Summary: Mrs X complained on behalf of her father, Mr Y, about the care provider, Christadelphian Care Homes and how it calculated care charges. The Care Provider was at fault. It was not clear and transparent in how it calculated care fees and did not provide an adequate notice period before it changed the fees. This caused Mr Y and Mrs X frustration and uncertainty. The Care Provider has agreed to apologise to Mr Y and Mrs X. The Care Provider will also make service improvements to prevent a recurrence of fault.

The complaint

1. Mrs X complained on behalf of her father, Mr Y, about the care provider, Christadelphian Care Homes and how it calculates care charges. Mrs X said the Care Provider was not fair and transparent with how it completed assessments of Mr Y’s care. She said the assessments have had a negative impact on the care fees. Mrs X said her father has felt victimised by the Care Provider and it has caused her distress. She wants the Care Provider to be fair and transparent with how it calculates the care fees.

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The Ombudsman’s role and powers

2. 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. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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(i), as amended)
5. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

7. Mrs X’s complaint is about changes to care fees which the Care Provider implemented in 2022. This is more than 12 months ago. As detailed in paragraph five, we cannot investigate late complaints unless there are good reasons. However, I have decided to exercise discretion and investigate Mrs X’s complaint from 2022. This is because Mrs X and Mr Y only became aware of the impact of the changes to the care fees in 2024.

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How I considered this complaint

8. I spoke with Mrs X and considered the information she provided.
9. I considered information from the Care Provider.
10. Mrs X and the Care Provider had the opportunity to comment on the draft version of this decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

11. The Competition and Markets Authority (CMA) has produced written advice on consumer law to help care homes comply with their legal obligations (UK care home providers for older people - advice on consumer law December 2021). The guidance states care providers must ensure:
• their terms set out all the rights and obligations between the resident and/or their representatives. Their terms must be simple, clear and easy to understand;
• their terms are transparent so residents and/or their representatives can foresee and understand in advance, how they might be affected;
• they give sufficient notice of any change. A notice of changes of less than 28 days is likely to be unfair; and
• provide prospective residents and their representatives with information they need such as an indication of fee rates.
12. In relation to changes to a resident’s fees during their stay, the guidance states it would not object to more frequent changes in a resident’s fees where:
• the resident requests and receives an enhanced service or a better room; or
• the resident’s care needs change. However, the resident should also receive a reduction in fees where their care needs reduce. There must be a significant and demonstrable change in the resident’s care needs to justify an increase in price for this reason; where you assess charges by reference to care ‘bands’, these should be limited and clearly defined according to significant steps in increasing care needs.
13. To ensure compliance with the law, the guidance also states care providers should be able to evidence and justify a decision to increase fees due to a change in care needs (for example through the use of recognised accredited dependency tools) and any increase must be reasonable and proportionate to the resident’s needs. Where the care provider anticipates or assess that a resident’s needs have changed, it should engage in meaningful and transparent consultation with them and their representatives and give them advance written notice (e.g. 28 days) before implementing a change in fees (including the reasons) so they can challenge the decision or avoid the increase if they wish.
14. The Care Quality Commission (CQC) is the statutory regulator of care services. The Health and Social Care Act 2008 (regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has issued guidance on how to meet the fundamental standards.
15. Regulation 19 says care providers must give timely and accurate information about the cost of their care and treatment to people who use services. 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.

The Care Provider’s assessment and fee model

16. In 2021, the Care Provider wrote to the residents of the Care Home and their representatives and told them it would be changing the way it calculated their care fees. It said it wanted the care fees to reflect the real cost of care so that residents were paying for the actual care they received. The Care Provider also held virtual meetings with representatives of the residents so it could discuss the changes further.
17. In April 2022, the Care Provider introduced its new way of calculating care fees. It separated the care fees into the following three categories:
• a service fee to cover the cost of maintaining the Care Home;
• a care fee to cover the cost of personal care, medical care and equipment such as hoists and profiling beds; and
• a hospitality fee to cover the cost of food, activities, cleaning and laundry etc.
18. All residents were expected to pay the same service fee. However, in relation to the care and hospitality fees, the Care Provider would assess the residents every three months, assign them a score and subsequently, place them into one of the following bands to determine their fees:
• acute (being the highest);
• high;
• medium;
• low; and
• foundation (being the lowest).
19. This meant every three months, the Care Provider could change what it charged residents, depending on the outcome of the care and hospitality assessments.
20. The Care Provider said it does not inform the resident and/or representative if there are no changes to the banding following an assessment. If there are changes to the banding following an assessment, the Care Provider will discuss the assessment and outcome with the resident and/or representative and explain the reason for the change.
21. The Care Provider shared with us the below assessment model which shows the range of points that fall under each band for care and hospitality.

22. The Care Provider said the points are based on factors such as the:
• activity of care or hospitality;
• number of staff required to support the activity;
• length of time required to support the activity; and
• frequency of the activity.

What happened

23. Mr Y has been a resident of Olivet Care Home, run by Christadelphian Care Homes (the Care Provider) for several years. Mr Y used to pay a flat rate for his care.
24. In July 2023, the Care Home assessed Mr Y and placed him in the ‘foundation’ band for care and hospitality. It reassessed Mr Y in October 2023 and January 2024 and his banding remained the same for both care and hospitality.
25. Between November 2023 and February 2024, Mr Y had three falls.
26. Mr Y used continence aids. The Care Provider said Mr Y refused to use the continence aids which his General Practitioner (GP) had prescribed. As a result, staff at the Care Home bought Mr Y a specific brand of continence aids.
27. In April 2024, the Care Home completed a care assessment of Mr Y. The assessment concluded that Mr Y was to be placed in the ‘low’ band. The Care Provider had increased Mr Y’s banding because of his recent history of falls and the Care Home having to purchase Mr Y’s continence aids. As a result, Mr Y scored more points. This meant Mr Y would have to pay more for his care fees. However, the Care Provider noted Mr Y’s care needs had increased due to acute matters which may reduce before the next care assessment was due to take place. It therefore decided not to charge Mr Y at the ‘low’ band rate and continued to charge him at the ‘foundation’ band rate.
28. At the same time, the Care Home completed a hospitality assessment of Mr Y and following this, the Care Provider increased Mr Y’s band from ‘foundation’ to ‘low’. This meant the Care Provider would increase Mr Y’s hospitality fees.
29. The Care Provider told us it had increased Mr Y’s hospitality band rate because since early 2024, it had decided to include all occupational activities under hospitality whereas before, they were under the service fee. The Care Provider said it made this change as it wanted the costs associated with hospitality to be more transparent. It said this meant the service fee had not increased as much as it would have as these costs were now included under hospitality.
30. The Care Provider met with Mr Y and Mrs X to discuss the outcome of the recent assessments. At the same time, Mrs X told the Care Provider she was unhappy with how it was calculating the fees. She said it was unfair because:
• if a resident scored more points, it would negatively affect their finances;
• the Care Provider increased her father’s points based on the number of meals he was having a day. Mrs X said the number of meals her father wants a day should be an informed choice and not detrimental to his health. She added by law, the Care Provider must provide a resident three meals a day; and
• the Care Provider increased her father’s points as he required staff to accompany him whilst a GP had visited him in the Care Home. Mrs X believed such tasks were a necessity and so the Care Provider should not increase the points because of them.
31. The Care Provider responded to Mrs X’s complaint and said:
• the points system allowed the Care Provider to allocate a band for each resident. If a resident’s needs increase, it would move the resident into a higher band;
• the number of meals a resident wants a day is an informed choice but the choice is reflected in the hospitality assessment with the relative costs; and
• it needed to charge the resident for the time staff take to accompany them during a GP visit.

The Care Provider added it believed it was not fair to charge all residents the same flat rate fee as some residents had lower needs compared to other residents.

32. In May 2024, the Care Home completed another care assessment of Mr Y which concluded there were no changes to his needs and so he remained in the ‘low’ band rate.
33. In July 2024, the Care Home completed a further care assessment of Mr Y. As Mr Y had no further falls and had started using the prescribed continence aids, it decided Mr Y’s needs had decreased and so the Care Provider changed his band rate to ‘foundation’.
34. The Care Provider also completed a hospitality assessment of Mr Y in July 2024. The assessment showed Mr Y’s needs remained the same and so he remained in the ‘low’ band rate.
35. Following the July 2024 care and hospitality assessments, the Care Provider met with Mr Y and Mrs X to discuss the outcome of the assessments. The Care Provider said it had continued to bill Mr Y at the ‘foundation’ band rate for hospitality, whilst his complaint was ongoing.
36. Mrs X remained unhappy with how the Care Provider was calculating the care fees and so complained to us.

The Care Provider’s response to our enquiries

37. The Care Provider shared its contract of terms and conditions. The terms and conditions do not reflect the Care Provider’s current assessment and fee model. The Care Provider has recognised this and said it will make changes so the terms and conditions are reflective of its current assessment and fee model.
38. The Care Provider referred to the CMA guidance for care home providers and said it has not been giving residents a 28-day notice period of any changes to their care fees. It said it will review its practice considering this.

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Findings

39. The Care Provider decided to change how it charges residents for the care and support it delivers to them. It created an assessment and fee model. I recognise it consulted with the residents and their representatives prior to making the changes, however, it failed to ensure the residents understood the assessment and fee model. This was fault.
40. The Care Provider said it decided to amend its hospitality and service fee in early 2024 as it wanted the hospitality fee to be more transparent. This means since then, it charges all residents at the ‘low’ band rate. There is no evidence which shows the Care Provider communicated this change with the residents and their representatives. Therefore, I am not satisfied it told the residents and their representatives of this amendment. This was fault.
41. The Care Provider’s contract of terms and conditions are not in line with its current assessment and fee model. This means current residents do not have this information at hand. It also means prospective residents and their representatives will not be aware of the Care Provider’s assessment and fee model and the impact that a change in their level of need may have on their care fees. The Care Provider has therefore not been clear and transparent with how it charges residents for their care. This is fault and is not in line with the CMA guidance. The Care Provider has acknowledged its contract of terms and conditions are not in line with its current assessment and fee model and said it will amend it so that it is up to date. This is appropriate.
42. The Care Provider does not give residents and their representatives a sufficient notice period when it makes changes to their care charges. This is not in line with the CMA guidance and so it is fault. It is also not in line with CQC regulation 19, as outlined in paragraph 15. The Care Provider has recognised it is at fault and said it will review its practice so that it does give residents and their representatives adequate notice before it implements changes to their banding and fees. This is appropriate.
43. The identified faults above caused Mr Y and Mrs X frustration and uncertainty.

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Agreed Actions

44. Within one month of the final decision, the Care Provider has agreed to:
• apologise to Mr Y and Mrs X for the frustration and uncertainty it caused them by not being clear and transparent with its assessment and fee model. The Care Provider will refer to our ‘Guidance on remedies’ to ensure its apology is effective.
45. Within three months of the final decision, the Care Provider will:
1. provide us with evidence it has amended its contract of terms and conditions so that it is in line with its current assessment and fee model. This is to ensure current residents and their representatives as well as prospective residents and their representatives are aware of the assessment and fee model; and
2. provide us with evidence it has amended its practice to ensure it gives residents and their representatives a notice period of 28 days or more when it makes changes to the band rate and fees.
46. The Care Provider will provide us with evidence it has complied with the above actions.

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Final Decision

47. I have now completed my investigation. The Care Provider was at fault. It has agreed to remedy the injustice caused and prevent a recurrence of fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman