Summary: Miss X complained about how the Care Provider billed her for her mother’s care fees. The Care Provider was at fault for delays in sending Miss X suitable written information on the fees and for delays in contacting Miss X for outstanding debt. This caused her distress. The Care Provider has already remedied this injustice by cancelling around £23,500 in care fees. It has agreed to remind its staff to respond to correspondence promptly to prevent the fault occurring again.

The complaint

1. Miss X complained on behalf of her mother, Mrs Y. Miss X complained about how the Care Provider billed her for her mother’s care fees. In particular, she says the Care Provider:
• did not give her sufficient information or warning about Mrs Y’s care fees after her NHS Continuing Healthcare funding ended;
• did not reduce the amount Mrs Y owed to take account of Mrs Y’s funded nursing care funding;
• overcharged for Mrs Y’s last week in the care home; and
• provided a poor and delayed complaints response.

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The Ombudsman’s role and powers

2. 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)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

5. I have considered:
• all the information Miss X provided and discussed the complaint with her;
• the supporting documents the Care Provider sent us;
• the relevant law and guidance and the Ombudsman's guidance on remedies.
6. Miss X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

NHS funding

7. 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. This is called NHS Continuing Healthcare funding (CHC).
8. Where someone with nursing needs is living in a care home, but the primary reason for being in care is not health-based, they may be eligible for NHS Funded Nursing Care (FNC). Through FNC the NHS meets the cost of care provided by registered nurses to residents in care homes. In the 2018/2019 financial year FNC was funded at a single rate of £158.16 per week. In the 2019/2020 financial year it increased to £165.56.

Paying for care

9. A person with assets above £23,250 may be responsible for the full cost of their care in a care home. Councils can carry out financial assessments to decide if someone’s capital is above the threshold.
10. Regulation 19 of the Care Quality Commission (Registration) Regulations 2009 says care providers should give timely and accurate information to residents about the cost of their care and treatment. This should include written information about any fees, contracts and terms and conditions where people are paying for some or all of their care.
11. The Care Provider’s contract says that after a resident dies, their room will be available to their family for seven days. The Care Provider will charge an “After Death Service Fee” equivalent to one week’s fee.

Complaints handling

12. The Care Provider says it will respond to both stage one and stage two complaints within twenty working days.

What happened

13. Mrs Y lived in a care home from 2018. She received CHC for the full cost of her care fees. When Mrs Y moved into the care home, Miss X signed the contract on Mrs Y’s behalf. The contract stated Mrs Y’s CHC funding was for £858 per week.
14. In early March 2019, the NHS stopped paying Mrs Y’s CHC. She was instead deemed eligible for FNC. As Mrs Y was no longer receiving full funding for her care, the Care Provider contacted the local council to find out if she was eligible for financial support from them.
15. The Care Provider says it spoke to Miss X on the phone to explain that Mrs Y may need to pay for her care. There is no evidence the Care Provider gave an expected cost.
16. In late September, Miss X sent the council information on Mrs Y’s finances. The council confirmed Mrs Y had capital above the threshold so would have to fund her care herself. Shortly after, the Care Provider wrote to Miss X to say Mrs Y’s care fees were £1436 per week minus FNC. Mrs Y was responsible for those costs from the date the CHC ended so had accrued almost £44,500 in care fees.
17. Miss X complained in early November 2019. She said:
• when Mrs Y moved into the care home, the Care Provider told Miss X self-funders paid between £1172 and £1328 per week;
• the NHS paid £858 per week; and
• the Care Provider had not sent her a new contract setting out the fees.

Miss X said that she had therefore made payment of £858 per week from March 2019.

18. The Care Provider responded in mid-December to explain how it calculated Mrs Y’s fees. It said Mrs Y now owed over £25,000.
19. In early January 2020, the Care Provider sent Miss X a new contract for Mrs Y’s care which set out her fees.
20. Miss X remained unhappy and escalated her complaint in mid-January 2020. She said the Care Provider had not given her sufficient information on what Mrs Y’s fees would be after the CHC ended. She was unhappy with how the Care Provider calculated its fees for self-funded residents. She said she would continue to pay £858 per week.
21. The Care Provider replied in early-March 2020. It said:
• there was a delay in confirming Mrs Y’s fees as it took the council until September 2019 to confirm she had to pay for her care fees;
• it felt that before it sent the first invoice in September 2019, it had adequately explained to Miss X that Mrs Y may have had to pay for her care;
• it accepted that once the council confirmed Mrs Y would have to pay for her care, it should have sent Miss X a new contract. It did not do this until January 2020 and apologised for the delay;
• Miss X now owed almost £40,000 as she had only paid £692.44 (£858 minus FNC of £165.56) per week; and
• in recognition of the delay in sending the contract, it offered to reduce Mrs Y’s care fees from £1436 minus FNC to £858 from early March 2019 to the end of May 2020. This reduced Mrs Y’s outstanding care fees by almost £23,500 to around £12,500.
22. Mrs Y died in April 2020. The Care Provider sent Miss X an invoice for £980.57. Miss X wrote to the Care Provider that month and agreed to the offer in its complaint response and made payment.
23. In March 2021, the Care Provider wrote to Miss X. It apologised for the delay in contacting her and said it was due to the COVID-19 pandemic. It said Miss X had accepted its offer of £858 per week but had then reduced it by £165.56 for FNC. She owed almost £10,000.

Findings

Information about care fees

24. Mrs Y became responsible for paying the cost of her care in March 2019. The Care Provider says it explained about this possibility to Miss X on the phone. Miss X has also confirmed she was aware self-funded residents had to pay up to £1328 per week.
25. However, there is no evidence the Care Provider gave Miss X an accurate idea of the fees to expect. The Care Provider did not send Miss X written information on Mrs Y’s care fees until September 2021, seven months after Mrs Y’s CHC funding ended. The Care Provider did not send a new contract to Miss X until January 2021. The delay in sending Miss X suitable written information on Mrs Y’s fees was fault. This caused Miss X distress when she received the large bill.
26. In March 2020, the Care Provider accepted it had delayed sending Mrs Y’s new contract and offered to reduce her weekly bill from £1436 minus FNC to £858 from March 2019 to May 2020. This removed almost £23,500 from Mrs Y’s outstanding bill. This remedied the distress caused by the Care Provider’s fault.
27. Miss X felt the weekly fee from March 2019 to May 2020 should be £858 minus FNC as Mrs Y’s contract stated her weekly fee was reduced by the value of the FNC. However, the amount the Care Provider offered was a remedy to resolve Miss X’s complaint, not a new fee rate in a contract. The issue is therefore whether the letter was sufficiently clear in stating that the amount outstanding. I am satisfied it was. The Care Provider was not at fault.
28. However, after Miss X paid the weekly amount of £858 minus FNC, leaving an outstanding bill of almost £10,000 there was a significant delay in the Care Provider asking Miss X to pay the outstanding amount. Miss X explained her intention in a letter in April 2020. The Care Provider did not contact her again until March 2021. This was a delay of almost a year. The Care Provider said it was because the letter went to its head office when it was closed due to the COVID-19 pandemic. While I accept some delay due to the pandemic was inevitable, the delay in this case amounts to fault. However, I do not consider this warrants a further personal remedy given that already offered by the Care Provider.

Fee for final week

29. Miss X says the Care Provider overcharged Mrs Y for her last week of care in the care home. Mrs Y’s contract stated that after a resident died, the Care Provider would charge for a further seven days. The invoice shows the Care Provider charged for the day Mrs Y died plus one week. This was in line with its contract and was not fault.

Complaints handling

30. Miss X feels the Care Provider’s complaint response was delayed and inadequate. In particular, Miss X was unhappy the Care Provider did not explain its charge for Mrs Y’s final week in the care home.
31. Both the complaint responses were delayed by two to three weeks. I do not consider this sufficient to make a finding of fault. The Ombudsman does not expect care providers to respond to every part of someone’s complaint. It is sufficient if they address the key points. I am satisfied the Care Provider did so. It was not at fault.

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Agreed action

32. Within three months of the date of this decision, the Care Provider will remind its staff they must respond to correspondence promptly, particularly where it relates to care fees and invoices.

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Final decision

33. I have completed my investigation. I have found fault leading to personal injustice. The Care Provider has already remedied that injustice. I have recommended action to prevent reoccurrence of fault I identified.

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Investigator's decision on behalf of the Ombudsman