Summary: Mr B complained about the standard of care his late father, Mr C received in a residential care home and about the information he received relating to his father’s financial assessment and contribution towards the care charges. On the evidence available we found some fault. We have asked the Council to pay Mr B £500 and improve its procedures for the future.

The complaint

1. Mr B complained in respect of his late father’s (Mr C’s) stay at a residential care home (the Home), that Norfolk County Council (the Council):
• failed to ensure Mr C received adequate care: specifically he was frequently dehydrated and did not eat his food, fell frequently, was left in soiled clothing for long periods and was left to take his medication unsupervised.
• failed to explain to Mr B that Mr C was liable for the full fees for the Home or provide any information about the financial assessment.
• failed to pay Mr C his weekly allowance while at the home to allow him to buy a newspaper, unlike other residents.
• sent a demand for the fees without explanation or warning several months after Mr C’s death.
2. These events have caused Mr B and the rest of the family significant distress and uncertainty. He is also concerned that there is a large outstanding bill for care fees which he does not think is due given the poor standard of care.

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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. I have considered the complaint and the documents provided by the complainant, made enquiries of the Council and considered the comments and documents the Council provided.

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What I found

6. Mr B’s father Mr C had dementia. Following a stay in hospital in September 2020 he was discharged to a short term bed in a care home to assess the next steps. The fees were paid by the Council. The placement was extended until March 2021.
7. Neither Mr B or any other family members had lasting power of attorney for Mr C (permission to make decisions on his behalf). In November 2020 the Council carried out a mental capacity assessment and decided Mr C did not have the mental capacity to make decision about his finances.
8. Later that month the Council asked Mr B if a family member would be able to take on responsibility for Mr C’s finances. They would have to apply to the Court of Protection for Deputyship to administer Mr C’s pensions and access his bank account. The Council explained that if no-one was able to do this it could refer Mr C’s case to the Client Financial Affairs Team (CFAT) to take on the role.
9. In January 2021 Mr B said no one in the family could take on this role as Mr C did not have the mental capacity to consent. so the Council referred the case to CFAT.
10. The Council carried out a review of Mr C’s care needs in February 2021. As part of this it noted that he had a history of self-neglect and could be very resistant to help with personal care, particularly with showering and changing into clean clothes.
11. Following another hospital admission, he moved to a long term placement at a different care home (the Home) in March 2021. Mr B was initially very happy with the placement.
12. Mr C’s care and support plan noted that he was a very independent person and got frustrated having to accept help with personal care. The plan said staff were to encourage Mr C with personal care, offering a daily shave and clean clothes, along with a shower twice a week. It noted he will often decline help but staff are to give him time and space and try to encourage him throughout the day. The plan recognised Mr C had some incontinence and was diabetic. The dietitian had advised a high protein diet with milky drinks to keep Mr C fuller for longer and discourage his wish to eat more sugary foods. It said staff in Mr C’s unit should ensure all sugar was locked up as Mr C liked to walk regularly and would access sugar if it was available. It also said that if significant weight loss was noted his doctor and dietician should be involved.
13. CFAT accepted Mr C’s case in April 2021 and Mr B informed the Council that Mr C also had two private pensions. CFAT carried out a financial assessment based on the figures provided by Mr B. This showed that Mr C needed to make a contribution of over £300 per week towards his care fees, but neither the family , nor CFAT at this point could access Mr C’s bank account or pensions to pay the care fees, so arrears accrued.
14. In July 2021 CFAT became appointee for Mr C which meant the Council was able to administer Mr C’s state pension. It was not able to access his bank account or private pensions. The Council said it does not automatically apply for Deputyship where a person’s assets are thought to be less that £10,000 because of the high fees involved in the process and ongoing administration. Instead, it contacted all known financial organisations and asked them to forward the pensions to the CFAT account. However, this was not successful and in October 2021 it applied for Deputyship. Until this was granted CFAT could not access Mr C’s private pensions and could only put the state pension towards Mr C’s contribution. This meant that care fee arrears accrued. Mr B says this was not communicated to him or other family members.
15. The Council has provided three invoices from January and May 2022 submitted to CFAT by the Home for personal expenses for Mr C. The Council says this was for things that Mr C needed on a daily basis, but no breakdown or details have been provided. Mr B says Mr C was not given a daily paper and was not given a regular allowance.
16. Between January and April 2022 Mr C lost approximately 9kg in weight and was noted to have a low mood. Staff took advice from the nurse and GP who prescribed some anti-depressants and discussed his case at the multi-disciplinary meetings with medical professionals. The mental health nurse visited in May 2022 to discuss his low mood and self-neglect. In their report they noted that Mr C was sometimes incontinent and refused help from care staff. They further noted that staff did not force the issue but waited until he was more relaxed and likely to accept care. The care records show that the Home weighed him monthly, tried to encourage him into the dining room to eat and to monitor his sugar intake. The dietician in May 2022 said his blood tests results were normal and to continue with the high protein diet and milky drinks. The records show the Home administered and recorded Mr C’s medication on a daily basis. There was no evidence of any recorded falls.
17. By early June 2022 he had lost a further 9 kg and was now considered high risk. He was refusing a lot of meals and hiding food in drawers or putting it in the bin. He just wanted to eat sweet things. From this point the Home weighed him weekly, continued with a fortified diet and to offer high calorie snacks between meals. Staff noted a general decline in his health and had regular contact with Mr C’s GP, discussed Mr C’s condition at multi-disciplinary meetings, with the nurse and the dietician. The dentist visited to see if there could be a teeth-related issue, but nothing was found.
18. The daily care records from the beginning of June show that staff made regular checks on Mr C and he frequently refused help with washing or changing his clothes even when they were visibly wet with urine. Staff monitored his food and fluid intake recording how much he drank and how many spoonfuls of food he ate. But there is no evidence he had any specific targets for the amount of fluid he should be drinking or that staff should be sitting with him while he ate and drank
19. Mr C’s condition deteriorated, and he was admitted to hospital on 27 June 2022. He died on 10 July 2022. CFAT had not been granted Deputyship by this point so the Council could not access his private pensions or bank account to pay the care fees. Instead it sent an invoice to Mr B in October 2022 for the outstanding arrears (approximately £20,000).
20. Mr B and the family were surprised to receive this invoice as they had no idea Mr C owed this much money. They believed CFAT had been paying his required contribution from his state pension.
21. Mr B complained to the Council about the lack of information about the financial assessment and payment of fees. He also complained about the standard of care provided to Mr C while at the Home and believed the outstanding fees should be waived.
22. The Council responded in March 2023. It explained the sequence of events with Mr C’s finances and the fact that CFAT had not obtained Deputyship before Mr C died so had not had access to his private pension in order to pay the full contribution. This meant Council had to invoice Mr C’s estate for the outstanding amount. It had waived the care charges from November 2020 to 14 March 2021, when Mr C was in the short term placement, which reduced the bill to under £15,000.
23. In respect of the complaint about the standard of care at the Home, the Council said it had referred this as a safeguarding enquiry and it would update Mr B as required.
24. It gave no further comment on the care issues but said it did not uphold the complaint against the Home and all charges remained payable.
25. Mr B complained to us in March 2023. In June 2023 he said he had received a call from the Council asking how he thought the care at the Home could be improved. The Council also said Mr C should have had a care needs review in April 2022 but this had not happened.
26. In response to my enquiries the Council sent me information that appears to have formed part of the safeguarding investigation. The Council had reviewed the care records from 4 to 26 June 2022. It noted that Mr C sat in his room most of the time, entering the communal areas on six occasions. There were no entries showing staff encouraging him to join in activities or sit in the communal areas.
27. The Council noted Mr C refused personal care on many occasions, despite staff offering this two to three times a day. He accepted personal care on 13 occasions.
28. The food and fluid charts show Mr C was offered a variety of food and drink and his intake was monitored daily. It noted staff were making hourly checks from 7 June 202 and half hourly checks from 24 June 2022 after staff raised concerns about self-neglect and weight loss. The Council’s evaluation of the evidence concluded that staff followed Mr C’s care plan but there was little evidence of encouragement to enter communal areas and activities and nothing to say that staff should sit with Mr C at all meals. Personal care was offered persistently, concerns were recorded, referrals made and recommendations made by professionals were followed.
29. I have not seen evidence this information was sent to Mr C.

Analysis

Financial issues

30. I acknowledge that Mr B did not have formal authority to act on Mr C’s behalf in respect of his finances and turned down the Council’s suggestion that he or another family member should apply for Deputyship. However, he was Mr C’s son and his next of kin. He visited regularly, was consulted as part of the care needs assessment and the finance team communicated with him about Mr C’s finances without concern.
31. Given this context I would have expected the Council to have provided more information about how paying for care worked, including the contribution and the potential for arrears to build up because neither Mr B nor the Council obtained Deputyship before Mr C died. The Council provided ample information about applying to be a Deputy or an Appointee but I have not seen evidence that it explained the contribution or the likelihood that Mr C’s state pension would be insufficient to cover the charge.
32. This was fault. At the very least I consider it should have provided some explanation and context, after Mr C died and before it sent out a bill for over £20,000. This was a shock which cause Mr B significant distress and worry.
33. However, I have not concluded that the bill was not payable: Mr C received the care and there is no evidence that complaints were made about the standard of care until after Mr C’s death.

Weekly allowance

34. The Council has provided three invoices showing the Home claimed back Mr C’s personal expenses from CFAT on three occasions in 2022. In the absence of a breakdown of what the money was spent on I am unable to say with certainty that Mr C received a daily newspaper. But I note this was included in the care and support plan and was not raised as a formal concern until after he died. I consider the Council should have been able to provide specific information to Mr B on this point and the failure to do so added to his uncertainty over his father’s care.

Care

35. I understand it must have been very distressing for Mr B to witness a deterioration in his father’s condition while at the Home. However, in the main the records show that the Council understood Mr C’s conditions, his propensity to self-neglect, including food and fluid intake and his day to day preferences. The care plan contained measures which staff followed, concerns were raised promptly, referrals made to relevant professionals and staff implemented the recommendations made.
36. Staff frequently tried to encourage Mr C to wash and change his clothes, but he often refused. Rather than escalate the situation risking an agitated response from Mr C, staff would try again several times in a day, sometimes with success. Although he was not always washed and in clean clothes, there is no evidence that this was due to fault by the staff.
37. Mr C’s weight loss was noted between January and April 2022, following monthly weighings. The Home consulted the dietician who was not concerned and advised to continue with the advice previously given. By early June 2022 the Home noted that the weight loss was accelerating, and Mr C was increasingly hiding food in drawers or the bin or refusing it entirely. In response staff started monitoring his food and fluid intake and checking his room on an hourly, then a half-hourly basis including checking drawers. The monitoring shows that staff were aware how much Mr C had eaten and drunk but there was no evidence staff were advised to sit with him or measure his progress against any targets. This was fault which caused uncertainty to Mr B and the family as to whether Mr C’s situation was improving at all or whether further advice should have been taken.

Complaint handling

38. The Council responded to Mr B’s complaints about the standard of care at the Home by making a safeguarding referral. The Council offered no explanation as to how this would be done or how Mr C would be involved. It is possible the call in June 2023 was part of that process, but this was not clarified.
39. While I welcome the Council’s acknowledgement of possible safeguarding concerns for residents at the Home and consider it was appropriate action to take, I consider Mr B should have received a response to his specific concerns within the complaint response, along with an explanation of the safeguarding process and its likely timescale. The failure to do so was fault which caused distress and uncertainty to Mr B at a difficult time.

Care needs review

40. I note that the Council during the telephone call with Mr B acknowledged a delay in carrying out a review of Mr C’s care needs. I have not received the Council’s formal response on this, but I note Mr C had a care needs review in April 2021, so an annual review was due in April 2022. The failure to do this on time meant Mr B has been left with uncertainty that further steps could have been taken to address the deterioration in Mr C’s condition.

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Recommended/ agreed action

41. In recognition of the injustice cause to Mr B I recommend the Council:
42. Within one month of date of my final decision:
• Pays Mr B £250 for the failure to properly explain the financial processes to him and £250 for the uncertainty around Mr C’s care, care needs review and safeguarding referral.
43. Within three months:
• Reviews its complaint procedure to ensure specific concerns about care are addressed within complaint responses in addition to any safeguarding referrals.
• Ensures it has a monitoring system in place for annual reviews of care needs assessments.
• Reviews its financial information sheets/leaflets/internet links to make sure complete information is provided to family members about care charges and contributions at an early stage and always before a large invoice is sent out.
44. The Council should provide us with evidence it has complied with the above actions.

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Draft decision

45. Subject to further comments by Mr B and the Council, I intend to complete my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman