Summary: Mr X complains Haythorne Place care home, where the Council placed his mother, Mrs Y, failed to look after her properly during the first COVID-19 lockdown before her death in May 2020. Haythorne Place’s records of the care provided for Mrs Y are inadequate, which leaves doubt over whether it was meeting all her needs properly. The Council should apologise to Mr X and Mr Y for the unnecessary distress this has caused them.

The complaint

1. The complainant, whom I shall refer to as Mr X, complains Haythorne Place care home, where the Council placed his mother, failed to look after her properly during the first COVID-19 lockdown before her death in May 2020. He says this resulted in it failing to seek treatment for a broken leg which resulted in her death. He has also complained about Haythorne Place moving Mrs Y from a nursing unit to a residential unit in 2018, and a delay in sending her to hospital in February 2019 with a broken leg.

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What I have investigated

2. I have investigated events from 2020.

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The Ombudsman’s role and powers

3. 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)
4. 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, sections 30(1B) and 34H(i), as amended)
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 Council and Care Provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
6. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
7. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)

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How I considered this complaint

8. I have:
• considered the complaint and the documents provided by Mr X;
• discussed the complaint with Mr X;
• considered the comments and documents the Council has provided in response to my enquiries; and
• shared a draft of this statement with Mr X and the Council, and invited comments for me to consider before making my final decision.

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What I found

Background

9. Having lived at home with her husband, Mrs Y went to live in Haythorne Place in 2012. This followed a series of strokes which left her with severe right sided weakness, impaired speech and double incontinence. The Council’s November 2019 assessment of her needs said:
• she needed help with mobility/transfers, eating/drinking and personal care;
• she needed repositioning every four hours;
• she weighed 41.3 kg, having lost 4.4 kg in two months, with a Body Mass Index of 16, which meant she was underweight;
• she had started a fortified diet and needed weighing weekly;
• she received care in her room, preferring not to socialise with other residents; and
• Mr X visited three times a week and her husband twice a week.
10. This was largely reflected in Haythorne Place’s care plans and risk assessments, which said Mrs Y’s skin integrity was at very high risk. Her end-of-life care plan said a do not attempt cardio-pulmonary resuscitation order was in place. It also said Mrs Y should only go to hospital if absolutely necessary and her wishes were to be nursed in a quiet, comfortable environment and to be free of pain.
11. Mrs Y’s falls risk assessment said she was at risk of falling during transfers from bed and from rolling out of bed. It said two staff were to assist with transfers and she had a profiling bed with bedsides.

What happened

12. Mrs Y’s family could not visit her after the country went into lockdown on 23 March 2020 because of COVID-19. Haythorne Place kept few records of contact with Mrs Y’s family during this time. It kept some records of the care provided for her. However, there are no records for personal hygiene, food and fluid intake, medication or repositioning.
13. The daily information records for March 2020 included general comments about Mrs Y’s diet, medication and personal care.
14. No daily information records have been provided for April. Other records said Mrs Y had two skin tears on her right leg on 7 April. According to the incident and accident reporting form this happened when Mrs Y accidentally knocked a plate off her table. Staff applied dressings to the bleeding wounds. On 16 April Mrs Y had a skin tear on her right shin. On 28 April she had an open sore on her right buttock and staff applied a dressing.
15. Haythorne Place weighed Mrs Y each month. During 2020 her weight was:
• 39.3 kg in January
• 39.8 kg in February
• 40.5 kg in March
• 39.7 kg in April.
16. The records for May say:
• 1st – Mrs Y was “very vocal” overnight. Staff called the GP about a possible infection and waited for a call back. There is no record of a call back or any follow up by Haythorne Place.
• 2nd – Mrs Y was “well watered”. There is no mention of what she ate.
• 3rd – a sore on Mrs Y’s bottom had healed. She ate very small amounts over the day.
• 4th – Mrs Y was “well watered”. There is no mention of what she ate.
• 5th – Mrs Y had a poor diet and fluid intake.
• 6th – Mrs Y was “well watered”. There is no mention of what she ate.
• 7th – Mrs Y had good diet and fluid intake.
• 8th – Mrs Y spent the day watching TV. There is no mention of food or fluid intake.
• 9th – Mrs Y was “a little vocal” overnight. She had a settled day watching TV. There is no mention of food or fluid intake.
• 10th – Mrs Y had a settled night. During the day she had a poor diet but good fluid intake. At 16.10 staff found her on the floor next to her bed, having last seen her at 15.10. A Nurse took her observations and noted no visible bruising or signs of pain. But Mrs Y was shivering. Another member of staff called 111 at 16.25. According to the incident and accident reporting form, staff told Mrs Y’s family about the fall at 16.40. When the Paramedics arrived, they got Mrs Y’s observations “back up”. A Paramedic called Mrs Y’s GP for advice. The GP advised taking another set of observations before 19.00, when they would call back. At 19.00 the GP said they would call Mrs Y’s family and discuss her remaining where she was, rather than going to hospital. After speaking to her family, the GP said Mrs Y should stay where she was and prescribed antibiotics. Mrs Y received the first dose at 20.00.
• By 22.00 Mrs Y had declined and she became unresponsive. Around 22.13 the GP said Mrs Y did not have long to live. Mrs Y died at 22.37. Haythorne Place called Mr Y, and then Mr X to let them know Mrs Y had died.
17. Mr X says his mother had two falls during the lockdown. Haythorne Place only has a record of the fall on 10 May. Its falls risk assessment says Mrs Y had no accidents in March, April or May.
18. Mr X complained to Roseberry Care Centres, which runs Haythorne Place, on 27 June. He said:
• after Haythorne Place closed to visitors in March staff told them his mother was well;
• when they went to pay Mrs Y’s fees in May, staff told them she was fine but had fallen from her chair;
• late afternoon on 10 May they received a call saying she was in a bad way, could not breathe and the GP had diagnosed COVID-19 but she was too weak to go to hospital; and
• the post-mortem did not identify COVID-19 but two broken legs, including a break which had been healing for several weeks.
19. When Roseberry Care Centres replied to Mr X’s complaint on 10 July, it explained about the events on 10 May leading up to Mrs Y’s death. It also referred to the cause of death recorded on the death certificate: “acute osteoporotic fractured neck of femur in context of coronary artery disease”.
20. When the Care Quality Commission (CQC) inspected Haythorne Place in February 2021 it found it “required improvement” overall, including in terms of being safe and well-led. It was “good” in terms of being effective, caring and responsive.
21. When responding to my enquiries, the Council said:
• the daily information records were incomplete, did not contain enough information and were not person centred;
• more detailed information on personal care, food and fluid intake was also missing;
• the weight charts showed Mrs Y’s weight was consistent;
• Haythorne Place reviewed Mrs Y’s care plans on 14 May 2020 (four days after she had died);
• Haythorne Place did not raise any safeguarding concerns with the Council, despite notifying CQC of a fractured tibia in February 2019;
• it was working with Haythorne Place to ensure it improved its record keeping; and
• recent submissions showed it was making timely reports of safeguarding concerns.

Is there evidence of fault by the Council which caused injustice?

22. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
23. Regulation 17 requires care providers to keep accurate, complete and detailed records. But Haythorne Place’s records for Mrs Y were neither complete nor detailed. The fact that it reviewed her care plans after she had died raises questions about whether previous reviews were accurate. The failure over record keeping is fault for which the Council is accountable (see paragraph 6 above). This means Haythorne Place cannot evidence the care provided for Mrs Y in the way it should be able to. That leaves some doubt over whether it was meeting all her needs, which is an injustice.
24. However, although the records are inadequate, what evidence there is shows the decline in Mrs Y’s condition on 10 May was rapid and is likely to have resulted from the fall she had that day. It seems unlikely she could have sat watching TV on previous days if she had been in pain or distress.
25. It is not possible to remedy the injustice to Mrs Y, as she has died. However, the Council should apologise to Mr Y and Mr X for the distress they have been caused.
26. As both the Council and CQC are already working with Haythorne Place to improve its working practices, there is no need for me to make other recommendations.

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Agreed action

27. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of Haythorne Place, I have made recommendations to the Council.
28. I recommended the Council within four weeks writes to Mr X and his father apologising for the failings at Haythorne Place and the distress this has caused. The Council has agreed to do this.
29. Under the terms of our Memorandum of Understanding and information sharing protocol with the CQC, I will send it a copy of my final decision statement.

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Final decision

30. There was fault leading to injustice. I have completed my investigation as the Council has agreed to take the action I recommended.

Parts of the complaint I did not investigate

31. I have not investigated events from 2018 and 2019 because of the restriction in paragraph 7 above. Mr X was aware of the problems at the time and could have complained about them before now. I can see no good reason to investigate these events now.

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Investigator's decision on behalf of the Ombudsman