Summary: Ms C complains the Council inappropriately charged for residential care after her father died and the residential care it commissioned was inadequate. The Council is at fault for failing to respond to Ms C and there was service failure by the care home. This caused Ms C uncertainty and avoidable charges for care. To remedy the complaint the Council has agreed to waive some outstanding fees. It will also make Ms C a symbolic payment for the time, trouble and distress the Council’s actions caused her. As part of its commissioning role the Council will also review the Care Provider’s recording.

The complaint

1. The complainant who I refer to as Ms C complains about services and charges for her late father’s, who I call Mr D’s, care. Ms C complains the Council commissioned service at Adelaide House Care Home, the “Care Provider” failed to provide acceptable care to Mr D. The Council also sought to recover charges for a two week period when Mr D was in hospital and told he could not return to Adelaide House. Ms C says the Council failed to advise her to remove Mr D’s belongings to prevent continuing charges.
2. Because of the service failure Ms C says Mr D did not receive the care he should have towards the end of his life. This caused distress to both him and his family. Ms C does not consider Mr D’s estate should be liable to pay for care when Mr D was not resident and after she told the Council he would not be returning.

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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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
5. 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)

6. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
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)

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How I considered this complaint

8. I read the complaint and the associated documents. I spoke with Ms C and made enquiries of the Council. This included asking for documents and specific questions about its actions. I considered:-
• the Council’s response;
• Mr D’s care records;
• The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of Care Providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences. I have used the fundamental standards as a benchmark for considering this complaint.
9. Ms C, the Care Provider and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Background information

10. Mr D had mobility problems because of multiple fractures in his back. In May 2023 Mr D went into hospital. He went into Adelaide House from hospital on 9 June. Ms C describes Mr D as restricted to his bed, unable to use his hands or arms or move his neck. Mr D went back into hospital on 17 June where on admission he had severe dehydration and a urine infection.

What should have happened

11. 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.
12. Regulation 12 aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Care providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks.
13. Regulation 14 says care providers must meet service user’s nutritional and hydration needs. The associated guidance says care providers
14. “must include people's nutrition and hydration needs when they make an initial assessment of their care, treatment and support needs and in the ongoing review of these. The assessment and review should include risks related to people's nutritional and hydration needs.
15. Providers should have a food and drink strategy that addresses the nutritional needs of people using the service.”
16. Regulation 17 says Care Providers should “maintain securely 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.”
17. National Institute for Health and Care Excellence (NICE), “Helping to prevent pressure ulcers – A quick guide for registered managers of care homes” says,
18. “Repositioning is recommended every 6 hours for people at risk of developing pressure ulcers and every 4 hours for people at high risk”.

What happened

19. On admission to hospital the family and emergency services made a safeguarding alert because of:-
• the Care Provider’s inability to provide a history of Mr D’s ill health;
• manual handling of Mr D;
• pressure sores on Mr D’s heels and buttocks;
• a pendant alarm which was out of reach;
• Mr D’s demeanour, he was slumped to one side, confused, unkept, and soiled;
• Mr D’s drowsiness, Ms C said the Care Provider was giving Mr D sleep medication during the day.
20. Ms C says she had raised concerns about Mr D’s confusion and drowsiness but the Care Provider took no action. The Council completed a safeguarding investigation and found the Care Provider had acted properly and there was no abuse or neglect. As part of this process the Council spoke with Mr D who said he was generally happy with the care provided and willing to return. The Council found :-
• Mr D had pressure sores when he arrived at the care home shown by photographs taken by the Care Provider at the time. There was also evidence care staff were applying cream to the sores, repositioning Mr D and had a suitable airflow mattress in place;
• the Care Provider had contacted the GP about Mr D’s drowsiness and confusion and had followed the advice and action prescribed by the GP which included testing and treatment for a urine infection;
• there was no evidence the Care Provider was giving Mr D medication at the wrong time, only as prescribed. The Care Provider had sought advice from the GP and this included a medication review;
• Mr D preferred to call out for help rather than use the pendant. Because of Mr D’s restricted movement he would also find it difficult to use the pendant alarm. The Care Provider said it carried out hourly checks to monitor safety. It said the pendant was not near Mr D when ambulance staff arrived as a nurse had moved the table so ambulance staff could access Mr D. The nurse was with Mr D apart from when they left to meet ambulance staff;
• the Care Provider had referred Mr D’s neck support to the GP and supported Mr D with pillows as advised by the hospital. It said Mr D must have moved to the left which dislodged the pillows. Care staff however did not consider Mr D was slumped to the side;
• the Care Provider explained care staff had supported Mr D with his personal care before the ambulance crew arrived but he did have secretions from his coughing. It also said when Mr D left the care home he was wearing a shirt and dark blue trousers;
• the care home identified Mr D had a urine infection the previous day and started Mr D on oral antibiotics;
• the care home recorded Mr D’s eating and drinking and there was no concern these were not at a suitable level;
• the care home said it called the ambulance due to a decrease in Mr D’s oxygen saturation levels;
• that Mr D appeared drowsy but not confused. He only seemed confused on the day of admission to hospital;
• the family had not raised any concerns during Mr D’s stay apart from him not having a shave on one occasion. The care home explained Mr D had refused a shave that day.
21. Ms C also complained the Council charged Mr D’s estate for care fees after it was aware Mr D was not returning. During this complaint investigation the Council has accepted its error and agreed to apologise and waive fees from 19 June. The Council also accepted it had not followed its complaints procedure as it failed to progress the complaint to stage two of its process.

