Summary: Ms C complained there was a delay by the care home in recognising her mother’s condition had deteriorated, which resulted in a delay calling an ambulance. While we did not find fault about the alleged delay, we found the care provider did not properly respond to Ms C’s complaint. The care provider has agreed to apologise for this.

The complaint

1. The complainant, whom I shall call Ms C, complained to us on behalf of her (late) mother, whom I shall call Ms M. Ms C complained that:
• The care home often failed to provide her mother’s Parkinson’s medication on time.
• The care home failed to recognise on 7 February 2021 that her mother’s condition was of concern.
• Staff did not allow a family member to visit her and failed to involve the family when it offered her mother to call an ambulance.
• The care home also failed to recognise the following day that her mother’s condition was of concern and had worsened. It failed to carry out a UTI test and failed to call an ambulance.
• The care home’s complaint response failed to properly respond to all the issues she raised in her complaint.

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What I investigated:

2. I investigated all of Ms C’s complaints but restricted the period of investigation for the first complaint to November 2020 - February 2021, because the Ombudsman can only investigate events going back up to 12 months. I did not find there were exceptional circumstances that persuaded me to look further than 12 months back.

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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. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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/care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
6. 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)

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How I considered this complaint

7. I considered the information I received from Ms C, the care provider and the ambulance service. I shared a copy of my draft decision with Ms C and the Council and considered any comments I received, before I made my final decision.

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What I found

The complaint about Ms M’s Parkinson medication

8. Ms C complained the care home failed to provide her mother’s Parkinson’s medication on time. She said staff often gave it too late and (more specifically) gave it ‘after meals’ instead of ‘before meals’ as needed. Ms C said this happened despite the family raising this with staff.
9. In response, the care provider said there was only one incident with regards to this and Ms M’s family had not raised any concerns before this. It said Ms M always received her medication at the correct time, except once when she received it late. It said that, when it became aware of this error, it gave a verbal warning to the care worker, explained the importance of giving medication on time, and gave her a refresher training update. The provider also asked the care worker to apologise, which she did.
10. The Medication Administration Record provided by the care home did not show this happened regularly.

Analysis

11. There is no evidence to support Ms C’s allegation that there were regular delays in her mother receiving her Parkinson medication.

The complaint about the care home’s response on 7 February 2021

12. Ms C complained the care home failed to recognise on 7 February 2021, that her mother’s condition was of concern. She said:
• Her mother was very distressed when she spoke to her on the phone, in considerable pain, saying she was dying, and her mother was too scared to put the phone down.
• Even so, the staff told family that her mother was fine.
13. Furthermore, Ms C said the care home failed to:
• Use its discretion to allow a family member to visit her mother that day to comfort her.
• Involve the family (who had Power of Attorney) when it offered her mother to call an ambulance.
14. As part of my investigation, I reviewed the care provider’s records and various statements provided by its staff to determine what happened that day.
15. I have seen several letters from doctors that said Ms M was known to be very anxious, especially in the morning. None of the letters mentioned any concerns about her capacity to make decisions.
16. The care provider told me that Ms M had Covid-19 at the time and, as far as the staff could tell, only showed mild symptoms in line with this.
17. The records and staff statements about 7 February 2021, state that:
• “Ms M has been anxious at times but reassured”. Statements from staff say she received her morning medication and displayed normal signs of anxiety.
• After Ms M’s daughter had called the care home about her mother, the care home manager checked again with Ms M. Ms M said she had intermittent stomach pain. The manager offered Ms M pain relief and called the Out of Hours GP service at 1045 to ask for advice and a visit.
• The out of hours GP service called back at 1240 and asked if Ms M had eaten, taken fluids and passed urine; which she had. The GP said he would not come out and advised to give pain relief if needed and wait until Tuesday when Ms M would have a planned scan. The care home updated Ms M and her daughter of the outcome. The GP did not ask the home to carry out an UTI test to see if she had a urinary infection.
• A staff member asked Ms M at 2pm how she felt. Ms M was resting and said she was ok. She said she wanted to rest and did not need help. The staff member said they would call an ambulance if she would deteriorate, but Ms M said she would not want this and just wanted to rest. The care home said she had capacity to make such decisions. However, it acknowledged it would have been good practice to update her Next of Kin about this.
• Staff carried out regular checks throughout the afternoon and Ms M received support when needed. Staff did not report anything unusual. The care home said that, besides showing mild Covid-19 symptoms, she remained very much in line with her usual behaviour. She showed no signs of distress besides showing heightened anxiety following conversations with her daughters. She complained that she just wanted rest.
• “Ms M had a settled afternoon. (…) She has been anxious at times as per usual”.
18. Ms C said the following, about the staff’s suggestion to Ms M to call for an ambulance if things would deteriorate: staff was fully aware her mother had acute anxiety and was therefore terrified to go into hospital. As such, the home should have involved her daughters in this, as her mother did not have capacity to make these decisions. She said this is why both of Ms C’s daughters had a PoA for Health and Welfare and were responsible for making and being involved in such important decisions in her mother’s best interests.
19. With regards to the care home not allowing Ms M’s daughter to visit, Ms C said: The care home had arrangements in place to allow family members of other service users to visit any end-of-life residents. Even though her mother was not labelled as ‘end of life’, in light of her mother being extremely distressed that day and telling family that she was convinced she was dying, the care home staff should have used its discretion and allowed a family member into her mother’s room to be with her and comfort her. She said the care home had Lateral Flow Tests which the family member could have taken, and there was easy access to her mother’s room from the back of the building. The family asked for this, but the home refused this.
20. In response, the care home said it had a Covid outbreak at the time and Ms M had tested positive. Within the circumstances, and Ms M not showing any signs that were out of the ordinary or concerning, it was therefore entirely reasonable not to allow such a visit.

Analysis

21. While I acknowledge that Ms C’s view of events and her mother’s condition that day is different, the care home’s records and statements of staff who were with her that day do not indicate that staff felt that Ms M’s presentation on 7 February 2021 was concerning to the extent that she needed hospital admission. The care home consulted the out of hours GP service who did not feel a visit was needed and an assessment of Ms M could wait until 9 February 2021 when she would have a planned medical appointment.
22. Staff offered Ms M to call an ambulance “if things would get worse”. However, Ms M said she would not want this. While there were no (recorded) concerns by those involved in her care that Ms M was unable to make this decision, the care home has said it should have informed Ms M’s Next of Kin/ Power of Attorney of this. In the end, this did not make a difference on 7 February 2021 because, according to the records and staff statements, Ms M’s situation did not deteriorate, and staff did therefore not offer Ms M to call an ambulance.
23. In the end it is up to the care home to come to a view, taking all available information and restrictions into account, whereas it believes it should allow a specific visit to go ahead. In taking this decision, the care home took account of the available government guidelines with regards to restricting visits, and the fact the care home was in lockdown and Ms M had tested positive for Covid-19.

The complaint about the care home’s response on 8 February 2021

24. Ms C complained the care home failed to recognise on 8 February 2021, that her mother’s condition was of concern and had deteriorated. Instead, she said the manager only complained to the family at around 10am that her mother had been using her alarm bell to alert staff every fifteen minutes and had been verbally rude to her staff. Ms C complained it should have been clear to staff that the above was completely out of character for her mother and that she needed to go into hospital. Instead, she said the care home refused to call an ambulance when the family said how concerned they were. In the end, it was the family who had to call for an ambulance.
25. Ms C said that, considering her mother’s observations/presentation at the time of hospital admission, it is clear the staff failed to realise her mother had deteriorated, which resulted in a delay in her hospital admission.
26. As part of my investigation, I reviewed the care provider’s records and various statements provided by its staff to determine what happened that day. The records state that:
• Staff provided all necessary personal care this morning.
• Ms M was anxious that morning as she usually was in the morning. Staff was having a chat with her to calm her down after which she had her breakfast. Night staff had monitored Ms M overnight, and she had a settled night. Ms M appeared ok, a bit anxious but said the pain was not worse.
• The home tried to speak to the local GP in the morning, to update them about the discussions they had the day before with the out of hours service. However, the telephone line was constantly engaged. Ms M’s daughter said she had also tried to call the GP and could also not get through. Ms M remained the same in the morning and did not raise any concerns.
• Ms M’s daughter called at 5pm to ask if the home could call an ambulance, as her mother told her on the phone that she was in pain. The home took some observations at 5.15pm and called the paramedics 10 minutes later as her pain seemed to be persistent. I obtained evidence from the ambulance service that the home called the ambulance service.
• Ms M was comfortable in bed and said before and after the medication round that she did not need any pain relief. While waiting for the ambulance Ms M asked to get changed for bed and have a rest. Ms M’s daughter called at 8pm to ask how her mother was. The home said Ms M was settled and asleep. As such, the daughter asked to cancel the ambulance. However, the home said it would be best if paramedics could check on Ms M.
27. Ms C says she does not agree with the information provided by the home. She said:
• The deputy manager said at 5pm that her mother was fine as she had taken observations earlier in the day and reported them to a medic. She asked the deputy manager the name of the medic but never received clarification.
• The deputy manager was adamant that an ambulance was not necessary and if she (Ms C) would call for one it would be “her choice”.
• The family did not ask the home to cancel the ambulance. It only discussed a concern with the home what impact it would have on her mother if she would be awoken and taken to hospital.
28. In response, the care provider said that:
• On 8 February, following observations from different staff members that were being carried out alongside our normal practice, we again deemed Ms M’s behaviour and demeanour to be as normal, whilst recovering from covid.
• Ms M’s demeanour and behaviour on 8 February was very consistent. Besides showing intermittent stomach pains throughout that day, her physical condition was very consistent with how she had been for the previous 14 days whilst isolating with covid. The manager communicated in a professional and reassuring manner to Ms M’s daughters. We kept them updated with our continuous observations whilst adhering to the government guidelines concerning the covid pandemic.
• Though by the afternoon of 8 February, Ms M started to show heightened anxiety levels and was complaining of a more constant pain in her stomach. Based on her now change in disposition and willingness for us to call an ambulance, the staff decided to do so.
• At no point did the manager state that Ms M was not eating or drinking. This is further backed up in the attached daily records that do not indicate a problem, and by the personal statements of all carers involved in her care at the time.
• At no point did staff refuse to call an ambulance. After Ms M’s daughters asked for an ambulance to be called, the staff member spoke to Ms M who agreed to call an ambulance.
• None of the doctors asked staff to do a urine test.
• The deputy manager denies Ms C’s version of the conversation. The only contact the deputy manager had this day with any medical practitioner was during her phone call to the ambulance service during which the service requested information/observations about Ms M whilst arranging for an ambulance.

Analysis

29. While I acknowledge that Ms C’s view of events and her mother’s condition that day is different, the care home’s records and statements do not indicate that staff felt that Ms M’s presentation was concerning for most of the day, to the extent that she needed an ambulance to be called. As mentioned above, Ms M was due for a pre-arranged medical appointment on 9 February 2021. The care provider said it called an ambulance at 5pm because her condition appeared to be deteriorating.
30. As such. I found there is insufficient evidence to conclude that it should have been clear to the care home that Ms M required an ambulance sooner.

The way the complaint was handled

31. Ms C complained that the care home’s complaint response failed to appropriately respond to all the issues raised in the complaint about the events on 7 and 8 February 2021.
32. Ms C said the response also failed to deal with the matter the family raised that three ‘unvaccinated’ doctors came into the home to administer Covid vaccines to residents. Their mother was tested positive for Covid five days later. The family asked if the doctors had undertaken a Lateral Flow Test before entering the home to eliminate the risk of contamination.
33. In response, the care provider said that it did a full investigation at the time. It went through all the records and took personal individual statements from all staff members involved.
34. It also told me that it was very common knowledge that no one was allowed access to the property without showing evidence of a negative test. All three medical professionals provided negative test results, which was standard practice at the time and which the family was aware of.

Analysis

35. Having read the care provider’s complaint response dated 2 July 2021, I agree that it lacks detail, especially with regards to the issues raised in relation to the alleged delay of calling an ambulance. It only said that, with regards to that, the outcome was that all staff members had acted in a professional manner. The response did not provide a response to many of the issues, including the one about the unvaccinated doctors.

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Agreed action

36. I recommend that, within four weeks of my decision, the care provider provides an apology for the faults identified above.

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Final decision

37. For reasons explained above, I found there was fault with the way the care provider responded to Ms C’s complaint, for which it should apologise.
38. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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Investigator's decision on behalf of the Ombudsman