Summary: Ms D complains the Care Provider failed to move her father to a less expensive room, provided substandard accommodation, and did not properly care for him. The Care Provider is at fault for failing to provide satisfactory accommodation, charging for services not provided, losing items and shortfalls in care. This has caused a financial loss to the estate, uncertainty and distress to Ms D. The Care Provider has remedied some faults and following our investigation has agreed to make Ms D a symbolic payment and service improvements.

The complaint

1. Ms D complains about services Russettings Care Limited, the “Care Provider”, gave to her late father Mr D. Ms D complains the Care Provider:
1. provided substandard accommodation to Mr D;
2. failed to move Mr D to a less expensive room, even though agreed;
3. failed to support Mr D with eating and follow Speech and Language Therapy (SaLT) advice;
4. did not properly support Mr D on a hospital visit and on his transfer back to the care home;
5. lost glasses;
6. invoiced for unneeded or requested podiatry services.
2. Because of these failures Ms D says Mr D paid more than he should have for care services. She also says the care services and accommodation Mr D did receive was inadequate and unsafe causing distress to both Mr D and his family.

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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 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 a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

5. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
6. If we are satisfied with an organisation’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)

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How I considered this complaint

7. I considered evidence provided by Ms D and the Care Provider as well as relevant law, policy and guidance.
8. Ms D and the Care Provider 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

What should have happened

9. 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) the statutory regulator of care services has issued guidance on how to meet the fundamental standards below which care must never fall.
10. Regulation 9 “Person Centred Care” says care providers should enable and support relevant people to make or participate in making, decisions relating to the service user's care or treatment to the maximum extent possible…”.
11. Regulation 10 says care providers must make sure they provide care and treatment in a way that always ensures people's dignity and treats them with respect.
12. Regulation 12 aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Care providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks. 
13. Regulation 14 says care providers must meet service user’s nutritional and hydration needs. The associated guidance says care providers
• “must include people's nutrition and hydration needs when they make an initial assessment of their care, treatment and support needs and in the ongoing review of these. The assessment and review should include risks related to people's nutritional and hydration needs.
• Providers should have a food and drink strategy that addresses the nutritional needs of people using the service.”
14. Regulation 15 aims to make sure property where care and treatment are delivered are clean, suitable for the intended purpose and maintained.
15. Regulation 17 says Care Providers should “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.”
16. Care Quality Commission (Registration) Regulations 2009: Regulation 19 – care providers must make written information available about any fees, contracts and terms and conditions, where people are paying either in full or in part for the cost of their care, treatment and support.
17. Russettings Care Home Service Users’ Guide is silent on what happens when someone goes to A&E or for hospital appointments.

What happened

18. Mr D went into the care home in February 2023 for respite. His room (room 20) cost £1400 per week and was the most expensive room at the care home. Mr D then became a permanent resident. There is no dispute the Care Provider agreed Mr D could move to a less expensive room when one became available. 16 months later on 21 June 2024 Mr D moved into room 15 which was £1200 per week.
19. Ms D says between February 2023 and June 2024 less expensive rooms were available but the Care Provider failed to move Mr D. The Care Provider disputes this and says Mr D moved into a suitable room when one was available.
20. The Care Provider’s report of available rooms for the period show the following:-
• Room 2 available for 15 January 2024 – room too small
• Rooms 14 and 18 - toilet too small
• Room 107 available from 22 December 2023 – first floor room, Mr D was mobile and high risk of falls so not offered;
• Room 115 possibility of a room change to a room costing less in July 2024
21. On 1 August the clinical lead contacted Ms D raising concerns about Mr D’s general health. The lead explained she had asked SaLT for an urgent review as Mr D was losing weight and despite thickening fluids Mr D continued to cough during meal times. Ms D says the care home missed a telephone appointment with SaLT on 29 August. Ms D also says her brother witnessed staff not properly following Mr D’s SaLT plan which resulted in him struggling to swallow and choking.
22. Ms D complained the standard of room 15 was inadequate. The Care Provider reduced the weekly rate to £1100 in acknowledgement of the poor standard of room 15 for the period 21 June to 23 September and refunded Mr D £1400. Mr D moved to room 112 on 24 September which cost £1200 per week but because of the complaints the Care Provider gave a reduced rate of £1100. Mr D died on 7 October.
23. Ms D complains Mr D went to A & E unaccompanied and without his glasses, hearing aids, shoes or socks. Ms D also says when Mr D returned from hospital with a dislocated shoulder, carers did not use manual handling equipment when supporting him out of the car. Ms D says she also saw carers on another occasion trying to help Mr D from a chair and lifting him from the same injured shoulder.
24. The Care Provider’s complaint response accepted and apologised for Mr D going to hospital without footwear. However it says Mr D did not need an escort as Ms D had agreed to meet Mr D at the hospital. The Care Provider also agrees it should not have tried to support Mr D without proper equipment. However it says Ms D chose to use her car to transport Mr D from hospital and this made transferring Mr D out of the car difficult. Ms D says she lives over two hours away.
25. Ms D also complained the Care Provider:-
• lost Mr D’s glasses – the Care Provider accepted this and repaid the cost of the lost glasses;
• charged for podiatry Mr D did not need or request – the Care Provider accepted the errors amended the invoice and removed the costs.

Is there fault causing injustice?

26. I do not intend to reinvestigate matters where the Care Provider has already accepted service failure. My role is to decide whether, on those matters, the Care Provider’s actions are sufficient to remedy the injustice caused.

Complaint (a) provision of substandard accommodation to Mr D;

27. The Care Provider has accepted the condition of Room 15 was not to an acceptable standard, a potential breach of Regulation 15. It provided a reduction of £100 per week on the new room and a reimbursement of £100 per week for the time Mr D was in room 15. This resulted in a payment of £1400. I have looked at the pictures provided by Ms D and consider £100 a week is a suitable remedy for the cosmetic defects and general repair in the room and ensuite.

Complaint (b) failure to move Mr D to a different less expensive room, even though agreed

28. The Care Provider has set out a schedule of when rooms became available at a less expensive rate. There were at least two rooms which may have been available but which the Care Provider did not offer to Mr D because of space. A further room costing less was available from July 2024 but not offered to Mr D. It appears charges for rooms are not set, it is therefore difficult to find out the accuracy of the information provided.
29. The Care Provider should however:-
1. have told Ms D/Mr D about any rooms which became available at a lower weekly price so they could make a decision about whether it was suitable;
2. regularly reviewed the situation;
3. recorded decision making around rooms offered.
30. It is however difficult for me to say now, if any room was available, which met Mr D’s needs and was available at a lower price. Ms D has the uncertainty and frustration that a room may have been available at a lower cost to Mr D.

Complaint (c) failure to adequately support Mr D with eating and following Speech and Language Therapy (SaLT) advice

31. The Care Provider has not provided any written records of Mr D’s SaLT care plan and how care staff supported him when eating and drinking. The failure to support and record a person’s swallowing where they have difficulties and a SaLT care plan is a potential breach of Regulations 12, 14 and 17 and is service failure.
32. The Care Provider was aware of Mr D’s difficulties and tried to get support from SaLT. However they missed an appointment which may have reduced the symptoms Mr D had when he was eating. This is a potential breach of Regulation 12 and is service failure.
33. Because of these failures Ms D has the uncertainty and distress Mr D’s eating difficulties would have been alleviated because staff did not follow Mr D’s SaLT plan or get follow up advice.

Complaint (d) The Care Provider did not properly support Mr D on a hospital visit and on his transfer back to the care home

34. I accept Ms D said she would meet Mr D at the hospital. However this is at least a two hour journey. The Care Provider is at fault for failing to tell Ms D Mr D would not have an escort so she could make an informed decision about whether to make alternative arrangements or be aware he would be alone.
35. The provision of escorts to hospital/medical appointments is usual in care provider contracts. I therefore consider the failure to have terms and conditions about escorting to hospital is a potential breach of Regulation 19.
36. The lack of personalised care when Mr D went to A&E, in particular the lack of footwear, hearing aids and glasses, is a potential breach of Regulation 9.
37. Ms D has the uncertainty and lost opportunity that but for the service failure identified the family or Care Provider would have arranged alternative support for Mr D until Ms D arrived. Ms D also has the distress of finding her father alone, without his shoes, hearing aids and glasses.

Complaints (e) and (f) lost glasses and invoicing for unneeded and unrequested podiatry services

38. I consider the Care Provider has properly dealt with these complaints and consider the remedies appropriate.

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Action

39. I have found the Care Provider’s actions caused Mr D and Ms D injustice. As Mr D has died I cannot remedy his personal injustice. I consider the following actions are suitable to remedy Ms D’s personal injustice and improve future services.
40. Within one month of the final decision the Care Provider will:
1. apologise to Ms D for the uncertainty and distress caused by the Care Provider’s service failure;
2. make Ms D a symbolic payment of £350 for the uncertainty and distress caused by the Care Provider’s service failure.
41. Within three months of the final decision the Care Provider will:
1. review and revise its terms and conditions to include information about when it will provide escorts and specifically when a resident needs to go to A&E;
2. provide staff training by way of a staff circular, team meeting, supervision or in person session on the importance of recording and review this training through staff supervision;
3. provide staff training by way of a staff circular, team meeting, supervision or in person session on the importance of proper manual handling procedures;
4. provide staff training by way of a staff circular, team meeting, supervision or in person session on the importance of following Speech and Language Therapy (SaLT) care plans;
5. provide staff training by way of a staff circular, team meeting, supervision or in person session on ensuring residents’ dignity;
6. review why the care home missed an important medical appointment and develop a plan to prevent a recurrence;
7. review why Mr D went to hospital without suitable footwear and vital equipment and develop a plan to prevent a recurrence.
42. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

43. I find the Care Provider’s actions caused injustice. I have ended my investigation and closed the complaint based on the agreed actions above.
44. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman