Summary: Mrs B says the Council failed to carry out proper care planning before she entered the care home, failed to ensure the care home provided for her cultural needs, failed to put in place sufficient support, failed to carry out proper risk assessments, carried out a financial assessment which left her with an inadequate amount to live on and gave her representative wrong information about the complaints process. There is no fault in how the Council carried out care planning or in how it carried out the financial assessment. There is some evidence of the care home not following through with some of the actions in the care plan and failing to provide Mrs B with culturally appropriate meals. There is also evidence of the Council giving Mrs C wrong information. An apology, payment to Mrs C, writing off some of Mrs B’s arrears and monitoring of the care homes records is satisfactory remedy.

The complaint

1. The complainant, whom I shall refer to as Mrs B, is represented by her daughter whom I shall refer to as Mrs C. Mrs B complained the Council:
• failed to carry out proper care planning before she entered the care home or involve her family in the assessment;
• failed to ensure the care home provided for her cultural needs;
• delayed sharing the care plan with her family;
• failed to ensure the care home put in place sufficient support or carried out risk assessments;
• failed to ensure she had access to a wheelchair in the home;
• carried out a financial assessment which left her with an inadequate amount to live on;
• failed to explain the implications of applying for NHS funded care to her representative; and
• gave Mrs C wrong information about the complaint process.
2. Mrs B says failures by the Council mean her representative has had to support her financially and provide her with culturally appropriate food. Mrs B says it has caused her and Mrs C significant distress.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. 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)

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How I considered this complaint

5. As part of the investigation, I have:
• considered the complaint and Mrs C's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
6. Mrs B, Mrs C and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

What should have happened

The care regulations

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets 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.
9. Regulation 9 says the care and treatment of service users must be appropriate, meet their needs and reflect their preferences.
10. Regulation 14 says the nutritional and hydration needs of service users must be met. This includes the meeting of any reasonable requirements of a service user for food and hydration arising from the service user’s preferences or their religious beliefs or cultural background.
11. Regulation 17 says care providers should “maintain secure” records and should have “an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.
12. The CQC guidance states culturally appropriate care is sensitive to people’s cultural identity or heritage. It means being alert and responsive to beliefs or conventions that might be determined by cultural heritage. This includes ethnicity and nationality.

Care and support

13. Care and support plans are for anyone who needs care or cares for someone else. A care and support plan says the type of support someone needs, how this support will be given and how much money the Council will spend on someone’s care. The care and support statutory guidance says the care plan should be person-centred, with an emphasis on the individual having every reasonable opportunity to be involved in the planning to the extent they choose and are able. Consideration of the needs to be met should take a holistic approach that covers aspects such as the person’s wishes and aspirations in their daily and community life, rather than a narrow view purely designed to meet personal care needs.

Care and support statutory guidance on financial assessments

14. People in a care home will contribute most of their income, excluding their earnings, towards the cost of their care and support. However, a local authority must leave the person with a specified amount of their own income so that the person has money to spend on personal items such as clothes and other items that are not part of their care. This is known as the personal expenses allowance (PEA). The amount is set out in regulations and updates sent via a local authority circular. Anything above this may be taken into account in determining charges. The current PEA is £25.65 per week.

