Summary: Mrs K complained about the way Care Plus Group moved her husband, Mr H, to The Old Library Residential Home. We consider CPG acted with fault when it moved him, which caused her distress and frustration. The Old Library then did not use the right equipment to transfer Mr H. It also caused Mrs K uncertainty from its poor record keeping. The CPG and The Old Library have agreed to apologise and take action to remedy her injustice.

The complaint

1. Mrs K complains on behalf of her husband, Mr H, about the actions of North East Lincolnshire Council (the Council) and Care Plus Group’s (CPG) Community Inpatient Unit (CIU). Specifically, she complains that the CIU placed her husband at The Old Library Residential Home (The Old Library) without giving them a choice of accommodation. That was despite their preferred choice of care home being open to accept him. Mrs K says that caused her distress and frustration.
2. She also says The Old Library was not suitable to meet his needs. It did not have the right equipment to support his mobility and pressure care needs and did not provide any activities for him. Mrs K says the lack of support led to her husband to fall, which was distressing for her to witness.
3. Mrs K would like the Council, CPG and The Old Library to carry out training for staff to learn from the fault in this case.

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The Ombudsmen’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
5. If it has, we may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
6. We cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
7. When investigating complaints, if there is a conflict of evidence, we may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
8. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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How I considered this complaint

10. I considered evidence provided by Mrs K and the organisations as well as relevant law, policy and guidance.
11. Mrs K and the organisations had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Background

12. The CIU admitted Mr H in early May 2024 for rehabilitation following an earlier operation to amputate his leg. During the admission at CIU, Mr H would regularly try to walk leading to falls.
13. In late May, the CIU assessed Mr H’s ability to decide his onward care and support needs. The CIU decided it was in Mr H’s best interests to move to a short term stay at The Old Library.
14. On 3 June, The Old Library agreed it could meet Mr H’s needs. Those needs included:
• Two people to use a Ross Return transfer aid to move Mr H from his bed to an armchair/wheelchair.
• A wheelchair to mobilise around the home.
• Using crash mats due to Mr H’s high risk of falling.
• Two hourly repositioning to reduce the risk of pressure sores.
15. The CIU told Mrs K the CPG would fund the first 72 hours at the Old Library, then Focus (who provide the Council’s adult social care service) would carry out a financial assessment of Mr H. Mr H moved to The Old Library the next day. Mrs K was keen to discuss her husband’s finances, but the CIU referred her to Focus.
16. On 5 June, Mrs K called Focus and wanted to explore alternative homes. Focus agreed to contact other homes, but because Mr H had funds above the threshold, he would pay the full cost of his care. A few days later, Focus decided it was in Mr H’s best interests to move to another care home. Mr H moved to that care home on 13 June.

The local arrangement

17. In North East Lincolnshire, the Council and the local NHS integrated board (ICB - not subject to this investigation) jointly fund the CIU. The CIU told me it was solely responsible for discharging Mr H to The Old Library. Therefore, I consider the CIU was acting on the Council’s behalf, and also as a health provider.
18. When the CIU moved Mr H to The Old Library, the CPG funded the first 72 hours. So, I consider The Old Library was acting as a health provider between 4 and 7 June 2024.
19. Focus took over responsibility for Mr H's stay at The Old Library after 7 June. It told me Mr H had funds above the threshold for local authority support, so was liable to pay the full cost of his support. While the Council did not contribute to the cost of The Old Library, the CIU arranged the placement on the Council’s behalf. So, after 7 June, the Council was responsible for Mr H’s placement at The Old Library because he was a full cost payer.

