where a contract term is ambiguous, inconsistent or is poorly drafted. We may also find fault where a contract contains conflicting terms or is silent on how the care provider treats FNCs.”

What happened

10. Mrs A, Mrs X’s mother, was discharged from hospital into the care home in September 2022: the local council made the initial arrangement. The care provider’s records show an email from the social worker to the care provider which says “funding in place at the rate of £1500”.
11. Mrs A became self-funding from October 2022. On 21 October the care provider wrote to Mrs X with a copy of the contract and a request to set up a standing payment for £1100 a week.
12. Mrs X was also awarded FNC from 20 October. The contract with the care provider says, “Funded Nursing Care (FNC) is the funding provided by the NHS to care homes with nursing, to support the provision of nursing care by a registered nurse for those assessed as eligible for FNC. You will be eligible for FNC if you have a need for care from a registered nurse. If you are a resident who has been assessed as requiring nursing care, some (but not all) of the nursing care provided to you by the home will be funded by the NHS instead of by you.” The contract also says, “Our charges are set out in the Admission Agreement and are payable monthly in advance”. Mrs X says they were never sent a copy of the admission agreement.
13. The contract also says in respect of the FNC award, “The amount that the NHS pays in respect of your nursing care is paid to the home and we shall use our reasonable endeavours to claim the NHS contribution for you. The weekly fee you are required to pay will be set out on the Admission Agreement, which will show the total amount required from you and how this is broken down, including the cost of the nursing care provided to you. Therefore, if the Funded Nursing Care payments change, the weekly fees required from you will not be affected. For example, if the Funded Nursing Care payments increase your weekly fees will not reduce and vice versa”.
14. In March 2023 the care provider notified Mrs X that the fees would be increased to £1215.50 per week. Mr X contacted the care provider to ask for a breakdown of the fees and confirmation that the FNC awarded was being deducted. Mrs X said she would not increase her payment to the care provider until she had the relevant information. On 20 April the care provider responded to say they would not deduct the FNC amount from the invoice.
15. In July Mrs X met the care provider. The care provider said she would send them a copy of the admission agreement and a breakdown of the invoices by the end of the month. She said the FNC award was not given to a person but to the care home to cover the cost of nursing care.
16. The care provider still did not send a copy of the admission agreement. In August the care provider wrote to Mrs X and said the admission agreement was a conversation between the care home manager and the social worker, followed by the social worker’s email about the fees “which is taken as the agreement for admission”. The care provider said this information had been forwarded to Mrs A as she had “insisted” on seeing the admission agreement. She said the home was charging less than the agreement, which they would now correct. She said they did not normally provide a breakdown of costs but would do to show their transparency. She asked Mrs X to change her payments.
17. Mrs X complained to the Ombudsman. She said they had never been given an admission agreement despite multiple requests. She said she believed the care provider should deduct the FNC amount from the weekly fees.
18. The care provider says the initial contract was with social services. The company issued a contract once Mrs A became self-funding. The care provider says they provided a breakdown of the fees. She agrees the FNC should be shown on invoices and says that will happen from now on. She says she believes the contract is clear and unambiguous in line with the Ombudsman guidance.
19. The care provider also explains that they did not implement the increase to local authority rates as suggested, “but maintained a reduced rate to ease their transition to private funding”.
20. In response to the recent draft decision, the care provider says “We have now fully implemented the inclusion of Funded Nursing Care (FNC) contributions on all invoices issued by our facility. This adjustment ensures complete transparency regarding how FNC payments are utilised in offsetting the total cost of nursing care provided to our residents. This change is reflective of our commitment to clarity and accountability in our billing practices, ensuring that residents and their families can easily understand the financial components of the care provided.”
21. Mrs X says she moved Mrs A from the home in September 2023. She did not pay the increase in fees which came into effect in April.

Analysis

22. The contract from the care provider is clear about the FNC award, which is an award given direct to the home in respect of a person (here Mrs A) who is eligible, but the amount awarded is not deducted from the weekly fees. There is no evidence of fault there.
23. However, the care provider should have given an admission agreement (as the contract says it will) and clarified from the start how the fees were broken down. That failure to do so led to confusion and distress for Mrs X.
24. The care provider was within its rights to increase the fees in April 2023. It was within Mrs X’s power to move Mrs A from the home as she did, in disagreement with the increase. However, the care provider was wrong to say, during its handling of Mrs X’s complaint, that it would now backdate an increase of the fees to the rate agreed with the Council in October 2022. There was no justification for it to do so and its statement that it would do so caused worry and concern for Mrs X. But there is no reason why Mrs X should not pay the normal fee increase between April and October 2023.
25. The care provider says it does now show the FNC award on all invoices.

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Recommended action

26. Within one month of my final decision the care provider should apologise to Mrs X for the confusion and distress its actions caused.
27. Within one month of my final decision the care provider should provide us with an example of a current invoice showing how the FNC is included in a breakdown
28. The care provider should provide us with evidence it has complied with the above actions.

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Final decision

29. I have completed this investigation on the basis that the actions of the care provider caused some injustice to Mrs X which the recommendations at paragraphs 26 and 27 will remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman