Summary: Mrs X complained about the actions of the Care Provider, Leaf Care Services Ltd and its Care Home, Ixworth Dementia Village and the care and support it provided to her late father, Mr Y. The Care Provider was at fault because it increased Mr Y’s care and support hours without supporting evidence. Its decision to terminate Mr Y’s contract was flawed. It provided care and support to Mr Y which was not safe and attempted to pursue action against Mrs X as she did not agree to changing her father’s care and support. The faults caused Mrs X distress, frustration and uncertainty. The Care Provider has agreed to apologise to Mrs X and provide her with a symbolic payment of £500.

The complaint

1. Mrs X complained about the actions of the Care Provider, Leaf Care Services Ltd and its Care Home, Ixworth Dementia Village and the care and support it provided to her late father, Mr Y. She said the Care Home:
• increased Mr Y’s care and support hours without a proper assessment to show his needs had increased;
• gave Mr Y notice to leave the Care Home without following its own policy;
• did not support Mr Y to move to another placement;
• reported to other agencies about Mrs X’s behaviour;
• administered Mr Y’s medication incorrectly;
• did not seek medical assistance when Mr Y was unwell; and
• did not give Mrs X all her father’s care records despite her requesting them.
2. Mrs X said the overall matter caused her significant distress, frustration and uncertainty. Mrs X wants the Care Provider to acknowledge its faults and provide her with a written apology.

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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 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)
4. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We provide a free service but must use public money carefully. We do not start or continue an investigation if we decide:

• there is not enough evidence of fault to justify investigating, or
• further investigation would not lead to a different outcome, or
• there is no worthwhile outcome achievable by our investigation.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

6. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

7. 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)
8. Under our information sharing agreement, we will share the final decision with the Care Quality Commission (CQC).

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How I considered this complaint

9. I spoke with Mrs X and considered information she provided.
10. I considered information provided by the Care Provider.
11. I considered information provided by the Council.
12. Mrs X and the Care Provider had the opportunity to comment on the draft version of this decision. I considered their comments before making a final decision.

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What I found

The Care Quality Commission and regulations

13. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out fundamental standards of care which registered care providers must achieve. The Care Quality Commission (CQC) is the statutory regulator of care services and has guidance for care providers which they must comply with to meet the fundamental standards of care. The guidance states:
• Regulation 9: the person using the service or the person acting lawfully on their behalf must be actively involved, overseeing or making decisions about their care or treatment. This may include managing their medication.
• Regulation 9: the person using the service or the person acting lawfully on their behalf, must be given relevant information in the most suitable way for them and in a way that they can understand.
• Regulation 11: care and treatment must only be provided with the consent of the person using the service or the person acting lawfully on their behalf.
• Regulation 12: medicines must be administered accurately, in accordance with any prescriber instructions.
• Regulation 12: providers should use risk assessments about the health, safety and welfare of people using their service to make required adjustments.
• Regulation 12: providers must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Regulation 18: providers must have arrangements in place to ensure sufficient and suitable staff are working to cover both routine work and emergencies.

Safeguarding adults

14. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

The Care Provider’s terms and conditions

15. The Care Provider’s policy sets out its terms and conditions in relation to increasing its fees and terminating the contracts of residents. It says the Care Provider:
• has the right to review charging fees if for example, a resident’s care and support needs have changed;
• can terminate a resident’s contract by issuing a notice period of 48 hours, seven days or 28 days; and
• can terminate a resident's contract if it believes it is unable to provide the degree of care and support required to meet the resident's assessed needs.

Background

16. Between March 2021 and May 2023, Mr Y resided at the Care Home. Mr Y had complex health needs including dementia which affected his ability to make certain decisions such as those related to his health care. He was under a dementia specialist team for further support. His children including Mrs X, had lasting power of attorney for his health and welfare. This meant Mrs X and her siblings were able to legally make decisions about Mr Y’s health and welfare on his behalf.

What happened

17. The Care Home had concerns about Mr Y’s declining health. It said it was concerned Mr Y’s behaviour had become more challenging, particularly when staff supported him with personal care and during the evenings.
18. In March 2023, the Registered Manager of the Care Home wrote to Mrs X and advised her Mr Y would require one-to-one care and support between 3pm and 1am daily which would help keep him safe. The one-to-one care and support would cost around £500 extra per week. The Registered Manager told Mrs X if she was happy to go ahead with the change, they would employ a care worker to deliver the care and support. In response, Mrs X asked the Registered Manager to explain to her why her father’s care needs had increased. She asked for any assessments staff had completed to support the decision.
19. The Registered Manager gave Mrs X a copy of a ‘behaviour risk assessment’ they had recently completed with Mr Y. The risk assessment concluded Mr Y was at high risk because he was confused and walking around, presenting a risk to himself and others. It said Mr Y required one-to-one care and support. However, the risk assessment did not explain how the Registered Manager had assessed Mr Y and it did not explain what the potential impact of the risk was.
20. Mrs X did not agree for the Care Home to increase her father’s care and support hours and as a result, towards the end of March 2023, the Care Home issued Mr Y with an eviction notice. The notice period was initially two weeks however, the Care Home then amended the notice period to two days only. Later, the Care Home decided to give Mrs X and the family more time to look for another placement for Mr Y.
21. The Care Home’s records show the Registered Manager spoke with Mrs X and said her father did not have to leave the Care Home if she was willing to agree to pay for the increased care and support hours. However, Mrs X and the family decided to look for a new placement.
22. Mrs X said when she and the family were looking for a new placement, the Care Home did not support them in doing so. Instead, the Care Home told the other care homes Mr Y’s behaviour was challenging. She said because of this, it was difficult to find another placement for Mr Y as the other care homes were concerned whether they could meet his needs. Eventually, Mrs X and the family were able to find Mr Y a new care home which was able to accept him without requiring information from the existing Care Home. He moved out of the Care Home later in May 2023.
23. The Care Home’s records show towards the end of March 2023, the Registered Manager told Mrs X’s family that they would be referring Mrs X to the Council’s safeguarding team and the Office for Public Guardian. The Office for Public Guardian is a government organisation which supports people to stay in control of decisions about their health and finances. This was because Mrs X did not agree to the Care Home increasing Mr Y’s care and support hours.
24. Later in May 2023, the Office for Public Guardian wrote to Mrs X and said it had investigated the Registered Manager’s concerns and concluded Mrs X’s actions to challenge the Care Home’s reasons for Mr Y to have one-to-one care and support, were done in Mr Y’s best interests. It therefore closed the investigation.
25. There is no evidence the Registered Manager alerted the Council’s safeguarding team.
26. Mr Y took daily medication prescribed by his GP (General Practitioner) to manage any challenging behaviour he displayed due to his diagnosis of dementia. Mrs X and the family had previously raised concerns about the side effects of this medication which Mrs X said worsened her father’s behaviour.
27. As the Care Home was concerned about Mr Y’s decline in health, on 13 April 2023, the Registered Manager advised Mr Y’s GP to increase the dose of the medication. The GP agreed to increase the dose.
28. Mrs X and the family were unhappy with the change to their father’s medication and told the Registered Manager they did not give permission to alter Mr Y’s medication. They then asked for their father’s care records. Mrs X told us she had received some of the care records but not all.
29. The Care Home’s records show Mr Y’s GP called the Care Home on 28 April 2023. They said Mrs X had raised her concerns with the GP about the medication and as a result, the GP agreed to reduce the dose. However, staff continued to administer the increased dose until 6 May 2023, when they had no more medication to administer to Mr Y.
30. In mid-May 2023, Mrs X visited her father and said he was having pain in the chest, he was breathless and looked pale. Mrs X asked staff to call an ambulance however, staff said they were not allowed to seek medical assistance without consulting with the Registered Manager. Staff then called the Registered Manager who said there was no need to seek medical assistance. Mr Y later became stable.

Mrs X’s complaint to the Care Provider

31. In mid-April 2023, Mrs X complained to the Care Provider. She said:
• the Care Home wanted to increase her father’s care and support hours as his health needs had increased. However, when she had spoken to his GP and visited the Care Home, she had not been informed about any changes to his behaviour;
• the risk assessment the Care Home had sent to Mrs X was difficult to understand;
• she was concerned the Care Home had already increased her father’s care and support hours; and
• the Care Home had issued her father an eviction notice to leave.
32. Mrs X also shared her concerns with the Council.
33. At the beginning of May 2022, the Care Provider responded to Mrs X’s complaint and said:
• the Registered Manager had consulted with professionals in relation to increasing Mr Y’s care and support hours. The decision to increase the hours was in her father’s best interest;
• the Registered Manager had attempted to speak with Mrs X about their decision to increase the hours and the risk assessment which supported it however, they had received no response from Mrs X;
• it had served her father the eviction notice in line with its terms and conditions however had allowed extra time for Mrs X and the family to find an alternative placement. It had decided to issue the eviction notice as Mrs X did not agree to the additional hours; and
• the Registered Manager had increased her father’s hours by three hours a day and this appeared to have made a positive difference to his behaviour.

The Council’s safeguarding investigation

34. Prior to the events above and Mrs X’s complaint, the CQC had inspected the Care Home and issued it an ‘Inadequate’ overall rating. The CQC and the Council were closely monitoring the Care Home.
35. In May 2023, the Council’s safeguarding team commenced a safeguarding investigation into the care and support Mr Y had received at the Care Home. This was in response to two alerts it had received from a safeguarding coordinator and a CQC inspector.
36. The Council completed an assessment of the referral to determine the appropriate action to take if Mr Y was at risk of abuse, harm or neglect. The assessment found:
• the Care Home had continued to administer an increased dose of medication to Mr Y for a further eight days, despite Mr Y’s GP contacting the Care Home and instructing staff to reduce the dose. The Registered Manager’s reasons for continuing to administer the increased dose was because the GP did not write to the Care Home, instructing staff to reduce the dose. However, this practice did not exist for any other resident;
• the Registered Manager had advised the GP to increase the dose without consulting with Mr Y's family or the dementia specialist team;
• Mrs X and the family were concerned the Care Home wanted to increase his medication to change Mr Y’s behaviour in attempts to increase Mr Y’s care and support hours;
• the Care Home had given Mr Y notice to leave but deliberately undermined any attempts to have other care homes assess his needs; and
• staff had no autonomy to seek medical assistance.
37. The assessment highlighted the Registered Manager had been suspended. It is unclear whether this was solely related to the issues around Mr Y’s care and support.
38. The Council’s safeguarding team did not progress the investigation further as Mr Y had moved out of the Care Home by this time and so was no longer at risk of abuse, harm or neglect. It was however, conducting an organisational safeguarding investigation due to the potential risks to other residents.
39. Shortly after Mr Y had moved to another care home, he was admitted to hospital where he died.
40. In June 2023, the Care Home closed. Mrs X did not receive any further correspondence from the Care Provider. She remained unhappy and complained to us.

The Care Provider’s response to my enquiries

41. In response to my enquiries, the Care Provider:
• shared two risk assessments it had completed with Mr Y which it said supported the Registered Manager’s decision to increase Mr Y’s care and support hours. The first risk assessment which it also shared with Mrs X states Mr Y was at high risk because he was confused and walking around. The second assessment states Mr Y was at medium risk of ‘walking’;
• shared a recorded discussion which had taken place between the Registered Manager and the dementia specialist team in which the Registered Manager said it would be best if Mr Y had one-to-one activities which would be funded by the family. The Registered Manager believed the activities would keep Mr Y safe and stimulated. In another record from the Care Provider, it states the dementia specialist team did not think one-to-one activity support was required;
• shared the activities record it completed which stated Mr Y was losing interest in group activities;
• said it did not reduce Mr Y’s medication when the GP called the Care Home on 28 April 2023 because it had not received anything in writing from the GP about reducing the dose. It said it was required to receive instructions in writing so that its actions were in line with health care guidelines. Staff had contacted the pharmacy to check whether it had received an update on Mr Y’s prescription and was told no;
• accepted it did not evict Mr Y within timescales outlined in its policy and explained this was because it wanted to give Mrs X and the family more time to look for a new placement; and
• said it had provided Mrs X with her father’s care records.

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Findings

Mr Y’s care and support hours

42. The Care Home wanted to increase Mr Y’s care and support hours because staff believed his care and support needs had increased due to a decline in his health. However, the records do not provide evidence to support this need. The Care Home did not seek appropriate advice and support to look at less restrictive options and did not hold a best interests meeting before it decided to increase Mr Y’s support hours. This was fault.
43. The Registered Manager completed two risk assessments which the Care Provider said supported Mr Y’s care and support needs had changed. However, the risk assessments:
• do not explain how the Registered Manager risk assessed Mr Y;
• do not explain what the potential risk was; and
• were unclear on whether Mr Y was at high risk or medium risk.

Mrs X also told the Care Provider in her complaint that she found it difficult to understand the risk assessment it had shared with her. The Care Provider was at fault. The risk assessments were not clear or accurate and did not demonstrate why the Care Home wanted to increase Mr Y’s hours.

44. In addition, the information I have reviewed states the additional support would keep Mr Y ‘safe’ and/or ‘stimulated’. It would include one-to-one activities and be delivered between 3pm and 1am. The Care Provider did not clearly explain to Mrs X what the activities would look like, how they would help Mr Y and the duration of them.
45. The Care Provider’s records of contact with the dementia specialist team do not evidence Mr Y required one-to-one support. The records show Mr Y was losing interest in group activities but that in itself was not sufficient to justify Mr Y needing to pay for one-to-one support.
46. The Care Provider’s complaint response to Mrs X suggested the Registered Manager had increased Mr Y’s care and support hours by three hours a day. This was despite Mrs X not agreeing to the Care Home increasing the hours when she had lasting power of attorney for his health and welfare. This was also not in line with CQC regulations. The Care Provider was at fault.

Termination of Mr Y’s contract

47. Mrs X said the Care Provider issued her father with a two-week notice period towards the end of March 2023 to leave the Care Home. The Care Provider issued the notice because Mrs X did not agree with it increasing her father’s care and support hours. The Care Provider can terminate a resident's contract if it believes it is unable to provide care and support to meet their assessed needs. However, as set out above, the Care Provider failed to clearly evidence why Mr Y needed one-to-one support. The decision to terminate Mr Y’s contract was therefore flawed and was fault.
48. Mrs X said the Care Provider changed the notice period to 48 hours but later allowed Mrs X and the family additional time to find another placement. Mr X moved out of the Care Home towards the end of May 2023. The Care Provider did not evict Mr Y within timescales outlined in its policy as it wanted to give the family more time to find a new placement but changing the notice period on three occasions caused Mrs X distress. The Care Provider was at fault.

Support to find Mr Y a new placement

Mrs X said it was difficult to find a new placement for her father because the Care Home told other potential care homes Mr Y’s behaviour was challenging. I cannot say what information the Care Home shared with other care homes however, Mr Y did eventually move to another care home. I have decided not to investigate this aspect of Mrs X’s complaint further as there is no worthwhile outcome achievable.

Mrs X’s behaviour

49. Mrs X had lasting power of attorney for Mr Y. If the Care Provider had concerns that Mrs Y was not acting in his best interests it was open to the Care Provider to raise its concerns with the Office of the Public Guardian. However, the Registered Manager referred Mrs X to the Office for Public Guardian because she did not agree to the Care Home increasing Mr Y’s care and support hours and the evidence did not support that this increase was necessary. The Care Provider was at fault for why it referred Mrs X to the Office for Public Guardian.
50. The Registered Manager said they would also refer Mrs X to the Council’s safeguarding team but there is no evidence they did so.

Mr Y’s medication

51. At the beginning of April 2023, the Care Home asked Mr Y’s GP to increase the dose of the medication. There is no evidence the Care Home consulted with Mrs X or the family before discussing the matter with the GP. Mrs X and the family also told the Registered Manager they did not consent to the increased dose. There is no evidence the Registered Manager considered their concerns. The Care Provider was at fault and this was not in line with CQC regulations.
52. The GP later decided to reduce the dose and there is evidence they called the Care Home to do so. However, the Care Home continued to administer the increased dose for a further eight days. The Registered Manager said this was because they did not have the GP’s instructions in writing. I recognise the Care Provider told us the Care Home required instructions to change medication in writing so that its actions were in line with health care guidance and that staff called the pharmacy for an update however, there was no evidence of staff contacting the pharmacy. There also would have been an expectation for staff to contact the GP to follow up their request which they did not do. Instead, staff continued to administer the increased dose for several more days. This was fault.

Medical assistance

53. Mrs X asked staff at the Care Home to call for an ambulance when she saw her father had pain in the chest, was breathless and pale. Staff responded and said they had to seek authorisation from the Registered Manager before doing so. This was fault and not in line with CQC regulations. The Care Home should have had a procedure in place where staff could seek medical assistance when required to do so, without asking for authorisation from the Registered Manager.

Mrs X’s request for Mr Y’s care records

54. Mrs X and the family asked the Care Home for their father’s care records. The Care Provider said it sent Mrs X the care records she requested. Mrs X said she received some but not all care records. I have decided not to continue with this aspect of Mrs X’s complaint because there is not enough evidence of fault to justify investigating it further and a further investigation would not achieve anything more.

Injustice

55. Mr Y has died so I cannot remedy any personal injustice caused to him. However, the faults identified have caused Mrs X significant distress, frustration and uncertainty. The injustice of distress cannot generally be remedied by a payment, so we seek a symbolic amount to acknowledge the impact of the fault.
56. I have not recommended any service improvements to prevent a recurrence of the fault as the Care Home has since closed down.

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Agreed actions

57. Within one month of the final decision, the Care Provider has agreed it will:
• provide Mrs X with a written apology for the distress, frustration and uncertainty the matter caused her. The apology will reflect what the Care Provider did wrong and how it caused an injustice to Mrs X. The Care Provider will refer to our ‘Guidance on Remedies’ on how to make an effective apology; and
• pay Mrs X a symbolic payment of £500 for the distress, frustration and uncertainty the matter caused her.
58. The Care Provider will provide us with evidence it has complied with the above actions.

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Final decision

59. I have now completed my investigation. The Care Provider was at fault. It has agreed to remedy the injustice caused to Mrs X.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman