Summary: Mrs X complained Avery Healthcare (the care provider) failed to promptly tell her of the fees payable and invoices for Mrs Y’s care when she became self-funding. She also complained the care home charged for care not needed or provided. Mrs X said the care home caused distress and frustration, and impacted Mrs Y financially. Mrs X and Mrs Y suffered an injustice. Avery Healthcare agreed to apologise, make a financial payment and provide guidance to relevant staff.

The complaint

1. Mrs X complained Avery Healthcare (the care provider) failed to promptly tell her of the fees payable and invoices for Mrs Y’s care when she became self-funding. She also complained the care home charged for care not needed or provided. Mrs X said the care home caused distress and frustration, and impacted Mrs Y financially.

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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. (Local Government Act 1974, sections 34B and 34C)
3. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
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 read Mrs X’s complaint and spoke to her about it on the phone.
6. I considered evidence provided by Mrs X and Avery Healthcare as well as relevant law, policy and guidance.
7. Mrs X and Avery Healthcare 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

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
9. Regulation 9 says care providers must provide care that is appropriate, meets the needs of the person receiving care and, reflects that person’s preferences. To do this, care providers must involve the person receiving care in planning the care they need, help the person make decisions where they can and involve the person in their own care as much as possible.
10. Regulation 16 says the care provider must take appropriate action on complaints without delay.
11. Regulation 17 requires care providers to keep accurate, complete and contemporaneous records of the care it provides and the decisions it makes about that care.
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.
13. Regulation 19 of the Care Quality Commission Regulations 2009 says when a service user will be responsible for paying the costs of their care, the registered person must provide a statement to the service user specifying the terms and conditions of the service including the fees. The regulations also say the statement must be in writing and as far as reasonably practicable provided before the commencement of the services.

What happened

14. This is a summary of events, outlining key facts and does not cover everything that has occurred in this case.
15. The NHS placed Mrs Y in an Avery Healthcare home in September 2023. Continuing Healthcare (CHC) funded this placement.
16. CHC withdrew this funding in February 2024. Mrs Y began to fund her own care.
17. Avery Healthcare sent Mrs X an invoice in October 2024 totalling nearly £60,000. This was £1,695 per week since Mrs Y funded her own care. Mrs X contacted Avery Healthcare and stated the NHS told her the charge would be around £1,400 per week. She also asked about the scales of the care as she believed the care cost was too high. Avery Healthcare confirmed the cost was £1,265 per week for accommodation and £430 per week for care. Mrs X disagreed Mrs Y needed the level of care in the invoices.
18. Avery Healthcare sent Mrs X the contracts for accommodation and care in November 2024. The contracts were dated for February 2024. Mrs X has not signed the contracts.
19. Avery Healthcare amended the invoices in November 2024. It refunded the £1,695 per week and invoiced Mrs X £1460 per week. It sent the invoice for the remaining amount, funded by FNC to the NHS.
20. Mrs X complained to Avery Healthcare in December 2024. She complained about the delayed contract, invoices and disagreed with the amount of care Mrs Y was charged for. She also complained about the care plan including a medication the doctor stopped in September 2024.
21. Avery Healthcare responded to the complaint 3 weeks later. The response confirmed it updated the care plan and Mrs Y did not receive the medication after the doctor stopped prescribing it. The response apologised for not sending the contracts and invoices promptly and detailed the level of care Mrs Y received.
22. Mrs X responded to the complaint the following day. She said the response did not answer her questions and asked the care home to escalate her concerns.
23. Mrs X was not satisfied with the care home’s response and has asked the Ombudsman to investigate. Mrs X would like Avery Healthcare to provide clear information and compensate Mrs Y.
24. In response to my enquiries Avery Healthcare accepted its actions fell below required standards. It said the NHS should have informed Mrs X, Mrs Y needed to fund her own care and stated Mrs X confirmed she knew she would need to pay for care.

My findings

25. Avery Healthcare noted in its response the NHS “should” have told Mrs X Mrs Y needed to fund her care from February 2024. The regulation detailed in paragraph 14 confirms the care home “must” provide a statement to the service user specifying the terms and conditions of the service including the fees. This must be in writing and as far as reasonably practicable provided before the commencement of the services. Avery Healthcare has a responsibility for providing a statement of fees. The fees are in the contract. The response to my enquiries confirmed Avery Healthcare sent the contract in November 2024, nine months after Mrs Y started funding her own care.
26. Mrs X stated Mrs Y did not receive the level of care she was charged for. The Ombudsman conducts proportionate investigations. I considered care records for ten days over a three-month period. The days were not consecutive and covered different days of the week. On nine of the days, Avery Healthcare recorded more than the two-hour care it charged for. I have not seen any evidence to support Mrs X’s claims.
27. Mrs X was aware Mrs Y needed to fund her own care. The amount Mrs Y needed to pay was similar to the amount Mrs X mentioned in her communication. However, Avery Healthcare has not met its duties to provide a statement of service, terms and conditions and fees, as set out in regulation 19 of the Care Quality Commission Regulations 2009. This distressed Mrs X when she received a large bill in November 2024.
28. Regulation 16 says the care provider must act on complaints without delay. Avery Healthcare accepted it had not considered the complaint in accordance with its policy. The breach of this regulation frustrated Mrs X.
29. Regulation 17 says Avery Healthcare is required to keep accurate records. The response accepted it did not update the care plan when Mrs Y’s medication changed. While Mrs Y did not receive the medication, Avery Healthcare has failed to meet its duties under this regulation when it failed to update the plan. This distressed Mrs X.

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Agreed action

30. To remedy the outstanding injustice caused to Mrs X and Mrs Y by the fault I have identified, Avery Healthcare agreed to take the following action within 4 weeks of my final decision:
• Apologise to Mrs X and Mrs Y for the distress and frustration caused by not providing the contract and invoices within a reasonable timescale, receiving a large bill, not updating the care plan and not following the complaint procedure. 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 in my findings.
• Pay Mrs X £500 to recognise the distress, frustration and uncertainty caused by the fault identified in this investigation.
• Remind relevant staff of the importance of effective complaint handling and responding to complaints.
• Remind relevant staff of the requirement to keep accurate records, in accordance with CQC’s fundamental standards.
31. Avery Healthcare should provide us with evidence it has complied with the above actions.

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Decision

32. I have completed my investigation. I have found fault by Avery Healthcare, which caused injustice to Mrs X and Mrs Y.

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Investigator's decision on behalf of the Ombudsman