Summary: Mrs X complained the Council did not explain the costs involved when it arranged for her mother to move into residential care. She also complained about the care provided. The Council was at fault for not providing adequate cost information and for the delay in carrying out a financial assessment. It should pay Mrs X £250 to acknowledge the worry and stress caused by receiving a large, unexpected bill for care. There is no fault with the care provided.

The complaint

1. Mrs X complains the Council did not explain the costs involved when it arranged for her mother, Mrs M, to move into residential care in January 2018.
2. She also complains about the care provided. She says the care home:
• left her mother in prolonged unsanitary conditions;
• did not provide appropriate personal care;
• took no action to address Mrs M’s weight loss; took no action to address Mrs X’s concerns about the level of care provided;
• inappropriately issued an eviction notice.

She also says some of Mrs M’s belongings were stolen.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
5. 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)
6. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
7. If we are satisfied with a council’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 spoke to Mrs X and considered the information she provided.
9. I considered the Council’s replies to my enquiries, including the care records from the care home for the period January to July 2018 when Mrs M lived there.
10. I considered relevant law and guidance, as set out below, and our guidance on remedies.
11. I have gave Mrs X and the Council an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

12. The Health and Social Care (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.
13. Regulation 9 says providers must work in partnership with the person using the service to provide person-centred care. This includes providing support to help them understand and make informed decisions about their care.
14. Regulation 13 says a person must not suffer any form of abuse or improper treatment whilst using the service. This includes neglect, degrading treatment, or inappropriate limits on the person’s freedom.
15. Regulation 15 says the care provider must keep the care home and equipment used in it clean.
16. Regulation 16 says the person receiving care must be able to complain about their care. The care provider must have a process for investigating complaints and must take action if it identifies problems.
17. Regulation 17 says care providers must maintain accurate, complete and detailed records for each person using the service.
18. The CQC is the statutory regulator of care services. It keeps a register of care providers, carries out inspections and has the power to take formal action if it identifies breaches of the fundamental standards.

Needs assessment and care costs

19. The Care Act 2014 says councils must carry out an assessment for any adult who may need care and support. Where the council identifies eligible care needs it should meet those needs. A care and support plan will set out how it will meet those needs and will show the budget allocated to meet them.
20. Where the person’s eligible needs are to be met by residential care, the council must identify at least one suitable care home that is available within the budget.
21. If the person wants to go into a more expensive home, the council can ask a third party to pay a “top-up” to cover the difference between the budget and the actual cost of the more expensive home.
22. The charging rules for residential care are set out in the “Care and Support (Charging and Assessment of Resources) Regulations 2014”, and the “Care and Support Statutory Guidance 2014”. If the person’s capital is less than the upper capital limit, they have to pay a contribution towards their fees. The council will carry out a financial assessment to decide how much they should contribute towards the cost of the care home fees.
23. Our Focus Report “Counting the cost of care: the council’s role in informing public choices about care homes” (September 2015) says councils need to provide information in writing at the earliest opportunity so that people can make informed choices about the choice of care home, including the costs and how to meet them.

What happened

24. Mrs M was struggling to manage on her own at home. In January 2018 she was hospitalised after a fall and the Council carried out a needs assessment. It decided she needed residential care. It identified two care homes that could meet her needs in its area. Mrs X chose the care home and Mrs M moved there in late January 2018.
25. In mid July 2018 Mrs M moved to a new care home so she could be closer to her sister who was also in residential care.

