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Springhill House (Accrington) Limited (17 005 640)

Category : Adult care services > Residential care

Decision : Not upheld

Decision date : 26 Mar 2018

The Ombudsman's final decision:

Summary: There is no evidence that the way the care provider looked after Mrs X resulted in a deterioration of her condition, or that the care provider exaggerated Mrs X’s dependency to increase her fees.

The complaint

  1. The complainant (whom I shall call Ms X) complains that the actions of the care provider in the way the home treated her late mother (Mrs X) resulted in a deterioration of her abilities and a loss of mobility. She complains that the care provider increased Mrs X’s care home fees disproportionately without a matching increase in her care.

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The Ombudsman’s role and powers

  1. 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)

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How I considered this complaint

  1. I considered the written information provided by the care provider and by Ms X. I spoke to Ms X. Both Ms X and the care provider had the opportunity to comment on an earlier draft of this statement and I took their comments into account before I reached a final decision.

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What I found

  1. 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.
  2. Regulation 9 says that care providers must provide person-centred care which is appropriate, meets the resident’s needs and meets their preferences. The CQC guidance says that “Assessments [of need] should be reviewed regularly and whenever needed throughout the person’s care and treatment.”
  3. Regulation 12 says that “Care and treatment must be provided in a safe way for service users.”

It goes on: “the things which a registered person must do to comply with that paragraph include—

(a) assessing the risks to the health and safety of service users of receiving the care or treatment;

(b) doing all that is reasonably practicable to mitigate any such risks;”

  1. Regulation 19 says, “Where a service user will be responsible for paying the costs of their care or treatment (either in full or partially), the registered person must provide a statement to the service user, or to a person acting on the service user’s behalf—
  1. specifying the terms and conditions in respect of the services to be provided to the service user, including as to the amount and method of payment of fees;”
  1. Regulation 20 says, “Registered persons must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity”
  2. The NHS can provide continuing healthcare at home or in a care/nursing home. The NHS is responsible for meeting the full cost of care in a care home for residents whose primary need for being in care is health-based. The 2012 Regulations say the NHS should assess for NHS Continuing Healthcare where it appears somebody may be in need of such care. Complaints about NHS CHC are dealt with by the Parliamentary and Health Service Ombudsman.
  3. The NHS is also responsible for meeting the cost of care provided by registered nurses to residents in all types of care homes. Council funded and self-funding residents who need to move into care homes with nursing should have a comprehensive assessment to identify any nursing needs, including the possible need for NHS-funded continuing healthcare (CHC) or for NHS-funded nursing care (FNC). FNC was funded at a rate in 2017 of £156 per week, an increase of £52 since 2016.

What happened

  1. Mrs X went to live in the care home in 2012. She was assessed for CHC funding but was not then deemed eligible. She was assessed as eligible for Funded Nursing Care (FNC).

