Summary: Mr X complained that the Care Provider unfairly banned him from visiting his mother following an incident. We did not find the Care Provider was at fault because it had to consider the welfare of its staff and other residents, and it offered Mr X a less restrictive option that he chose not to accept.

The complaint

1. Mr X complains about the decision of Avery Homes (the Care Provider) to ban him from visiting his mother at Birchmere Care Home (the Care Home).
2. He says this caused significant distress and prevented him for spending time with his mother at the end of her life.

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The Ombudsman’s role and powers

3. 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)

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How I considered this complaint

4. I considered evidence provided by Mr X and the Care Provider as well as relevant law, policy and guidance.
5. Mr X and the Care Provider have an opportunity to comment on my draft decision. I will consider any comments before making a final decision.

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What I found

Relevant law and guidance

Mental capacity

6. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves.
7. The Mental Capacity Act 2005 introduced the “Lasting Power of Attorney (LPA)”.. An LPA is a legal document, which allows a person (‘the donor’) to choose one or more persons to make decisions for them, when they become unable to do so themselves. The 'attorney' or ‘donee’ is the person chosen to make a decision on the donor’s behalf. Any decision has to be in the donor’s best interests.

Care Standards Commission guidance on visits to care homes

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
9. 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.
10. Regulation 9A aims to make sure people staying in a care home can receive visits from people they want to see. It states care providers must support residents to receive visits, unless there are exceptional circumstances. Where a risk has been identified, providers are expected to implement appropriate precautions and apply the most proportionate and least restrictive option that may include the use of technology.

Background information

11. Mrs D became a permanent resident at the Care Home in July 2023. In October 2023, the Care Home called the police on response to Mr X’s conduct. There was a further, similar incident in February 2024.
12. Mr X’s sister, Ms P, was Mrs D’s Lasting Power of Attorney.

What happened

13. In June 2024, the Care Home acted in response to ongoing conflict between Mr X and Ms P. It was proposed that Mr X and Ms P would visit their mother at different times. In July 2024, Mr X was asked not to visit on a particular morning.
14. Despite this, Mr X arrived to visit Mr D. He was asked by staff to return another time but refused to do so. An incident took place that resulted in the police being called. This led to Mr X being charged with assault. Mr X strongly denies he acted inappropriately and is challenging the ongoing prosecution. The Care Home says Mr X caused significant distress to staff and other residents. Staff said they were frightened of him because of his unpredictability and what had occurred on previous occasions.
15. Mr X reported the actions of the Care Home to the CQC. He also raised concerns about the standard of care. The CQC asked the Care Provider to comment. In response to the CQC’s enquiries, the Care Provider:

• denied several allegations of poor care and explained there was no evidence to support what Mr X had reported; and
• confirmed safeguarding concerns about possible financial abuse had been raised with the local Council but were not a matter for the Care Home to be involved with.

16. This letter was subsequently shared with Mr X.
17. The Care Home, whilst concerned about the risk posed by Mr X to its staff and other residents, said it was mindful of requirement to facilitate visits between family members. The Care Home contacted the safeguarding team of the local council’s social services department (the Council) for advice about how to manage the situation. The social worker assigned to the case said she would meet with Mr X and investigate.
18. Another incident took place when Mr X visited his mother in August 2024. The police were called, but Mr X left before they arrived. Mr X denies the allegation that he aggressively banged on the door. He says it was the relative of another resident. Mr X did not visit the Care Home again.
19. Shortly afterwards, Mr X was informed that he could only visit his mother with a police escort, but the Care Home would support Mrs D to receive video calls. The Care Home made several such calls to Mr X, but he refused to accept them because they were both upsetting and insulting.
20. In September 2024, Mr X complained directly to the Care Provider. He explained video calls were not appropriate and would be distressing to Mrs X. Instead, he suggested a family member could be made available to supervise his visits.
21. In response, the Care Provider agreed to support a weekly visit supervised by Mr D’s cousin.
22. Later that month, Mr X attended a meeting with the Care Home that was arranged and chaired by the Council. Mr X says it was agreed that he would be allowed supervised visits. The proposed supervisor was to be Mrs D’s niece (Ms J). This had to be discussed with Ms P, who was not in attendance.
23. Although Mr X objected in principle to this arrangement says he was prepared to accept it in order to see his mother, who was by that time receiving end of life care. He provided the Care Home with Ms J’s contact details, but Mr X says nothing was arranged.
24. In October, the Care Provider served Mrs D with a notice to quit. Ms P was asked to move Mrs D to another home because it was unable to manage the family conflict and excessive demand on staff dealing with Mr X’s correspondence. It is not clear whether Mr X was told about this by Ms P.
25. Because of Mr X’s understanding that supervised visits had already been agreed, he was shocked to receive a letter from the Care Provider that stated his ban on visiting the home would continue for the foreseeable future. This was because Mr X had refused to agree to any form of visiting plan and there were significant risks to health, safety and welfare of staff and residents.
26. After discussions with Ms P, the Care Provider agreed to allow Mrs D to remain at the Care Home due to her fragile state of health. Mrs D sadly passed away in January 2025.
27. The Care Provider’s position is set out below.

• The decision to restrict contact was not in response to an isolated incident, but rather a cumulative situation that escalated over many months.
• The decision to restrict Mr X’s visits was made by the Council, not the Care Provider.
• Although it was agreed in principle that supervised visits could take place, the proposed supervisors were assessed as being unsuitable. Ms P, in her capacity as Lasting Power of Attorney, said they should not take place, and staff should focus their attention on Mrs D and put her care needs first. She made this decision in the best interests of Mrs D.

Analysis

28. This was clearly a difficult situation for all parties to navigate. CQC guidance is clear that a ban should only be used as a last resort and any restriction should be proportionate to the risk the visitor poses to residents and staff.
29. I am satisfied the Care Provider acted in accordance with this guidance and was not at fault. I say this for the following reasons.

• The correct procedure was followed prior to the decision to ban Mr X temporarily. The Care Provider sought advice and guidance from the Council because it has safeguarding responsibilities for all care homes in its area. This safeguarding duty extends to all potentially vulnerable residents living at the Care Home who may potentially have been affected by Mr X’s conduct.
• The events that led to Mr X’s ban were serious in nature and a criminal prosecution is pending. During my investigation, I have read copies of four police incident reports. The Care Provider had a duty of care to residents, staff and other visitors to the Care Home and this had to be balanced alongside the need for contact between Mr X and Mrs D.
• The case records show the decision to refuse supervised visits was ultimately made by Ms P, not the Care Provider. I am satisfied that up to this point, the Care Provider was actively pursuing less restrictive options such as video calls and sourcing an appropriate supervisor. However, once Ms P, in her capacity as Lasting Power of Attorney, decided it was not in Mrs D’s best interests for any visit to take place, the Care Provider was obliged to support this. If Mr X wanted to challenge her decision, he would have had to seek a court order.

30. Overall, I am satisfied the Care Provider acted appropriately in trying to navigate this difficult situation. I acknowledge it took approximately two months to advise him that supervised visits would not take place. I accept this delay caused Mr X some frustration, but it is clear from the case records that dealing with the matter took a disproportionate amount of time, in part because the Care Provider had to try and accommodate the differing views of Mr X and Ms P, as well as responding to the Council, the CQC and complaints and requests for information by Mr X. Mindful of this context, I do not consider this delay amounts to fault.

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Final decision

31. I find no fault. On this basis, I have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman