Summary: Mrs Y complains about several aspects of the care delivered to her father, Mr W, whilst resident in Isle Court Nursing Home. We find the home did not properly document the change from respite to permanent care and did not record times when it said Mr W refused personal care. The care provider has also acknowledged it should have had a discussion with the family before serving notice to end Mr W’s placement. The care provider will make a symbolic payment and implement some service improvements.

The complaint

1. Mrs Y complains about the quality of care provided to her father, Mr W, in Isle Court, Welford Healthcare. She complains that the care provider:
1. Did not involve the family with Mr W’s care planning, provide a written copy of the care plan or a chance for the family to review the care plan.
2. Mishandled the admissions process and failed to explain the difference between a respite and permanent contract.
3. Misrepresented the level of care available at the home for Mr W.
4. Failed to meet Mr W’s assessed personal care needs.
5. Failed to properly monitor and safeguard Mr W.
6. Failed to provide transparent advice about financing and how Funded Nursing Care (FNC) was factored into invoicing.
7. Served notice on 4 December 2024 to terminate Mr W’s placement without first discussing any concerns with his family.
8. Did not communicate in an open and transparent manner and failed to deal with her complaint properly once submitted.

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The Ombudsman’s role and powers

2. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
3. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
4. 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(1), as amended)

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How I considered this complaint

5. I considered evidence provided by Mrs Y and the care provider as well as relevant law, policy and guidance.
6. Mrs Y and the care provider had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Complaint a)

8. Mrs Y, who is bringing this complaint on her father's behalf, complains that Isle Court (‘the home’) did not provide a copy of Mr W’s care plan once he was admitted and did not involve his family with care reviews. The records show that Ms W was actively involved in Mr W’s care planning. This is evidenced from the review on 3 October 2024 with the memory team and the monthly review completed on 14 November 2024, both of which Mrs W attended.
9. Mrs Y holds a valid Lasting Power of Attorney (LPA) for Mr W. His wife is also a joint attorney. Under the Mental Capacity Act 2005, attorneys acting under a Health and Welfare LPA have the legal authority to be involved in decisions about the person’s care and to access relevant care information, including care plans, once the person lacks capacity to make those decisions themselves. Statutory guidance makes clear that care providers must recognise and work with attorneys as the lawful decision-makers in these circumstances.
10. The Care Act 2014 and the Care and Support Statutory Guidance further explain the importance of involving those with legal authority, and of working in partnership with families and representatives to ensure care is planned, reviewed, and delivered in a transparent and person-centred way.
11. In my view, regular visits by the family do not remove or replace the care home’s obligation to share relevant care information. While informal updates during visits may support communication, they are not a replacement for sharing the care plan, which sets out assessed needs, planned interventions, and agreed outcomes.
12. Given the existence of a Health and Welfare LPA, it is my view the care home should have shared Mr W’s care plan with his attorneys. However, I consider this fault caused limited injustice because the records show the attorneys were involved in care reviews. Those reviews provided key information about Mr W’s ongoing needs and agreed outcomes. The care home has agreed to remedy the injustice caused with an apology.

Complaint b)

13. When a family member asks for a placement to change from respite to permanent, this represents a material change in the care arrangement, even if the terms and conditions are the same. This is because a temporary placement becoming permanent has legal, financial, and care-planning implications.
14. In my view, any such changes should be dealt with by the care provider as follows.
• Confirm the request in writing and clearly explain what the change means. This includes confirming the start date of the permanent placement, the ongoing nature of the arrangement, and any notice provisions.
• Formally record the change in status. Even where the same contract applies, good practice requires either a written variation, addendum, or clear written confirmation that the placement is now permanent.
• Review and update the care plan. Permanent placements require a care plan that reflects long-term needs, outcomes, and reviews, rather than short-term or interim goals typical of respite care. This expectation is supported by the Care Act 2014 and the Care and Support Statutory Guidance, which require care planning to be person-centred, proportionate, and responsive to changes in circumstances.
• Ensure that funding and charging arrangements are clear. This includes confirming who is responsible for fees, how any statutory contributions (such as FNC) will be applied, and whether there are any changes to notice periods or financial liability.
15. The fault caused limited injustice to Mr W because the change in the status of his placement did not affect the type or level of care he received at the home. However, the fault did create some confusion and frustration for the family which the home should apologise for as well as completing a service improvement.

Complaint c)

16. Mrs Y complains the home misrepresented the level of care it could provide and that the family received assurances Mr W would receive one-to-one care. At the time of admission, the home assessed that it was able to meet Mr W’s needs. The home says it is common for residents living with dementia to require a period of adjustment when moving into a new environment, which can take several weeks. In Mr W’s case, the care records show that he did not settle as expected and that his behaviours escalated significantly after the initial period.
17. Having reviewed the pre-admission documentation, I found no evidence of any agreement that Mr W would receive one-to-one care, nor was there any misrepresentation by the home about how it would meet Mr W’s needs. For these reasons, I do no find fault in this part of Mrs Y’s complaint.

Complaint d)

18. Mrs Y complains about the level of personal care provided to Mr W. In response, the care home said staff did their best to meet Mr W’s care needs, but this was challenging as Mr W sometimes resisted certain elements of care such as teeth brushing and getting dressed. The staff also explained how Mr W often wanted to dress himself and preferred not to shave.
19. Mrs Y also said the home had neglected Mr W’s chiropody and hairdressing needs. The care notes show that Mr W received treatment from a Chiropodist on 18 October 2024 and future appointments arranged at a frequency of six weeks. The home acknowledged in the complaint response that there was a short period of time when it did not have access to a hairdresser due to sickness, but a member of staff who was a qualified hairdresser temporarily filled that vacancy.
20. The care provider’s policy ‘Supporting Personal Care’ contains the following information for staff.
• If a service users decline to receive personal care, staff must first rule out whether the care is causing discomfort or pain, or whether they are experiencing pain from another cause. If so, administer pain relief and monitor.
• If a service user repeatedly refuses personal care, staff should contact social services to consider an assessment, including Mental Capacity. Failure to maintain personal care may become a safeguarding issue and all actions to be documented in care notes.
• The service user’s personal hygiene plan includes how refusal is managed.
21. In its complaint response, the provider said that Mr W sometimes resisted tooth brushing and dressing. However, there is no evidence of this in the daily care logs, and no reference to resistance or refusal in the personal hygiene risk assessment or care plan. Therefore, either the refusals were not happening as described, or the care provider did not follow its own policy to record refusals, assess causes, observe outcomes, and document how it would monitor any such situations.
22. In either case, the lack of recorded evidence creates doubt about the provider’s response and suggests a failure to apply its own policy consistently and transparently. This is fault causing injustice which the care provider will remedy with an apology and service improvement.

Complaint e)

23. Mrs Y raised concerns that Mr W did not receive appropriate monitoring from staff which in turn meant that his actions created risk and sometimes injury. The care records provide details of the following injuries sustained by Mr W and the care home’s response to those injuries.
• 25 November 2024: Mr W had a wound on his leg which was dressed by a Nurse. Mrs W reported he had removed the dressing, and she was worried about the risk of sepsis due to redness around the wound.
• 26 November 2024: The GP reviewed Mr W’s leg and was “not concerned, the redness has not spread".
• 27 November: Wound cleaned, dried and re-dressed.
• 28 November: Mr W removed his dressing. Wound cleaned and re-dressed
• 30 November 2024: Wound cleaned, dried and re-dressed. Healing well.
• 1 December 2024: Wound cleaned and re-dressed. Mr W happy and not in pain. Wound appeared to be healing.
24. In its response to Mrs Y’s complaint, the home acknowledged that, due to the layout of the building, there were times when Mr W was not under continuous supervision. The care records show that Mr W sometimes entered other residents’ bedrooms and at times dismantled furniture. The evidence does not indicate that these behaviours arose from a failure by the home to monitor or safeguard Mr W; they were an unfortunate effect of Mr W’s dementia.
25. The records also show the home completed a behaviour risk assessment which said that staff would re-direct Mr W away from certain activities, but that Mr W would often forget those instructions within a few seconds due to his dementia.
26. Staff also raised concerns with the memory clinic and medical professionals and explored whether changes to Mr W’s medication might reduce the risks and help keep him safe. Medical advice confirmed that Mr W was already prescribed the maximum dose of the relevant medication.
27. I am satisfied that the home took appropriate steps to safeguard Mr W during his placement there. Mr W received appropriate treatment for any injuries sustained. As Mr W’s behaviours escalated, those behaviours increasingly placed both Mr W and others at risk. The home recognised that it was no longer able to meet Mr W’s needs safely and, as a result, gave notice to end the placement. I do not find fault with the home in relation to this part of Mrs Y’s complaint.

Complaint f)

28. Funded Nursing Care (FNC) is an NHS payment made under the National Health Service Act 2006 and the NHS Funded Nursing Care Guidance. It is paid directly to care homes to contribute towards the cost of registered nursing care for residents who are not eligible for NHS Continuing Healthcare. The payment is not made to residents and is not an “extra” charge.
29. Regulation 19 of the Care Quality Commission (Registration) Regulations 2009 says care providers should provide the resident or their representative with a written statement which should:
• Set out the terms and conditions of service, including the amount and ways to pay the fee; and
• Include a contract.
30. Guidance for the CQC ‘Fundamental Standards’ explains:
• People must receive a copy of the contract, and they must agree to the terms before their care and support begins;
• Care providers should tell people about any changes in terms and conditions in advance, including increases in fees. This is so people have time to consider whether to continue with the service; and
• Care providers should give an estimate of costs if a fixed price is not possible. This should include details of additional costs.
31. The purpose of Regulation 19 and the Fundamental Standards guidance is to ensure care providers give timely, clear and accurate written information about any fees and terms and conditions.
32. Mr W’s contract, as signed by Mrs W, sets out a clear charging structure in relation to FNC. It explains that the weekly care fee remains payable in full regardless of whether FNC is awarded, and that any statutory contribution, including FNC, is paid to the care home and is not deducted from the resident’s fees. On ordinary reading, the contract adopts a “fees plus FNC” model and is clear about how FNC is treated. As such, the contract is not silent or unclear on this point and meets the requirement under Regulation 19 of the Fundamental Standards to provide written and transparent information about fees and charging.
33. The LGSCO’s published guidance confirms that a resident’s contribution may stay the same or fall depending on the provider’s terms and conditions, and we are unlikely to find fault where the contract clearly explains how FNC is treated. In Mr W’s case, the contract explicitly states that the statutory contribution is additional to, and not offset against, the care fee.
34. I am satisfied the contract is sufficiently clear and did not contradict any other pre-admission information or verbal assurances. The care home was therefore entitled to rely on its stated charging model. On that basis, there is no fault in the way the care home structured or applied its charges in relation to Mr W’s FNC.

Complaint g)

35. On 4 December 2024 Mrs W attended a meeting at the care home. She thought the meeting was to discuss Mr W’s ongoing care needs. However, during that meeting, the home explained that it was providing 28 days’ written notice to terminate Mr W’s placement because it could no longer meet his needs.
36. The care provider has already acknowledged that, whilst it was entitled to serve notice in the circumstances, it could have communicated better with Mr W’s family. In the complaint investigation the care provider noted “lessons learnt” and concluded that: “communication regarding serving of notice was not handled as it should have been”.
37. The care provider has apologised for this and introduced a new format for serving notice which is a meeting called “risk of serving notice”. The care provider has rolled this new process out to the team and management at the home.
38. I am satisfied the care provider has already provided an appropriate remedy for this part of Mrs Y’s complaint and I do not recommend anything further.

Complaint h)

39. The communication issues about the serving of notice have already been addressed and so I will not repeat those here. In terms of the home’s general communication with Mrs W during her husband’s residency there, I am satisfied the records show there was a good level of contact. There is also evidence that Mrs W was involved with reviews of her husband’s care and often thanked staff for the care provided to Mr W.
40. The evidence shows the care home acted in line with its complaints policy. Mrs W and Mrs Y submitted their complaint on 29 January, and the home issued its written response on 24 February, which was within the 28-day timescale set out in the policy. The investigation included a review of relevant care records and discussions with staff involved in Mr W’s care. I am satisfied the provider considered the complaint in a sufficiently thorough and timely manner, and I find no fault in the home’s handling of the complaint.

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Action

41. Within four weeks of our final decision, the care provider will:
• Apologise to the family for the fault found in this statement. This apology is in addition to the one already provided as we have found further areas of fault which the first apology did not cover. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• Make a symbolic payment of £250. This is in recognition of the uncertainty caused by a failure to record Mr W’s refusal of personal care and any confusion caused by the failure to document the change from respite to permanent care.
42. Within twelve weeks of our final decision, the care provider has also agreed to:
• remind all care staff of the importance of delivering care in line with the ‘Supporting Personal Care’ policy, particularly in situations where a resident is refusing care. The purpose of this recommendation is to reinforce best practice and ensure consistent, person-centred care; and
• remind relevant staff that any changes in a resident’s placement status, including transitions from respite to permanent care, are clearly and promptly recorded. This should include completion of all relevant paperwork, updates to care plans, and documentation of the resident’s long-term outcomes. Remind staff they should share copies of care plans with next of kin or LPAs, unless there is a justified reason not to. The purpose of this recommendation is to ensure continuity of care and appropriate oversight.
43. Both reminders will be provided in a way which can be evidenced to the LGSCO, such as staff supervision, refresher training, or a written briefing note.

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Decision

44. I find fault causing injustice. The Care Provider has agreed to complete the actions listed in the section above to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman