Summary: We upheld Mrs X’s complaints about communication with her about a safeguarding enquiry and about her late mother Mrs Y’s care and supervision during a visit. The Care Provider will apologise for the avoidable distress to Mrs X.

The complaint

1. Mrs X complained about her late mother’s (Mrs Y’s) care in Gainsborough Hall Care Home (the Nursing Home), owned and managed by Restful Homes (Worcestershire) Ltd (the Care Provider).
2. Mrs X complained about:
1. Inadequate communication and failure to share information that was part of the safeguarding enquiry
2. Mrs Y’s care in the last weeks of her life
3. A lack of care and supervision during a visit in January 2021.

Back to top

The Ombudsman’s role and powers

3. 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 or others. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If we are satisfied with a care provider’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)

Back to top

How I considered this complaint

5. I considered Mrs X’s complaint to us, the Care Provider’s responses and documents described later in this statement. I discussed the complaint with Mrs X.
6. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

Relevant law and guidance

7. This complaint involves events 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”.
8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
9. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
10. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
11. Regulation 20 of the 2014 Regulations sets out the duty of candour in relation to specific incidents which have caused harm to a person. Guidance on Regulation 20 explains the duty of candour is also a general professional duty to be open and transparent with people receiving care.
12. Visits from family were generally not possible in care homes during most of the pandemic until the government relaxed visiting restrictions in November 2020. The Nursing Home installed a visiting pod to enable relatives to visit in person. Before this, only phone calls and video calls were possible in most cases. And then at the start of January 2021, visits were again not possible generally due to the government imposing a further national lockdown. There was an exception if a resident was at the end of their life where they could have a relative visit them.

What happened

13. The information in this section is from the Nursing Home’s care records and from records from the local authority’s safeguarding team.
14. Mrs Y’s care was arranged and paid for privately. She moved into the Nursing Home at the end of October 2020 following a hospital stay. The hospital discharge letter said:
• Mrs Y had been admitted for worsening confusion and poor mobility and delirium (a serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment)
• Mrs Y had dementia.
15. The Nursing Home completed assessments and care plans for Mrs Y to meet her care needs. These were reviewed regularly and updated. There were also risk assessments, including a risk assessment for COVID-19 for residents and a separate risk assessment for visiting. The manager shared copies of Mrs Y’s care plans with Mrs X and incorporated her comments.
16. The Nursing Home weighed Mrs Y monthly. The charts indicate her weight remained stable in November and December within one kilogram. She was a healthy weight.
17. I have summarized some of Mrs Y’s care plans below:
• Eating and drinking: Mrs Y had changes to her appetite and her interest in food had diminished. She needed assistance to eat, her meal preferences were noted. She needed a soft, easy to chew diet and normal fluid. Following communication between catering staff and Mrs X, staff were aware of Mrs Y’s preferences and while these were repetitive, she usually ate all food offered and this promoted good intake.
• Daily life: Mrs Y would be supported to have daily calls with her daughter, staff needed to sit with her and hold the handset. Staff were to show her pictures of her family. She often spoke to family members who were not there, these appeared to be hallucinations.
• Mobility: Mrs Y became unable to weight bear after a few weeks in the Nursing Home and needed a hoist, slide sheet and wheelchair to change position/move around.
• Continence: Mrs Y was incontinent and needed full support around using pull up pads.
• Emotional needs: Mrs Y was generally settled and relaxed in mood. When she experienced hallucinations, she could get frustrated and needed reassurance. A referral to a psychiatrist had been made.
• Safety: She slept at the edge of bed. Bed and door sensors were in place, the bed was at the lowest setting, there was a crash mat at the side of the bed and staff were to try and position her in the middle of the bed.
• Death and dying: the doctor had signed a do not resuscitate form. Her wishes were unknown and were to be discussed with family if her health declined. Mrs X was to be contacted immediately. She was not to receive invasive treatment, but relief of symptoms and staff would need to liaise with the GP.
• Communication: Mrs Y could no longer converse well and was reliant on staff to anticipate her needs. When she was hallucinating, she could get loud and staff needed to listen, engage and try and distract her. Staff needed to speak clearly and allow her time to process information.
• Visiting: Mrs Y could have one visit a week from up to two members of the same household. Staff would assist Mrs Y to get to the visiting area and her visitors needed to wear PPE. Staff would clean the furniture between visits. Visitors would be asked questions to see if they had any symptoms of COVID-19. Visitors needed to socially distance.
18. The Nursing Home had an outbreak of COVID-19 at the end of December 2020 which lasted through January 2021. A director told me many staff were absent from work with COVID-19 and they had to use agency staff. Staff were extremely busy dealing with sick residents, health professionals and fielding calls from worried relatives. The director accepted the phones were not always answered during this period. The Nursing Home sent me emails between senior staff and Mrs X. The emails answered Mrs X’s questions and queries, although there were occasions when Mrs X had to chase for a response.
19. Mrs Y became unconscious one day in December and staff called an ambulance. When it arrived, she started to come round and respond. The paramedic felt there was no need for her to go to hospital. Staff checked this out with Mrs X and she agreed.
20. The daily records suggest Mrs Y’s interest in food began to decline, her general frailty was increasing at the end of December 2020 and into January 2021. Mrs Y was often sleepy and stayed in bed. On one day she had two episodes of diarrhoea and was coughing. Staff tested her for COVID-19, the result was negative. They took her vital signs including oxygen levels and all were within a normal range.
21. Mrs X visited Mrs Y in the first week of January. The day after the visit, Mrs X contacted the local authority’s safeguarding team to report concerns about her mother’s condition and the lack of appropriate support during the visit.
22. The Council’s safeguarding decision-making record noted what Mrs X reported:
• The visit was supervised by a receptionist and not a carer. Previous visits were supervised by a carer sitting in the room next to Mrs Y.
• There were other staff around in the visiting area, including the Head of Care who had her back to the visiting area and two other care staff who were taking down a Christmas tree.
• The receptionist did not stay with Mrs Y to support her (she was also answering the external phone).
• Mrs Y could not hold the phone handset and tried to put it in her mouth. Her mother’s fingers and hair were dirty and she also had food in her mouth. She looked like she had lost weight.
• Mrs Y was not strapped into the wheelchair and she was worried Mrs Y would fall on to a tiled floor.
23. The following day, an officer in the safeguarding team spoke to Mrs X to go through her concerns. The officer also spoke to the manager of the Nursing Home and asked for an internal investigation into Mrs X’s concerns.
24. The following day, Mrs Y tested positive for COVID-19. She was noted to be frail and weak. Staff contacted the GP out-of-hours service. A specialist paramedic from the out-of-hours service called back. Staff told the paramedic Mrs Y was restless, agitated and uncomfortable. The paramedic referred her to a nurse practitioner who visited Mrs Y and prescribed medication to calm her. Mrs Y also saw the out of hours GP who assessed her for pain and checked her vital signs which were ok. The GP spoke to Mrs X after and Mrs X said she did not want Mrs Y to go to hospital. Staff also spoke to Mrs X and explained her mother’s chest was clear and she was having pain relief to help with any general pain. Mrs Y and Mrs X spoke on the phone.
25. Mrs Y was receiving all personal care in bed. Staff updated Mrs X and said she could visit. Mrs X did not visit due to her own health issues. Mrs Y died the following day. Staff told Mrs X immediately, passed on their condolences and made arrangements for death certification and for the body to be collected. Mrs X was updated by phone.
26. The manager sent an email report to the Council’s safeguarding team at the start of February saying:
• The Nursing Home allowed visits, but as the period was so busy, support of all staff within the home was required. The reception team supported visits during the Christmas and New Year period.
• Mrs X said her mother was unkempt and dirty. The care records indicate she’d had a bed bath on the day, but her most recent shower was five days earlier. The dirty nails were not acceptable and this was discussed with staff.
• The phone was on speaker phone, so Mrs Y could hear Mrs X’s voice.
• The receptionist had to deal with phone calls from other relatives during the visit. Mrs Y was still within her eyesight. The receptionist did see Mrs Y put the phone in her mouth and so put the phone in Mrs Y’s lap so she (Mrs Y) could still hear. With hindsight, the receptionist should have sat next to Mrs Y during the visit.
• There was some dispute about how the receptionist offered a drink to Mrs Y. Mrs X said the receptionist poured water into Mrs Y’s mouth. The receptionist said Mrs Y pursed her lips and took none of the fluid.
• The receptionist suggested Mrs Y went back upstairs and then after she had taken Mrs Y back, the receptionist came to sit with Mrs X to speak to her. The receptionist did not mean to upset Mrs X by talking to her about moving Mrs Y closer to home.
• The receptionist was sorry for any distress caused.
• She (the manager) felt Mrs X did not appreciate Mrs Y’s condition was deteriorating.
27. The Care Provider’s response to Mrs X’s complaint said it had no safeguarding report to share with Mrs X and the local authority was the lead agency for safeguarding. It also said Mrs Y received a high standard of care, staff loved her and it was very sorry for her loss and distress.

Findings

Complaint a: Inadequate communication and failure to share the information that was part of the safeguarding enquiry

28. Overall, I consider communication with Mrs X was appropriate. The emails evidenced senior staff making reasonable attempts to respond to Mrs X and to address any concerns she raised. The care notes indicated staff gave regular updates and offered to arrange a visit or calls. Mrs X declined to visit for understandable reasons (she was vulnerable due to her own health and the Nursing Home had a COVID-19 outbreak.)
29. The Care Provider’s ability to respond to the daily phone calls that were an agreed part of Mrs Y’s care plan was hampered by an outbreak of COVID-19 in December/January. It acknowledged this in response to my enquiries. I accept this caused Mrs Y avoidable distress and frustration at not being able to contact her mother or speak to staff to get a daily update, but these events were outside the Care Provider’s control and so I am not critical. These were truly exceptional times and the records indicated there was a level of email contact that was acceptable in the circumstances. I am satisfied with the phone contact between staff and Mrs X to update her about any healthcare intervention and about Mrs Y’s general decline.
30. The Care Provider was correct in saying the local authority was the lead agency in the safeguarding enquiry and so any final report would be for it (the local authority) to disclose. However, the manager gave some relevant information to the local authority to assist the safeguarding enquiry as I have described in paragraph 26. I consider the Care Provider could have been more open with Mrs Y about the information it had given to the local authority about the visit. The general duty of candour applied and the Care Provider accepted something had gone wrong because the manager said Mrs X’s personal care was not as it should have been on the day and the receptionist should have sat with Mrs Y during the visit. The Care Provider should have been open about that to Mrs Y in its complaint response.

Complaint b: Mrs Y’s care in the last weeks of her life

31. I am satisfied Mrs Y’s care was in line with her care plans which were reviewed and updated regularly. Staff liaised with NHS professionals to ensure Mrs Y was comfortable and had appropriate pain relief. Care was in line with Regulations 9 and 12(i) of the 2014 Regulations. I do not uphold this complaint.
32. I realise it would have been very distressing for Mrs X to see her mother become increasingly frail, unresponsive and confused and for the decline to have happened so rapidly. But these symptoms are not uncommon when a person has dementia and is at the end of their life. They are not indicative of any failings in the care provided.

Complaint c: A lack of care and supervision during a visit in January 2021.

33. The Care Provider acknowledged in the safeguarding investigation that the receptionist should have stayed with Mrs Y during the visit. Care was not in line with Mrs Y’s needs on this occasion. The Care Provider also accepted Mrs Y’s hair and nails were dirty and so her care was not in line with Regulation 9 of the 2014 Regulations on this occasion. Seeing her mother this way caused Mrs X avoidable distress.

Back to top

Agreed action

34. The Care Provider will, within one month, apologise for the failings I have identified in paragraphs 30 and 33.

Back to top

Final decision

35. We upheld Mrs X’s complaints about communication with her about a safeguarding enquiry and about her late mother Mrs Y’s care and supervision during a visit. The Care Provider will apologise for the avoidable distress to Mrs X. I have completed the investigation.
36. 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.

Back to top

Investigator's decision on behalf of the Ombudsman