Summary: The complainant (Mr X) complained about the quality of the residential care provided by the Green Nursing Homes Limited (the Care Provider) to his father (Mr Y) and its failure to present him with the details of its terms and conditions. We did not find any of the Care Provider’s actions caused or could have caused injustice to Mr Y.

The complaint

1. Mr X complains about the standards of care his late father (Mr Y) received when staying in the Green Care Home with Nursing in Dronfield (the Care Home). He says the Care Home failed to:
• allow Mr Y making food choices and to help him with eating;
• appropriately address Mr Y’s medical needs, including irregular use of skin cream and administering unrequired medication;
• ensure proper standards of personal hygiene;
• properly handle Mr Y when moving him from him from his chair or bed;
• encourage Mr Y to join in the activities, leaving him for hours alone in his room;
• appropriately react to the episodes of Mr Y waking up at night
2. Mr X says he was very concerned at the time about his father’s treatment in the Care Home. He considers he should not pay the full outstanding fees for Mr Y’s residential care in the Care Home and after the investigation the Care Home should make improvements in the standards of care offered to its residents.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)

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How I considered this complaint

6. I considered the information Mr X provided.
7. I made enquiries with the Care Provider and considered the information it provided.
8. I reviewed the Green Care Home with Nursing, Dronfield, CQC Inspection Report of 27 January 2022.
9. I referred to our Focus Report “Caring about complaints: lessons from our independent care provider investigations” issued in March 2019.
10. Mr X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Legal and administrative framework

Quality of care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 describe fundamental standards which a registered person who carries out any regulated activity must comply with. It says the care and treatment of service users must be appropriate, meet their needs and reflect their preferences.
12. To comply with its duties of providing required level of care and treatment a registered person must:
• Carry out collaboratively with the relevant person, an assessment of the needs and preferences for care and treatment;
• Design care or treatment with a view to achieving service users’ preferences and ensuring their needs are met;
• Enable and support service users to make or participate in making decisions relating to their care or treatment to the maximum extent possible;
• Where meeting a service user’s nutritional and hydration needs, having regard to the service user’s well-being.

(The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regulation 9(3))

Terms and conditions of privately funded care

13. Where a service user will be responsible for paying the costs of their care or treatment, the registered person must provide a statement to the service user specifying the terms and conditions in respect of the services to be provided including the amount of fees and the form of contract, if applicable. The statement must be in writing and as far as reasonably practicable provided prior to the commencement of the service. (The Care Quality Commission (Registration) Regulations 2009 regulation 19)

What happened

Background

14. At the time of the events complained about Mr Y was 95 and had medical history of stroke, acute renal failures, swelling of his legs and recurrent ulcers.
15. Mr Y had two sons, Mr X who lives abroad and another one (Mr Z) who lives in the United Kingdom (UK) but did not visit his father for a long period of time. Mr Y did not want Mr Z to be involved in any decision-making about his finances or health.
16. Mr X applied for Power of Attorney for My Y when Mr Y was staying at the Care Home. The application did not get completed until a few days after Mr Y’s death later in the year.

Residential care funded by National Health Service (NHS)

17. In the second week of February 2022 Mr Y was admitted to the Care Home from the hospital where he was treated following the fall. As Mr X was abroad, this was arranged by Mr Y’s social worker (the Social Worker) who was in communication with Mr Z.
18. On Mr Y’s arrival the Care Home carried out several assessments and prepared a care plan for him. The assessments were for staying safe in bed, continence, falls risk, waterflow and mobility and function. The care plan made it clear Mr Y was not happy about being placed at the Care Home as he wanted to be cared for at home. The Care Home was intended to be a temporary arrangement until a domestic care package was ready. Despite possibility of getting confused Mr Y was assessed as being able to make everyday choices.
19. Until the end of March Mr Y’s residential care at the Care Home was funded by NHS at the rate of £959.52 per week. At the end of the period funded by NHS the Council decided it was in Mr Y’s best interest to remain in the Care Home.
20. Until Mr X’s arrival in the UK, Mr Z was the Social Worker’s point of contact. The Social Worker told Mr Z about Mr Y being transferred from the hospital to the Care Home and invited him to the meeting at the end of March. During this remote meeting with the representatives from NHS and Continuing Healthcare teams, the Social Worker and Mr Y’s friend the circumstances of Mr Y’s care were discussed.

