Summary: Mrs X complained on behalf of her late father, Mr Y about the care he received and the fees he paid at his care home. The care provider acknowledged mistakes were made with Mr Y’s fees. It has apologised and offered a financial remedy for this. The care provider was at fault on the day Mr Y fell and when it failed to report the incident. The care provider has agreed to remedy Mr Y’s and his family’s injustice.

The complaint

1. Mrs X complained on behalf of her late father, Mr Y about the care he received and the fees he paid at his care home. She said, the care provider failed to:
• clarify and agree Mr Y’s fee structure;
• care for Mr Y appropriately, leading to his fall; and
• provide a timely and accurate report about Mr Y’s fall to the family and the Care Quality Commission (CQC).
2. Mrs X said the care provider’s failures caused an injustice to her father and her family. She said:
• her father’s quality of life deteriorated after his fall;
• her mother’s (Mrs Y’s) mental and physical wellbeing was affected as she constantly worried about Mr Y, and the care he received;
• she has experienced time, trouble and stress throughout this whole process; and
• she and her family are unable to grieve properly whilst the issues remain unresolved.
3. In terms of a personal remedy, Mrs X would like the care provider to:
• correct the report about her father’s fall submitted to CQC; and
• pay financial compensation to her mother for the stress caused. This sum should reflect her mother’s distress, and also act as a deterrent to the care provider to prevent a similar occurrence in the future.
4. To prevent similar issues occurring, Mrs X thinks the care provider should:
• strengthen its procedures to ensure incidents are properly recorded and reported to the correct organisations;
• ensure in the future a full investigation is carried out in relation to incidents;
• give families a written account of incidents, and ensure appropriate information appears of the resident’s file;
• give guidance, encouragement and reward to employees who develop a professional but caring relationship with the residents and a sensitive response to visiting family members;
• have a clear, written charging policy with different fee levels fully explained; and
• overhaul the accounting and administrative systems. This should ensure the information is accurate and presented appropriately so it can be easily understood by family members.

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The Ombudsman’s role and powers

5. 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)
6. We investigate complaints about adult social care providers. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we could add to any previous investigation by the care provider, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants, or
• there is another body better placed to consider this complaint.

(Local Government Act 1974, sections 34B(8) and (9))

7. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves, or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. Part 3A covers complaints about care bought directly from a care provider by the person who needs it or by a representative, and includes care funded privately or with direct payments under a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
8. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
9. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
10. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
11. 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

12. I have considered Mrs X’s complaint and the supporting information.
13. I have also considered the care provider’s response to Mrs X and to my enquiries.
14. I have written to Mrs X and the care provider with my draft decision and considered their comments.

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What I found

Background

15. The Local Government and Social Care Ombudsman would not normally investigate late complaints (more than 12 months after the event) unless we decide there are good reasons.
16. I have exercised discretion in Mrs X’s case.
17. Although her father, Mr Y fell in February 2018, she was not aware of the details or that the care provider had not accurately recorded the incident until months later. Therefore, she had no reason to complain when the incident happened.
18. The care provider informed Mrs X about the increase in her father’s fees in February 2018. However, the care provider delayed in responding to Mrs X’s concerns about this issue. Therefore, she did not know the care provider’s position on the matter until its correspondence in August 2018.
19. I have decided to consider the whole complaint as in time.

Legislation

20. Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 specifies a range of events or occurrences that must be notified to CQC so that, where needed, CQC can take follow-up action.
21. Care providers must notify CQC without delay of all incidents that affect the health, safety and welfare of people who use services. This would include a fall that resulted in injury.

What happened

Mr Y’s care fees

22. Mr Y moved into the care home in January 2018. In February 2018, the care provider wrote to Mrs X to inform her that Mr Y’s fees would increase from 1 April. Mrs X wrote several times to the care provider in March, April, May and June 2018 to ask for an explanation of the fee increase. The care provider responded in August 2018. It apologised for the delay and provided a brief explanation of Mr Y’s fee structure. Two weeks later, the care provider wrote to Mrs X again with a ‘polite reminder’ about Mr Y’s outstanding fees. The evidence showed Mrs X remained unclear about the care provider’s two fee levels.
23. The correspondence between Mrs X and the care provider about the fees continued until after Mr Y’s death in February 2019. During this time, Mrs X and her mother, Mrs Y continued to send cheques to the care provider. After Mr Y’s death, the care provider sent Mrs X a letter asking for payment of the outstanding fees of £3,918.94.
24. Mrs X wrote to the care provider to question the outstanding fees. She also raised several issues regarding her father’s care, in particular the circumstances around his fall.

Mr Y’s fall in February 2018

25. When Mr Y moved into the care home in January 2018, the staff carried out the relevant risk assessments. His care plan showed Mr Y was at high risk of falls. His plan included the need for Mr Y to sleep on a low level bed with crash mats either side and a sensor mats to alert staff during the night. It also showed he required a zimmer frame and carer support to stand, transfer and walk.
26. In February, he was admitted to hospital with an infection. Three days later he was discharged and returned to the care home.
27. The care provider said it did not receive a discharge letter from the hospital. It is also unable to find any care notes from this day. It said Mr Y was only in the care home for a few hours this day.
28. That same evening, at 11pm, a member of staff found Mr Y on the floor next to a chair in the day room. The incident reports states that he had no visible injuries but upon moving him, Mr Y experienced pain. Records show a member of staff called an ambulance and Mr Y was admitted to hospital.
29. Mr Y had suffered a fractured pelvis. He was discharged back to the home the next day.
30. Mrs X raised concerns about the circumstances surrounding her father’s fall. The care provider told her that her father liked to stay up late to chat and watch TV. Mrs X said her father was blind and deaf and did not watch TV. She said he liked to go to bed early.
31. Mr Y’s person-centred plan of nursing care stated he did not watch TV as he lost his sight in 2007. He also said he liked to go to sleep after his tea, when his wife, Mrs Y, leaves.
32. From the evidence I have seen in Mr Y’s general daily/night report for the months after February 2018, he usually went to bed between 7pm and 8pm and was always ‘settled in bed’ by the 10pm check.
33. After Mr Y’s fall, Mrs X asked the care home to add details of the incident to her father’s records. She repeatedly contacted the care provider about this. Over a year later, the care provider said that Mr Y’s fall was fully recorded and reported to CQC. Mrs X contacted CQC in May 2019. It had no record of Mr Y’s fall.
34. In July 2019, the care provider shared an extract of the report to CQC with Mrs X. I have seen this. There is no submission date.

Care Quality Commission (CQC) inspection and report

35. In 2018, CQC inspected the care home and identified a breach in Regulations regarding the care provider’s records and quality systems. The CQC 2019 report, whilst still requiring improvement, showed the provider was no longer in breach of the Regulations.

The care provider’s response regarding the fees

36. The care provider responded and apologised for not being able to clarify Mrs X’s queries about funding. It suggested that a phone call or meeting might be helpful.
37. In May 2019, after the care provider reviewed Mr Y’s financial statement, it identified an error. The care provider reduced the outstanding fees to £2,458.10.
38. Mrs X continued to question the care provider’s fee structure. In June 2019, the care provider wrote to Mrs X. It apologised for the mistakes made regarding Mr Y’s fees. In this letter, the care provider offered to write off the outstanding balance of £2,458.10 on Mr Y’s account and pay £1000 compensation to Mr Y’s estate.

The care provider’s response regarding Mr Y’s fall

39. The care provider maintained that Mr Y chose to stay up late in the day room. It said he fell from his chair when staff were looking after other residents. It went on to explain the fall was fully reported and recorded within Mr Y’s care plan but apologised this was not adequately communicated to Mrs X or Mrs Y.
40. Mrs X continued to question the circumstances regarding her father’s fall. She repeatedly requested to see the relevant records of the incident.
41. In June 2019, the care provider wrote to Mrs X. It acknowledged that Mr Y’s fall was not fully reported at the time. The care provider apologised that its policy and procedure was not followed on that occasion, and also for its poor communication with the family.

Mrs X’s complaint and the care provider’s response

42. In July, Mrs X wrote to the care home to confirm she would be proceeding with an official complaint.
43. In response to Mrs X’s complaint, the care provider confirmed it had acknowledged there had been some failings in its systems and processes of which it had reflected and implemented further checks to ensure it does not repeat them:
• The care home has a new administrator who is trained to follow financial processes.
• If it receives any financial queries that are not resolved in two forms of correspondence, the care home will escalate them to the financial director.
• It has implemented a new care plan system and the manager personally checks all notifications to ensure they are sent in a timely manner.
• It will review its statements to ensure they are up to date and clear.
44. The care provider also confirmed its financial offer was based on both financial and operational processes not being followed and for assurances being made that these processes had been followed but on further investigation found it had not:
• Posted the credit note allocated to Mr Y’s account as should have been the case;
• Reported to the Health and Safety Executive and Care Quality Commission.

My Findings

Care provider’s mistakes regarding Mr Y’s fees

45. The care provider acknowledged the mistakes it made regarding Mr Y’s fee calculations. It has apologised to Mrs X for the inconvenience it caused and has offered financial compensation. I consider the care provider’s offer to write off the outstanding fees to go some way in remedying the injustice caused to Mrs X and her mother regarding mistakes made to Mr Y’s account. However, the time it took for the care provider to respond and acknowledge its mistake to Mrs X and Mrs Y was fault and caused avoidable time, trouble and distress.

Mr Y’s fall and the care provider’s records and reporting

46. The care provider was aware of Mr Y’s high risk of falls. Mr Y’s care plan shows the care provider assessed his needs and put measures in place to reduce the risk of injury. This included staff supervision when he walked and transferred, and crash mats and a pressure sensor near his bed.
47. However, the care plan did not include anything about when Mr Y was sat in a chair. The care home records show Mr Y would sometimes try to get out of a chair himself so staff needed to ensure he was comfortable and stimulated.
48. I asked the care provider for the daily records for 16 February 2018 so I could determine how long Mr X was left unattended before he fell.
49. The care provider was unable to provide me with records from the day Mr Y was discharged from hospital and later fell. This means there is no record of:
• what time Mr Y returned to the home from hospital (no discharge note);
• a handover between the ambulance staff and the care home staff;
• a handover between day and night staff at the care home; or
• daily notes taken regarding Mr Y’s movements, meals, or medicine.
50. Given the presence of the above information for other days during Mr Y’s stay at the care home, I consider the absence of such information for the 16 February 2018 a concern. Without these records, I am not able to confirm whether the care staff were even aware Mr Y had returned from hospital or whether he was left alone in the day room until he tried to move himself and fell.
51. The care provider acknowledged that Mr Y’s fall was not fully reported at the time. More worryingly, I consider the events leading up to his fall were not fully recorded and this could have contributed to the incident.
52. After Mr Y’s fall, it is evident that the care provider did not follow procedure and report the incident to CQC. It took a further 17 months for the care provider to submit a report to CQC. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. The care provider should have notified CQC, without delay, of the incident that resulted in Mr Y’s injury. Whilst this error did not cause a personal injustice to Mr Y, my decision will be shared with CQC who may decide to take this matter further.

Agreed action

53. Within 4 weeks of my final decision, the care provider will:
• Apologise to Mrs X and her mother, Mrs Y for the mistakes made to Mr Y’s account and for the failure to provide adequate care to Mr Y on 16 February, leading to his fall
• Write off the outstanding balance of £2,458.10 on Mr Y’s account.
• Pay Mrs X £750 for the time and trouble she experienced whilst handling Mr Y’s fees and pursuing the complaint with the care provider and for the distress she experienced when pursuing the care provider for details surrounding her father’s fall.
• Pay Mrs Y £750 for the distress she experienced whilst worrying about the care her husband received at the care home, and the mistakes made with his fees.
54. Within 12 weeks of my final decision, the care provider will provide evidence of:
• the new administrative processes in place to reduce the occurrence of mistakes being made regarding residents’ fees.
• the processes in place to manage any financial queries raised by residents or their families/representatives.
• the new care plan system and how this will ensure residents’ individual needs are met.
• the process for record-keeping of residents’ daily/nightly lives and any incidents that occur.
• the processes staff follow when reporting incidents to CQC.

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Final decision

55. I uphold Mrs X’s complaint. The care provider’s actions caused significant injustice to Mr Y and his family. The care provider has agreed to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman