Date of decision: 23 July 2025
Summary
An individual, Ms D, complained that Russettings Care Limited provided substandard accommodation for her father, Mr D; it failed to move him to a cheaper room as agreed, lost essential items and delivered poor care, including inappropriate support during hospital visits and inadequate adherence to SaLT plans.
What happened
In February 2023, an elderly man moved into Russettings Care Home for respite, occupying its most expensive room at £1400 per week, later becoming a permanent resident.
The Care Provider agreed to move him to a less costly room when one became available. 16 months passed, before he was moved to Room 15 at £1200 per week, though the family contended cheaper options had come available earlier.
Analysis of room availability records revealed several options had been rejected due to insufficient space, accessibility, or high falls risk, whilst some had not been offered, for less clear reasons.
In August 2024, staff raised concerns about the resident’s health and his need for an urgent Speech and Language Therapy (SaLT) review, but missed a key telephone appointment and failed at times to follow his SaLT plan, resulting in choking incidents.
Room 15’s poor state led to a further rate reduction to £1100 and a £1400 refund after Ms D complained about the inadequacy of the room. Mr D was then transferred to another room with a further discount.
During a hospital visit, he was sent, unaccompanied, by staff, without glasses, hearing aids, or even shoes. His family was only informed after the fact and lived over two hours away. Manual handling equipment was not used following his return from hospital with a dislocated shoulder.
The home admitted sending him without footwear, acknowledged difficulties in transferring him due to use of a private car, and did not have clear policies on escorting to hospital.
The care provider lost the man’s glasses, for which they reimbursed the cost, and incorrectly charged for podiatry services, amending these invoices after complaint.
Mr D passed away on 7 October 2024.
What was found
The Ombudsman found Russettings Care Limited potentially breached the Health and Social Care Act 2008 Regulations, particularly Regulations 12, 14, 15, 17, and 19. They failed to offer safe, person-centred accommodation, uphold dignity, meet nutritional needs, keep accurate records, and clearly communicate about fees and support arrangements.
Failures led to uncertainty, distress, risk, and financial loss for the resident’s estate and his daughter. The Ombudsman found the Care Provider’s actions caused Mr and Ms D injustice, which could not be remedied for Mr D, given his passing.
The investigator considered £100 a week is a suitable remedy for the cosmetic defects and general repair in Room 15 and ensuite.
The investigator noted that fault had been acknowledged but opined that the Care Provider should still, however:
- 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;
- regularly reviewed the situation;
- recorded decision-making around rooms offered.
A symbolic payment of £350 was ordered to be paid to Ms D for distress, alongside apology and requirements for service improvements and training, including better documentation on hospital escorting, care planning, manual handling, dignity, and nutritional support.
The Care provider was told to:
a. 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;
b. review why the care home missed an important medical appointment and develop a plan to prevent a recurrence and why Mr D went to hospital without suitable footwear and vital equipment and develop a plan to prevent a recurrence.
c. provide staff training on the importance of:
– recording and reviewing the training through staff supervision;
– proper manual handling procedures;
– following Speech and Language Therapy (SaLT) care plans;
– ensuring residents’ dignity;
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
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. The LGSCO took great care here not to find a direct breach of the regulations, because that is not for the Ombudsman. It is only for CQC to determine that regulations have been breached.
The regulations we should especially highlight here are 9, 10, 12, 14, 15, and 17 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
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…”.
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.
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.
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.”
Regulation 15 aims to make sure property where care and treatment are delivered are clean, suitable for the intended purpose and maintained.
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.”
Care Quality Commission (Registration) Regulations 2009: Regulation 19 says 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.
There is no reason why the council in question, responsible for safeguarding, could not have become involved, and we are puzzled as to why that aspect is not mentioned. The fact that the client was a self-funding person with assets presumably above the threshold does not explain this omission as a matter of law. Perhaps the daughter did not know that she could have referred her concerns to the Council in the area?
The lack of a clear protocol for escorting residents to hospital, as identified by the Ombudsman, should be analysed not just as a provider failing but through the lens of public law principles on safeguarding, risk management, and the Mental Capacity Act.
A public sector care plan would have needed to address foreseeable risks, and would have clarified what should have been happening about accompaniment, equipment, and communication with relatives.
Nothing is said about how this man was discharged from hospital in relation to being returned back to this Home, and that omission puzzles us too.
Service improvements should prioritise creating and updating clear, transparent care plans and risk protocols, systematically involving representatives, and swiftly addressing complaints through formal review rather than ad-hoc remedies after harm has occurred.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Russettings Care Limited (24 014 108) report. If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
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