Summary: Mrs X complained about the charging and care service provided by Athena Healthcare for Miss Y. Mrs X has disputed the charges owed and is unhappy with some care Miss Y received before her death. She says that this caused her added distress while Miss Y was going through end-of-life care. We found Athena Healthcare at fault. It should apologise and refund some of the charges paid.

The complaint

1. Mrs X complains about the charging and service provided by Athena Healthcare (Care Provider) for Miss Y. Mrs X says that she did not receive a contract after Miss Y transferred care homes, and disputed the amount the Care Provider charged. Mrs X also raised several issues into the care provided towards Miss Y from the Care Provider which includes:
• Falls and referral errors
• Severed finger
• Repeated personal disrespect
• Missed Transient Ischemic Attack (TIA)
• Delayed pain relief and end of life care
• Excessive paracetamol given to Miss Y
• Conduct of staff in final hours before Miss Y died
• Lack of emergency contact numbers
• Debt correspondence
• Complaint handling
2. Mrs Y confirms that this issue caused her distress in a difficult time and she has requested for the care provider to review its processes and to provide training to its staff.

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The Ombudsmen’s role and powers

3. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
4. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
5. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
6. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
7. We may investigate complaints made on behalf of someone else if they have given their consent. We may also investigate a complaint on behalf of someone who cannot authorise someone to act for them, if we consider them to be a suitable representative. (Health Service Commissioners Act 1993, section 9(3) and Local Government Act 1974, sections 26A(1) and 26A(2), as amended)
8. When investigating complaints, if there is a conflict of evidence, we may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
9. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)
10. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have not investigated

11. Mrs X has raised concerns about the Care Provider’s handling of her Subject Access Request. This would be a matter for the Information Commissioner’s Office to consider.
12. Mrs X has also raised a complaint about the Care Provider referring her to the Office of the Public Guardian (OPG) due to safeguarding concerns. From reviewing the matter, I note the OPG declined to proceed with its investigation. Although I accept that Mrs X is unhappy with the decision from the Care Provider to refer the matter to OPG, it is not for the Ombudsman to say whether a care provider generally should refer a matter to the OPG when it has safeguarding concerns.
13. It is for the OPG to investigate this concern, and I note in this circumstance, it decided not to proceed with an investigation. The injustice therefore to Mrs X is limited.
14. Furthermore, we need to consider that an adverse finding against a care provider for raising a safeguarding complaint to OPG, could have an adverse effect going forward on that care provider in escalating further concerns to the OPG. This in turn could potentially lead to future safeguarding failures.

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How I considered this complaint

15. I considered evidence provided by Mrs X and the Care Provider as well as relevant law, policy and guidance.
16. Mrs X and the Care Provider had the opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

What should have happened

Care Quality Commission Fundamental Standards

17. 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 which care must never fall below.
18. Regulation 19 concerns care home fees and requires registered care providers to give timely, accurate, and written information to service users on the cost of care and treatment before services commence, including clear terms on payment methods, amounts, contractual conditions, and notice of any fee changes. This obligation applies where residents fund their care in whole or in part and includes the provision of the contract itself.

Funded Nursing Care

19. 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.

Consumer Rights Act 2015

20. The Consumer Rights Act 2015 (the Act) provides that written terms in consumer contracts must be fair and transparent, meaning they should be expressed in plain, intelligible language and not create a significant imbalance in the parties’ rights and obligations to the detriment of the consumer. Terms which fail these requirements may be unfair and contractually non-binding as set out under section 62(1) of the Act.

Competition and Markets Authority (CMA) Guidance

21. In the care home context, the CMA has issued specific guidance clarifying that terms relating to NHS-funded nursing care (FNC) must be clear about how such payments affect the resident’s overall fees. A lack of transparency, or a provision allowing a care home to retain FNC without adjusting the resident’s contribution, risks being considered unfair under the Act and therefore unenforceable. Specifically, its guidance to care homes states:
22. Paragraph 4.64: “Your terms, together with the upfront information you provide to residents about your fees, should clearly explain what FNC is, the resident’s potential entitlement to it, and how you treat FNC payments when the eligible resident is self-funded. In particular, you should clearly set out:
1. “The relationship, if any, between FNC payments and a self-funded resident’s own contribution to their overall residential fees (i.e. very clearly defining the services that are paid for by the FNC payments and those paid for by the resident).
2. “What will happen to a resident’s own contribution to their fees if there is a change in the amount of the FNC payment (i.e. where it increases, decreases or ceases).”
23. Paragraph 4.66: “If your terms do not clearly define the services that are paid for by the eligible resident and those paid for by the NHS, you are at risk of unfairly reserving the right to charge an eligible resident for nursing services which are covered by the FNC payments.”

General healthcare guidance

24. The Medication Administration Record (MAR) sheet lists a patient’s medication, the quantity of tablets received, the dose, frequency and time of administration over a four-week period. The pharmacy or GP surgeries usually print the MAR. Home staff sign it acknowledge receipt of medication, to record when they administer it or to record if, for any reason, it is not given.
25. The National Institute for Health and Care Excellence (NICE) issued clinical guideline [NG142] for organising and delivering end of life care services. This provides guidance for providing care and support in the final weeks and months of life (or for some conditions, years) and the planning for this. It aims to ensure people have access to the care they want and need in all care settings. It also includes advice on services for carers.

What happened

26. In May 2024 due to the care needed, Miss Y transferred from one care home owned by the care provider to another.
27. At the time of the transfer, Mrs X says the Care Provider advised her that Miss Y’s charges would be inclusive of FNC.
28. In May 2024, Mrs X made a complaint into the transfer and later also included further complaints into the care provided at the new care home.
29. In December 2024, Mrs X explains that Miss Y started to receive end of life care, and Mrs X is also unhappy with the care provided during this time.
30. Miss Y died in February 2025. Mrs X says that she received the Care Providers’ final response to the complaint in June 2025.
31. The Care Provider confirms that in December 2025, it sold its care homes including the home that Miss Y stayed at. The CQC website shows the sale of the care home.
32. The Care Provider states that under the agreement, it has agreed to handle existing complaints made about it, with the new care provider responsible for the care service going forward.
33. We are therefore unable to recommend service improvements against the Care Provider, as it no longer provides care. We shall investigate the complaint about the distress this issue caused Mrs X and the contractual dispute with the care contract.
34. Before the investigation, Mrs X raised safeguarding concerns to the local Council. We have a copy of its investigation, which we will also refer to in our analysis.

Analysis

Charging

35. Mrs X says that she did not receive a contract at the point of Miss Y’s transfer from one care home to another. She says she agreed by email an amount inclusive of FNC. However, once she received a bill from the Care Provider, it did not contain the correct weekly charge on it.
36. Mrs X also states the Care Provider promised to investigate and produce a report into the transfer between the care homes. She says that she told the Care Provider that once it completed the report, she would settle the outstanding balance, however it later confirmed that it did not complete an investigation.
37. The Care Provider confirm that there is no signed contract for the new care home, only the previous home. However, at the time, it owned both care homes, and the terms and conditions are almost the same.
38. Due to Miss Y’s changing care needs, she needed to transfer care homes to one that could better support her. However, while I recognise the contracts were similar, the Care Provider must ensure the charges at this new home were transparent. This would include the services provided to Miss Y and her liability towards this. It was not enough to rely on a previous contract.
39. In the email correspondence between the Care Provider and Mrs X, it includes a discussion about FNC and the reduction that this will have in the weekly charge. The Care Provider is not clear about when FNC charges would apply from and gives the impression that FNC would start immediately. It is only later, after Miss Y moves into the care home, the Care Provider told Mrs X that FNC could take several weeks and or months to receive. Also, the Care Provider failed to tell Mrs X of a rate increase which the Care Provider accepted and agreed to reduce the invoice accordingly.
40. The failure to provide and agree to (signed) contract terms at the point of transfer has led to the ambiguity surrounding the charges. There is no dispute that Miss Y lived and used the services of the care home and so would be liable to pay the care home for this. However, I also consider the Care Provider failed in its responsibilities to ensure that its charging was transparent.
41. I therefore find the Care Provider should provide the estate of Miss Y with the difference in fees quoted. The Care Provider has previously quoted this figure to be £4,953.48.

Falls and referral errors

42. Mrs X says that Miss Y suffered from several falls. Mrs X explains that she raised this to the Care Provider, who then applied to the local NHS trust. It rejected the application because the falls team do not treat dementia patients. Mrs X says that she believes the Care Provider should have known this before the application.
43. The Care Provider says the reason for the rejection was that Miss Y was receiving palliative care, and this came under a different service.
44. In the pre-admission notes to the care home, it shows that Miss Y is at risk of falls. The date of the application to the falls team was 27 September 2024, with a further referral made on 12 November 2024. The NHS sent a letter to Miss Y dated 30 September 2024 which accepted her on to a therapy course but stated the waiting time was ten weeks.
45. According to care notes, the GP prescribed end of life care in December 2024. At this point Miss Y was still on the waiting list for therapy.
46. While I recognise Mrs X’s frustrations about the referrals process, due to Miss Y’s changing medical needs, this changed the therapy she could receive. I do not find the Care Provider at fault for the information it provided.

Severed finger

47. Mrs X says the Care Provider told her that Miss Y had cut her finger. However, on arrival it became clear the tip of Miss Y’s finger had been severed in a door which had no guard fitted. Mrs X is unhappy the Care Provider downplayed the severity of the injury
48. The Council in its safeguarding investigation, found the door should have had a guard fitted to it and the Care Provider had referred this matter to CQC.
49. The care notes show the Care Provider took pictures of the injury at the time. It called a nurse and a doctor and arranged for Miss Y to visit the hospital the following day. The care notes do not show how it presented the severity of the injury to Mrs X. Its actions including referring the matter to CQC support that it took this matter seriously. However, on the balance of probabilities I consider the Care Provider did lessen the extent of the injury Miss Y incurred when it first told Mrs X.
50. The discovery of the injury being more extensive than first reported would have been distressing to Mrs X and I consider the Care Provider should apologise for this.

Repeated personal disrespect

51. Mrs X says the Care Provider placed Miss Y’s TV remote on top of the wardrobe out of her reach on repeated occasions.
52. From reviewing the care notes, there are plenty of observations over many months which show Miss Y in her room watching TV. There were also notes to support that staff members had showed Miss Y how to use the remote.
53. I do not consider therefore that this complaint can be upheld against the Care Provider.

Missed TIA

54. Mrs X reports that she noticed that Miss Y showed signs of a mini stroke. She says that she raised this immediately, however the Care Provider only consulted the doctor over the phone. She had to insist that a GP visit in person and the doctor diagnosed TIA and prescribed end of life medications.
55. The Council’s safeguarding investigation refers to notes it has seen from a GP who reports they believe Miss Y did have a stroke. The Council recommended for staff training and for this to be followed up on.
56. The care notes show that it reported the symptoms and suggests that a GP had seen and examined Miss Y. However, the investigation from the Council suggests that this was a telephone consultation with the doctor.
57. Either way, it is not for the Care Provider to diagnose a medical condition. Even if it suspected a stroke, its role was to report this to a medical professional and then to take advice. The notes show the Care Provider took Miss Y’s temperature and pulse and the doctor prescribed antibiotics for a chest infection.
58. I accept there is a difference from the care notes taken and the findings from the Council (which had access to the GP records). This makes it difficult to confirm what action the Care Provider took precisely. I do consider this doubt to be distressing to Mrs X and find the Care Provider should apologise in consideration of this.

Delayed pain relief and end of life care

59. Shortly before Miss Y’s death, Mrs X reports the Care Provider delayed giving her pain relief. Mrs X asked for a morphine driver at 9:40 however the Care Provider did not give this until 16:40 despite the doctor prescribing it at 12:36. Mrs X says the Care Provider refused to give pain relief as it told her that this would knock Miss Y out, and Mrs X would be unable to talk to her. Mrs X also disputes the care notes recorded around this time including the reported actions of the staff.
60. The Council’s safeguarding investigation found there was an issue with the doctors after they prescribed the medication. However, the Council did recommend several training matters for the Care Provider about end-of-life care.
61. Overall, the care notes for this day are minimal and do not record in detail what actions the Care Provider took and when. It does show however the Care Provider sought the medication in the morning, prescribed by the doctor at lunchtime and then gave it at 16:40.
62. I do not consider there to be a significant delay in the giving of the pain relief. I have considered that a doctor needed to prescribe this and there is a reported delay in the GP procedures.
63. However, I do find the care notes surrounding this matter could have provided greater detail and led to a better understanding of what happened and when. It is difficult to fairly conclude the statements Mrs X has made about what staff told her and their actions.
64. I do consider that this maladministration has caused Mrs X distress in the uncertainty of whether Miss X was experiencing excessive pain while receiving end of life care. I find in consideration of this the Care Provider should apologise.

Excessive paracetamol given to Miss Y

65. Mrs X says that visiting health care professionals highlighted concerns that Miss Y had been receiving excessive paracetamol for her weight.
66. The Council’s safeguarding investigation into this matter found that it was inconclusive. It highlighted that throughout Miss Y’s care notes the Care Provider would write summaries of the actions taken throughout the day. This included the recording of medication and could give the impression the Care Provider gave Miss Y excessive medication.
67. The medical records provided show the doctor recorded that if Miss Y’s weight dropped below a certain threshold, for the Care Provider to check with it about the doses provided. The care notes show that this was on the back of it raising concerns to the doctors.
68. During the following month, the care records show that Miss Y’s weight dropped below the threshold amount, however by the end of the month, she had gone above this level once again. After this the doctor prescribed end of life medication.
69. There are no clear notes to show the Care Provider consulted with the GP after Miss Y’s weight dropped below the threshold. I consider this to be fault by the Care Provider and find that it should apologise to Mrs X for the distress the discovery of this information caused her.
70. However, I also must consider that Miss Y’s weight did increase afterwards above the threshold, and the paracetamol given was in response to pain relief. There is no evidence the Care Provider overdosed Miss Y or that she suffered any adverse effect from being given too much paracetamol.

Conduct of staff in the final hours before Miss Y died

71. Mrs X says that when she arrived at the care home, staff had their backs to Miss Y and were talking to themselves. She said nobody had called her to explain the severity of Miss Y’s condition. In the final days of Miss Y’s life, Mrs X explains that staff were laughing, dancing and shouting outside Miss Y’s room.
72. The Council’s safeguarding investigation decided that it could not prove the behaviour of staff shortly before Miss Y’s passing as the notes do not record the members of staff present.
73. As the Council’s investigation reports, the care records for the day of Miss Y’s death are minimal. It is difficult for us to fairly decide therefore the actions of the staff during this time. I note that in its response to the complaint, the Care Provider offered to apologise for the actions of its staff ‘if it happened’. While I understand the frustration this issue must have caused Mrs X, there is no additional evidence to clarify what happened. Without this, I cannot find fault and therefore I cannot recommend the Care Provider should take more action about this issue.

Lack of emergency contact numbers

74. Mrs X says the Care Provider did not have a contact number for the district nurse team or the hospice. She says that she had to find these out herself and is unhappy as she believes the care home should know about this information.
75. In the care notes, the first mention of a hospice refers to a previous conversation the care provider had with the hospice which the Care Provider did not record in the notes. There is no evidence to support the Care Provider did not have contact numbers for the district nurse or hospice. I accept that again the care notes could have provided greater detail, however overall, I do consider there is a lack of evidence to support a fair conclusion.

Debt correspondence

76. Mrs X says that she is unhappy with the way the Care Provider acted towards the outstanding balance on the account. She says that she understands that it is a business. However, that at the same time she believes that it could have shown more care considering that Miss Y was entering end of life care.
77. The Care Provider says that after the transfer to the new care home, there was no active payment on the account and so the balance accrued.
78. Overall, the Care Provider without a payment agreement in place, can conduct debt recovery. While I understand Mrs X’s sentiment, that this was insensitive when Miss was receiving end-of-life care, ultimately, I cannot find fault in the Care Provider’s actions.

Complaint handling

79. Mrs X reports that she is unhappy the Care Provider made an offer to remove some charges that Miss Y owed in exchange for ending the complaint.
80. The Care Provider can offer what it feels is suitable to resolve a complaint. Mrs X also can reject that offer and escalate the complaint if she so wishes. I note the Care Provider did not object to the complaint coming to us. I do not find fault therefore with the actions of the Care Provider.

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Action

81. Within four weeks, I find that Athena Healthcare should:
1. Provide an apology to Mrs X for the distress that she has experienced in the handling of some care issues and for the dispute into the contract fees.
2. Pay the estate of Miss Y £4,953.48 for the difference in contract fees quoted.
82. 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.
83. Athena Healthcare should provide us with evidence it has complied with the above actions.

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Decision

84. I find fault causing injustice. Athena Healthcare has agreed to apologise and payment to Mrs X for the difference in contract prices quoted.

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Investigator's decision on behalf of the Ombudsman