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Athena Healthcare (Oxford Road) Limited (20 014 130)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 01 Dec 2021

The Ombudsman's final decision:

Summary: The Care Provider failed to keep adequate records of the care offered to Mr & Mrs Y during a residential respite stay. It also failed to deal with Mrs X’s complaint about this in a timely manner.

The complaint

  1. Mrs X complains the care provider failed to provide her grandparents Mr & Mrs Y, with the agreed care and support during their respite stay.

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The Ombudsman’s role and powers

  1. 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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
  2. We can decide whether to start or discontinue an investigation into a complaint within our jurisdiction. (Local Government Act 1974, sections 24A(6) and 34B(8), as amended)

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How I considered this complaint

  1. I have:
  • considered the complaint and discussed it with Mrs X;
  • considered the correspondence between Mrs X and the Care Provider, including the Care Provider’s response to the complaint;
  • made enquiries of the Care Provider and considered the responses;
  • taken account of relevant legislation;
  • offered Mrs X and the Care Provider the opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

  1. 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.
  2. 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.
  3. When investigating complaints about the standards of care in a care or nursing home, the Ombudsman considers if the 2014 regulations and the fundamental standards have been met. If they have not, we consider whether any identified faults have resulted in injustice.
  4. The Care Quality Commission Regulation 17 (2)(c) says:
  • Records relating to the care and treatment of each person using the service must be kept and be fit for purpose. Fit for purpose means they must: be complete, legible, indelible, accurate and up to date.


  1. Mr & Mrs Y went into Birkdale Tower Lodge Care Home (Care Provider) for a planned 4-week respite stay beginning 15 October 2020. Mrs X signed a contract on Mr & Mrs Y’s behalf the same day.
  2. Prior to Mr & Mrs Y’s admission, the Care Provider completed individual assessments and care plans. I have seen copies of these documents and I can confirm they are sufficiently detailed and completed properly. I have also had sight of the daily care records.
  3. Mrs X says she did not receive copies of the care plans.
  4. I have had sight of the daily care records for Mr & Mrs Y for the duration of their stay.
  5. In respect of Mrs Y, the records show her to have dementia and that she required assistance with washing, dressing, and grooming. There is only entry in the daily care records relating to personal care, 19 October 2020, it records Mrs Y to have been up, washed and dressed when seen by a carer. There is no information to show if, and when Mrs Y was offered personal care at any other time.
  6. The records show Mrs Y to have been tearful at times, but she settled after reassurance was given. On some occasions Mrs Y’s distress related to her desire to go outside for a cigarette, on each occasion care staff escorted Mrs Y to the smoking area. For the most part Mrs Y was settled and engaged with activities in the home, including a birthday celebration of another resident. She enjoyed meals in the dining room and had the occasional glass of wine. She spent most of her day in the main lounge with Mr Y and other residents.
  7. In respect of Mr Y, the records show he liked a shower every 2/3 days and required the assistance of one carer. There is no entry in the care records to show he was offered a shower. The records show he was able to get himself washed and dressed, and he only required support if he had not managed to do this himself.
  8. There is only one entry in the records, 20 October 2020, which records Mr Y to have been independent with washing and dressing that morning. There is no information to show if and when he was offered a shower or support with personal care at any other time.
  9. The records show Mr Y was upset on one occasion because he had forgotten to pack his electric razor. A carer immediately contacted Mrs X who agreed to check Mr Y’s home. Apart from this, Mr Y was reported to be settled and happy. He engaged with activities and enjoyed his meals in the dining room with the occasional glass of wine.
  10. Mr & Mrs Y’s daughter, and Mrs X contacted the care home daily to check on Mr & Mrs Y’s wellbeing. Care staff reported Mr & Mrs Y to “be ok”. The family also enquired about window visits as visiting was restricted because of the pandemic.
  11. The records show Mrs Y became very emotional during Mrs X’s visit on 20 October 2020 and was asking to go home. Mrs X made the decision to take Mr & Mrs home the same day.
  12. The day Mr & Mrs Y arrived home Mrs X found bruising to Mr Y’s back whilst helping him to shower. Mr Y said he had not been assisted to shower throughout his five-day stay.
  13. Mrs X submitted a complaint to the Care Provider on 26 October 2020 and asked for a refund of the care fees paid, minus the days the couple were resident in the care home.
  14. The Care Provider acknowledged receipt of the complaint the following day and said it would investigate the issues raised.
  15. Mrs X did not receive a response. She chased various employees on numerous occasions between October 2020 and February 2021.
  16. The Care Provider provided a formal written response on 23 February 2021. It reminded Mrs X she had signed a contractual agreement which set out that refunds were not permitted for four weeks respite care. It said Mrs X had removed Mr & Mrs Y without any notice, and that care staff were unaware that Mr & Mrs Y were unhappy. It went onto say, “…we do understand this was a distressing time for you all and as a gesture of good will we are willing to refund the amount of £2980.65 which is the full amount minus 2 weeks’ notice and the 5 days your grandparents stayed at the lodge”.
  17. Mrs X was dissatisfied. She says the care provided was inadequate and Mr & Mrs Y should be refunded all the care fees minus the days they were resident at the care home.
  18. In response to my enquiries the Care Provider was unable to explain the absence of personal care records for Mr & Mrs Y. It says, “Staff have been spoken to in regards to ensuring all care needs are documented on a daily basis. It had no record of Mr Y complaining of back pain and had no knowledge any bruising to his back.


  1. There are numerous elements to this complaint, whether adequate personal care was provided to Mr & Mrs Y, communication from the Care Provider, and the issue of the refund Mrs X is seeking.
  2. The Care Provider failed to keep adequate records of the personal care offered or provided to Mr & Mrs Y. This is fault and contrary to the CQC’s fundamental standards. This has left Mrs X with uncertainty about the quality of care provided. For this, the Care Provider should apologise to Mrs X.
  3. The assessments and care plans completed by the Care Provider were of a high standard. It would have been good practice to provide Mrs X with a copy of the care plans.
  4. The Care Provider did not inform Mrs X that Mrs Y was distressed on some occasions. I cannot criticise this decision. The episodes were infrequent and resolved by reassurance.
  5. In respect of the refund of care fees. Mrs X removed Mr & Mrs Y without notice. The contract makes clear no refunds will be given. The Care Provider has no obligation to refund any care fees paid. However, it offered to refund £2980.65 as a gesture of goodwill. Mrs X declined because she wanted the matter considered by this office. The Care Provider has reiterated its offer, and Mrs X now accepts.
  6. The Care Provider took too long to respond to Mrs X’s complaint, consequently she had to chase the company for a response. I have taken account of the time and trouble Mrs X was put to pursing this. For this, the Care Provider should apologise and make a payment to Mrs X of £150.

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Agreed action

  1. The Care Provider will within four weeks of the final decision:
  • provide Mrs X with a written apology for its failure to keep adequate records of the care offered to Mr & Mrs Y
  • refund £2980.65
  • apologise for the delayed complaint response, and make a payment to Mrs X of £150
  1. Provide evidence of the above to this office.

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Final decision

  1. The Care Provider failed to keep adequate records of the care offered to Mr & Mrs Y. It also failed to deal with Mrs X’s complaint about this in a timely manner.
  2. The above recommendations are a suitable way to settle the complaint.
  3. It is on this basis; the complaint will be closed.
  4. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

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Investigator's decision on behalf of the Ombudsman

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