The Ombudsman's final decision:
Summary: The care provider was not at fault in deciding not to readmit the late Mrs X to a residential placement once her nursing needs were evident. It could have communicated at an earlier stage with her family about Mrs X’s increasing needs. It has already apologised and taken action to review its systems, however, and those actions have remedied any injustice to Mrs X’s family.
- Ms A (as I shall call the complainant) complains about the way the care provider decided not to readmit her elderly mother back to her residential placement after a period in hospital. She also complains that the care provider did not reimburse her the correct amount, did not give proper notice and sent a condolence letter while her mother was still alive.
The Ombudsman’s role and powers
- 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)
- If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
How I considered this complaint
- I considered the information provided by the care provider and by Ms A. Both the care provider and Ms A had an opportunity to comment on an earlier draft of this statement before I reached a final decision.
What I found
Relevant law and guidance
- 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.
- Regulation 9 says the care and treatment of service-users must be appropriate and meet their needs.
- Regulation 12 says care must be provided in a safe way for service-users.
- The contract signed by Mrs X’s family states that after the four week trial period, the contract can only be terminated by four weeks’ notice or on written notice where “we decide with confirmation by a health professional or social worker that you require a level or category of service which cannot be provided by us”.
- Ms A and two other family members (Mr A and Ms B) have power of attorney for Mrs X.
- Mrs X, who had dementia, had been resident at the care home since November 2016. Ms A says Mrs X was registered blind: her care plan says “my eye sight is very poor without my glasses”.
- The care provider says Mrs X’s needs increased significantly during the early part of 2019. She required a hoist and two carers to transfer her, although sometimes she could move independently with a walking frame. She was assessed as being at high risk of falling. The care provider’s risk assessments stated she could become easily agitated and verbally aggressive towards staff.
- Mrs X had type 2 diabetes which the care plan said should be controlled with a low-sugar diet. Ms A says latterly the care provider was also giving doses of insulin by injection as Mrs X often refused food. She says Mrs X could hardly see what was on her plate but when she asked staff to cut food up or mash it for her mother, she was told staff could not do so as it wasn’t on her care plan. The care plan (dated June 2018) says she can eat and drink independently. Ms A says staff gave Mrs X snacks to supplement her poor food intake but these were often sweet and sugary, unsuitable for a diabetic.
- On 27 March 2019 Mrs X had an unwitnessed fall in her room to which staff were alerted when the sensor alarm in her room sounded. The care provider called paramedics who decided to take Mrs X to hospital. The care provider informed Ms A of Mrs X’s hospital admission.
- When Mrs X was deemed medically fit to be discharged, the hospital telephoned the care home manager on 11 April to reassess Mrs X’s needs prior to discharge. Two care managers attended. Their assessment form states: “While (Mrs X) has been in hospital, her care needs have increased. She is refusing to eat and drink and has also declined personal hygiene.” The managers went on to record that Mrs X had been refusing medication, had suffered several episodes of diabetic hypoglycaemia, and had developed pressure sores. It was agreed that Mrs X now needed 24-hour nursing care, not a residential placement.
- Ms A says she received a call from the care provider on 11 April to say the managers would be assessing Mrs X on 12 April. She says a member of the hospital ward staff told Ms B on the afternoon of 12 April that Mrs X would not be returning to the care home. Mr A telephoned the care home and a member of staff there told him Mrs X would not be readmitted to the home. A carer then also told Ms A on 13 April (when she attended to clear her mother’s room) that the home could no longer meet Mrs X’s needs. She says the care provider itself has never formally notified her in writing of the termination of contract.
- There are two different versions of the assessment sheet completed by the care managers: both are identical in content, but one is dated 11 April and the other is dated 12 April (they are signed by different managers). The hospital record (provided by Ms A) is clear the assessment took place on 12 April.
- Ms A complained to the care provider on 4 May. She complained no formal notice had been given and she said she expected a substantial refund of the fees which she had paid in advance on 26 March (but which had not been paid in and cleared by the care provider until 10 April).
- The care provider acknowledged receipt of the complaint and said it would be investigated.
- On 15 May the head of finance wrote to Ms A with condolences “at this difficult time” and said there would be a refund of £975. Mrs A complained further about the inappropriate letter.
- On 7 June the care provider wrote to Ms A and said once it had been established the home could no longer meet Mrs X’s needs, the care manager had telephoned Ms A (who was not at home) and left a message for her to call back. The care provider said when Ms A called back she had told the manager she would inform the rest of her family of the decision. Ms A says this is not true: the care home did not contact any family member, they contacted the care provider.
- The care provider said Mrs X’s needs had reached a level which the home could no longer meet. The care provider acknowledged it should have written formally to inform her family but there had been an administrative oversight and this had not happened. The care provider said there was no requirement for four weeks’ notice as readmission would have been detrimental to Mrs X’s health and well-being.
- The care provider apologised for the administrative error which meant the reason for the contract termination was incorrectly entered, and so the letter of condolence had been issued with the incorrect refund. A revised refund of £1185 was issued which took into account that Mrs X had been admitted to hospital on 27 March and was discharged on 13 April (the date on which Ms A cleared Mrs X’s room).
- Mrs X died on 27 July 2019.
- Ms A complained to the Ombudsman. She said Mrs X’s needs had been increasing for several months before her hospital admission and she could not see why the home could not continue to meet the needs it had been meeting for that time. She complained the care provider never formally gave notice in writing. She said once Mrs X was admitted to hospital, care staff kept saying they were expecting her back any day. She queried the dates on the assessment sheets recorded by the care managers.
- Ms A says the so-called increased needs which the care provider said had developed in hospital had been evident for some time. She says the daily care notes refer to “cream applied to sacrum” as evidence that pressure sores were already developing. She says the care provider should have recognised much sooner that it could no longer meet Mrs X’s needs and then the family could have arranged a transfer to another home in a gradual manner. Instead Mrs X could not understand why she could not return to the care home.
- The care home manager says “my two floor managers and I were concerned that (Mrs X) now required 24-hour nursing care, something that Derwent residential care home could not provide. we were all in agreement that we would be putting (Mrs X’s) health at risk if we were to accept her back to the home”.
- The care provider should have discussed Mrs X’s increasing needs with her family sooner. That would have given the family time to arrange a different placement if necessary. As it was, the hospital admission and assessment clarified the extent of Mrs X’s needs and that they could no longer be met at the care home.
- So it was not fault on the part of the care provider to decide not to readmit Mrs X after her hospital admission. Her needs had been increasing beyond the extent to which they could be met in a residential placement. The care provider would not have been complying with the regulations if it had readmitted her in that knowledge.
- The care provider was wrong not to write formally to the family with its decision. It has already taken action to resolve that administrative matter.
- It was a clumsy and distressing error on the part of the care provider to offer condolences while Mrs X was still alive and to miscalculate the refund necessary. It has apologised for the error and refunded the correct amount.
- The actions of the care provider caused injustice but it has already remedied the injustice caused by miscalculation of the refund.
Investigator's decision on behalf of the Ombudsman