Summary: Mrs X complained about the visiting arrangements in place at her mother’s care home between July and November 2020. The Care Home was not at fault.

The complaint

1. Mrs X complains that Windmill Care Limited:
• failed to ensure her mother, Mrs M, had adequate and appropriate visiting arrangements in place to see her daughter;
• failed to carry out timely and accurate risk assessments;
• caused avoidable harm in September 2020 when they took Mrs M out of her room for a visit when she should have been nursed in bed.
2. Mrs X says that because of a lack of family stimulation and company, Mrs M’s health has deteriorated. Mrs X says her own mental health has also been detrimentally affected.
3. Mrs X would like the Care Provider to:
• apologise for its failure to carry out a risk assessment earlier and admit this led to her mother’s collapse in September 2020; and
• provide more effective and appropriate contact with Mrs M.

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The Ombudsman’s role and powers

4. 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)
5. 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”.

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How I considered this complaint

6. I spoke to Mrs X and considered her view of her complaint.
7. I made enquiries of the Care Provider and considered the information it provided. This included its visitor risk assessment, visiting policies, records of visits with Mrs M and Mrs M’s care plans.
8. I wrote to Mrs X and the Care Provider with my draft decision and considered their comments before I made my final decision.

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What I found

Visiting arrangements in care homes

9. The events that form this complaint took place between June and November 2020. During that time, visiting arrangements in care homes underwent some changes as COVID-19 lockdown restrictions altered. This led to care homes introducing restricted visiting arrangements.
10. For the period covered by this complaint, government guidance included the following:
• care homes could now develop a policy for limited visits on the basis of “a dynamic risk assessment taking into account the significant vulnerability of residents in most care homes”;
• the risk assessment should consider the following points:
1. a balance of the benefits to the residents, against the risk of visitors introducing infection into the care home;
2. limiting the numbers of visitors to a single constant visitor per resident, wherever possible;
3. the health and wellbeing risks arising from the needs of the cohort of residents in that setting. This would include both whether their needs made them particularly vulnerable to COVID-19 and whether their needs made visits particularly important (for example, for people with dementia, restricting visitors could cause some of the residents to be distressed);
4. the likely practical effectiveness of social distancing measures between the visitor and the residents, having regard to the cognitive status of the resident and their communication needs; and
5. the ability of a particular setting to put in place practical measures to mitigate any risks arising from visits such as visits in communal gardens, window visits and/or drive-through visits.
11. The government guidance also stated that where a care home allowed for different rules for different residents or categories of resident, further visiting decisions would be necessary, taking various factors into account such as:
• the benefits to a person’s wellbeing by having a particular visitor or visitors;
• the extent of the harm that would be experienced by the resident from a lack of visitation or whether the individual was at the end of their life;
• the provisions and needs outlined in the person’s care plan;
• the level and type of care provided by external visitors and the ability of care home staff to replicate this care; and
• the extent to which remote contact by telephone and/or video addressed any wellbeing issues and was available and reduced any distress or other harm caused by the absence of visits.
12. Where risk was considered to be heightened, the guidance said the provider could adopt a general policy for all of its residents stating that visits would only be permitted in exceptional circumstances.
13. In relation to visiting for end of life residents, initial guidance provided little guidance on visiting arrangements for residents who were end of life. However, the Government update on 15 October 2020 stated “In the event of an outbreak in a care home and/or evidence of community hotspots or outbreaks leading to a local lockdown, care homes should rapidly impose visiting restrictions to protect vulnerable residents, staff and visitors… Any imposed visitor restrictions should have regard to exceptional circumstances such as end of life”. The guidance did not state what the restrictions should be, nor give a definition of what the guidance meant by ‘end of life’ in relation to COVID-19 visiting arrangements.
14. The Government update on 5 November 2020 clarified what was meant by ‘visiting restrictions’, stating “In the event of an outbreak in a care home, the home should rapidly move to stop visiting (except in exceptional circumstances such as end of life) to protect vulnerable residents, staff and visitors”.
15. Subsequent updates on visiting arrangements repeated the November 2020 guidance.

