Summary: Ms X complains the Laurels Care Home was wrong to prevent her mother from returning when she was discharged from hospital on 24 February 2023, as this resulted in her spending three nights on a trolley in A&E and a further eight weeks in hospital before she could move to another care home. The Care Home was wrong to prevent Mrs Y from returning. This caused avoidable distress which warrants an apology and financial redress.

The complaint

1. The complainant, whom I shall refer to as Ms X, complains the Laurels Care Home (the Care Home) was wrong to prevent her mother from returning when she was discharged from hospital on 24 February 2023, as this resulted in her spending three nights on a trolley in A&E and a further eight weeks in hospital before she could move to another care home.

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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 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)

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How I considered this complaint

3. I have:
• considered the complaint and the documents provided by Ms X;
• discussed the complaint with Ms X;
• considered the comments and documents the care provider has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Ms X and the care provider, and taken account of the comments received.

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What I found

4. The Care Home is run by Aegis Residential Care Homes Ltd (the care provider).

Key facts

5. Ms X’s mother, Mrs Y, went to live in the Care Home in November 2022. She moved there from hospital, having been admitted after taking paracetamol and alcohol with the intention of ending her life.
6. Mrs Y’s care plan said:
• she occasionally hid her medication, having pretended to take it and spat it out, so staff needed to make sure she had swallowed her medication;
• she had made an allegation of a sexual nature against a member of staff, so two members of staff had to attend her when in her bedroom or out of sight of anybody else.
7. On 26 January 2023 the Care Home contacted the Community Mental Health Team (CMHT) about Mrs Y’s threats to kill herself. The CMHT said it would contact her GP about starting her on anti-depressant medication to see if it improved her mood. Mrs Y started taking the medication in February.
8. According to the Care Home’s records, on 24 February:
• it called an ambulance around 04.12 due to Mrs Y “self-harming and going floppy when attempting to walk”;
• she was very unhappy so was given lots of emotional support;
• the ambulance took Mrs Y to hospital to do a blood test to see “if she has taken anything extra”.
9. The hospital discharged Mrs Y around 10.30 on 24 February.
10. Ms X took her mother out for lunch to celebrate a birthday. While she was there, the Care Home told Ms X it would not take her mother back as there was no care plan in place to meet her needs. Ms X e-mailed the Care Home and said her mother’s needs remained the same as they were when she moved there.
11. The Care Home updated Mrs Y’s care plan. It increased the risk of a suicide attempt from low to medium.
12. The Care Home told Ms X the Mental Health Team had advised contacting Social Services, as Mrs Y needed a new care home placement. It told her to call an ambulance or return Mrs Y to A&E if she threatened to take her own life or was unwell. It suggested contacting nursing homes for the elderly mentally impaired and provided a link to a list of local care homes. It said there was not much social services could do to help, as Mrs Y had enough money to fund her own care. It said the care plan it had in place did not identify Mrs Y “as a high risk and there was no intent to her life on admission”. However, it said the incident that morning meant she was now a high risk and as a residential care home it could not provide a secure/safe environment as it could not provide the increased supervision she needed. It said it had reported a safeguarding concern, as the hospital should not have discharged Mrs Y without contacting the Care Home and with nothing in place to protect her.
13. While agreeing to look for another care home, Ms X said her mother should have been entitled to a notice period. She asked the Care Home to reconsider its decision, as it was by now late on Friday afternoon and they were unlikely to find another care home that day.
14. Ms X took her mother to A&E, where she spent three nights on a trolley before being moved to a ward. She spent a further eight weeks in hospital before Ms X could arrange an alternative care home placement for her. The hospital discharge form said Mrs Y had been admitted with an episode of self-harm, having tried to stab herself with a ballpoint pen. She had also had an unwitnessed fall, but x-rays revealed no injuries. Liaison Psychiatry saw Mrs Y while in hospital and dismissed her from its service, but asked her GP to review her anti-depressant medication.
15. Ms X complained to the care provider about the Care Home’s decision not to let her mother return there.
16. When replying to her complaint in April 2023, the care provider said:
• after the incident on 24 February, the Care Home felt Mrs Y required more support medically than a residential care home could provide at that time;
• the Care home felt Mrs Y needed a more thorough medical assessment to ensure a residential setting was the safest place for her;
• it accepted a contract had not been issued for Mrs Y but said it had the right to end the contract agreement if any point in the contract gave concern;
• it had no option but to end the contract because of issues to do with Mrs Y’s wellbeing and safety;
• it refused to take her back until she had the appropriate assessment to ensure the Care Home was the safest place for her, but the hospital did not put support in place which would have enabled it to take her back, so it was not safe to discharge her;
• the Care Home did not have the staff in place to provide one-to-one support for Mrs Y;
• the Care Home acted quickly to ensure Mrs Y was not put at risk;
• the Care Home reached out for support but that was not offered, so it had to halt the unsafe discharge.
17. When reporting the safeguarding concerns to the local authority, the Care Home said Mrs Y had become increasingly confused and agitated the previous day, thinking she was being held against her will. She had settled in the evening but during the night she was sat crying on her bed saying she was sorry, having stabbed her arm with a pen, and that she did not want to live anymore. It said when assessed in hospital, medication was found in Mrs Y’s handbag.
18. When the local authority completed its safeguarding enquiries in March 2023, it substantiated the allegation of “neglect and acts of omission”. Its report said:
• the Care Home had not managed Mrs Y’s medication properly, as she had been found with 10 or more tablets on her person;
• the Care Home had known Mrs Y was at high risk of self-harm when she moved there but had failed to manage the risk after she injured her elbow with a pen;
• although the hospital did not communicate with the Care Home during Mrs Y’s admission on 24 February 2023, the Care Home could have managed the risks to her until further assessment were completed by:
1. implementing hourly checks;
2. engaging Mrs Y in activities to distract her;
3. chasing medication so she could start taking it to address her low mood;
4. risk assessing Mrs Y’s room and removed objects she could have used to harm herself;
5. asking Mrs Y’s GP to prescribe her medication in liquid form to prevent her from concealing it.
19. The local authority identified learning for all the professionals involved, including improved communication between A&E and the Care Home. It recommended the Care Home:
• Reassess its management of residents with poor mental health, including when the resident is in crisis.
• Address the communication with A&E and request updates on processes and assessments.
• Be more mindful of the impact decisions have on an individual suffering with a mental health crisis and keep in mind best practice and the individual’s best interests.
20. The Care Home says it will now ring the hospital one hour after a resident’s admission and take the names of staff, so it can take action if the hospital discharges someone without a verbal handover. It says this should prevent further harm or distress to the resident.

Did the care provider’s actions cause injustice?

21. The Care Home’s decision to prevent Mrs Y from returning did not take into account her wellbeing and best interests. Ms X could not care for her mother herself and had no option but to return her to hospital. This resulted in Mrs Y spending weeks in hospital when there was no clinical reason for her to be there, including three days on a trolley in A&E. As the local authority pointed out, it should have been possible for Mrs Y to return to the Care Home if it had taken steps to reduce the risk of her trying to end her life. It had been aware of that risk from the time when Mrs Y moved to the Care Home and had referred her to the CMHT when she continued to express the wish to end her life. Contrary to what it told Ms X at the time, Mrs Y’s risk level had increased from low to medium.
22. CQC provides guidance on how to comply with the Care Quality Commission (Registration) Regulations 2019. Regulation 19 relates to fees. The guidance says care providers “must make sure they give a copy of any contract detailing the service to be provided to the person using the service and/or the person lawfully acting on their behalf”. The care provider accepts it did not give Ms X a copy of her mother’s contract. Nor did it give a contract to Mrs Y.
23. Terminating a placement should be a last resort. The Competitions & Markets Authority (CMA) has produced guidance: Helping care homes comply with their consumer law obligations. This says terms which allow a care home to terminate a contract on short notice or without any notice at all, are likely to infringe consumer law, as the resident may not have enough time to make alternative arrangements.

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Recommended action

24. I recommend the care provider within four weeks:
• Writes to Ms X apologising for the distress caused to her and her mother by the Care Home’s decision to prevent Mrs Y from returning there in February 2023
• Pays Mrs Y £1,000 to remedy the distress caused to her by having to spend over eight weeks in hospital when there was no need for her to be there.
• Pays Ms X £250 for the distress caused to her and the time and trouble she has been put to in pursuing the complaint.
• Takes action to ensure residents and/or their representatives always have a contract for their stay at the Care Home.
25. I also recommend the care provider within eight weeks reviews the contents of its contracts to ensure they comply with CMA’s guidance: Helping care homes comply with their consumer law obligations.
26. The care provider should provide us with evidence it has complied with the above actions.

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Final decision

27. I have completed my investigation on the basis of the care provider’s actions have caused injustice which requires a remedy.

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Investigator's decision on behalf of the Ombudsman