Was there fault causing injustice?

22. The Ombudsman welcomes the Council’s early acceptance of fault and willingness to provide a remedy both for charging and the complaints process. Ms C has the uncertainty the Council could have resolved matters earlier without the extra time and trouble she has had in escalating the matter to the Ombudsman. I therefore consider in addition to the steps the Council has agreed to take, it should also make a symbolic payment to Ms C to reflect the uncertainty.
23. I have carefully considered the care records, the Care Provider’s explanation as stated in paragraph 20 above, and the Council’s safeguarding investigation.
24. The care records evidence the Care Provider followed the discharge plan and medication record from the hospital. It contacted the GP for a medication review and raised concerns about Mr D’s drowsiness. It followed the GP’s advice and took actions correctly when it identified Mr D had a urine infection. Mr D had complex needs and the Care Provider got advice about how to meet these needs. While I acknowledge Ms C’s comments, that some of these actions were prompted by her, the Care Provider did take appropriate action and I therefore find no service failure in this part of the complaint.
25. The Care Provider can evidence Mr D was eating and drinking within prescribed limits and that it provided personal care to Mr D 20 minutes before the ambulance crew arrived. While I understand Mr D entered hospital dehydrated and Ms C’s description of Mr D, I cannot say on balance this was because of the actions or omissions of the Care Provider.
26. The Care Provider reflected the limited use of the pendant alarm in Mr D’s care plan. To overcome the risks attached to the limitation it said it would monitor Mr D hourly. There is nothing to suggest this did not occur and it does not appear Mr D did not have support when he needed.
27. The Care Provider took pictures and recorded the pressure sores Mr D entered with. It repositioned Mr D at least every four hours which is in line with NICE guidance detailed in paragraph 18 above. However the Care Provider’s recording is inconsistent. One note says Mr D had a grade 2 pressure sore and others that record his pressure sores were Grade 1. Similarly Mr D’s care plan says he needed repositioning every two to three hours; however the repositioning records do not reflect this. I consider the failure to provide a consistent record is a potential breach of Regulations 12 and 17. Ms C has the uncertainty care staff did not reposition Mr D as regularly as he needed and whether this affected his pressure sores.
28. Ms C says the care home did not know how to properly reposition Mr D and this caused the respiratory difficulties he had on the day of his admission. Ms C says once repositioned Mr D’s oxygen levels stabilised. There is no detail about this part of Mr D’s care either in the original discharge summary from the hospital or in the Care Provider’s care records. Without this information it is difficult to know what Mr D’s care needs were around his positioning. Because of this and the limited injustice caused to Mr D I do not intend to continue with this part of the complaint further.

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Agreed action

29. I have found fault with the actions of the Council and Care Provider which has caused Mr D and Ms C injustice. As Mr D has died I am unable to remedy his personal injustice but can remedy any losses to Mr D’s estate.
30. 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 I found fault with the service of the Care Provider, I have made recommendations to the Council only to remedy the injustice caused. The Council has agreed to my recommendations.
31. Within one month of the final decision the Council will:
1. apologise to Ms C for:-
1. the failure to escalate her complaint;
2. failing to act on information Ms C provided which caused unnecessary charges;
3. uncertainty caused by the Care Provider’s service failure;
2. pay Ms C a symbolic payment of £100 for the uncertainty, time, trouble, and frustration caused by the faults identified;
3. as agreed waive outstanding charges for Mr D from 19 June.
32. Within three months of the final decision the Council will:
1. review the communication shortfall both in the complaint handling and charging in this complaint and consider what actions the Council can take to prevent a reoccurrence; and,
2. through contract monitoring with the Care Provider:-
1. provide a reminder about the importance of consistent recording;
2. consider how the Care Provider assesses and supports people who are at high risk of pressure sores to ensure the processes are consistent and provide an accurate account of needs and the support required.
33. The Council should provide us with evidence it has complied with the above actions.

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Final decision

34. I have found fault with the actions of the Council and the Care Provider acting on its behalf. I consider the agreed actions above are suitable to remedy the complaint and I have completed my investigation and closed the complaint on this basis.
35. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman