Summary: Mrs X complained about the care provided by the Council commissioned care home, Greycliffe Nursing Home to her grandmother, Mrs G. The Care Provider has already admitted it was at fault when the Nursing Home informed Mrs X by text that Mrs G has COVID-19 and when it returned possessions that did not belong to Mrs G. It has apologised for these actions which is satisfactory to remedy the injustice caused. The Nursing Home was at fault when it failed to actively monitor Mrs G’s fluid intake. The Council has agreed to apologise to the family for the uncertainty this caused them and make service improvements.

The complaint

1. Ms X complained about the care provided by the Council commissioned care home, Greycliffe Nursing Home (the Nursing Home) to her grandmother, Mrs G. Specifically, she complained:
1. the Nursing Home failed to take adequate infection control precautions which led to Mrs G and other residents catching COVID19;
2. the Nursing Home did not inform her there was an outbreak of COVID-19 in the Home and she only discovered that there were first nine and then 23 cases when she phoned to check on Mrs G;
3. the Nursing Home informed her by text that Mrs G had COVID-19 which she found distressing;
4. the family was told to bring in two full sets of clothing within five days of each other even though Mrs G had brought in enough clothes on her admission;
5. the hot water tap in Mrs G’s room was broken and the Nursing Home had failed to reduce the cost of the room which was being paid for by the Council;
6. the Nursing Home employed agency staff for night-time cover with no regular staff to support them and did not have staff onsite who were qualified to administer medicine during the night;
7. when Mrs G was admitted to hospital following her stay at the Nursing Home she was severely dehydrated; and
8. When the Nursing Home returned Mrs G’s possessions after her admission to hospital, many were missing and the suitcase they were returned in contained dirty clothes, private correspondence, medication and a syringe containing medication, none of which belonged to Mrs G.
2. Ms X says Mrs G’s safety was compromised and she was financially disadvantaged. Ms X also states Mrs G was distressed because she was very attached to some of the items which were lost.

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The Ombudsman’s role and powers

3. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
4. In this case, the Council is responsible for paying for Mrs G’s care. Therefore, the actions of the Care Provider, including any fault, remain the Council’s responsibility.
5. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
7. The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended)
8. We do not start or may decide not to continue with an investigation if we decide any fault has not caused injustice to the person who complained or any injustice is not significant enough to justify our involvement. We may also decide to stop or discontinue an investigation where:

• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome, or
• we cannot achieve the outcome someone wants, or
• there is another body better placed to consider this complaint (Local Government Act 1974, section 24A(6))

9. If we are satisfied with a council’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)
10. 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 council and care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
11. We normally expect someone to refer the matter to the Information Commissioner if they have a complaint about data protection. However, we may decide to investigate if we think there are good reasons. (Local Government Act 1974, section 24A(6), as amended)
12. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

13. I spoke to Ms X and considered her view of her complaint.
14. I made enquiries of the Council and considered the information it provided. This included Mrs G’s daily care records, her food and fluid charts and complaints correspondence.
15. I wrote to Ms X and the Council with my draft decision and considered their comments before I made my final decision.

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What I found

Mrs G’s contract with the Nursing Home

16. Mrs G’s contract with the Nursing Home contained the following statements:
• Section 1.1 Laundry – “All clothing should be clearly labelled prior to admission”.
• Section 3 – “The Home will not take responsibility for the… service user’s… personal effects”.
• Section 9.3 Clothing – “Please ensure that all clothes you bring in at admission are given to a senior carer to mark with the resident’s name…similarly before giving further clothes to residents… please inform a senior carer who will make sure the items are appropriately labelled”.

What happened

17. After a stay in hospital, Mrs G was discharged to Greycliffe Nursing Home (the Nursing Home), on 30 December 2020. Greycliffe Nursing Home is run by Rose Care Group (the Care Provider) Prior to admission to the Nursing Home, Mrs G tested negative for COVID-19.
18. Mrs G’s notes stated she was at moderate risk of dehydration and her recommended daily fluid intake was two litres. Mrs G’s care plan noted that she needed prompting with drinks and it was important that drinks were offered to her every time staff were with her or passing her room. It was not recorded that Mrs G required food or fluid monitoring at that time.
19. On 7 January a former resident who had been admitted to hospital, tested positive for COVID-19 and the Nursing Home was informed. On 8 January, more residents tested positive for COVID-19. The Nursing Home sent an email to their families.
20. The Care Provider said the Nursing Home was put into isolation and full testing of residents and staff took place. Previously during the pandemic, all the Care Provider’s care and nursing homes had not been allowed to use agency staff unless approved as emergency cover. Where agency staff were needed more than once in a week, the same staff member was used and not offered work in any other home. They also had to have a negative COVID-19 test dated within 48 hours.
21. The Care Provider said COVID-19 positive residents were separated off and were only supported by one staff member “as much as practicably possible”. That staff member was segregated from the rest of the staff to avoid any cross contamination. The Care Provider sent me a copy of its COVID-19 policy.
22. At the beginning of January 2021, during a telephone call to the Nursing Home, Mrs X said she was told there were cases of COVID-19 in the Home. Mrs X said this was the first time she was made aware of the situation.
23. On 11 January, Mrs X says she received a phone call from the Nursing Home asking her to bring in some more clothes for Mrs G. Mrs X says she bought a number of items and another family member took them in on the same day.
24. On 14 January, staff at the Nursing Home alerted Mrs G’s GP to the fact her fluid intake was low. The GP recommended her intake and output was monitored and she was prompted to drink more.
25. On 15 January, Mrs X said staff told her 23 of the 25 residents at the Nursing Home had tested positive for COVID-19 but Mrs G had tested negative.
26. On 16 January, Mrs X received a text from the Nursing Home to say Mrs G had now tested positive for COVID-19.
27. Also on 16 January, Mrs X says she received a call from the Nursing Home saying that Mrs G again required more clothes. Mrs X says she bought these and arranged for them to be dropped off that same day.
28. Mrs G’s health deteriorated and on 25 January, she was admitted to hospital.
29. The family decided not to send Mrs G back to the Nursing Home and asked for her clothes and possessions to be parcelled up for collection by the family later that month.
30. Mrs X said when she went through the items returned from the Nursing Home, many of Mrs G’s clothes were either missing or damaged beyond repair. She said some personal items which Mrs G was very attached to were also missing. Mrs X said she found correspondence and financial letters addressed to other residents in the items as well as an unused syringe containing medication.
31. Mrs X complained to the Care Provider about this and about the care provided. She included receipts for the clothes she had bought and photographs of the correspondence, medication and syringe she had found.
32. The Care Provider responded and said it was not liable for the missing items but as a goodwill gesture it would reimburse the family for the missing items where there was a receipt. It offered approximately £108. Mrs X states this is not enough.
33. The Care Provider also stated the Nursing Home would write and apologise for sending Mrs G the items which did not belong to her and for informing her by text that Mrs G had COVID-19. The Care Provider said these actions were unacceptable.
34. In relation to Mrs X’s other complaints the Care Provider said:
• it could not send Mrs G’s fluid charts without Mrs G’s consent;
• the Nursing Home’s COVID-19 procedures were too large to send to her; and
• it acknowledged her comments about the lack of hot water in Mrs G’s room and would talk to the Council about whether it felt it had been overcharged.
35. Mrs X also raised a safeguarding alert with the Council. After consideration of the facts, the Council decided not to carry out a safeguarding investigation into Mrs X’s concerns.
36. Mrs X remained unhappy and complained to the Ombudsman.
37. In its response to my enquiries, the Care Provider reiterated the points it had made to Mrs X. It also said:
• it used a staffing tool to calculate the number of staff required at night. It said this had been reviewed by the CQC and Council with no issues;
• the Nursing Home was undergoing refurbishment when Mrs G was admitted but these plans were delayed because of the COVID-19 pandemic. The repair man struggled to repair the lack of hot water in Mrs G’s bedroom because of the lockdown at the Nursing Home and nationally and because it was the Christmas period. Carers had used the main bathrooms;
• agency staff alone had provided night cover at times because of sudden staff sickness relating to COVID-19;
• up to start of the pandemic, there was always a medication trained member of staff on duty at night. Once the pandemic started and staffing levels dipped, the situation was managed by an on-call system and a person would come out as required. When that was not possible, the Care Home was supported by the Council and its team of emergency support workers.
• it had no records of asking the family to bring in additional items of clothing. Its contract made it clear it was not liable for missing items although it made best efforts to keep them safe;
• the Care Provider could not explain how the letters had got into Mrs G’s items. It said the resident had left the home over five years previously and the room had been cleaned many times since then; and
• the syringe in the items returned to Mrs X contained a saline solution so would have caused no harm. The medication was a cream that had originally been for another resident but because it was still sealed, the nurse had authorised its emergency use by Mrs G. The Care Provider said it should have removed the previous resident’s details.
38. The Care Provider sent me Mrs G’s fluid intake charts. These were started on 15 January after advice from the GP and continued until her admission to hospital on 25 January. Mrs G’s fluid intake was significantly less than 1 litre for each day. In response to my enquiries, the Care Home stated Mrs G also had access to soft drinks of her own as well as water and squash which she was able to access independently.

My findings

39. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.

COVID-19 procedures followed by the Nursing Home (complaint a)

40. The Care Provider had sent me a copy of the COVID-19 procedures in force when Mrs G was at the Nursing Home. These are comprehensive and are in line with the guidance in place at that time. Testing and the movement of staff at the Nursing Home, as described by the Care Provider, also indicate they were in line with guidance. There was no fault.

Poor communication with Mrs X (complaints b and c)

41. The Care Provider has already admitted it should not have texted Mrs X with the news Mrs G had tested positive for COVID-19. It also agrees it could have communicated more effectively with families over the outbreak of COVID-19 at the Nursing Home. This was fault. The Care Provider has already apologised which is appropriate to remedy any injustice caused to Mrs X.

Requests to bring in more clothes (complaint d)

42. Mrs X says she was asked on two occasions to bring in additional clothing for Mrs G even though Mrs G had enough clothing when she was admitted. The Nursing Home says it has no recollection of asking Mrs X to do so. I cannot say, even on the balance of probabilities what happened. I will not investigate this further.

Lack of hot water in Mrs G’s room (complaint e)

43. The Nursing Home used the main bathrooms to support Mrs G. There is no evidence Mrs G’s care was compromised by the lack of hot water in her room. Any issues relating to the reduction in fees for the room is a matter for the Council to pursue if it wishes. As there is no evidence this caused a significant injustice to Mrs G, I will not investigate this matter further.

Overnight staffing (complaint f)

44. The Care Provider accepts agency staff were sometimes used alone during the COVID-19 pandemic. This was in response to staff sickness. The Council has provided information to demonstrate there were procedures in place to ensure the Care Home could administer medication during the night. There was no fault.

Dehydration on admittance to hospital (complaint g)

45. The GP advised the Nursing Home to monitor Mrs G’s fluid intake after it informed them her intake was low. Although the Nursing Home did as instructed, there is no record it considered whether or what action to take when it regularly recorded her intake was less than half her recommended levels. This was fault. Its response to our enquiries that she may have accessed her own fluids is unsatisfactory, given the GP’s advice was to monitor her intake. Her care plan clearly stated she benefitted from staff prompting her to drink and it was inappropriate for the Nursing Home to make such an assumption. Furthermore, there were steps the Nursing Home could have taken to ensure that even if Mrs G did access drinks independently, effective monitoring took place. The failure to properly monitor her intake was fault.
46. I cannot say, even on balance, that the fault I have identified was a direct cause of Mrs G’s dehydration on admission to hospital. However, Mrs G and the family have been caused uncertainty that this could have been avoided if the fault had not occurred.

Missing possessions and medication, syringe and correspondence belong to someone else in items returned to the family (complaint h)

47. In relating to missing possessions, the contract contains contradictory statements about the labelling of clothing. The Care Provider has refused to accept liability and Mrs X is unhappy with the amount offered by the Care Provider as a goodwill gesture. Matters such as this are best left to the courts and this would be an appropriate course of action if Mrs X wished to pursue this further.
48. The Care Provider had already admitted it acted with fault when it returned items which did not belong to Mrs G. It has apologised to Mrs X and said it will make service changes. These were appropriate steps to take and I do not intend to investigate further because:
• it is unlikely Mrs G’s family or others could have come to harm from the syringe;
• the cream was prescribed for Mrs G, albeit without her name on the tube; and
• any injustice over the inclusion of the letter in Mrs G’s belongings would be to others. If Mrs X wishes to pursue this matter, the ICO is best places to deal with matters of data breaches.

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Agreed actions

49. Within one month of the date of the final decision, the Council has agreed to apologise to Mrs X for uncertainty over whether its failure to record any oversight of Mrs G’s fluid charts contributed to her dehydration and admittance to hospital.
50. Within three months of the date of the final decision, the Council has agreed to ensure that the Nursing Home staff are reminded that when a resident requires their fluid intake to be monitored, regular oversight of the data is carried out and any outcomes recorded.

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Final decision

51. There was fault leading to injustice. The Council has agreed to my recommendations and I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman