Summary: Mrs X complained about the actions of Heathbrock Limited Care Provider who provided respite care for her husband. The Care Provider was at fault when it failed to provide Mrs X with written confirmation of additional costs associated with providing her husband with one to one care. The Care Provider has agreed to make procedural changes to prevent a reoccurrence.

The complaint

1. Mrs X complained the Care Provider:
• agreed to admit her husband, Mr X, to one of its care homes for respite care but then stated it could no longer meet his needs, despite those needs not changing;
• did not provide Mrs X with a written contract until after Mr X had left the Care Home;
• failed to carry out a needs or risk assessment;
• placed Mr X at unnecessary risk of harm when it allocated him a room close to an unlocked staircase; and
• failed to inform her in writing when it increased Mr X’s care.
2. Mrs X says that this caused Mr X to be exposed to unnecessary risk of harm. He also had to move care homes which was disruptive, causing him confusion and unnecessary distress. Mrs X says she was also caused distress by the care provider’s actions.

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The Ombudsman’s role and powers

3. 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)
4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. If we are satisfied with a care provider’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)
7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

8. I spoke to Mrs X and considered her view of her complaint.
9. I made enquiries of the Care Provider and considered the information it provided. This included a copy of the complaint correspondence, Mr X’s daily records, the contract, the Council social care assessment and the Care Provider’s risk assessment.
10. I wrote to Mrs X and the Care Provider with my draft decision and considered their comments before I made my final decision.

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What I found

The law and the Care Provider’s contractual arrangements

Care Act 2014

11. The Care Act 2014 and Care and Support Statutory Guidance 2014 require local authorities to carry out an assessment for any adult with an appearance of need for care and support. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve.
12. The person's needs and how they will be met must be set out in a care and support plan.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

13. The Regulations 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 which care must never fall below. Regulation 12 says that care must be provided in a safe way for residents. This includes assessing and as far as possible mitigating risks, safe care planning and ensuring premises are safe.
14. Regulation 19 states providers must give timely and accurate information about the costs of the service user’s care. To meet this Regulation, providers must provide written information available about any fees, and as far as reasonably practicable, they should do so before the service begins.

Care Provider’s contractual terms

15. The Care Provider’s contract states there is a trial period of four weeks in which residents can consider whether they wish to stay, and the Care Provider will confirm it can meet their needs. During the trial period, the Care Provider can give 14 days’ notice and the service user can give one week’s notice to end the contract.

What happened

16. Mr X, who has now died, had a number of health conditions including Parkinson’s Disease and dementia. His wife, Mrs X, used to care for him.
17. Mrs X had lasting power of attorney for finance and welfare for Mr X. This meant she had the authority to make decisions on Mr X’s behalf about matters such as his care placement and associated fees.
18. In January 2020, Mrs X asked the Council to carry out an adult social care assessment. This was because she wanted Mr X to go into a care home for a period of time so she could have a break from her caring role.
19. The Council assessed Mr X on 22 January 2020. The assessment stated Mr X needed substantial care and was at risk of frequent falls.
20. The family carried out its own search for a care home and selected Chester Lodge. Chester Lodge is run by Heathbrock Limited. It is registered with the CQC as having specialist care in several fields including Parkinson’s Disease. It does not provide specialist dementia care.
21. Mr X moved in on 24 January 2020. His bedroom was on the first floor close to the fire escape stairs. The stairs were separated from the corridor by an unlocked door.
22. The Council’s assessment had recorded Mr X was at risk of falls and so the Care Home carried out a falls assessment. This recorded Mr X was at medium risk and used walking aids to help him walk.
23. The care records for 26 January show that Mr X had become unsettled by “impulsively wandering around unsteadily and pushing staff away when attempting to intervene. As a result, carer has been advised to not leave [Mr X] out of sight”.
24. The care records for the 27 January recorded Mr X had been on one to one care all day because he was trying to leave the Care Home. Later he managed to avoid triggering his sensor mat in his room and was found entering other residents’ bedrooms looking for his wife and trying to get down the fire escape stairs which could not be locked for safety reasons. The records stated that as a result, he was put under frequent monitoring throughout the evening and then again during the night when he became unsettled again.
25. There were further issues on 28 January and then Mr X settled into the Care Home and the records did not report any significant issues until 8 February.
26. On 8 February, the care notes recorded Mr X had woken in the night and had tried to enter other residents’ bedrooms and to go down the fire escape stairs. Staff monitored him for the rest of the night.
27. There were further disturbed nights. As a result, the Care Home gave Mrs X notice for Mr X to leave because it decided it could not meet his needs. During the notice period, the Care Home decided Mr X needed one to one monitoring. It was unable to provide this from its own staff and hired in agency carers to provide the care at night from 15 to 19 February. The Care Provider said the Care Home agreed this with the family who said they would provide help with Mr X during the day. The care notes record a family member was present at the Care Home every day after one to one care was introduced.
28. On 20 February Mr X left the Care Home.
29. Mrs X received the bill for Mr X’s care. This included additional charges of £915 for the extra one to one care Mr X received from 15 – 19 February.
30. Mrs X complained to the Care Provider on 16 March. The Care Provider responded on 1 April. The letter stated “It is true we weren’t fully aware of [Mr X’s] needs this must have been by misunderstanding or perhaps exaggerated behaviour…due to being unsettled by the move. As we are only a nursing home and have no specialty nurses or carers whom deal with the more advanced needs [Mr X] was displaying, a room by the stairs would never be ideal… the need to provide one to one care during the evenings was only ever in place to protect him whilst we were waiting for a suitable placement… we did make you aware at the time one to one cover was our only option if we were to avoid transfer to hospital”.
31. Mrs X remained unhappy and complained to the Ombudsman.
32. During my enquiries the Care Provider informed me it sent Mrs X a copy of Mr X’s contract to sign but she did not send this back. Mrs X informed me she did not get a copy of the contract until after Mr X had left the Care Home.
33. The Care Provider said the Care Home discussed the need for additional care with the family and it was agreed that the family would monitor him during the day and he would have extra one to one care at night. Mrs X informed me a discussion may have taken place with her daughter but not with her.

My findings

Care Provider did not provide Mrs X with a written contract prior to Mr X’s care starting

34. 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.
35. The Care Provider informed me it sent Mrs X a copy of the contract to sign but she did not send this back. Mrs X informed me she did not get a copy of the contract until after Mr X had left.
36. Even on the balance of probabilities, it is not possible for me to say whether the Care Provider sent Mrs X a contract, or if it did, whether she received it. I will not investigate this matter further.

Care Home was unable to meet Mr X’s needs

37. Mrs X is unhappy because she believes the Care Home should not have accepted Mr X as a resident because it could not meet his needs.
38. Initially, both parties thought the Care Home could meet Mr X’s needs. Mr X’s care and support assessment was detailed and provided comments from his family. His family provided additional information about Mr X for the Care Home. There was nothing in either of these documents to indicate Mr X had previously wandered. It is likely this was new behaviour triggered by the move to a new setting.
39. Although Mr X settled after a few days, he began to wander again a couple of weeks later. The Care Home decided it could not meet his needs and gave Mrs X notice. This was in line with the terms of the contract and was not fault.

Care Home failed to carry out a needs assessment

40. The Council carried out a care and support needs assessment shortly before Mr X was admitted to the Care Home. The Care Home used this, and the information provided by the family, to plan Mr X’s care. There was no need for the Care Home to carry out another assessment immediately. When Mr X’s care needs changed, the Care Home adapted its care to meet those new needs. There was no fault in the Care Home’s actions.

Care Home failed to carry out a risk assessment

41. Mr X’s care plan said he was at high risk of falls. The Care Home carried out a risk assessment when Mr X first entered the Care Home. This recorded Mr X’s level of risk of falling and the measures taken by the Care Home to prevent this happening. There was no fault in the Care Home’s actions.

Care Home allocated Mr X a room close to an unlocked staircase

42. Mr X’s tendency to wander could not have been identified before he was admitted to the Care Home. Therefore, there was no fault when the Care Home allocated Mr X a bedroom close to the unlocked fire escape stairs. When Mr X began to wander shortly after arriving, the Care Home took appropriate steps to manage this. It put a sensor mat by his bed, but soon discovered he was able to avoid this. The Care Home then increased its monitoring of Mr X but this was not sufficient to prevent him leaving his room. The Care Home gave notice and introduced one to one care for Mr X until he left. These were appropriate actions and there was no fault in the Care Home’s actions.

Care Home failed to inform Mrs X in writing when it increased Mr X’s care

43. The Care Home said it discussed the need for one to one care at night with the family and obtained their consent. Mrs X said a discussion may have taken place with her daughter, but the matter was not discussed with her, the fee-payer. The Care Home has not been able to provide a record of this discussion so I cannot confirm what was said or to whom
44. On balance, it is likely the Care Home discussed the need for an increase in Mr X’s care package with someone in the family. In addition, a family member was present each day during the period the additional care was in place, including, at times, Mrs X. Under these circumstances, it is likely they were aware of the additional care and therefore there would be additional fees. However, the Care Home failed to provide written confirmation to Mrs X, the fee-payer. This is not in line with Regulation 19 and is fault.
45. Because the Care Home failed to give notice of the additional fees in writing, it is possible Mrs X was uncertain of the precise costs. However, this is not sufficient injustice to warrant a payment or reduction in the fees, given the short period of time involved. It is not disputed Mr X needed the additional care during the five nights before he left the Care Home. On balance, therefore, even if Mrs X did not know the precise costs of this care, it is likely she would have agreed to it. This is because it was needed for Mr X’s safety and her refusal would have meant his immediate return home, followed almost straightaway by a second move to another care home. This was something Mrs X wanted to avoid because of its negative effect on Mr X’s mental wellbeing.
46. However, the Care Provider should make procedural changes to ensure this does not happen again.

Agreed action

47. Within three months of the date of the final decision, the Care Provider has agreed to review its processes to ensure that when service users require additional care, the person responsible for approving that care and associated costs is informed in writing and their approval obtained.
48. We will ask the Care Provider to evidence it has carried this out.

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Final decision

49. There was fault but this did not cause a significant injustice. The Care Provider has agreed to my recommendation. Therefore, I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman