Summary: Mr X complained about the poor quality of care provided to his late mother, Mrs Y, at Drayton Village Care Centre which caused him distress, and which resulted in him moving Mrs Y to another care home and the subsequent care charges. The care provider was at fault as there was poor care, a failure to refer Mrs Y for funded nursing care and to properly consider whether to charge for the full notice period. The care provider has already refunded two weeks of care costs. It has agreed to make a payment to Mr X to acknowledge the distress, frustration and uncertainty caused to him. It has also agreed to review its procedure to ensure residents are appropriately referred for funded nursing care and to remind staff to refer residents or their representative to the complaints’ procedure where appropriate.

The complaint

1. Mr X complained about the poor quality of care provided to his late mother, Mrs Y, at Drayton Village Care Centre which caused him and Mrs Y distress, and which resulted in him moving Mrs Y to another care home. Mr X also complained the care provider charged a four week fee after Mrs Y left the care home, even though the stay was originally arranged as a temporary one and the care provider was aware Mr X was unhappy with the quality of the care provided.

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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 a significant injustice or that could cause injustice to others in future we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. 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)
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

5. I discussed the complaint with Mr X on the telephone and have considered the information he provided. I have considered the care provider’s response to my enquiries which includes Mrs Y’s care notes and care plans and third party information provided by the Council which carried out a safeguarding investigation into Mr X’s concerns.
6. I gave Mr X and the care provider the opportunity to comment on a draft of this decision. I considered the comments I received in reaching a final decision.

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What I found

Relevant law and guidance

The Care Quality Commission (CQC)

7. 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:
• providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences (regulation 9).
• Providers must treat those using their service with dignity and respect at all times when they are receiving care and treatment (regulation 10).

Pressure sores

8. Pressure sores (also called pressure ulcers or bed sores) are wounds caused by pressure on part of the body interrupting the blood supply to the skin. People with mobility difficulties and who are over 70 are more at risk. Under the European Pressure Ulcer Advisory Panel classification system, pressure sores are graded in severity from 1 to 4.
9. Grade 1 indicates the first signs of pressure damage; including redness, discolouration, swelling or heat but with intact skin. Grade 2 is usually an abrasion or blister and involves a partial thinning of the skin. Grade 3 involves full loss of skin thickness with damage to, or death of, the underlying tissue. Grade 4 indicates severe pressure damage, usually a deep wound that may go down to the bone and involve the death of underlying tissue. 

Safeguarding

10. 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)

Continuing Health Care assessment (CHC)

11. NHS CHC is a package of ongoing care arranged and funded solely by the NHS where the individual has been found to have a ‘primary health need’ as set out in the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care. Such care is provided to people aged 18 years or over, to meet needs arising from disability, accident or illness.
12. 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.

What happened

13. The following is a summary of events relevant to this complaint.
14. Mrs Y was struggling to cope at home. She had a number of health conditions. In December 2022, following a short hospital stay, Mrs Y moved into Drayton Village Care Home (care home 1), on its nursing floor. Mr X said this was with a view to her receiving physiotherapy and eventually getting back home. Care home 1 carried out an assessment of Mrs Y’s needs. Mrs Y had mental capacity to agree to the assessment and to move to a care home. Care home 1 assessed Mrs Y required the assistance of two staff with personal care, with transfers using a hoist, support with medication administration and management of a grade 3 pressure sore.
15. Mrs Y’s contract with the care home, signed by Mr X and Mrs Y, highlighted she was to be admitted for a short stay for general (part) nursing care. It set out that fees would be paid by monthly direct debit in advance. In relation to ending the agreement it set out the contract would end:
• ‘[short stay placements only] when within the first 12 weeks you have given 7 days written notice to us; or
• [permanent placements or short stay placements after 12 weeks]: when you have given 28 days written notice or
• [in any case]: if you are terminating because we are in breach of this agreement, when you have given us reasonable written notice proportionate to the serious of that breach.
• 14 days after your death occurs (during which time your room has been cleared of our personal effects or when a new resident has moved in, whichever is the earlier date).
16. Mrs Y’s care plans showed she was able to communicate her needs. The plans said Mrs Y was to sit out of bed only for one hour at a time to promote pressure healing and should be repositioned regularly. She was to receive hourly welfare checks, assistance with meals and social support.
17. In late December Mr X met with the manager of the care home. He said he had raised concerns with carers about a broken socket in Mrs Y’s room, the television did not work and Mrs Y’s glasses were missing. He said these had not been addressed.
18. In early January 2023 Mr X visited and thought Mrs Y may have a urine infection. The notes record Mr X asked if Mrs Y’s urine could be tested. The following day a staff member noted in the daily care records there was blood in Mrs Y’s urine. They told a nurse who said night staff would keep an eye on Mrs Y. The daily care notes provided by care home 1 do not refer to any attempt by staff to test Mrs Y’s urine. Mr X followed up his concern that Mrs Y had a urine infection and eight days after he raised his concern the care home 1 carried out a test which was positive.
19. The following day Mr X met with a staff member at their request who said the Unit Manager was visiting the floor to look to see what improvements were needed.
20. Around this time there was an incident where Mrs Y slipped from her wheelchair in the dining room and on one visit Mr X found Mrs Y in her wheelchair alone in the day room. There was a further incident where Mrs Y gashed her leg whilst being moved out of bed to her wheelchair by three staff members.
21. In January 2023 the manager of care home 1 spoke with Mrs Y’s grandson as Mr X was away. They said there had been a meeting with the GP and Mrs Y would now been given end of life palliative care (care to manage pain and symptoms towards the end of life rather than treatment). Mr X says his son visited again the next day and a member of staff said the manager wanted to speak with Mr X about Mrs Y’s end of life palliative care but the conversation was interrupted.
22. In February, Mr X visited late morning on four occasions and found Mrs X still in bed in her night dress without her teeth or glasses. Her alarm button was also out of reach. Mr X raised the above concerns, by email, with care home 1’s manager who responded that they would look into the concerns.
23. In mid February a physiotherapist visited Mrs Y who was in bed. They noted she had no core strength and could sit on the edge of the bed only with the support of two staff. The physiotherapist left an exercise sheet with the carer to see if they could practice sit-stands. They then discharged Mrs Y from their service.
24. Later that month Mr X told staff a dressing on a gash on Mrs Y’s leg had not been changed for nine days. Staff changed it that day.
25. Also in late February care home 1 telephoned Mr X to report Mrs Y had slipped from her wheelchair when left in the day room unattended
26. In mid-March 2023 Mr X arranged for another care home, care home 2 to assess Mrs Y and Mrs Y then moved to care home 2. Care home 1 charged Mrs Y a month’s notice as she had been in the care home for 12 weeks and three days.
27. Mr X raised concerns with care home 1 about the care Mrs Y received at the care home including:
• lack of comfort and appropriate support,
• that she was categorised as needing nursing care rather than residential care,
• delays in testing for a urine infection and getting antibiotics,
• inappropriate transfers to a wheelchair,
• an inappropriate mattress,
• lack of supervision in the day room, and
• Mr X did not consider he should have to pay one month’s notice as he removed Mrs Y from the home for her own safety.
28. Mr X also raised these as safeguarding concerns with the Council. Mr X believed Mrs Y was overcharged for her care due to being unfairly required to give a month’s notice and because he considered she needed residential not nursing care.
29. Mrs Y died in care home 2, 11 days later.
30. The Council investigated Mr X’s concerns under its safeguarding procedures. It obtained a statement from care home 1’s manager and from various staff at the care home, spoke with Mrs Y’s GP, received evidence of staff training, visited care home 1 and spoke with Mr X and care home 2.
31. The safeguarding investigation substantiated some of Mr X’s allegations, found others unsubstantiated or inconclusive. In summary, in relation to some of the concerns, it found:
• It was appropriate for Mrs Y to have been on a nursing floor. However, care home 1, as a nursing provider, could have referred Mrs Y for a continuing healthcare assessment and claimed funded nursing care for Mrs Y which could have reduced the overall cost.
• Care home 1 had made Mr X aware Mrs Y had a palliative care/end of life diagnosis but failed to provide him with sufficient support to enable him to understand the implications for his mother’s care needs. It failed to produce an advanced palliative care plan to look at how Mrs Y’s care needs should be met which could be discussed with the family and it failed to communicate this with care home 2. So Mrs Y was transferred to care home 2 without an accompanying referral to the relevant Palliative Care Team. It failed to share a copy of the medical decision about the prognosis of end of life with Mr X or to consider whether Mrs Y should be referred for a CHC assessment.
• It may no longer have been safe for Mrs Y to be out of bed for long periods, but she still needed assistance to get dressed in a morning. It said records showed Mrs Y was not assisted until late morning and was sometimes left without her buzzer which undermined the personal care she needed to ensure her comfort.
• Mrs Y’s sitting posture was deteriorating leading to her slumping in a wheelchair. It would have been appropriate for her to be supervised, to monitor and manage the risk of falls/slips or to use a sensor mat or pendant alarm. This could have avoided her falls/slips. Mrs Y may have benefited from further physiotherapy or Occupational Therapy support to assess the suitability of her wheelchair/seating to achieve optimum balance/support.
• Staff had received additional moving and handling training after the incident where Mrs Y gashed her leg.
• There was an extended delay in changing Mrs Y’s leg dressing.
• Mr X believed the culture at the care home was restrictive, not encouraging her out of bed and impacting Mrs Y’s rehabilitation potential. It said Mrs Y had poor sitting balance and a pressure sore. Care home 1 failed to properly explain Mrs Y’s changing needs to Mr X to enable him to fully understand what care she needed.
• Mr X’s concern that Mrs Y did not have an appropriate mattress was unsubstantiated. It found she had a foam pressure care mattress suitable for pressure sore relief which was then changed to an airflow mattress to provide more comfort.
• It partially substantiated Mr X’s concerns about the delay in testing her urine. Care home 1 said several attempts were required due to her inability to stand and the difficulty getting a clean sample.
• Mrs Y had received appropriate antibiotics for a urine infection and a chest infection.
32. It noted the payment for the notice period was a contractual issue not for the safeguarding enquiry.
33. In late June, after the closure of the safeguarding case the care provider responded to Mr X’s complaint. It apologised for those instances when the care did not meet the expected standards. It said Mrs Y was required to give 27 days notice as per the contract terms. As a gesture of goodwill, it said it had credited two weeks of the charges back to Mrs Y.
34. Mr X remained unhappy and complained to us. He said Mrs Y’s admission to the care home was as a short stay and the care home never discussed that her status would change. He said the move to care home 2 was urgent and necessary due to the risks of neglect at care home 1.

CQC inspections

35. The Care Quality Commission inspected care home 1 in January 2023 and rated is at requiring improvement and identified action for the care home to take to address the concerns it identified. The CQC inspected care home 1 again in January 2024. It rated the care home as good.

Findings

36. When Mrs Y first moved to care home 1, it properly assessed her needs and there is no fault in the way it reached a decision she should stay on a nursing floor. However, given it had decided she had nursing needs it should have referred her for an assessment for funded nursing care. Its failure to do so was fault which caused Mr X uncertainty over whether Mrs Y paid too much for her care.
37. Mrs Y’s contract with care home 1 set out that after 12 weeks, one month’s notice was required by permanent and short stay residents. The decision to charge Mrs Y a month’s notice was therefore in line with the contract. However, the contract also referred to there being only a 14 day notice period where a resident has died. Mrs Y died 11 days after leaving care home 1 and she left shortly after 12 weeks. Care home 1 should therefore have considered exercising its discretion, in the circumstances of the case and Mrs Y’s subsequent death to reduce the notice period. This was fault. In response to the complaint, care home 1 agreed to remove two weeks charges as a goodwill gesture. This remedies the injustice caused.
38. There was fault in the care provided to Mrs Y. Mr X’s concerns about the care at care home 1 were considered through the Council’s safeguarding process and it identified areas of poor care which I have summarised at paragraph 31. I am satisfied the safeguarding investigation properly identified the areas of fault.
39. From the records I have seen I also consider care home 1 delayed taking a urine sample when Mr X suspected Mrs Y had a urine infection. Consideration of appropriate treatment was therefore likely delayed. In addition, the care home manager failed to adequately respond to the concerns Mr X raised and failed to consider whether they should have referred Mr X to its complaints process. These faults meant Mrs Y’s care needs were not appropriately met and her care was not in line with the CQC fundamental standards.
40. As Mrs Y has died, I cannot now recommend a remedy for the injustice caused to her by the poor care. However, the faults also caused Mr X distress. This was in addition to the frustration and uncertainty over whether Mrs Y may have received funded nursing care which would have reduced Mrs Y’s care costs. I have recommended a payment to acknowledge this.
41. The CQC inspected the care home earlier this year and rated it good and therefore I do not consider it necessary to now make recommendations regarding areas covered by the fundamental standards.

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Agreed action

42. Within one month of the final decision care home 1 has agreed to apologise to Mr X and pay him £500 to acknowledge the distress he was caused by the faults in the care provided to Mrs Y at care home 1 and £300 to acknowledge the frustration and uncertainty caused by its failure to refer Mrs Y for funded nursing care. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended.
43. Within two months of the final decision the care provider has agreed to:
1. Review its procedures to ensure those on the nursing floor are referred, on admission, for an assessment for funded nursing care.
2. Remind staff of the need to consider whether to refer representatives to the complaints procedure when they are repeatedly unhappy with the care provided.
44. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

45. I have completed my investigation. There was evidence of personal injustice caused by fault which the care provider has agreed to remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman