Summary: Mrs X and Mrs Y complain about the care their mother (Mrs Z) received at Care UK’s Britten Court in the weeks leading to her death in April 2020 and the failure to arrange suitable contact with her during lockdown. There are gaps in Mrs Z’s records and Care UK was not as open with Mrs X when responding to her complaint. This has caused avoidable distress for which it needs to apologise.

The complaint

1. The complainants, whom I shall refer to as Mrs X and Mrs Y, complain about the care their mother received at Care UK’s Britten Court in the weeks leading to her death on 15 April 2020 and the failure to arrange suitable contact with her during lockdown.

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The Ombudsman’s role and powers

2. 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)
3. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the Care Provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
4. We consider basic record keeping vital during a crisis. There should always be a clear audit trail of how and why decisions were made, summarising any reasons for departing from normal practice.

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents Care UK has provided in response to my enquiries;
• shared a draft of this statement with Mrs X and Care UK, and taken account of the comments received.

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What I found

Key facts

6. Mrs Z, whose daughters have made the complaint, went to live in Care UK’s Britten Court in October 2019 when she was 99. She had dementia and other age-related conditions. Britten Court’s assessment shows she needed help with most activities, including mobility, continence, eating and drinking. Mrs Y used to visit their mother regularly, but Mrs X could not do this as she lives in another part of the country.
7. Britten Court kept records of the care provided for Mrs Z, which also record some of the contact with her daughters. I refer to the key contents below.
8. On 2 March 2020 Mrs X raised concerns about her mother “shutting down”, making it difficult to get her to eat and drink. She asked questions about her mother’s medication. Britten Court agreed to ask a Nurse Practitioner to do a medication review. When the Nurse Practitioner visited Mrs Z on 2 March she said she would prescribe an anti-depressant and trial a new food supplement but made no other changes to her medication.

The days leading up to the first lockdown

9. On 18 March Mrs Y went to visit her mother but Britten Court declined entry after checking her temperature. She later called Britten Court and offered to move in to help look after Mrs Z if it went into lockdown. It told her that would probably not be possible as it had 79 residents whose families may want to do the same.
10. Mrs Y took her mother’s washing back to Britten Court on 19 March. It agreed to take over doing her washing. She asked Britten Court to ensure Mrs Z ate. It assured her it would look after her mother. Mrs Y called Britten Court several times to check what Mrs Z had eaten (a good breakfast, an “OK lunch” and half her evening meal with 50 mls of fluids). The records show Mrs Y continued to call Britten Court each day, often several times, to check on her mother’s condition, including her diet. Mrs Y had occasional contact with her mother over the internet. Mrs X says this was difficult to arrange as there was often no tablet available.
11. On 20 March Britten Court called Mrs X, who had concerns that without her sister’s visits, Mrs Z would not eat or drink enough. Britten Court told her Mrs Z ate well at breakfast and lunch but only wanted half her main course. They arranged a call with Mrs Z over the internet at 14.30. Britten Court also mentioned the possibility of Mrs Y having a window visit.

The first lockdown

12. On 23 March England entered its first lockdown because of COVID-19. This meant people had to stay at home, unless there was a specific reason not to do so. Visiting people in care home was not one of those reasons. On 2 April, the Government first issued guidance on Admission and care of residents during COVID-19 incident in a care home. This said: “Family and friends should be advised not to visit care homes, except next of kin in exceptional situations such as end of life”.
13. On 23 March Care UK told Britten Court Mrs X and Mrs Y had concerns that Mrs Y could not enter the home or its grounds. Britten Court noted it was following Government Guidelines which meant it could not allow visits into the home.
14. Mrs X called on 24 March to check on her mother, who was having breakfast. When Mrs Y called later, Britten Court told her Mrs Z had gained some weight (half a kilo).
15. Britten Court’s records show:
• it stopped recording its contact with Mrs X and Mrs Y in April;
• Mrs Z had a poor appetite, would push food and drinks away if she did not want them;
• during March and April Mrs Z never met her target for fluid intake, which during April was: 1st 840 mls, 2nd 870 mls, 3rd 505 mls, 4th 890 mls, 5th 915 mls, 6th 300 mls, 7th 460 mls, 8th 115 mls, 9th 400 mls, 10th 435 mls, 11th no record, 12th 800 mls, 13th 50 mls;
• Care Workers were to encourage fluids throughout the night. It is unclear what opportunity there would have been to do this, as Mrs Z usually slept through the night and Care Workers had stopped turning her during the night at Mrs Y’s request;
• Mrs Z weighed 48.0 kg on 24 March, 48.2 kg on 29 March, 47.6 kg on 5 April. Despite her fluctuating weight, Mrs Z’s Body Mass Index remained within the average range;
• Mrs Z would sleep a lot, although she sometimes engaged in other activities;
• Care Workers repositioned Mrs Y every four hours during the day. Her skin remained intact. There are no repositioning records after 6 April;
• Mrs Z had a temperature of 38.2 C and received paracetamol at 0.15 on 7 April. By 10.30 her temperature had fallen to 36.7 C.
• Mrs Z had been prescribed 15ml of a laxative to be taken daily, or twice daily if needed;
• Mrs Z did not open her bowels from 4 to 11 April. There is no record for 12 April and no meaningful record for 13 April;
• the bowel chart says: “If no bowel action for two days this must be reported to the Team Leader / Nurses”. In March Mrs Z took 10 mls of a laxative when she did not open her bowels after four days, but this did not happen in April;
• Care Workers took Mrs Z to the dining room for her breakfast each day until 10 April when she was hoisted into a chair in her room. Mrs Z remained in bed on 11 and 12 April but sat out in her room again on 13 April. There is nothing in her records to explain why that was the case. However, it appears that after some residents had raised temperatures, including Mrs Z, there were concerns that some may have COVID-19, so Britten Court cared for residents in the affected units in their rooms.

