Summary: Mrs X complains about the care her late mother, Mrs Y, received while she lived in Care UK’s Pear Tree Court in 2020 and a lack of communication during the weeks leading up to her mother’s death. Mrs Y did not receive poor care, but there was a lack of communication. Care UK needs to apologise and make a symbolic payment to Mrs X.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains about the care her late mother, Mrs Y, received while she lived in Care UK’s Pear Tree Court (the Care Home) in 2020 and a lack of communication during the weeks leading up to her mother’s death.

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The Ombudsman’s role and powers

2. 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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 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”.

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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 the care provider has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Mrs X and the care provider, and taken account of the comments received.

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What I found

5. Mrs Y had dementia. She went to live in the Care Home in April 2019.

Key facts

6. When the Care Home reviewed Mrs Y’s needs on 16 April 2020 she was “quite happy”. She enjoyed taking part in activities (crafts, singing and other group activities). She had a normal diet. Although she did not say much she appeared to understand when spoken to.
7. At 07.00 on 29 April Mrs Y’s temperature was 37.8 C. Her oxygen levels had gone down from 98% to 94%. She was shivering and flushed. She was assumed to have COVID-19. She remained in bed as she was unsteady on her feet. The Care Home updated Mrs X. Mrs X says the Care Home said her mother had a urinary tract infection and did not mention COVID-19.
8. On 30 April the Care Home told a GP Mrs Y was unwell. Her temperature was 38.2 C. Her oxygen level was 89%. Mrs Y told the GP she felt tired but was otherwise feeling well. The GP suspected Mrs Y had COVID-19 and prescribed antibiotics to avoid further deterioration with potential pneumonia. The Care Home spoke to Mrs Y about Mrs Y’s end-of-life care plan and wishes.
9. On 1 May Mrs Y told a GP she was feeling better. Her oxygen level was 93% and her temperature was 36.2 C. She was tested for COVID-19.
10. On 2 May Mrs Y was “in a good mood”. Her temperature was 37.4 C, and oxygen level was 97%.
11. On 3 May Mrs Y walked around in her room.
12. On 4 May Mr Y’s temperature was 35.4 C and her oxygen level was 89%. She was shaky on her feet and her appetite was poor. She had another test for COVID-19.
13. On 5 May Mrs Y was poorly during the night and struggled taking her epilepsy medication. She said her throat was not sore and she was not in pain, but she was agitated. Her temperature was 37.1 C but rose to 38.4 and her oxygen level was 93% but went down to 92%. She drank little.
14. On 6 May Mrs Y’s temperature was 37 C and oxygen level was 97%, but she had developed a cough, was off her feet, and had light sensitivity and a headache. When she called, the Care Home told Mrs X her mother was still off her feet and not eating or drinking without support. A GP prescribed another antibiotic for Mrs Y and said to stop taking some of her other medication while taking the antibiotic. The Care Home updated Mrs X and asked her to consider whether she would want her mother to go to hospital if the treatment did not work. Mrs Y ate and drank very little.
15. After her condition deteriorated, Mrs Y went into hospital on 7 May. This followed a discussion with Mrs X. Mrs Y tested positive for COVID-19 and received treatment.
16. On 11 May the hospital told the Care Home it had referred Mrs Y for speech and language therapy, as she was not tolerating the thickened fluids she had started taking.
17. Mrs Y returned to the Care Home on 18 May. She was very sleepy and her diet was poor.
18. On 20 May a GP said it would take Mrs Y time to recover as she was still positive for COVID-19.
19. Over the next few days Mrs Y remained sleepy and had a poor appetite.
20. On 25 May Mrs Y received a positive test result for COVID-19. The Care Home told a member of Mrs Y’s family about the result.
21. On 28 May the Care Home told a GP Mrs Y seemed confused, was not very co-ordinated and did not seem to understand simple tasks. The GP said it was all part of COVID-19. Later, the Care Home contacted NHS 111, which advised monitoring Mrs Y more regularly. Her blood pressure was higher than normal and her oxygen level was 88%.
22. On 30 May Mrs Y’s oxygen level was 78% in the early hours of the morning, but increased to 96% later in the day, and her blood pressure was low.
23. On 1 June Mrs Y spent time in the lounge playing bingo, but was tired afterwards.
24. On 2 June Mrs Y spent time in the garden and had a video call with Mrs X.
25. Mrs Y’s condition remained the same until 10 June, when she appeared unwell (shaking limbs), although her vital signs were within the normal range. The Care Home noted to monitor Mrs Y for any further decline. A GP said her condition may be the residual effect of having been exposed to COVID-19.
26. On 11 June the Care Home reported a mild tremor to a GP, who ordered blood tests.
27. On 14 June Mrs Y had a call with one of her daughters.
28. When the Care Home reviewed Mrs Y on 16 June, she appeared “happy and contented” but could not communicate. She had recovered from COVID-19. She was on a soft and bite sized diet. She needed prompting to eat and to use the right cutlery. She continued to enjoy social activities, playing balloon tennis that day, but was not always an active participant due to her memory problems.
29. On 18 June the Care Home told a GP Mrs Y was lethargic and had a reduced appetite. The GP was not too concerned and put this down to COVID-19. The GP said to push fluids and to allow Mrs Y to rest after meals.
30. On 19 June Mrs Y spent the day in her room asleep. Her diet was poor.
31. On 21 June Mrs Y was confused all day. She did not eat much, despite being prompted.
32. On 22 June a Nurse from the GP Practice prescribed medication for oral thrush.
33. Mrs Y continued to have problems swallowing and her appetite remained poor.
34. On 29 June the Care Home told a Nurse Practitioner Mrs Y’s oral thrush symptoms had improved but her oral intake remained variable. The Nurse suggested referring Mrs Y to speech and language therapy, offering her sweet nourishing food (e.g. custard) and arranging video calls with her family. Mrs Y had a video call with a daughter.
35. On 1 July the Care Home told one of Mrs Y’s daughters the result of a COVID-19 test had been unclear.
36. The Care Home contacted a GP on 2 July over concerns Mrs Y was not eating or drinking properly. The GP had a video consultation with Mrs Y but could identify no specific cause for the decline in her condition other than that COVID-19 could have led to a stepdown in her dementia. The GP prescribed fortified drinks to supplement her diet.
37. On 11 July the Care Home put Mrs Y on a pureed diet and decided to refer her back to speech and language therapy. Her food and fluid intake remained poor.
38. On 13 July Mrs Y developed a category 2 pressure ulcer. She was agitated and unsteady on her feet. The Care Home did not tell her family about the pressure ulcer but Mrs Y told Mrs X when she visited.
39. On 16 July the Care Home reviewed Mrs Y. She was too poorly to participate in social activities, spending most of her time watching TV and sleeping. She was having difficulty swallowing and was taking very little fluids. The Care Home told the GP Practice Mrs Y had deteriorated further. A GP said Mrs Y required end-of-life care. The GP spoke to Mrs Y’s family about this.
40. The Care Home’s Acting Manager told Mrs X they could visit anytime, and the Home would apply for NHS Continuing Healthcare (if eligible, the NHS could have funded the full cost of Mrs Y’s care).
41. Mrs X visited her mother on 17 July.
42. When Mrs X tried to book another appointment to see her mother the Care Home told her one person could visit once a week. She and her sister agreed to alternate their visits. There is nothing in the Care Home’s records to explain this decision.
43. According to its records, the Care Home told Mrs X her mother was sleepy when she rang on 18 July. It said she was resting in bed and would be assisted with food and fluids.
44. According to its records, the Care Home spoke to Mrs X twice on 20 July and agreed to submit a fast-track application for NHS Continuing Healthcare. The Care Home started completing the forms on 21 July.
45. On 22 July the Care Home told Mrs X it would be best for her to go to hospital for rehydration. It said it would ask a GP to review her. When the Care Home was unable to contact a GP, it called 999 as Mrs Y was lethargic and had not eaten all day. Paramedics contacted an out of hours GP and it was agreed Mrs Y should remain at the Care Home and a GP should visit her there. The Care Home updated Mrs X.
46. The Government first issued guidance on visiting arrangements in care homes on 22 July. This set out the principles of a local approach and dynamic risk assessment. It therefore left individual decisions to care providers. However, it identified the need for any restrictions to have regard to exceptional circumstances such as end of life.
47. According to the Care Home’s records, on 23 July a GP spoke to Mrs Y’s family and explained that her condition was due to dementia and taking her to hospital for rehydration would not solve the problem. Unless she developed a treatable illness (e.g. infection), there was little point in putting her through the stress of going to hospital. The GP said to keep in contact with Mrs Y’s family so there was no misunderstanding about her getting better. The Care Home told Mrs X it was treating Mrs Y for a sore throat.
48. On 3 August the Care Home added further information to the application for NHS Continuing Healthcare. Mrs X signed the form as Mrs Y's appointed decision maker. Mrs Y had contact with her family over the internet.
49. On 7 August Mrs Y slipped to the floor in her bathroom when she tried to sit on the toilet. A care worker was with her. She had no injuries and her family was informed. The Care Home monitored her for 72 hours.
50. On 13 August the Care Home asked a GP to complete the forms to apply for NHS Continuing Healthcare. The information provided by the GP says:
• Mrs Y had cognitively declined since leaving hospital in May;
• her ongoing rapid deterioration was likely a step down in her dementia; and
• she was likely entering the terminal phase of her life.
51. When the Care Home reviewed Mrs Y on 17 August, she was joining in quite a lot of activities (for example singing). She was eating her meals in the dining room, taking small amounts. The pressure ulcer was “healing well”. No changes were made to her care plans.
52. Following a telephone call with the Care Home on 24 August, the NHS e-mailed on 25 August asking it to provide a short statement confirming it was content to rescind the application for NHS Continuing Healthcare. The Care Home did this on 26 August on the basis Mrs Y did not meet the criteria for a fast‑track application. Mrs X says the Care Home told her the application had been turned down, but that was not the case. She says it did not fill the forms in properly.
53. On 3 September a GP prescribed an alternative fortified drink as Mrs Y’s appetite remained poor.
54. The Care Home asked a District Nurse to see Mrs Y on 8 September, as her right eye was red and sore. The Nurse advised bathing the eye in warm water, as it did not appear to be infected.
55. On 11 September a GP prescribed antibiotics for the symptoms of conjunctivitis.
56. According to the Care Home’s records, Mrs X called to speak to her mother on 12 September, but could not do so as she was having continence care, and said she would call back in the afternoon. Mrs X says this is inaccurate as no one answered the phone all day.
57. Shortly before midnight on 13 September, staff found Mrs Y sitting on the floor between her bed and her chair. She had red marks on her back and left side which looked as though they would turn into bruises. Staff monitored her for 72 hours.
58. Mrs X visited her mother in her room on 17 September. The Care Home spoke to a GP who said Mrs Y’s deterioration was due to her dementia. It is recorded that they could not force her to eat and drink.
59. Mrs X visited her mother on 21 September. She was concerned about the decline in her condition. She says she wanted to remove her mother from the Care Home but recognised it was too late.
60. On 22 September Mrs Y had been awake most of the night tapping her tummy. She struggled to swallow her medication. She declined all help with eating and drinking. A GP prescribed palliative care medicines.
61. The Care Home spoke to Mrs Y’s family on 23 September about her grandchildren visiting. It said one grandchild could visit but that would be instead of a visit by Mrs X or her sister. It suggested a video call so everyone could see and speak to her.
62. On 24 September two of Mrs Y’s grandchildren had video calls with her. She declined food and drink.
63. On 25 September Mrs Y had deteriorated. She did not respond to communication, just opened an eye. She died at 12.30, having had a “settled morning”.
64. Mrs X complained to Care UK in November about the support provided for her mother. When Care UK replied to Mrs X’s complaint on 5 January 2021, it said:
• it apologised for the Care Home saying there was no COVID-19 in April 2020 when that was not the case;
• Mrs Y was not eligible for COVID-19 funding implemented from 1 September 2020, but it had applied a discount for the time she was in hospital;
• it apologised for telling Mrs X they could visit when they wanted on 16 July. It said this was not in line with its pandemic plan at the time;
• the fast-track application for NHS Continuing Healthcare was completed on 13 August. It would provide any information needed to support a retrospective application for funding;
• the management of the Care Home had fallen below expected standards; and
• it apologised for any stress and anxiety caused.
65. Mrs X complained again on 19 January, as she was not satisfied with Care UK’s response. When Care UK replied in June it said:
• it apologised for the delay in responding;
• the Care Home had been free of COVID-19 when Mrs Y was admitted on 25 April 2020 (Mrs Y was admitted in 2019);
• on 29 April Mrs Y had a temperature (39.2 C) and COVID-19 symptoms. A resident who was already in hospital tested positive for COVID-19;
• it could not say how COVID-19 was brought into the Care Home, given the incubation period and the lack of testing at the time;
• it apologised for failings in communication before September 2020, including a lack of empathy; and
• there was nothing in Mrs Y’s records to suggest she did not receive the care she needed,
66. When the Care Quality Commission (CQC) inspected the Care Home in December 2020, it found it required improvement to make it safe and well-led.
67. Mrs Y’s family made a retrospective application for NHS Continuing Healthcare. The NHS wrote to the Care Home in July 2021 asking for Mrs Y’s records from 18 May to 25 September 2020, so it could complete its assessment.
68. Mrs X says the Care Home did not return all her mother’s jewellery, which had sentimental value, after she died. She says she signed an inventory of her mother’s possessions when she went to live at the Care Home in 2019, which a Manager also signed. Care UK has provided an inventory which is not signed by anyone. It includes no jewellery but has been updated with later additions, each of which has been initialled by someone at the Care Home. The form says to advise residents to take out their own insurance and that the Care Home will not be responsible for loss or damage unless it has been negligent.

Did the care provider’s actions cause injustice?

69. I cannot say Mrs X caught COVID-19 due to poor care by the Care Home. The early stages of the pandemic were a particularly difficult time, with shortages of personal protective equipment and a lack of testing to identify asymptomatic people with COVID-19.
70. The Care Home was not at fault for the fact Mrs Y did not receive free care when she returned from hospital in May 2020. The Government gave the NHS extra money to ensure people could leave hospital as quickly as possible when they were ready to do so. Its main purpose was to fund packages of care in peoples’ homes, but it could also be used to fund urgent placements in care homes. The Care Home did not have a claim on that money. Besides, it was not needed for Mrs Y as she already had a place available for her.
71. There is nothing in the Care Home’s records to suggest it was not meeting Mrs Y’s needs. The records show the Care Home was concerned about the decline in her condition. It regularly consulted medical professionals. She received treatment for various conditions, including infections and a pressure sore. But nothing could be done to halt the decline due to dementia.
72. Care UK accepts there were failures in communication, including a lack of empathy. There are gaps in the Care Home’s records relating to the contact with Mrs Y’s family. It did not always keep the family informed, or record what it was telling them. Our guidance on Good Administrative Practice during the response to COVID-19 emphasises the importance of basic record keeping during crisis working. The Care Home failed in this regard. On 23 July a GP advised the Care Home to keep in contact with Mrs Y’s family, so there was no misunderstanding about her getting better. But the Care Home did not do that. This left Mrs Y’s family wondering if there was more that could have been done and shocked by the decline in her condition. That is an injustice which warrants a remedy.
73. I cannot say whether Mrs Y’s application for NHS Continuing Healthcare would have been successful if the Care Home had filled in the forms differently. Mrs X has made a retrospective application, which will resolve the question of Mrs Y’s eligibility.
74. The Care Home did not deal properly with the inventory of Mrs Y’s possessions. It appears it may have mislaid the original inventory. Either way, the inventory it used was not signed and cannot therefore be regarded as accurate. While I cannot say what happened to Mrs Y’s jewellery, this has caused avoidable distress to Mrs X.

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Recommended action

75. I recommend Care UK:
• within four weeks writes to Mrs X apologising for the Care Home’s failings and pays her £300 for the distress she has been caused and the time and trouble she has been put to in pursuing the complaint;
• within six weeks, provides evidence that it has taken action to ensure:
1. staff at the Care Home keep families informed of key events and changes in the relative’s conditions, and record their contacts with family members; and
2. inventories of possessions are signed by staff and residents or their relatives.
76. Under the terms of our Memorandum of Understanding and information sharing protocol with CQC, I will send it a copy of my final decision statement.

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Final decision

77. I have completed my investigation on the basis the care provider’s actions have caused injustice which requires a remedy.

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Investigator's decision on behalf of the Ombudsman