What happened - care provision

15. Mrs B was in the rehabilitation unit in 2022 following a period in hospital. The Council’s social worker met with Mrs C on the ward in April 2022. The social worker assessed Mrs B as lacking capacity to make a decision about a care home placement. The social worker involved Mrs C in the best interests decision which was for a care home placement to be sought. The Council asked Mrs C to complete a financial assessment form.
16. Mrs B moved into the care home in May 2022. The Council completed an assessment and told Mrs C that Mrs B should pay the full cost pending a full assessment. The Council sent out a revised financial assessment in July 2022.
17. Mrs C queried the financial assessment. The Council explained it had left Mrs B with the statutory amount of £25.65 per week and the rest of her income was taken into account. The Council explained if Mrs B gave up the mobility car and received the PIP mobility allowance of £64.50 per week that would not be taken into account.
18. In September 2022 Mrs C asked for information about continuing healthcare funding and raised concerns about the food provided by the home. The Council suggested a meeting with the home to discuss the menu available.
19. In September 2022 an optometrist carried out a low vision assessment and made some recommendations for the home to implement. The home subsequently implemented those recommendations.
20. A placement review took place on 21 September. The home manager agreed to make a referral for a continuing healthcare assessment. It was noted Mrs B wanted to remain in the care home and her representative had said the food had improved. Mrs C asked for a copy of the support plan.
21. In November 2022 the NHS confirmed eligibility for funded nursing care. This was backdated to the date of admission to the nursing home and was paid direct to the nursing home. In December 2022 the Council explained the NHS funded nursing care was deducted from the Council’s contribution and therefore made no difference to the amount Mrs B would pay.
22. The Council provided Mrs C with the updated support plan in January 2023. Mrs C raised concerns about the lack of changes to the care plan and said she was providing daily food and company to Mrs B.
23. Following concerns about Mrs B falling the home asked the occupational therapist for advice. The occupational therapist recommended a floor bed which was ordered by the home. The home also told the Council it had fitted Mrs B’s room with a call bell, sensor mat and pendant to alert staff. The home told the Council its kitchen staff had met with Mrs C to explore how to improve Mrs B’s dietary needs but said what Mrs C wanted her to eat is not always what Mrs B preferred.
24. The Council’s social worker visited the home and Mrs B on 16 February. On that visit Mrs B told the social worker she found the meals satisfactory but would welcome support from a carer who spoke her language. Mrs B said she would like to take part in activities.
25. Following a placement review the home agreed to provide instructions in Mrs B’s room for the Bipap machine. The home also agreed to look into funding for a carer who spoke Mrs B’s dialect.
26. Mrs C told the Council she would not pay any contributions until the Council agreed to cover the extra expenses she was incurring to meet Mrs B’s dietary and cultural needs. The Council suggested identifying a more culturally appropriate care home but Mrs C said she wanted Mrs B to remain in Camden.
27. In March 2023 the Council approved funding for a Hindi speaking carer to visit Mrs B.
28. At the end of March the social worker visited the care home to review the care plan and noted most of the updates had been made. The social worker said the care plan needed to be updated to require an interpreter for major reviews and assessments so Mrs B could participate. The social worker met with the manager of the home and recommended staff make mask cleaning part of the morning personal care routine.
29. The Council has also proposed the following actions:
• to monitor the provision of culturally appropriate foods at regular placement reviews and to review the care home records every three months to monitor that;
• complete a placement review within one month;
• monitor the homes provision of culturally appropriate food for all its residents in quarterly quality assurance visits and an improvement plan.

What happened - complaint

30. Mrs C put in a complaint in March 2023. The Council responded to that on 6 April and told Mrs C if she was dissatisfied she could ask for the complaint to go to stage two. Mrs C asked the Council to take the complaint to stage two on 11 April. The Council said it would respond within 25 working days. Mrs C chased the Council for a response on 2 June. The Council initially told Mrs C it would respond within 25 working days. However, the Council subsequently told Mrs C as it was an adult social care complaint she did not have the right to stage two.

Analysis

31. Mrs C says the Council failed to carry out proper care planning before Mrs B entered the care home. In particular, Mrs C says the Council failed to involve the family or an interpreter and therefore the care plan does not reflect Mrs B’s needs.
32. Having considered the documentary records I note Mrs B moved into the care home directly from a rehabilitation unit. The evidence I have seen satisfies me Mrs B and Mrs C were involved in discussions about care planning, the mental capacity assessment and the best interest decision. While the documentary evidence is not clear about whether Mrs C was involved in drawing up the care plan I am satisfied the care plan is comprehensive and sets out Mrs B’s needs. There is no evidence in the documentary records to suggest changes to the care plan were required because of Mrs B not being able to properly contribute to the care plan. I am also satisfied the documentary records show the need to involve Mrs C when reviews are carried out and I note Mrs C took part when a review took place. Given all of that I could not say the Council failed to carry out proper care planning.
33. Mrs C says the Council failed to ensure the care home provided for Mrs B’s cultural needs. Mrs C says the care home is still not providing culturally appropriate food for Mrs B and delayed putting in place a carer who spoke Mrs B’s language.
34. The Council accepts it delayed putting in place a carer who spoke Mrs B’s language. That is fault. For Mrs B’s dietary needs though the Council suggests the concerns raised by Mrs C relate more to acquired taste rather than culturally appropriate foods. However, regulation 9 says care and treatment of service users must meet their needs and reflect their preferences. In failing to properly consider whether culturally appropriate foods should be provided for Mrs B the Council failed to take into account her individual rights in line with the requirements of the Equality Act. As a result, I am satisfied despite regular discussions with Mrs C the home has not been able to put in place culturally appropriate food. That has led to Mrs C having to bring food in. That is fault and not in line with regulation 14.
35. Mrs C says the Council delayed sharing the care plan from September 2022 with them. The evidence I have seen satisfies me the Council did not share that care plan with Mrs C until January 2023. That delay is fault. As remedy for that I recommended the Council apologise to Mrs C. The Council has agreed to my recommendation.
36. Mrs C says the Council failed to ensure the home put in place sufficient support for Mrs B’s mobility. Mrs C says because of that Mrs B has experienced several falls. The documentary evidence I have seen satisfies me the Council identified Mrs B was at high risk of falls before she entered the care home. I am also satisfied the home has involved an occupational therapist and this led to provision of a sensor mat, pendant alarm and floor bed to address any issues with falling. Alongside that I am satisfied the home has completed a risk assessment. I am therefore satisfied the Council has acted appropriately to mitigate the risk of falls for Mrs B.
37. I understand Mrs C is concerned though given Mrs B has continued to experience falls. However, the documentary records show most of those falls have been caused by Mrs B trying to mobilise without seeking support from care staff. I am satisfied the care home has put in place additional support which involves care staff carrying out regular checks on Mrs B when she is in her room to address this issue. I have therefore found no evidence of fault by the Council.
38. Mrs C says the Council failed to ensure there is support for Mrs B’s visual difficulties. The evidence I have seen satisfies me the care home has taken appropriate advice on measures to address Mrs B’s sight issues. As a result of that advice I am satisfied the care home has put in place the following measures:
• provision of a yellow visor;
• white LED bulb on the ceiling and a light by her bed on the wall;
• big numbers on her watch so she can still see it;
• tape applied on her Zimmer frame handle and on her bed frame as well as around the table;
• arrangements for mugs in communal areas in see-through plastic glass.
39. I therefore could not say the Council failed to ensure provision for Mrs B visual difficulties was made.
40. Mrs B uses a Bipap machine and Mrs C says Mrs B needs help to use that machine and in cleaning it and the care home has provided neither. The daily care records show some evidence of staff helping Mrs B use the machine. However, despite the fact care plans note the need for daily cleaning of the machine there is no evidence of that taking place in the daily care records. I therefore could not say proper cleaning has taken place. That is fault and could potentially cause Mrs B a significant injustice if she contracted an infection. As remedy for that I recommended the Council remind the home of the need to ensure the machine is cleaned daily. I also recommended the Council monitor the daily records over the next three months to ensure the machine is cleaned. The Council has agreed to my recommendations.
41. Mrs C says the care home failed to carry out any monitoring of Mrs B’s diabetes or hypertension. Control of Mrs B’s diabetes is a matter for the health service, rather than the home. It is not clear from the documentary records though how often the GP recommended the home carry out blood pressure checks. I recommended the Council ensures the home contacts the GP to confirm how often blood pressure checks need to be undertaken and then ensure this is passed on to care staff. The Council has agreed to my recommendation.
42. Mrs C says the care home failed to provide any physiotherapy for Mrs B. I am satisfied the arrangements for physiotherapy are a matter for the health service rather than the care home. There is no evidence the care home was tasked with providing any physiotherapy, other than encouraging Mrs B to mobilise. I therefore have no grounds to criticise the Council here.
43. Mrs C says the care home failed to provide Mrs B with activities between October 2022 and March 2023. The Council accepts limited activities took place for residents in the care home between those dates as the activities coordinator had left. Failure to provide Mrs B with activities during that period is fault. I am satisfied the care home has addressed this as a new activities coordinator is in post.
44. Mrs C says the Council failed to provide Mrs B with transport to hospital appointments. Mrs C therefore says she is having to transport Mrs B to her appointments. While I understand Mrs C’s concern I note Mrs B has a mobility vehicle which Mrs C uses. Of course it is for Mrs B to decide how she uses her mobility payments but as the mobility vehicle is intended to provide her with transport and as she is not entitled to hospital transport I do not consider the Council at fault for failing to put in place transport to hospital appointments. That should be covered by Mrs B’s mobility payment or, in the alternative, the mobility car if she chooses not to take the mobility payment.
45. Mrs C complained the home regularly fails to provide Mrs B with fruit. Mrs C says this is important as Mrs B is a vegetarian and does not eat eggs. Having considered the documentary records I am satisfied there are regular entries to show fruit provided to Mrs B. I therefore do not consider the Council at fault here. It is open for Mrs B or her representative though to ask for changes to the care plan if they believe there is a need for fruit to be provided daily.
46. Mrs C says the Council failed to ensure Mrs B has access to a wheelchair in the home. Mrs C says as a result she had to buy a wheelchair privately. The evidence I have seen suggests the care home provided a wheelchair to Mrs B but she did not consider that wheelchair appropriate. In those circumstances I have no grounds to criticise the Council.
47. Mrs C says the Council failed to explain if she applied for funded nursing care it would not make any financial difference to the amount Mrs B had to pay towards her care. Having considered the documentary records it is clear Mrs C regularly asked for a continuing healthcare assessment following Mrs B moving into the care home. I am satisfied the Council acted on that. However, there is no evidence the Council explained to Mrs B how funded nursing care would work. That meant Mrs C believed if she applied for continuing healthcare the amount Mrs B would have to pay towards her care would be reduced when that was not the case for funded nursing care. I would have expected the Council to explain that to Mrs C. Failure to do that is fault. I recommended an apology as well as a reminder to officers. The Council has agreed to my recommendations.
48. Mrs C says the Council’s financial assessment is inadequate as it has left Mrs B with too little money to live on given she has to pay for culturally appropriate foods and entertainment.
49. I set out in paragraph 14 what the care and support statutory guidance says about how financial assessments should be undertaken for those living in a care home. I am satisfied the Council followed that guidance in assessing Mrs B’s income and expenditure. I recognise leaving Mrs B with £25.65 per week may seem harsh. However, that amount is set by Government and the Council is therefore not at fault for taking into account Mrs B’s income minus the £25.65 per week personal allowance she is entitled to and the PIP mobility allowance. As there is no fault in how the Council carried out the financial assessment I have no grounds to criticise it. The remaining £25.65 per week personal allowance Mrs B has, plus the PIP mobility allowance which she could access if she chose to give up her mobility car, would be expected to cover any additional expenses such as the entertainment costs Mrs B incurs.
50. In reaching that view I am aware Mrs C says it is unfair as Mrs B has to buy culturally appropriate foods because they are not provided by the home. Mrs C therefore says those amounts should be deducted from the financial assessment. There is no provision for that in the care and support statutory guidance. I have, however, made some recommendations around improving the provision of culturally appropriate food, which the Council has accepted.
51. Mrs C says the Council gave her the wrong information about the complaint process. The evidence I have seen satisfies me when responding to the complaint the Council told Mrs C she had a right to ask for a review at stage two of the Council’s complaints procedure. Then, when Mrs C chased the Council for a response two months later it initially told her it would respond within 25 working days but then said it could not do so because it was an adult social care complaint and there was no second stage of the complaints procedure.
52. I am concerned the Council gave Mrs C the wrong information. Given the person dealing with Mrs C in June 2023 is from the complaints department I would have expected him to know there was no second stage in the Council’s complaints procedure for adult social care complaints. I would also have expected the officer responding to the complaint at stage one to have known that. Giving Mrs C wrong information is fault. The Council has apologised for that. I consider that a satisfactory remedy for this part of the complaint.
53. So, I have found fault by the Council led to Mrs B not receiving culturally appropriate food, experiencing a delay in having a carer who speaks her language so she can interact, not receiving sufficient activities between October 2022 and March 2023, not having her Bipap machine cleaned daily and not being clear about how often her blood pressure should be checked. I consider the Council’s offer to deduct £500 from Mrs B’s arrears for care home fees sufficient remedy to reflect the distress caused to her, alongside its agreement to work with the home to address the issue of culturally appropriate food and its agreement to monitor the records for the areas on which I have found fault over the next three months to ensure those issues are addressed.
54. I also consider Mrs C has suffered any injustice though as she has had to provide culturally appropriate food for Mrs B. There is also evidence the Council failed to properly advise her about the implications of applying for NHS nursing care and gave her incorrect information about the Council’s complaints procedure. As remedy for that I recommended the Council pay Mrs C £250. The Council has agreed to my recommendation.

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Agreed action

55. When a Council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although we found fault with the actions of the care provider, we have made recommendations to the Council.
56. Within one month of my decision the Council should:
• apologise to Mrs B and her representative for the distress and frustration they experienced due to the faults identified in this decision. The Council may want to refer to the Ombudsman’s updated guidance on remedies, which sets out the standards we expect apologies to meet;
• pay Mrs C £250;
• deduct £500 from Mrs B’s arrears (if the Council has not already done so);
• send a reminder to the home about the need to ensure Mrs B’s Bipap machine is cleaned daily;
• check with Mrs B’s GP to confirm how often blood pressure checks need to be undertaken and then pass on that information to care staff.
57. Within two months of my decision the Council should arrange a meeting with the home to discuss how it can provide more culturally appropriate food for Mrs B.
58. Following my final decision the Council should carry out three month monitoring of the home’s records for Mrs B to ensure carers clean the Bipap machine, to ensure culturally appropriate meals are being provided and to ensure coloured cutlery and plates are being used.

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Final decision

59. I have completed my investigation and uphold the complaint.

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Investigator's decision on behalf of the Ombudsman