The hours leading up to Mrs Z’s death

16. On 14 April Mrs Z spent the day in her chair. Mrs X arranged for her sister to have a chat with her mother over the internet in the afternoon. At 11.50 Mrs Z had a temperature of 38.5 C and received 10 mls of paracetamol. At 17.00 her temperature was 37.4 C.
17. By 21.45 it was clear to Britten Court that Mrs Z was unwell. It therefore called Mrs Y so she could visit her mother. It called paramedics at 21.50. The paramedics arrived around midnight. Mrs Y wanted her mother to go to hospital, but the paramedics told her she could not go with her. Mrs Y, after speaking to Mrs X, agreed Mrs Z should remain at Britten Court. A GP dropped off medication for Mrs Z if she was in pain or distress. However, Mrs Z died peacefully at 05.30 on 15 April.
18. Mrs X complained to Care UK on 18 May. She said they wanted to know what happened to their mother during the lockdown and, in particular, the last week of her life.
19. When Care UK replied on 17 June it said:
• it disclosed most of its daily records for Mrs Z from 7 to 15 April, but did not include all the records of her fluid intake and the fact she never met her target;
• its pandemic plan had been to check the temperature of people visiting its care homes, but did not explain why it did not do this for staff until much later;
• when there were concerns over residents with raised temperatures Britten Court put the affected units on lockdown and allocated Care Workers to specific units;
• there was no evidence that 5 people were insufficient to meet the needs of the residents on Mrs Z’s unit;
• visiting relatives did not count as essential travel during the lockdown;
• Mrs X and Mrs Y had contact with Britten Court 28 times between 1 and 31 March;
• they also had contact with Mrs Z over the internet, although some attempts had been unsuccessful because of her dementia; and
• Mrs Z had not died alone as Mrs Y had been with her.
20. Care UK did not explain why Britten Court did not tell them it suspected Mrs Z had COVID-19.
21. Mrs X contacted Care UK again as she was not satisfied with its response. When Care UK replied in August it said:
• it required at least two entries in its records for each 24 hours period, but on some days there were more than two entries;
• however, the pressures arising from the COVID-19 pandemic meant there were fewer entries than they would have liked;
• with the benefit of hindsight, it would have managed some things differently (e.g. checking the temperatures of staff);
• it had avoided Care Workers working across the affected units as much as possible, but sometimes had to do this to ensure the right balance of skills on each unit;
• staffing levels were based on its dependency tool but it had increased them due to the increased pressure arising from COVID-19 (e.g. caring for residents in their rooms);
• it had drawn up its pandemic plan and updated it in line with Government guidance and Public Health England guidance.

Did the care provider’s actions cause injustice?

22. There were very limited grounds on which people could leave home during the first lockdown. While the lack of contact with Mrs Z no doubt caused much distress to Mrs Y and Mrs X, this was not due to fault by Care UK. It discussed the possibility of a window visit but that was before the first lockdown started. If some care providers interpreted the law differently, that does not mean Care UK was wrong to do what it did.
23. The records show Mrs Z’s condition was in decline from before the first lockdown started on 23 March. There is no evidence to suggest this was due to anything but her age and the fact she had a degenerative illness (dementia).
24. However, there are some gaps in Britten Courts records, including those for contact with Mrs X and Mrs Y, and Mrs Z’s records for turning and bowel movements. There is nothing to explain why no action was taken when Mrs Z did not open her bowels for seven days in April. That is fault by Care UK (see paragraph 4 above). Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires care providers to maintain an “accurate, complete and contemporaneous record” for each service user.
25. While the records do not give as full a picture of Mrs Z’s circumstances as they should have done, they show that her condition was in gradual decline. It is not clear why she remained in bed on 11 and 12 April. But she was well enough to sit out in her room on 13 and 14 April. This suggests the decline in her condition on 14 April was fairly rapid. There is nothing to suggest she was left alone in distress.
26. The early part of the first lockdown was a difficult and often confusing time for everyone. The situation developed rapidly as we learned more about COVID-19. People were not tested for COVID-19 unless they went into hospital, so there was no way of knowing whether Mrs Z had COVID-19. However, Care UK should have been more open with her family about what was going on. Its lack of openness continued when responding to Mrs X’s complaint, by concealing most of the information about Mrs Z’s poor fluid intake. This had been an issue for some time, but the records show it declined during April.
27. The inadequacy of its records and the lack of openness has caused avoidable distress to Mrs X and Mrs Y, which is an injustice. Care UK needs to apologise for this.

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Recommended action

28. I recommended Care UK writes to Mrs X and Mrs Y apologising for the distress caused by the inadequacy of its records and its lack of openness. Care UK has agreed to do this.
29. 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

30. I have completed my investigation on the basis that Care UK will take the action I have recommended.

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Investigator's decision on behalf of the Ombudsman