Information about care costs

26. Mrs X says she met a Council social worker (officer 1) in the hospital. He told her if the family chose a care home that was more expensive than Council rates they would need to pay a top-up. Mrs X says the family told him they could not afford to pay a top-up. She says she understood the care costs would be fully funded by the Council if the fees did not exceed the Council rate, although a panel would need to confirm this. She says she heard nothing more about costs until the care home sent her a bill in May 2018, at which point the outstanding fees were about £3,000. She says the Council did not complete a financial assessment until August 2018, which was after her mother had moved to a new care home.
27. The Council says there were discussions with the family about the financial implications of the care placement before Mrs M moved to the care home. The Council has no record of this information being provided in writing. In its complaint response it said it would remind staff to give families financial information leaflets when their family member left hospital.
28. It says officer 1 told Mrs X the cost would be £134.45 per week for the first four weeks. However, it has no record of this. In its complaint response, the Council said people are asked to pay a provisional amount of £134.45 per week for the first four weeks after moving into residential care. It said this contribution is usually increased when a financial assessment is completed.
29. The Council failed to send the care home the usual financial agreement when Mrs M moved there. It says the care home also overlooked this. Although officer 1 noted in April 2018 that a financial assessment was needed, he did not make the referral for this.
30. In early May 2018, the care home sent Mrs X an invoice for the care provided from late January when Mrs M first moved there. It also sent her its terms and conditions to sign and return. It asked Mrs X to set up a monthly standing order for the fees from mid May.
31. The Council completed the financial assessment in July 2018. It wrote to Mrs X in August 2018 to explain her mother should have been paying a contribution from February 2018. It set out how it calculated the contribution and the amount owed. This was after Mrs M had moved to a new care home.
32. Mrs X also complained about hairdressing costs incurred by the care home. She says it continued to charge for hairdressing even after she told it not to do so after it sent her the first invoice for sundry costs. She told me her mother did not need her hair cutting every week. I have seen the agreement with the care home about sundry costs that Mrs X signed in late January 2019 when Mrs M moved into the care home. This states the charges for hairdressing are £10 for a wash and blow dry or set, and £18 for a hair-cut. I have seen invoices that show the care home charged £36 for sundries in May (when it first started sending bills), and £30 in July. The July bills is for three hairdressing appointments at £10 each. I understand Mrs X has refused to pay these bills.

Findings – care costs

33. Before she moved into the care home Mrs M was receiving care at home but because of the different way the contribution for care at home is calculated she did not have to pay towards the cost of that care.
34. The Council says it discussed the cost of residential care with Mrs X whilst her mother was in hospital. It does not have a record of those conversations, nor can it show it provided costs information in writing. There is no record to show the Council officer discussed the provisional rate with Mrs X. The Council did not send the financial agreement to the care home and delayed carrying out Mrs M’s financial assessment.
35. The statutory guidance says councils must ensure there is sufficient information for the person needing care or their representatives to understand the contributions they need to make towards the care. Our Focus Report suggests information about costs should be given “in writing at the earliest opportunity”. The Council’s failure to do this and the lack of records to show what was discussed with Mrs X is fault.
36. The Council assessed Mrs M as needing residential care. Mrs M received the care and the Council is entitled to charge for the care services it provides. However, Mrs M had not paid towards the cost of care before and Mrs X was unaware of how the residential charging system worked. The failure to provide adequate information about the costs and the delay in completing a financial assessment meant Mrs X did not understand what the costs would be and the large unexpected bill caused her some worry and distress.
37. Mrs X also complained about the charges for sundry items such as hairdressing. The Council provided a copy of the agreement she signed, which agreed to additional costs for sundry items, including hairdressing. Mrs X signed an agreement to pay these charges when Mrs M moved into the care home. She says she told it not to incur further costs after receiving the first bill. This would have been in May 2018 or later. I have not seen any evidence of this in the care home records. There appears to be a dispute about what was agreed about sundry costs and I am unable to resolve this. I am not able to conclude the care home was at fault.

Moving care home

38. Mrs X says her mother always wanted to be close to her sister who lives in a care home in a different county. However, she was told her mother was bed-blocking and would have to move into a care home locally on a temporary basis. She says Officer 1 later told her moving her mother was not a priority because she was already in a care home. She says Officer 1 did not identify any suitable care homes in the other county until July 2018.
39. The Council says it was not aware that Mrs X wanted a care home outside its area in January 2018. I have reviewed the Council’s records and the care home’s records. The first mention of a home near Mrs M’s sister is at the care review in mid April 2018. Officer 1 agreed at that meeting to identify possible care homes in the other county that had availability and set out the costs involved. Council records show he provided this information in late June. Mrs X visited one of those homes with Mrs M in mid July and moved her there the next day.
40. With her comments on the draft decision Mrs X provided a copy of text sent to her by officer 1 which mentions a care home outside the council’s area, which shows he was aware of this whilst Mrs M was still in hospital. It appears he omitted to record this and I assume he then overlooked it. There is no record of Mrs X asking about this until April 2018.

Findings – moving care home

41. Although Mrs X says Mrs M was placed at the care home on a temporary basis, the records show the Council and care home considered it was a permanent placement. Although it appears there was a misunderstanding about this it does not amount to fault. It would not be fault for the Council to place her in its area initially given that she was ready to leave hospital. It would not be unusual in these circumstances for a person to be placed in a care home and moved to another one after further assessments are carried out. There is no evidence the move caused an injustice to Mrs M.
42. After being asked about moving area in April 2018 the Council did make enquiries about suitable care homes in the new area and provided the information to Mrs X just over a month later. This was not an undue delay by the Council. It was not at fault.

General cleanliness

43. Mrs X complained the communal parts of the care home were not kept clean and her mother’s room was not clean. She says Mrs M had a commode in her room because she could not always manage to get to the bathroom but this often had no pan so urine and faeces would end up on the floor. She also says Mrs M often had accidents leaving wet patches on the carpet the care home did not clean up. She says Mrs M was having toileting accidents most days and was left in wet clothing and bedding for long periods of time.
44. The care home says managers walk the floor regularly. It says bathrooms are cleaned daily and as needed during the day. It says as it is a dementia home toileting accidents do happen and staff will manage any problems as soon as they are told about them. It says if Mrs X had reported a problem with Mrs M’s room or a communal area its staff would have addressed it immediately. It says it was inspected by CQC in January 2017 and the Council carried out a contract review in April 2019 and no problems with cleanliness were identified.
45. The care home says Mrs M had an ensuite bathroom and the commode was only for night-time use. It uses disposable commode pots that are removed in the morning and replaced in the evening. Staff supported Mrs M to use the bathroom during the day.
46. The care home says Mrs M was incontinent on occasion but her level of incontinence did not reach the level where incontinence pads were needed. It says its general approach is to encourage independence and to assist residents to maintain their continence as much as possible thereby promoting skin integrity. In its response to my further enquiries the Council explained a continence assessment was carried out by the district nurse team using criteria set by the health authority and Mrs M did not qualify for incontinence pads.

Findings – general cleanliness

47. Mrs X has provided photographs to show a communal bathroom was not clean on at least one occasion. The care home says that when problems were reported staff dealt with them straightaway. I have seen no evidence of problems generally with cleanliness in communal areas.
48. Care records show Mrs M was checked regularly through the night and that when she was incontinent (during the day or night) her clothing and bedding was changed. A continence assessment was carried out by the district nurse team, which concluded she did not meet the criteria for incontinence pads. The care home encouraged Mrs M to use the toilet during the day and the commode at night, which explains why there was not always a pan in the commode during the day. There is no evidence of fault.

Personal care

49. Mrs X complained her mother’s face was often dirty, her hair left unwashed, and her nails dirty. She also says her mother’s toenails grew so long they were curling into her toes. She said her mother lost a lot of weight and, although the care home monitored her weight, it did not take action to address the weight loss.
50. The care home says Mrs M had a bath twice a week in the evening and her hair was washed when she agreed to this. This is not specifically referred to in the care records, which simply refer to personal care being provided.
51. Care records show the chiropodist attended Mrs M on 16 February and was due to call again after three months. Mrs M refused the appointment on 1 May.
52. Care records show Mrs M lost five pounds between 1 February and 10 July 2018, the last time she was weighed before leaving the care home. The care home says it was not concerned by this weight loss. It says its policy is to re-weigh after seven days when weight loss is recorded and in Mrs M’s case the doctor was monitoring her closely because of a medication change.

Findings – personal care

53. The care records show the care home provided personal care twice each day and throughout the day as needed. There is no specific record about when Mrs M had a bath or hair wash, although it is clear there were appointments with the hairdresser. Records show the care home monitored Mrs M’s weight and there was no significant weight loss. Records also show chiropodist appointments were offered but not always accepted by Mrs M. There is no evidence of fault.

Loss of belongings

54. Mrs X complained that her mother’s glasses and hearing aids were lost within a week of her moving there. She says the care home refused to look for them because it said it could not look in other residents’ rooms. She says when replacement hearing aids were ordered they did not fit and when replacement glasses were provided these were also lost. She says although everything was labelled lots of other things went missing including some expensive watercolour pencils, colouring books and clothing.
55. The care home says staff made a thorough search for Mrs M’s hearing aids in her room and communal areas when they went missing. Its care records confirm this. It says it told Mrs X that she could not look in other residents’ rooms.
56. The care records show audiology advised the care home that replacement hearing aids could be ordered without new ear moulds. When it became clear the hearing aids did not fit properly the care home ordered replacements.
57. The care home says Mrs M regularly removed her glasses and left them lying around. Care records show staff frequently looked for them. Mrs X gave them a photograph of the glasses to help care staff identify them.

Findings – loss of belongings

58. The care records show the hearing aids were lost on 6 March and that replacements were ordered on 20 March because they had not been found. Replacements were fitted on 4 April and lost by 9 April but were apparently found quite quickly because the records refer to Mrs M refusing to wear them on 10 April. At the care review on 18 April the care home agreed to look into getting new hearing aids and its records show it made an appointment the same day. The care home was not responsible for the fit of the replacement hearing aids.
59. Care records show staff did look for Mrs M’s glasses, and for the other items Mrs X refers to, at various points. It is unfortunate when items go missing and frustrating for the family but I am satisfied the care home did try to find missing items. It is not at fault.

Response to concerns

60. Mrs X attended a meeting in March 2018 with the care home manager to discuss her concerns. After the meeting Mrs X sent the care home a letter confirming the issues. The care home said it would investigate and write to her with its findings. Mrs X says it did not address her concerns nor did it write to her. She says it looked for ways to ask Mrs M to leave because she had complained.
61. It is not clear what action the care home took immediately after the meeting in March. However, it did hold a review meeting a month later at which Mrs X went through her concerns and staff explained how they were addressing them.
62. Care records show that staff were concerned Mrs M was unhappy and closely observed her mood. Staff talked to Mrs X about what activities and TV programmes Mrs M would enjoy and tried to establish more of a routine for her.
63. The records show a number of incidents where Mrs M was aggressive towards other residents (see further below), which prompted the care home to ask for a review meeting in July 2018.
64. Mrs X complained the care home initially planned to hold the review on the day she was taking her mother to look at an alternative care home. She says it initially refused to change the date and only did so after she complained to the Council.
65. Care records show Officer 1 arranged the review meeting. The care home asked him to change the day and he re-arranged it for the next day.
66. I have seen the Council’s record of the review meeting. This shows:
• the care home was finding Mrs M’s behaviour increasingly difficult to manage. It thought her aggressive behaviour was due to stopping her medication;
• the family thought Mrs M’s behaviour was because she was unhappy and said the level of care was poor;
• the care home felt the relationship with the family had broken down and was considering giving four weeks’ notice for Mrs M to leave;
• the family said they did not want Mrs M to stay there. Mrs M had visited an alternative care home the day before, which could meet her needs;
• “all parties agreed” Mrs M would leave that day. Officer 1 agreed to arrange contracts with the alternative care home and funding through the Council’s panel.

My findings – response to concerns

67. Mrs X met the care home manager in March 2018. Although it did not write to her after the March meeting, as promised, it did meet with her again in April 2018 to review the action taken and any outstanding concerns Mrs X had. Its records show it did consider the issues she raised and was taking steps to address them, for example, looking for missing belongings and reordering hearing aids and glasses. The care home was not at fault.
68. Its records show it took seriously points she made on other occasions, too, and where it was not able to do what she asked, it explained the reasons for this. For example, Mrs X wanted Mrs M to stop taking some medication but care staff explained the doctor would need to make that decision. Also, Mrs X wanted Mrs M to drink water and not juice but Mrs M preferred to drink juice. Care staff agreed to offer water but if this was refused it would offer an alternative to ensure Mrs M remained hydrated. The care home was not at fault.

Aggressive behaviour and record-keeping

69. The family were unhappy with Mrs M’s medication and wanted her to stop taking it. Care staff worked closely with medical staff to monitor Mrs M as the medication was reduced and stopped. Care records show that there were a number of incidents where Mrs M was aggressive towards staff and other residents. The Council confirmed it had received a number of safeguarding alerts, which prompted the review meeting in July 2018.
70. Mrs X does not accept Mrs M was aggressive. She says other residents and staff were aggressive towards Mrs M, which made her defensive. Mrs X says a carer told her on one occasion two staff members found Mrs M lost in a corridor and each grabbed an arm to pull her away. She believes this was traumatic for Mrs M. She also says other residents would sometimes take things that belonged to Mrs M, such as chocolates, which upset Mrs M.
71. In her complaint to us she said the care home altered its records to make it look like Mrs M was aggressive to staff and other residents. She did not raise this with the care home. Mrs X believes the records were altered to justify asking Mrs M to leave. She also says she could access the records remotely and often found they were completed the night before for morning personal care tasks.

Findings – aggressive behaviour and record-keeping

72. The Council confirm there was one incident where a male resident was aggressive towards Mrs M. Care home staff dealt with this immediately and a safeguarding referral was made. This incident is recorded in the care records, which state Mrs X was informed about what happened and the action taken.
73. There are a number of reports of Mrs M being lost in corridors and it is unclear when the incident Mrs X complains about occurred. Although Mrs X believes staff acted inappropriately on that occasion there is insufficient evidence to make a formal finding of fault. Even if I were able to find fault, there is no evidence the incident caused significant injustice to Mrs M.
74. In my review of the care records I noted that on some occasions there appear to be two times recorded for personal care. The Council explained the system for care recording shows an entry for personal care twice a day, which enables an alert to be sent to management if the deadline is missed. The time the care is actually given may therefore differ from the set recording times, which accounts for there being two times detailed in the records. However, I have found no evidence that records were completed in advance of care being given, nor of records being amended later, for example to show Mrs M was aggressive. The Council confirmed the care home made safeguarding referrals when Mrs M was aggressive towards another resident.

Agreed action

75. The Council will, within one month of the date of the final decision:
• Apologise to Mrs X for its failure to provide information and advice on the costs of her mother’s residential care, and for its delay in carrying out a financial assessment; and
• Pay Mrs X £250 for the uncertainty caused by this fault and the distress of receiving a large and unexpected bill.

It is open to the Council to offset this amount against the outstanding care costs.

76. The Council will, within one month of the date of the final decision, remind relevant staff of the need to keep proper records of the information given about the costs of adult social care and to confirm the advice given in writing.

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Final decision

77. I have completed my investigation. I have found fault leading to personal injustice. I have recommended action to remedy that injustice and prevent reoccurrence of this fault.
78. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share the final decision with CQC.

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Investigator's decision on behalf of the Ombudsman