Summary: Mrs X complained that her mother, Mrs Y, was served with an eviction notice as retaliation for complaints made by the family about the standard of care, saying this caused distress to all involved. There is no evidence to show that Care UK raised issues with the family about the impact they were having on staff, made efforts to resolve this or considered the impact an eviction would have on Mrs Y which is fault. A suitable remedy is agreed.

The complaint

1. Mrs X, on behalf of her mother Mrs Y (deceased), complains Care UK carried out a revenge eviction because the family made complaints about the standard of care. She says no attempts were made to explore or resolve the issues before the eviction notice was served.
2. Mrs X says this was distressing to all involved but especially Mrs Y who died four weeks after leaving Amberley Lodge,

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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 an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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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How I considered this complaint

6. As part of the investigation, I have:
• considered the complaint and the documents provided by the complainant;
• made enquiries of the care provider and considered the comments and documents it provided;
• discussed the issues with the complainant;
• sent my draft decision to both the care provider and the complainant and

taken account of their comments in reaching my final decision.

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What I found

7. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

Fundamental Standards of Care

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:

• Regulation 16: The provider must have a system in place to handle and respond to complaints. This says Complainants must not be discriminated against or victimised. An individual’s care must not be affected if they make a complaint, or if somebody complains on their behalf.

8. Complaints should not provide grounds for asking someone to leave and a care provider should only give notice to a resident as a last resort. If the relationship between a relative and a care home has broken down, steps should be taken to resolve the problem, such as:

• writing to the person about any inappropriate behaviour;
• seeking mediation; or
• asking someone to address any concerns to the Head Office, rather than to staff at the care home.

Consumer law advice for care home providers

9. This states that even where a resident might be in serious breach of contract, care home providers should give sufficient opportunity to the resident and their representatives to address the conduct and, where necessary appeal a decision to end the contract. It says providers should not ask a resident to leave a care home without first consulting with them and their representatives, and any other relevant independent professionals, and after efforts have made to meet the resident’s care needs. The reasons for consultation should be fully discussed, together with possible solutions, before any final decision is made on the resident's continued stay in the care home.

Key facts

10. This section sets out the key events in this case and is not intended to be a detailed chronology.
11. Mrs Y broke her hip while living in another residential care home. This resulted in a charge of grievous bodily harm against the carer who dealt with Mrs Y and a hearing in the crown court. As a result Mrs Y did not return to that care home and so moved to Amberley Lodge Care Home, Purley, Surrey.
12. Mrs Y moved into Amberley Lodge on 12 January 2023 and Mrs X signed a contract on that date. I asked the Care Provider to send a copy of the signed agreement but was provided with an incomplete document.
13. A pre-admission assessment was completed on 6 January. This stated that Mrs Y was currently fully supported with eating and drinking due to an arm injury and any changes to this should be reported.
14. On 1 February the Care Home contacted the Speech and Language Therapist via a rapid response referral regarding the type of diet it should be providing to Mrs Y. This stated that a “level five minced and moist” diet should be provided. The Care Home took this action after the family raised concerns. The Care Home said that this detail had not been provided to it at the time of admission.
15. The care notes for 24 February indicate a family meeting had been held the previous day. They show the Manager explained to Mrs Y’s other daughter, Mrs Z, the difference between a formal complaint and raising issues as a concern. The notes indicate Mrs Z preferred to have a matter dealt with as a concern and resolved.
16. Mrs X wrote to the Care Home Manager on 7 March about two incidents which happened during a visit to the home the previous day. She raised the issue of a carer blocking the lounge doors by sitting on a chair in front of them. She said that later on she returned to the lounge and the same carer was asleep in a chair. She asked the manager to look into this. The Manager replied on 9 March saying that she would like a meeting to discuss the findings of her investigation as well as Mrs Y’s residency.
17. During a visit on 15 March, Mrs X reported seeing a carer asleep in the lounge. The carer denied he had been asleep and said that he saw Mrs X taking a photograph of him. It is my understanding this resulted in a confrontation between a member of staff and Mrs X which resulted in the member of staff shouting at Mrs X. The Manager consequently altered the date of the meeting with Mrs X as she wanted a Regional Manager to attend.
18. A meeting was held on 16 March 2023. I have not seen any minutes or notes of this meeting but it is my understanding that this resulted in the Care Home saying it was giving notice to terminate the contract with Mrs Y.
19. The Care Home wrote to Mrs X on 18 April and formally served notice to end Mrs Y’s placement at Amberley Lodge. The letter said that it was terminating the contract because the home was unable to meet the family’s expectations without providing one to one care and it could not accommodate that. It said the contract would end in 28 days.
20. Mrs Y actually moved out of the Care Home on 17 April. A dispute between the family and the care home about the date it served notice to end the contract was ultimately heard in the County Court. It found the notice was essentially served at the meeting on 16 March. Because this issue has been determined in a court it falls outside the Ombudsman’s jurisdiction.
21. Mrs X made a formal complaint to the Care Home on 27 April. She raised the following issues:
• Failure to complete formal assessment before Mrs Y’s admittance
• Issues around the termination of the contract
• Failure to provide the correct type of food causing weight loss
• Risk of falls due to wet floors
• Issue with administration of medication
• Deprivation of liberty
22. The Care Provider replied on 26 May. In this letter it explained that a pre-admission assessment was completed on 6 January. It said the contract was terminated in line with the signed agreement and it further explained the reasons for termination. It said the concerns were not to do with the care being provided to Mrs Y but rather the way the relatives communicated with staff around the Care Home and this is why the term “expectations” was used.
23. It said the care plan did not include information regarding problems with Mrs Y’s swallowing needs and this was picked up in February. Regarding fall risks, it has not records of any accidents in the home and the sensor mat by Mrs Y’s bed was removed at Mrs X’s request. Regarding the incident with medication, the Care Home said that it had investigated as far as it could but found no concerns. It also said that the carer reported sitting in front of the door to ensure the residents’ view of the television was not blocked.
24. It also mentioned the issue of the carer falling asleep and Mrs X taking photographs. It noted Mrs X had declined to share the photographs and the carer denied being asleep so it could not comment further.
25. Mrs X escalated the complaint to stage two of the complaints process. The Care Provider responded on 21 June. It upheld the responses to the stage one complaint. It noted Mrs X’s view that her mother’s eviction was a “revenge eviction" because they raised concerns about her mother’s care and safety. The Care Provider said trust and communication had deteriorated on both sides making for a difficult time for all. It confirmed Mrs Y was given the eviction notice because the relationship between the family and the home had broken down.
26. Mrs Y died in May 2023, four weeks after moving out of Amberley Lodge.

Analysis

27. Mrs X complains that her mother’s eviction was unfair and that staff at Amberley Lodge did so without trying to resolve the issues. As stated above, the timing of the eviction and the amount owed to the care home as a result has been determined in court and so falls outside the Ombudsman’s jurisdiction. However, the courts found the eviction notice was given during the meeting on 16 March and I consider that date to be relevant.
28. It should also be noted that an incident at a previous care home in respect of Mrs Y’s care resulted in a serious injury and a prosecution. This experience must have had an impact on the family and made them more vigilant regarding their mother’s care.
29. Mrs Y moved into the care home on 12 January and was given an eviction notice just over two months later. The Care Home says it had no issue providing the necessary care for Mrs Y and there is nothing to suggest any breaches of contract. The reason for giving notice two months after Mrs Y moved into the home was the home being unable to meet the expectations of the family.
30. A meeting with the family was held on 24 February. While I do not know what was discussed at that meeting, there are notes which indicate the family raised concerns but did not make a formal complaint at that time. Mrs X wrote to the Care Home on 7 March raising concerns about the conduct of a carer. It seems that this complaint was the catalyst for the Care Home seeking a meeting with the family that ultimately led to notice being given to Mrs Y.
31. As agreed by the Care Home, it was able to meet Mrs Y’s care needs. The reason for eviction was a breakdown in the relationship between the care home staff and the family. While contractually four weeks’ notice can be given to end the contract, evicting a vulnerable elderly person should always be the last resort. Efforts should be made to resolve any problems and find solutions so the resident can remain in the home. I have not seen evidence to show the Care Home took such action in this case.
32. While there is evidence the home asked the family not to take photographs of staff and residents, I have not seen any written communication from the Care Home to the family about it being unable to meet their expectations or asking them to amend their behaviour. As Mrs Y had only been in the home for two months when notice was given, I would expect to see more evidence to show the relationship had irretrievably broken down as well as efforts to repair the relationship in order to maintain the placement. The failure to do this is fault.
33. I note the Care Provider has provided responses to the issues the family raised about the care in the home. The responses from the Care Home seem appropriate. A pre-assessment form was completed; there is no evidence Mrs Y fell due to the perceived trip hazards; evidence of dietary needs was not provided at the time of admittance but was resolved when it was identified; there was no evidence Mrs Y suffered a significant choking incident; an apology was given for the unacceptable comments by the contractor and the issue of the carer falling asleep was investigated but was inconclusive.
34. Giving notice because of problems between the Care Home staff and the family without making significant efforts to address and resolve this is fault. It is also a breach of the fundamental care standard to provide person-centred care. I cannot see anything which suggests consideration was given to how an eviction would impact on Mrs Y. The care notes indicate concerns about her general health at that time including weight loss and urinary tract infections. While we cannot say that Mrs Y’s death four weeks after she left Amberley Lodge was a direct consequence of the decision to evict her, it seems the eviction may have been avoided if effort had been made on both sides to resolve the situation.

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Agreed action

35. To remedy the injustice as a result of the fault identified above, the Care Provider will, within one month of my final decision, take the following action;
• Apologise to Mrs X;
• Make Mrs X a symbolic payment of £500 to recognise the distress resulting from the eviction; and
• Share this decision with all Care UK care homes to make them aware of it and remind them that evictions should always be a last resort, should not be used without first trying to resolve issues and they should give consideration to the impact an eviction will have on the resident.
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 ended my investigation and uphold the complaint. I have made recommendations the organisation has agreed to carry out.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman