Summary: Mrs X, complains Blenheim Care Home failed to look after her father, Mr Y, properly, resulting in him spending time in hospital. Blenheim Care Home was ill equipped to deal with the demands arising from COVID-19. It failed to meet Mr Y’s needs or identify the fact he was unwell. Regal Care needs to apologise to Mrs X and pay financial redress to Mr Y.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains Blenheim Care Home, run by Regal Care Trading Ltd, failed to look after her father properly, resulting in him spending time in hospital.

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What I have investigated

2. I have investigated Mrs X’s complaint about the care her father received.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(4), as amended)

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How I considered this complaint

4. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents Regal Care Trading Ltd (Regal Care) has provided in response to my enquiries;
• considered the safeguarding records provided by Essex County Council (the Council);
• consulted the inspection reports for Blenheim Care Home (Blenheim) on the Care Quality Commission’s website;
• shared a draft of this statement with Mrs X and Regal Care Trading Ltd (Regal Care), and taken account of the comments received.

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What I found

Key facts

5. Mrs X’s father, Mr Y, went to stay at Blenheim in December 2019, where his wife had been living since 2017. This was for a respite break but after two weeks his placement, which he funds himself, became permanent.
6. According to the Council’s records, Blenheim had been under an “organisational safeguarding” with “little improvement” after a November 2019 safeguarding concern revealed poor care plans and recordings of the care delivered. Care plans were on an electronic system which few staff knew how to access or navigate. Paper care plans were neither updated nor detailed.
7. The Care Quality Commission (CQC) inspected Blenheim on 3 and 4 March 2020. When it published its report in May, it found the service to be inadequate overall, including in terms of being: safe; effective; caring; and well-led. It found Blenheim required improvement to make it more responsive. Among many other things, the report says Blenheim did not have enough staff to meet the needs of the 37 people living there.
8. Shortly after the inspection the Registered Manager left. Regal Care appointed an Interim Manager who received remote support from two Regal Care Managers.
9. On 16 April Regal Care reported that, because of COVID-19, 25 of Blenheim’s staff were either sick or self-isolating, which meant it could not meet the residents’ care needs. The Council helped Blenheim recruit agency staff.
10. After visiting Blenheim on 21 April, a Community Nurse reported safeguarding concerns to the Council about the conditions affecting all 28 of the people living there (16 have since died). Community Nurses helped Blenheim staff at lunchtime and did preliminary assessments of the residents. The Council arranged for 10 agency staff to help for the rest of the day. Many residents were covered in urine, some with urine burns. Blenheim staff (one Senior Care Worker and two from an agency) did not know:
• some of the residents’ names;
• when they were last seen;
• when they last had a drink;
• how they mobilised;
• that four of the residents were dying (three of whom died within 36 hours).
11. Many residents had extensive pressure and moisture damage and unexplained bruising. They were unkempt, sad and distressed. Some had COVID-19 symptoms but there was nothing in place to identify them. Mr Y and six other residents, suspected of being unwell and at high-risk from COVID-19, were admitted to hospital. Four of them, including Mr Y, were diagnosed with COVID‑19 in hospital.
12. The Council provided three healthcare assistants to help run Blenheim. District Nurses went in to assess the adults living at Blenheim.
13. Regal Care appointed a new Manager who started work on 23 April.
14. Regal Care called Mrs X on 23 April to let her know her father had gone into hospital because of confusion and mobility issues.
15. On 23 April the Council registered safeguarding concerns relating to all the residents at Blenheim. This was on the basis there were not enough staff to meet basic needs, including:
• Medication;
• personal care;
• continence;
• meals and drinks;
• laundry; and
• keeping observations on vulnerable resident.
16. When Mrs X called the hospital on 24 April, it told her it had admitted seven residents from Blenheim because of safeguarding concerns. That evening, the new Manager at Blenheim told Mrs X her mother was well.
17. According to the record of a multidisciplinary meeting at Blenheim on 27 April, swabs were taken on 23 April to test people for COVID-19. However, the record also says Public Health England would send out testing kits and would visit over the next couple days to do the tests.
18. District Nurses tested the Blenheim residents and staff for COVID-19 on 1 May. Unfortunately, no results were received so Community Nurses redid the tests on 15 May. However, staff found Mrs Y’s test on the floor the next day, so hers was redone on 22 May. The results for Mrs Y and all the other residents and staff were negative.
19. Mrs X complained to Regal Care on 12 May about:
• the lack of transparency over the safeguarding concerns and her father’s admission to hospital;
• after her father went to hospital the new Manager told her everyone had been re-tested for COVID-19 but when she called the following Saturday she was told they were being tested that day. CQC told her the tests had been delivered on the Tuesday, but Blenheim could not do the tests;
• when her father moved to Blenheim she was told it would arrange delivery of his medication but that did not happen, so Mrs X had to collect it herself;
• her father’s toiletries cupboard had been locked when she last visited and no one could find the key, so she was concerned he did not have access to his toiletries;
• her concerns had increased as she could not visit the home because of COVID-19; and
• she asked Regal Care to explain how it had provided adequate care before she would pay the invoice for her father’s care during May.
20. Mr Y returned to Blenheim on 21 May. Blenheim’s records since then suggest it has been meeting his needs.
21. When Regal Care replied to Mrs X’s complaint on 22 July, it said:
• the new Manager was very experienced and had spoken to Mrs X to give reassurance and confidence;
• it apologised for misleading Mrs X about the reason for her father’s transfer to hospital;
• all his care needs were being met;
• it was working with CQC and the Council;
• there had been confusion over COVID-19 testing (see paragraph 14 above) but everyone had now tested negative;
• Blenheim had misplaced the key to her father’s cabinet but had now found it; and
• Blenheim and the staff working there had been under enormous pressure because of COVID-19.
22. Mrs X was not satisfied with Regal Care’s response so wrote again to Regal Care. When Regal Care replied, it said:
• a member of staff went off sick early in April, tested positive for COVID-19 and went into hospital;
• other staff had symptoms, some of whom also went into hospital;
• other staff self-isolated as they had been in contact with those who were sick;
• a few residents showed symptoms of COVID-19;
• the Council agreed to help and provided a Manager;
• on 21 April Blenheim could no longer cope so the seven residents with COVID-19 symptoms were taken to hospital;
• this meant Blenheim could meet the needs of the other residents, although infection control procedures increased the workload of its staff, as did the increased needs of the residents;
• it had been in daily contact with the CQC;
• the people working at Blenheim had risked their own lives to protect the residents;
• the new Manager started work on 23 April and stayed at Blenheim to protect the residents;
• COVID-19 spread around Blenheim and was too much for it to handle;
• they did not know who had COVID-19 as no tests were done until 1 May;
• the testing had been a “real mix up” but everyone had tested negative;
• it was taking precautions to prevent COVID-19 from striking again;
• it appeared staff had not been aware Mr Y would be staying longer than two weeks when his medication needed collecting;
• Blenheim has two keys for the toiletry cupboards;
• its staff did not have the time to label residents’ clothing and other possessions, so this was the responsibility of their relatives;
• it had not charged extra fees for the additional care provided during the COVID-19 pandemic;
• its Manager and staff were heroes; and
• it hoped Mrs X would now pay the outstanding fees.
23. When the Council completed its safeguarding enquiries, it substantiated the safeguarding concerns. In summary, it found:
• there were not enough staff to meet the needs of the residents and the staff had inadequate knowledge of the individual residents’ needs;
• residents did not receive medication at the right time;
• they were not receiving personal care or having their continence needs met;
• staff were not completing records of the care provided to meet the residents’ needs;
• some residents were not having their need for help with food and drink met, and had lost weight;
• the residents were not being referred to health services for the help they needed;
• laundry was not being completed;
• the cleaners were off work so this was not being done; and
• problems with poor care plans and recordings had been identified in November 2019 following another safeguarding concern.
24. The Council noted action was being taken to reduce the risks to those living at Blenheim.
25. CQC inspected Blenheim again on 8 September. Overall it found the home continued to be inadequate, including in terms of being effective and caring. This meant it was no longer inadequate over being safe and well-led, although it still required improvement in those areas as well as in being responsive.
26. Mrs X would like to move her parents to another care home. But Mrs Y is on end‑of-life care so cannot be moved and her father wants to be with his wife.

Did the care provider’s actions cause injustice?

27. Blenheim’s problems predated the COVID-19 crisis. When the pandemic arrived, it was no longer able to cope when staff went off sick or self-isolated. This left the home relying on agency staff who did not know the residents and a lack of direction from Management. The problems were compounded by a lack of records and a lack of staff to meet the increasing needs of its residents. By 21 April Blenheim was no longer meeting their basic needs. This included Mr Y, and is likely to have caused him distress.
28. In addition, Mr Y was unwell, but nothing had been done to identify or address this. Such failings will have contributed to the spread of COVID-19 around Blenheim, which affected both staff and residents.
29. Regal Care was not open with Mrs X about what was going on, leaving her to get information from other sources. This increased her concerns about whether Blenheim would look after Mr Y properly. Fortunately, Mr Y went to hospital where he recovered from COVID-19.
30. While Regal Care and Blenheim were not responsible for COVID-19, or necessarily for the fact Mr Y caught it, they are accountable for the fact Blenheim was so poorly equipped to deal with the pandemic.
31. Despite some improvements since March 2020, Blenheim’s CQC rating remains inadequate. CQC and the Council continue to work with Blenheim and Regal Care to make sure it delivers the necessary improvements.

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Recommended action

32. I recommend Regal Care within four weeks:
• writes to Mrs X apologising for the failure to meet Mr Y’s needs and the lack of openness over what was going on in April 2020; and
• pays Mr Y £300 for the injustice caused by failing to meet his needs.
33. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of my final decision statement.

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Final decision

34. I have completed my investigation on the basis Regal Care will take the action I have recommended.

Parts of the complaint I did not investigate

35. I have not investigated Mrs X’s complaint about the care her mother received, as this is the subject of a separate complaint against the Council, which funds her care.

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Investigator's decision on behalf of the Ombudsman