What happened

16. Mrs X’s mother, Mrs M, has dementia and has been a resident of Windmill House Care Home for a number of years.
17. In March 2020, the country went into lockdown because of the COVID-19 pandemic. Before lockdown, Mrs X used to visit her mother most days.
18. Between March and June, the Care Home stopped all visiting. From 2 July, the Care Home adapted its front porch so visits could take place.
19. In July 2020, Mrs X complained to the Care Home. She said her mother was often asleep when she visited and she had tried on numerous occasions to call to arrange a video call with her mother with the help of carers but had not been phoned back. Mrs X wanted to be able to visit her mother in person.
20. The Care Manager replied and suggested a daily call, together with three video calls a week. She said Mrs M spent a lot of her time asleep. In relation to Mrs M’s hearing, the Manager said all hearing aids were checked every Thursday.
21. In mid-July, Mrs M experienced a fainting episode. The Care Home called the GP who recommended all care be in bed. The GP also recommended making video calls to the family from Mrs M’s bed rather than hoisting her into a chair.
22. Later in July, Mrs X asked for increased visits. The Care Manager responded and said it was currently not possible. The Manager said “all our ladies and gentlemen are extremely vulnerable and at very high risk of serious complications… due to mum’s frailty she is one of the most vulnerable. I therefore cannot increase the number of visitors entering Windmill House as each visitor increases the risk of the virus entering”.
23. In September, the Care Home arranged for Mrs X to see her mother in person at the entrance to the Home. Over the weeks prior to the visit, the Care Home staff had hoisted Mrs M into her chair on occasions to get her used to being out of bed and in preparation for in-person visiting starting. Mrs M fainted during the visit and had to be taken back to her room. The Care Home telephoned Mrs M’s GP who recommended she was cared for in bed.
24. Mrs X complained the next day. She asked for a copy of Mrs M’s individual risk assessment because she felt the Care Home was failing to meet Mrs M’s mental health needs. Mrs X said she had repeatedly asked to visit Mrs M from outside her window (window visit) or inside her room but the Care Home had refused this on the basis of risk. Mrs X said the Care Home needed to tailor its policy to Mrs X’s needs because she had dementia, mobility issues, sight and hearing issues and fatigue.
25. The Manager replied the following day. She said that she had regularly considered Mrs M’s mental health needs during lockdown but had “concluded on all these occasions that mum’s mental health neither was enhanced or compromised by restricted visiting… through observations her behaviour did not change either pre or post visit”. The Manager said the arrangements for daily phone calls and three Skype calls a week was significantly more communication than any other resident received. The Manager included a risk assessment for Mrs M which she had written following Mrs M’s last fainting episode.
26. In September 2020, the Manager amended Mrs M’s visiting arrangements to allow Mrs X to visit her in her room. Mrs X visited on 1 October and shortly afterwards complained to the Manager that the carers would only let her sit 2 metres away. She said this meant her mother could not properly see her. Following this, a carer sat in at the visits to support communication between Mrs X and Mrs M.
27. Mrs X also complained about the risk assessment. She said the Care Home should have carried one out before September 2020. She also said there were significant flaws and omissions in it. Mrs X said if the Care Home had had a risk assessment in place earlier, she would have been allowed to see her in her room and so she would not have collapsed when she was taken outside for the visit in September. Mrs X sent back an annotated version of the risk assessment.
28. The Care Home replied later that month. The Manager stated:
• the Care Home was at full capacity and could not offer any more care or support;
• she had never agreed to Mrs X being closer than 2 metres to Mrs M;
• the Care Home had a generic risk assessment and only residents who fell outside the ‘normal parameters’ had individual ones. In initial assessments, Mrs X was assessed to fall under the generic risk assessment. Following her collapse in September she became less mobile and so a specific risk assessment was carried out and amended to allow Mrs X to visit Mrs M in her room; and
• she disagreed the collapse could have been avoided. Mrs M’s GP had recommended but not insisted that Mrs M be nursed on her bed. The Care Home had been preparing her for a visit by hoisting her to her recliner chair daily for several weeks and she had coped well. Mrs M had managed four visits with no problems.
29. Mrs X complained again in October and asked for increased visits for both herself and her sister several times a week in Mrs M’s room with close contact.
30. The Manager responded and provided more details about the reasoning behind Mrs M’s risk assessment. She said she could not agree to Mrs X’s requests.
31. Mrs X continued to complain but the visiting arrangements did not change. Therefore, she complained to the Ombudsman.
32. In response to enquiries during my investigation, in relation to moving Mrs M from her bed, the Care Provider stated “We were advised by the GP in July that keeping [Mrs M] on her bed would prevent collapses however this was not an instruction. On balance of keeping good quality of life (being able to get to a recliner chair and therefore wheelchair for visits) vs being bed bound we took steps to minimise the risk whilst acknowledging that we could not prevent this entirely. It was felt the benefits outweighed the risk”.

My findings

Care Home’s visiting policy

33. The government issued guidance for care homes during lockdown. Although this changed throughout the period, a number of key issues remained substantively the same. At all times the priority was to reduce the risk of COVID-19 transmission in care homes and prevent future outbreaks.
34. Care homes were given authority in July 2020 to allow visiting arrangements to be put in place. Care homes had to have regard to the guidance but it was for each care home to determine the type of arrangements to put in place after completing a risk assessment for the home.
35. The Care Home amended its visiting policy a number of times during the period of this investigation. Each time, it was in response to changing government guidance. It initially made the decision that in-person visits would not be allowed. It decided this would apply to all residents which fell within normal parameters. At this time, it determined Mrs X fell within these parameters. It was, therefore, entitled to refuse in-person visits to Mrs M’s family. There was no fault in the Care Home’s actions.
36. As dementia is a life limiting illness, Mrs X believed this meant she should be allowed increased visiting arrangements. It was for the Care Home to decide whether to allow increased visiting, thinking carefully about the risks and benefits to Mrs M and the other residents and staff. The Care Home gave consideration to Mrs X’s requests and Mrs M’s individual circumstances but refused in-person visits until September 2020 when it considered Mrs M’s circumstances had changed following the unsuccessful in-person visit in the visiting area with Mrs X. There was no fault in the Care Home’s actions.

Mrs M should have been nursed permanently in bed

37. Following a fainting episode in July, Mrs M’s GP recommended Mrs M be cared for in bed. However, the Care Home was under considerable pressure from Mrs X to facilitate in-person visits with Mrs M. It would not allow visits in the rooms of its residents unless the resident was in the final days of life. It assessed the GP’s recommendation, Mrs X’s requests for in-person visits and its current visiting policy. It then attempted a compromise by attempting to prepare Mrs M for an in-person visit with Mrs X by trying to accustom her to sitting in a chair. Mrs M seemed able to manage being in her chair. Although the attempt at in-person visiting did not succeed, there was no fault in the way the Care Home made its decision.

Risk assessments

38. Mrs X is unhappy because the Care Home did not carry out an individual visiting risk assessment for Mrs M until September 2020. There was no duty for the Care Home to do so as it had determined Mrs X fell under the general visiting policy, having appropriate regard to her circumstances. When Mrs M’s circumstances changed in September 2020 after she fainted, the Care Home considered putting individual visiting arrangements and at this stage, carried out an individual assessment. There was no fault in the Care Home’s actions.
39. Mrs X is unhappy with the risk assessment the Care Home carried out. She says it is inaccurate and full of omissions. Her annotations and notes on it indicate she is clearly unhappy with its contents. She says if it had been carried out correctly, Mrs M would have been allowed increased visiting arrangements earlier and her collapse would have been avoided in September 2020.
40. There was no fault in the Care Home’s risk assessment of Mrs M in relation to visiting arrangements. It considered details of her individual circumstances, including her medical conditions and how these impacted on visiting arrangements. Mrs X disagrees with the Care Home’s assessment and subsequent decisions around visiting arrangements. However, because there was no fault in the way the Care Home made its decision, I cannot criticise the decision itself.
41. As a result of the assessment, the Care Home approved in-room visiting. Mrs X remained unhappy because she wanted to be physically closer to Mrs M. The Care Home was entitled to restrict this to a minimum of 2 metres on the grounds of safety. It put arrangements in place for a carer to sit in during the visits to aid with communication. There was no fault in the Care Home’s actions.

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Final decision

42. I have completed my investigation. There was no fault in the Care Provider’s actions.

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Investigator's decision on behalf of the Ombudsman