Residential care for Mr Y as a self-funder

21. At the end of April the Care Provider told the Social Worker how much fees Mr Y owed for his residential care. It sent the Social Worker reminders of the overdue fees twice in the beginning of May. Until Mr X arrived in the UK and aware of Mr Y’s wish not to involve Mr Z in any decision-making, the Care Provider contacted Mr Y’s Social Worker with any issues around Mr Y’s well-being and finances.
22. A day after the second reminder the Council told the Care Home it had completed Mr Y’s financial assessment. It found Mr Y should fund his residential care.
23. Following conversation with Mr Y, the Care Provider received reassurance Mr Y would pay the fees for his residential care. There was further correspondence about this issue between the Care Home and the Social Worker.
24. The Social Worker told the Care Provider of Mr X’s planned arrival to the UK in the second part of May.
25. In mid-May the Care Provider sent Mr X an email, telling him of the end of the NHS funding for Mr Y’s residential care in March. The email contained the details of the Care Home fees and information on the outcome of Mr Y’s financial assessment. The Care Provider attached the invoice for the overdue fees.
26. After his arrival in the UK in the fourth week of May most days Mr X visited his father up to several hours at the time. On his first visit Mr X was informed of the Care Home fees and received the invoice. Neither he, nor his father ever received a contract with terms and conditions included.
27. In the beginning of June when visiting his father Mr X, his father’s friend and Mr Y’s Social Worker met up in the Care Home. They had some concerns about Mr Y’s care and discussed them with the Care Home’s representative. They talked about:
• Mr Y’s disrupted nights with shouting episodes; Mr X asked the Care Home staff to use hi/low bed with crash mat and sensor mat on the floor in case his night terrors are caused by his fear of the bed rails;
• Mr Y’s swollen ankles.
28. On the same day the Care Home contacted Mr Y’s General Practitioner (GP). Mr Y’s GP advised to visit the Accident and Emergency department of the hospital for a scan and blood tests. Mr X, who practises as a doctor abroad, discussed Mr Y’s health with his GP. Cancelling the hospital transport, Mr Y’s GP prescribed him antibiotic and other medication aimed to reduce the swelling. The following day the Care Home staff found out Mr X refused to collect medication prescribed by Mr Y’s GP claiming they were inappropriate. On the third day the Care Home contacted the GP out-of-hours surgery and got another prescription for antibiotics and other medication issued. These were collected the following day and the Care Home started giving them to Mr Y.
29. At the same time the out-of-hours GP practice and the Care Home sent a safeguarding referral to the Council, raising the issue of Mr X withholding medical treatment without holding Power of Attorney for Mr Y.
30. During Mr X’s visit to his father on the next day after starting the course of antibiotics Mr Y was sick. Once Mr X found out about the new medication, he demanded the Care Home stopped this treatment as he considered it caused Mr Y’s sickness and was, in his opinion, life-threatening.
31. In the beginning of June the Care Home reviewed Mr Y’s care plan, carrying out pressure injure prevention assessment and bedrails assessment.
32. At the end of the first week of June the Care Provider sought from Mr X an outstanding balance of £13,300.
33. On 9 June the Social Worker told the Care Provider of Mr X’s decision to move Mr Y to a different care home, which happened four days later.
34. Once told of Mr Y’s imminent moving out, the Care Provider amended the invoice to £9,907. The fees covered residential care for Mr Y from the beginning of April till 12 June.

Complaints following Mr Y’s change of care home

35. On 12 June Mr X asked for a copy of the signed agreement and queried standards of care offered to Mr Y by the Care Home. He refused to pay the outstanding fees as he considered they should have been lower in view of the care the Care Home provided to Mr Y. A few days later Mr X sent another letter to the Care Home explaining circumstances of Mr Y’s departure from the Care Home and requesting an apology.
36. In its response the Care Home explained to Mr X that due to Mr Y’s mobility issues he needed a wheelchair transport and it would not be safe to transfer him to and from an ordinary car. Although on one occasion the Care Home staff helped Mr X to move his father to the ordinary car, that proved difficult and triggered safety concerns. As the Care Home made it clear to Mr X, its staff refused to help Mr X when he transferred his father to a car on the day of his departure. The Care Home insisted it acted professionally and refused to apologise.
37. In mid-July Mr X asked the Council for a contract between the Care Home and Mr Y with the details of standards of nursing care. Mr X mentioned the Social Worker also raised concerns about standards of care provided by the Care Home.
38. In the beginning of September the Care Provider:
• Denied receiving concerns from the Social Worker about the quality of care for Mr Y in the Care Home;
• Listed removal of bedrails and placing a sensor mat by Mr Y’s bed as actions which followed from the meeting in the beginning of June with no mention of withholding fees;
• Confirmed care notes showed a pattern of generally good care practice with no evidence of neglect. The Care Home staff:
1. encouraged Mr Y to eat and helped him whenever necessary or asked. Mr Y’s appetite was variable however his weight increased during his stay at the Care Home;
2. applied required pressure care including regular pad checks, turns and personal care, including cream application, to prevent Mr Y developing sores;
3. oversaw Mr Y’s ulcer on his leg and ensured it was successfully treated resulting in Mr Y’s discharge from the district nurses care in the first week of June;
4. acted properly when it referred Mr Y to the GP in the beginning of June to address Mr Y’s swollen legs and followed GP’s recommendations;
39. There was further correspondence between the Care Provider and Mr X. Mr X repeated his concerns about the quality of care received by his father when staying in the Care Home. The Care Provider asked Mr X to pay overdue fees of £9,907 saying the Care Home staff had a duty to follow medical recommendations and could not be held responsible for any effects when applying medical advice.

Analysis

Quality of care

40. Having reviewed all the evidence I do not find the level of care provided to Mr Y by the Care Home throughout his stay there would have caused him injustice for the following reasons:
• The Care Home carried out various assessments for Mr Y both when admitting him and in the course of his stay and prepared care plans for him;
• Case notes show the Care Home staff followed Mr Y’s care plans when carrying out their duties;
• Mr Y was assessed as able to make everyday decision about his care therefore the Care Home staff respected his reluctance to leave the room and his refusal to get changed, eat or drink. There is, however, evidence the staff encouraged Mr Y to eat and drink and regularly changed his clothing as well as supported him with his continence needs but at times had to overcome Mr Y’s resistance;
• Although Mr X criticised the Care Home for the way it gave antibiotics and other medication to Mr Y in the beginning of June, it is clear from the case records the staff followed Mr Y’s GP’s recommendations. We cannot be critical of that as it would not be acceptable for the Care Provider to override medical advice;
• When admitted to the Care Home Mr Y asked for the bedrails to be used at night. The Care Home staff followed Mr Y’s request. When Mr X suggested in the beginning of June the bedrails might upset Mr Y, the Care Home staff carried out a new ‘staying safe in bed’ assessment and agreed to apply a different way of keeping Mr Y safe during the night-time. This is what we would expect;
• When faced with concerns in the beginning of June, the Care Home staff tried to address issues raised which is the right approach. At this stage we don’t have the evidence any concerns were raised with the Care Home or the Care Provider before then.

Terms and conditions of privately funded care

41. As explained under paragraph 13 of this decision before starting to charge Mr Y for his care in the Care Home, the Care Provider should have provided Mr Y or his representative with the agreement specifying terms and conditions of his residential care. This did not happen however this failing did not cause Mr Y and/or Mr X injustice as:
• Mr Y would have been notified of the care fees by his Social Worker, who knew about the change of the circumstances and the end of the NHS funding;
• In the email correspondence to Mr X in mid-May 2022 the Care Provider explained the change in Mr Y’s funding arrangements and provided details of its fees;
• On his first visit to the Care Home Mr X was again informed of the fees due for Mr Y’s residential care. Until the second week in June neither Mr Y nor Mr X raised any concerns about these fees;
• Even if Mr Y and/or Mr X had received an agreement for Mr Y’s residential care at the Care Home, on balance of probabilities it is more likely Mr Y would still continue staying there until the second week of June. Mr X only arrived in the UK in the fourth week of May and expressed his concerns about his father’s care in the beginning of June. It is unlikely he would have been able to arrange another residential care for Mr Y sooner than he did, so the care fees would have still accrued.

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Final decision

42. I do not uphold this complaint. I did not find the actions of the Green Nursing Homes Limited caused or could have caused injustice to Mr Y.

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Investigator's decision on behalf of the Ombudsman