Increase in fees

  1. Ms X complains that the care provider increased her mother’s fees by 10% in 2016 and a further 10% in 2016. She says she does not believe the increase reflected value for money: she says when her mother first entered the home her behaviour was quite aggressive and staff gave her a lot of attention, but this dwindled.
  2. In April 2016 Ms X met the care provider to discuss the fee increase. The care provider subsequently wrote to Ms X and agreed that the 10% increase was higher than the usual increase (around 4%). The manager said that the introduction of the National Living Wage had had a particular impact on fee levels as well as other factors (for example utilities, food and insurance costs). At the meeting Ms X also raised some concerns about care and the managing director arranged for contact with a care manager to discuss.
  3. In November 2016 Ms X complained to the care provider again about the fee increase and about some care provided. She asked that her mother’s fees should be frozen. She said she had a duty to safeguard her mother’s finances as she held power of attorney. She noted that the care provider’s fees were considerably higher than the amount funded by the local council. She also wanted an independent assessment to validate her mother’s exact condition and the itemised costs of her care.
  4. The care provider responded explaining that the care sector had been generally underfunded for some years. The manager referred to a national costing model for residents with dementia (like Mrs X) and pointed out that the rate suggested was similar charge to the care provider’s charge. The manager acknowledged Ms X’s duty to look after Mrs X’s finances and said the care provider was making sensible decisions based on residents’ best interests. The manager also responded to Ms X’s suggestion that her mother’s fees should be frozen. The manager said it could not commit to such a suggestion. The response concluded, “any review will need to consider increases in costs and also any changes in your mother’s care required to ensure her needs are met.”
  5. Ms X says the care provider’s suggestion that the cost of nursing care was part of the increase was unfounded as there was no individual nurse overseeing her mother’s care.
  6. The care provider responded separately to Ms X’s concerns about her mother’s care, and in particular some concerns about reddening or marking of Mrs X’s skin, and the presence of a lump on her breast. The care provider said that she had examined all the records for the preceding months and contrary to Ms X’s belief, there was no observation about a lump or reddening until November 2016 when it was immediately reported to the GP. She said there was no evidence at all to suggest that a lump had been missed. Ms X points to an observation in the care provider’s GP’s notes from December 2014 that suggested Mrs X had a “non-tender lipoma” in a place which corresponded to where the breast lump was. The GP’s note continues, “observe only - will review if growing larger or painful”.
  7. The director of quality responded separately to concerns about the extent of Ms X’s dependency, which Ms X queried. The director of quality said Mrs X had consistently scored in the ‘very high dependency’ bracket and while the home would co-operate with an independent assessment as Ms X requested (the planned CHC assessment), it could not freeze her fees in the meantime. She also drew attention to an outstanding debt of around £2500 on Mrs X’s account.
  8. In March 2017, the care provider wrote to residents again notifying of a further 10% increase in fees. The manager said that the principal reason for the increase were again employee costs, insurance costs, food and utility costs. She referred to the increase in FNC and added that if it was raised again it would be reflected in the next year’s fee structure.
  9. Ms X said she would not pay the 10% increase in 2017. She says that in the end she did pay the increase, but there was no nurse overseeing her mother’s care and Ms X and her husband usually took her mother out as the range of activities was poor.

Complaint to the Ombudsman

  1. Ms X complained to the Ombudsman that the care provider was not providing an increase in value for money with the increase in fees.
  2. Ms X also complains that in her view her mother was hoisted far sooner than she should have been and was not supported to maintain her independence. Ms X says staff never encouraged Mrs X to walk with a frame. She queried again the extent of her mother’s dependency and said that staff had not tried to encourage her in activities.
  3. Ms X moved Mrs X to a different care home in 2017 and says that she engaged more readily in activities, she was helped to the toilet rather than being left in incontinence pads, and that her dependency levels reduced. She says the first care provider failed to offer her mother sufficient support in terms of physiotherapy even though she (Ms X) had requested it as early as February 2015. She also says she discovered that a Do Not Attempt Resuscitation (DNAR) notice had been put in place in October 2015 without family consultation. She queried the drugs prescribed to Mrs X which she was concerned had contributed to her falls. She disputes the records of her mother hitting out at staff and say she saw no sign of this reported aggression when she took her mother out.
  4. Ms X also queried the assessments for CHC funding. She said she believed all parties had failed in their duty of candour (Regulation 20) because they had not been open and transparent with her about Mrs X’s condition, to avoid blame and (on the part of the NHS) to avoid paying CHC funding.
  5. Ms X reviewed the care home’s records from 2013 onwards and sent me a chronology of events with her notes concerning the pain relief and other drugs prescribed for Mrs X, the use of the hoist, the implementation of the DNAR notice and other concerns.
  6. Sadly Mrs X died in September 2017.
  7. The care provider’s records show that in 2013, shortly after Mrs X entered the home, her mobility care plan target was for her to maintain mobility as much as possible. By 2015 it was noted that she was no longer able to walk independently and needed the assistance of two members of staff. The care provider used a handling belt to assist Mrs X and a wheelchair was also available for her use. By 2016, after treatment for the area under her breast, it was no longer possible to use the handling belt to help her. The home’s notes record that her needs in respect of moving and handling varied from day to day. Mrs X’s care plan was reviewed on a monthly basis. From April 2016 onwards it was recommended that a hoist was available for her use.
  8. A review of Mrs X’s care was carried out in December 2016 with a physiotherapist. Ms X was given a copy of the care home’s notes about the physiotherapy assessment. It was agreed that Mrs X would continue to be hoisted at all times. The monthly reviews show no change to her care plan after that. Ms X says she does not think her mother, who was wearing a pain patch at the time the physio assessed her which made it difficult for her to get out of bed, was ever really given an opportunity to be assessed on her actual abilities to walk. In fact she disputes whether the assessment ever took place at all.
  9. Mrs X’s initial care plan was to encourage her to become involved in activities in the home. A note from 2013 recorded that she preferred 1:1 activities rather than group activities. The care plan was reviewed on a monthly basis and her enjoyment in ‘singalong’ activities was recorded, and that she liked going out with her family. Ms X says the home advertised far more activities than it provided, and the activities it provided were for a limited range of residents.
  10. In terms of the DNAR notice which Ms X expressed concern about, the care plan dated 26 September 2014 notes “DNAR notice now in place following discussion with (Mrs X)’s daughter on 25/09/14. This will be reviewed every three months/as required.” A separate note in the “family” folder on 25 September 2014 records, “D/W (Ms X) (Mrs X’s daughter) re DNAR for if (Mrs X) suffers a heart attack/severe stroke – she is in agreement that it would not be in her mother’s best interests to actively treat her in this situation and had agreed to a DNAR being put in place.” Ms X says staff caught her unawares to discuss the DNAR and she did not realise she would not have chance to amend it. She does not believe the home reviewed it with her. She says she was shocked that the home would then contact the GP to institute the DNAR notice.
  11. Ms X expresses concern that she has not previously been shown the information which the care provider has sent in response to the Ombudsman’s enquiries, and that the care notes omit some incidents of importance, such as episodes when her mother vomited. She has concerns about the transparency of communication with her. She also has concerns that the care home was quick to use medication to manage her mother’s behaviour (although she accepts that the prescriptions were the responsibility of the GP) and failed to alert her that there were alternatives to some of the drugs being used.

Analysis

  1. The care provider’s records show that it regularly reviewed Mrs X’s care needs and responded appropriately.
  2. In terms of Mrs X’s mobility, the records show that the care provider kept this under review and was aware that Mrs X ‘s needs in this respect changed often. The care provider put in place systems to ensure that staff were moving and handling Mrs X safely. Although Ms X has concerns that the care provider was using a hoist before its use was “approved” (by the physiotherapist) it was the responsibility of the care provider to ensure that Mrs X was handled safely. The care provider’s records show that it was sensitive to her changing needs.
  3. The records show that Ms X was consulted about the DNAR and agreed to it in 2014. There is no evidence of fault there. It was not fault on the part of the care provider to consult the GP about it but the correct practice: the home could not approve the DNAR notice, that was for medical staff to agree.
  4. Mrs X’s interest in activities was documented in her care plan and reviewed as appropriate. It was noted from the start that she preferred 1:1 activities but would engage in other activities sometimes if encouraged. The care provider appeared sensitive to Mrs X’s preferences. Ms X makes the point that as a family they frequently took Mrs X out of the home although she felt the care home staff did not approve.
  5. I have not seen any evidence that the care provider exaggerated Mrs X’s condition to charge a higher fee, as Ms X suggests. The care plans and notes show in some detail that Mrs X had extensive needs. The fact that she was eligible for FNC and regularly review for CHC funding is additional evidence of her needs.
  6. The prescription of drugs was a matter for Mrs X’s GP and the role of the care provider was to follow his instructions in that respect. I recognise that Ms X has very many concerns about the appropriateness of some drugs used and questions the information given to the GP but it is open to Ms X to follow that up with the GP if she has continuing concerns.
  7. Ms X’s concerns about transparency largely stem from her view that the care provider did not give her sufficient information about the drugs Mrs X was prescribed. I can see that was a cause of concern for her. However, I have not seen any evidence that the care provider failed in its duty towards Mrs X in seeking medical attention for her or failing to act on the GP instructions about prescribed medications.
  8. The CHC assessment is a matter for the NHS and not for the care provider (or the Local Government Ombudsman).

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Final decision

  1. I do not find that the actions of the care provider caused injustice to Mrs X.

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Investigator's decision on behalf of the Ombudsman

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