The discharge from CIU to The Old Library

Relevant law and guidance

20. The CIU consider its ‘ISO 9001 Process Approach Document’ (Discharge Guidance) when they move people on to another setting.
21. The Care and Support and Aftercare (Choice of Accommodation) Regulations 2014 (the Regulations) set out what people should expect from a council when it arranges a care home place for them. Where the care planning process has determined a person’s needs are best met in a care home, the council must provide for the person’s preferred choice of accommodation, subject to certain conditions.
22. The council must ensure:
• the person has a genuine choice of accommodation;
• at least one accommodation option is available and affordable within the person’s personal budget; and,
• there is more than one of those options.
23. However, a person must also be able to choose alternative options, including a more expensive setting, where a third party or, in certain circumstances, the resident is willing and able to pay the additional cost. This is called a ‘top-up’. But a top-up payment must always be optional and never the result of commissioning failures leading to a lack of choice.
24. A temporary resident is someone admitted to a care or nursing home where the agreed plan is for it to last for a limited period, such as respite care, or there is doubt a permanent admission is required. A decision to treat a person as a temporary resident must be agreed with the person and/or their representative and written into their care plan.
25. Where a council has decided to charge a person, and it has been agreed they are a temporary resident, it must complete the financial assessment in line with the Care and Support (Charging and Assessment of Resources) Regulations 2014 and the Care and Support Statutory Guidance.

Analysis

26. In response to my enquiries, the CIU said it appropriately involved Mr H and Mrs K in the discharge plan. It completed a Pathway Facilitation Form as per the Discharge Guidance. Then shared that with The Old Library, who agreed it could meet Mr H’s needs. The Old Library told me it did not review Mr H at the CIU because Mr H’s case was not complex.
27. I consider the CIU acted with fault and will explain why.
28. Considering the CIU is jointly funded by the Council and ICB, the Discharge Guidance should fall in line with the Regulations around charging and offer a genuine choice of accommodation to service users. I am not persuaded it does.
29. In Mr H’s case, the CIU appropriately assessed Mr H’s ability to decide his care and support. Then it decided it was in his best interest to move to a care home in the short-term. At that point, the CIU should have discussed Mr H’s needs for support and his finances before he moved to The Old Library. I have not seen evidence that it did. Instead, Focus assessed Mr H’s needs and discussed finances after the CIU discharged him.
30. Mrs K says the CIU did not give Mr H any choice about where he moved to. Again, if the CIU acted as it should have, it would have considered Mr H’s needs and finances before he moved to The Old Library. That would have most likely included a discussion about preferred options around care home choice. Mrs K was clearly unhappy with the lack of options when the CIU moved him, that was recorded in Focus’s records. Therefore, on the balance of probabilities, I am not persuaded the CIU had a clear discussion with Mrs K about the options available around accommodation for Mr H. If the CIU had not acted with fault, Mrs K would likely have raised her concerns about The Old Library and discussed her preferred choice of another care home.
31. I have not seen any evidence the CIU showed how it considered The Old Library was an affordable option for Mr H and within his personal budget. That was because it left discussions about finances to Focus, after the move to The Old Library. Again, that was fault.
32. Mrs K has said that her preferred care home was happy to accept Mr H on discharge from the CIU. I do not doubt this, but I have not seen any evidence from the time to show that was true. However, I can understand how the fault in this case would have caused Mrs K distress and frustration.
33. Overall, I considered the CIU acted with fault in the way it moved Mr H to The Old Library. It should take action to remedy the injustice Mrs K has suffered.

The care and support at The Old Library

Relevant law and guidance

34. 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 Fundamental Standards). The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards which care must never fall below.
• 12(2)(f) states: “where equipment or medicines are supplied by the service provider, ensuring that there are sufficient quantities of these to ensure the safety of service users and to meet their needs”.
• 17(2)(c) states registered 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…”.

Analysis

35. The Old Library told me because Mr H only stayed for a short time, it did not have time to complete a full assessment and support plan for him. Therefore, I have based my findings against the needs identified in the CIU’s Pathway Facilitation Form and The Old Library’s daily care records.
36. Mrs K says The Old Library did not have the right equipment to support her husband’s mobility and he needed a wheelchair. In response, The Old Library said Mr H used a rota stand as recommended by the CIU. It also used crash mats at night.
37. Firstly, the CIU identified Mr H needed a wheelchair because he could not walk. I have seen evidence in The Old Library’s care records it used a wheelchair to move Mr H around the home. I do not consider that was fault.
38. Secondly, the CIU noted Mr H needed a Ross Return device to support his sitting to standing transfers (with the assistance of two staff). Instead, The Old Library used a rota stand to support that need. Both devices serve a similar purpose. However, the Ross Return is used more for people who have poorer balance and need extra support to transfer. I understand why the CIU recommended the Ross Return for Mr H, because of his leg amputation, likely poor balance and high risk of falls. He needed that extra support to transfer which the rota stand did not offer.
39. I have not seen any evidence The Old Library used a Ross Return as directed by the CIU. The CIU did not record why it used a different transfer aid for Mr H. I consider that was fault, and not in line with Regulation 12(2)(f) of the Fundamental Standards. The Old Library should have had the correct equipment to support Mr H when it decided to admit him.
40. While I have found The Old Library acted with fault, I have not seen any evidence the use of the rota stand impacted Mr H’s mobility or led to falls. So, I do not consider there was an injustice to him from those faults. However, The Old Library should take action to ensure similar fault does not impact future service users.
41. The CIU noted two staff needed to manually transfer Mr H using the Ross Return. The Old Library’s has shared evidence to show it was aware of that. There is no reference in Mr H’s care records that two staff transferred Mr H, just one. Robust record keeping is a crucial part of someone’s care. In this case, I consider The Old Library’s record keeping amounted to fault, and not in line with Regulation 17(2)(c) of the Fundamental Standards. Staff should have been recording that two carers were transferring Mr H on each occasion. Because of this, I cannot be satisfied that two staff were transferring Mr H as they should have. That leaves Mrs K uncertain at the quality of care when staff transferred Mr H. The Old Library should take further action to address that injustice to Mrs K. I also consider the Council should take action to ensure it has oversight of The Old Library’s response to our recommendations. As I mentioned earlier, the Council was ultimately responsible for the care provided to Mr H after 7 June.
42. Thirdly, Mrs K says The Old Library did not use a crash or sensor mat at night. I disagree. The Old Library has shared evidence it assessed Mr H’s ability to decide if he could have a crash mat by his bedside. That was good practice because he was at high risk of falls at night. I am persuaded The Old Library appropriately and correctly used crash mats at night.
43. Fourthly, Mrs K says The Old Library did not appropriately support her husband’s pressure care needs. In response, The Old Library said Mr H was on a two hourly pressure care regime and did not have any pressure sores during his stay.
44. I have reviewed The Old Library’s care records. It consistently recorded its two hourly repositioning. At those times, staff also checked the integrity of Mr H’s skin. I have not seen any evidence that Mr H’s skin deteriorated or that it missed opportunities to escalate any concerns to health professionals. I am not persuaded The Old Library acted with fault supporting Mr H.
45. Lastly, Mrs K says The Old Library did not provide any activities for her husband to get involved with. In response to my enquiries, The Old Library said Mr H did get involved in activities. However, Mrs K requested staff return him to his bedroom in the afternoon so she could spend time with him. That took him away from afternoon activities. Mrs K told me that only happened once.
46. I have reviewed The Old Library’s care records. It recorded inviting Mr H to participate in three different activities on 6, 11 and 13 June. He refused to engage on the first two occasions but did participate in a music session before he left for another care home. So, I do not agree that The Old Library did not provide any activities.

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Action

47. Within one month of this decision, CPG should apologise to Mrs K for the distress and frustration caused by the fault in the way it moved Mr H to The Old Library.
48. Within two months of this decision CPG should review its Discharge Guidance to ensure that it falls in line with the Regulations.
49. Within one month of this decision, The Old Library should apologise for certainty caused to Mrs K from its poor record keeping around Mr H’s mobility care.
50. Within two months of this decision, The Old Library should ensure it reviews the way it admits service users so that it does not accept someone if it does not have the correct equipment in place. Also, it should remind staff of the importance of robust record keeping in line with the Fundamental Standards.
51. Within three months of this decision, the Council should satisfy itself The Old Library has taken appropriate learning following the fault in this investigation and from our recommendations.
52. The organisations should provide us with evidence they have complied with the above actions.

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Decision

53. I find fault causing injustice. The organisations have agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman