Summary: Mrs Y, the late Ms X’s sister, complained to us about Ms X’s care, arranged for her by the Council and the ICB as S117 aftercare, and provided by EL Marsh Care Home. We have found fault by all the organisations because EL Marsh Care Home failed to: take adequate measures to protect Ms X from Covid-19; provide Ms X with adequate care from 5 August to 17 August and on 18 August; and provide Mrs Y with a proper response to her complaint. EL Marsh Care Home has agreed to remedy this by apologising to Mrs Y, making payments to reflect the distress, time and trouble its failures caused her and service improvements. The Council and the ICB have agreed to take steps to ensure they remain satisfied that EL Marsh Care Home can provide adequate S117 aftercare on their behalf.

The complaint

Legal background

1. EL Marsh Care Home (the care provider) provided Ms X with S117 aftercare services.
2. The legal basis for the provision of these aftercare services is:

• Under Section 3 (S3) of the Mental Health Act 1983 (the MHA), people with a mental disorder which is putting their, or someone else’s, safety at risk can be detained in hospital for treatment necessary for their health, safety or for the protection of other people; and
• Section 117 (S117) of the MHA imposes a duty on councils and Integrated Care Boards (ICBs - which have replaced Clinical Commissioning Groups) to provide free aftercare services to patients who have been detained under S3 of the MHA.

3. Although the Council and the ICB were not involved in Ms X’s day-to-day care I have included them as organisations under investigation. This is our usual process for complaints about S117 aftercare and because, regardless of the day-to-day, frontline management of the process, the Council and the ICB’s overarching responsibility for Ms X’s care cannot be delegated.

Mrs Y’s complaint

4. Mrs Y complained about the care provided to her late sister, Ms X, while she was living in supported living accommodation run by the care provider. She says, in August 2021, the care provider failed to take adequate measures to protect Ms X from Covid-19 and failed to provide her with adequate care. The specific failures referred to by Mrs Y are:
1. on 5 August 2021 care workers did not wear personal protective equipment (PPE) when in Ms X’s home;
2. on 5 August 2021 three or four care workers went into Ms X’s home for Covid tests even though they were not caring for her;
3. a care worker allocated to Ms X continued to work after she had symptoms of Covid and believed she had it;
4. care workers failed to dispose of used PPE appropriately and, instead, placed them in a normal waste bin in Ms X’s home;
5. when she (Mrs Y) went into Ms X’s isolation area on 18 August 2021 staff failed to ensure she was wearing PPE (which she did have but had forgotten to put on in her distress);
6. on 17 August 2021 a care worker left Ms X to sleep for six hours without food or drink during the day – despite Ms X being diabetic and this being out of character for her;
7. on 18 August 2021 care workers failed to carry out first aid measures in a timely manner after Ms X became unwell. From the point of care workers finding Ms X was not breathing, it took six minutes until they called 999 and 11 minutes until resuscitation efforts were started; and
8. a debriefing/report produced by the care provider and shared with her was unacceptable and inappropriate, because it:

• used terminology;
• had poor grammar;
• showed a lack of professionalism;
• showed a lack of compassion and failed to recognise the significance of Ms X’s death; and
• did not have an adequate level of detail.

5. Mrs Y says she has been left heartbroken by Ms X’s death. She was unable to work from August to November 2021 and continues to struggle on a daily basis.
6. In bringing her complaint to us, Mrs Y would like a full written investigation report which addresses all of her concerns.

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The Ombudsmen’s role and powers

7. The Ombudsmen have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
8. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended) If it has, we may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
9. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
10. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

11. I spoke to Mrs Y, made enquiries of the care provider, Council and the ICB. I read the information Mrs Y, the care provider, Council and the ICB provided about the complaint.
12. I invited Mrs Y, the care provider, Council, and the ICB to comment on a draft version of this decision. I considered their responses before making my final decision.

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What I found

The legal and administrative background

Section 117 of the Mental Health Act 1983 – aftercare services

13. The aftercare services councils and ICBs are required to provide to certain people under S117 can incorporate a wide range of services.
14. These services can include:

• Medication administration;
• Social work;
• Domiciliary care;
• Psychiatric treatment;
• Residential accommodation; and
• Supported living or extra care housing.

Social care - fundamental care standards

15. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards registered care providers must achieve. The CQC, as the statutory regulator of care services, has issued guidance on how to meet these standards, below which care must never fall.
16. It is not our role to decide whether any failings in care or treatment by a care provider are breaches of the fundamental standards. These are matters for the CQC with which we share our decisions.
17. But we consider the 2014 Regulations when determining complaints about poor standards of care. The following regulations, relevant to this complaint, require care providers to:

• provide appropriate and person-centred care and treatment based on an assessment of the person’s needs and preferences (regulation 9)
• assess the risk to people’s health and safety during any care or treatment (regulation 12)
• ensure a person has enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. Nutrition and hydration intake should be monitored and recorded to prevent unnecessary dehydration, weight loss or gain (regulation 14)
• keep accurate, complete and contemporaneous records of care and treatment (regulation 17)

What happened

18. I have set out a summary of the key events below. It is not meant to show everything that happened. It is based on my review of all the evidence provided about this complaint.

Background

19. Ms X had a diagnosis of learning difficulties and bi-polar disorder. She was detained for a time in a mental health unit under S3 of the MHA. When she was discharged, the Council and the ICB jointly arranged for her S117 aftercare services to be provided by the care provider.
20. Ms X moved to the supported living accommodation run by the care provider in 2017. The care provider provided her with S117 aftercare services.
21. Ms X’s condition deteriorated in 2021. She was admitted again to a mental health unit in May 2021 and detained under S3 of the MHA.
22. Ms X was discharged in July 2021. She returned to her supported living accommodation, and the care provider resumed provision of her s117 aftercare package arranged by the Council and the ICB, including day-to day social care and the 2:1 support Ms X needed at all times.

August 2021

23. Ms X had a Covid-19 test on 5 August. The result was positive. The care provider arranged for Ms X to isolate for 14 days, with care workers continuing to provide her with 2:1 support.
24. Staff told Mrs Y on 12 August Ms X was “good and recovering”. She was told on 16 August Ms X was “doing well”.
25. But Ms X’s condition had deteriorated from about 14 August. On 18 August, Ms X’s care workers found her unresponsive in her bedroom. Paramedics attended but were unable to resuscitate her and Ms X was pronounced dead.
26. I have set out a detailed account of Ms X’s care during the period from 5 August to 18 August in paragraphs 44 to 59 of this decision.

Mrs Y’s complaint to the care provider - August to November 2021

27. Mrs Y raised concerns with the care provider about what had happened on 18 August and Ms X’s care in the days before her death.
28. On 19 August, the care provider sent Mrs Y an account from its staff members of Ms X’s care on 18 August.
29. Mrs Y made a written complaint to the care provider on 27 August with full details of her concerns, including the issues set out at paragraph 5 a-h above.
30. On 1 September the care provider told Mrs Y it had engaged an external company to investigate the circumstances of Ms X’s death. It said it would provide a full written outcome of the investigation and action taken once this had been completed.
31. The investigator interviewed the staff members involved on 7 September and completed a report on 15 September. The care provider completed its disciplinary process in November,
32. On 30 November, in its response to Mrs Y’s complaint, the care provider said:

• It had arranged an independent investigation into her complaints about staff conduct. It had held disciplinary hearings and taken appropriate action in line with its policy and procedure;
• Ms X had been in contact with her allocated support care worker who was Covid positive on 5 August. Ms X was in isolation for 14 days from 5 August;
• All visitors were required to wear face masks in accordance with Covid-19 guidance. There was plenty of PPE available at Ms X’s accommodation. It apologised if Mrs Y had not been offered a face mask on 18 August. Its staff had explained this was an oversight as they were deeply saddened by the situation. It had addressed this concern with its staff; and
• It could not share Ms X’s medical information as she had not consented to this before she died.

Mrs Y’s complaint to us

33. Mrs Y was unhappy with the care provider’s response and asked us to investigate her complaint. The issues she has raised are about:

• the adequacy of the measures taken by the care provider to protect Ms X from Covid-19;
• Ms X’s care from 5 August to 18 August; and
• The care provider’s response to her concerns about Ms X’s care.

34. I will set out below what I consider to be the relevant information about each of these issues.

The measures taken by the care provider to protect Ms X from Covid-19

35. The care provider’s coronavirus policy and procedure as at August 2021 said it must:

• ensure service users considered particularly vulnerable to Covid-19 had a risk assessment in place;
• ensure national and additional guidance on shielding and protecting vulnerable individuals and people who were clinically extremely vulnerable to Covid-19 was followed;
• restrict movement between its different premises as far as possible to reduce risk of transmission of the virus; and
• contact the GP for further advice around escalation, if symptoms worsened during isolation or were no better after 10 days. And review and update the care plan and risk assessment.

36. Ms X was a diabetic. It is recognised that people with diabetes are more vulnerable to developing a severe illness if they get coronavirus. Because of this they are classed as being in a “clinical risk group”.
37. Ms X’s care plan relating to Covid-19 recorded her risk rating as high. Instructions included requirements for all visitors to the service to wear protective masks, and the care provider to carry out weekly PCR tests with all staff.
38. The care provider’s covid risk assessment document as at August 2021 said it had put in place an internal trained covid tester to ensure testing was offered to all staff on shift. Two lateral flow tests and one PCR would be offered a week.
39. The covid risk assessment also said:

• Staff bubbles in supported living would continue;
• Social distancing in supported living should be maintained where possible;
• Supported living staff were required to continue wearing face masks inside locations where clients were being supported unless a staff member was exempt;
• Visitors to clients in supported living should be reminded and provided with facilities for handwashing and sanitising on entering the home
• Visitor testing was not a requirement;

40. Mrs Y has told me:

• When she visited Ms X at her supported living accommodation on 5 August (before Ms X’s positive result was confirmed on 7 August) none of the three care workers in Ms X’s home were wearing PPE. None of the staff asked Mrs Y whether she had any Covid-19 symptoms (she had carried out a lateral flow test that morning) or offered her any PPE;
• Three to four other staff members came to carry out lateral flow tests in the staff room inside Ms X’s accommodation. One member of staff came into Ms X’s living area to talk to a care worker supporting her. None of these members of staff were wearing PPE. The door to the staff room was left open while the tests were being carried out;
• When she asked why staff were testing at in Ms X’s accommodation, she was told this was because they had run out of tests at other sites;
• Ms X’s key care worker told her on 7 August Ms X had tested positive for Covid-19. The care worker also told her she felt ill and thought she had Covid-19 but would have to continue working with Ms X until the care provider could arrange cover; and
• On 18 August, she saw a waste bin from the staff room in which PPE had been placed.

41. In its responses to Mrs Y and to us, the care provider has said:

• There was no report of staff not wearing PPE in the service on 5 August;
• It carried out testing in the staff room at Ms X’s accommodation on 5 August. The covid tester has confirmed only they, one manager and staff members who worked with Ms X were present. It spoke to staff when Mrs Y raised her concerns initially and they confirmed they all wore the correct PPE. The covid tester has also recently provided a statement confirming all staff were wearing PPE.
• Its policy was “catch, kill and bin it”, its staff were trained on how to do this and there was no requirement to use a medical bin.
• It was not aware of any staff members working with Ms X reporting any Covid-19 symptoms to their manager. Any staff that presented with symptoms were advised to stay away from work and carry out a test;
• It initially told us staff did not have did not have PCR tests in the week to 5 August. It provided us with lateral flow test (LFT) results for staff working with Ms X in the period from 26 July to 5 August which showed Ms X’s key worker tested positive for Covid-19 on 5 August;
• It later told us it had noted there had been an error in the way the data on test results had been recorded. Ms X’s key worker had taken a PCR test on 5 August. The result, which was positive, was not received until 8 August;
• It also provided further test records which showed Ms X and another care worker took PCR tests on 5 August and the results, which were positive, were received on 7 August. And that Ms X’s key worker tested positive on a work LFT test on 8 August.

Ms X’s care in August 2021

42. The care provider has sent us care plans, daily log sheets, fluid and nutrition charts, first aid policy and other records relating to Ms X’s care. I have also been provided with the external investigator’s report which included statements from, the care workers (A and B) who were caring for Ms X on the morning of 18 August.
43. I have reviewed these records and set out below relevant information about Ms X’s care in August.

6 August to 13 August

44. Ms X was diabetic and staff were required to monitor Ms X’s blood sugar levels. Her diabetes care plan said staff needed to administer daily medication and monitor blood sugar levels to secure levels stayed stable. If staff realised there were variations in Ms X’s levels they might need to contact the community nurse. Prior to 6 August, Ms X’s blood sugar level tests were being carried out twice a day. Her medication administration records showed 50 testing strips were issued for a four week period and indicated they should be used twice a day.
45. Ms X blood sugar was not monitored from 6 August to 9 August. This was because they had run out of testing strips and Ms X’s care workers were unable to use the alternative testing equipment.
46. From 10 August, when testing resumed, Ms X’s blood sugar levels were only being tested once a day.
47. From 9 August to 13 August, Ms X’s care workers recorded she was:

• not sleeping for any long periods of time, either at night or during the day. She slept for short periods and had periods of calm, and at other times she was disturbed, shouting or screaming and active; and
• generally eating well, up to three meals a day, with additional fruit, yoghurt and cereal. She was drinking fluids of between 1 to 1.9 litres over a 24-hour period.

14 August to 17 August

48. The care records show Ms X’s health deteriorated during this period.
49. On 14 August she was recorded as:

• having drunk 250ml of fluids (reference to a cup of tea and glass of water but not the amount or whether it was drunk) in the 24-hour period from 6am to 5am the next day, and a bowl of porridge in the period from 9am to 7pm; and
• eating little at tea and refusing to drink, not looking well, having a cough and being calm or asleep.

50. On 15 August she was recorded as:

• having 500ml of fluid in the period from 6am to 5am the next day, declining food and drink, eating only a few rice pudding and yoghurt pots; and
• not doing well, sleeping, lying on the floor or in bed awake, then screaming then asleep.

51. On 16 August she was recorded as:

• refusing drinks in the period from 6am to 2pm and drinking 280ml of fluids from 2pm to 5am the next day. Not eating meals. Only yoghurt and refused cereal; and
• had refused water and drinks and meals and was sleeping for long periods.

52. On 17 August she was recorded as:

• having 330ml of fluids from 6am to 3pm and no fluids from 3pm to 5am the next day. She had eaten a yoghurt and some cereal in the period from 9am to 1.30pm and nothing from 3pm to 5.30am the next day; and
• had refused meals and drinks. She was sleeping or lying on her bed for most of the day and evening.

The morning of 18 August

53. Care workers A and B took over Ms X’s care from the staff with her overnight. Care worker B said the overnight staff told her Ms X had been asleep all night, which was unusual.
54. Ms X was recorded as:

• refusing water at 8am and having yoghurt at 9am;
• in her bedroom sleeping from about 9.30am; and
• sleeping at 10am and 11am.

55. Care worker A checked Ms X at around 11.45am. Ms X was lying on her bed and unresponsive.
56. The care workers told the external investigator they did not start CPR on Ms X because care worker B was not first aid trained and had not undertaken any training while working for the care provider and care worker A had not received any CPR training. I appreciate the care provider has said the care workers had received training, but this is the reason they gave for not giving emergency first aid.
57. Care worker B called their line manager (manager C) (at 11.50am).
58. Care worker A:

• called, but was unable to speak to, another staff member;
• called 111 (at 11.51am) who told her to call 999;
• called 999 (at 11.51am) but terminated the call as she did not understand what was said; and
• called 999 again and asked for an ambulance.

59. Manager C called another manager (manager D). Managers C and D arrived at Ms X’s accommodation (at 11.56am). Manager D started CPR on Ms X until the ambulance crew arrived (at 12.03pm) and took over. The paramedics were unable to resuscitate Ms X and she was pronounced dead at the scene.

The care provider’s first aid policy

60. The policy in force as at August 2021 said the care provider would:

• ensure staff understood what to expect in the event of an incident and someone trained in basic first aid skills was able to attend an incident quickly and provide appropriate first aid or take appropriate action;
• undertake a risk assessment to highlight potential risks and hotspots; and
• ensure all staff on duty were aware who the qualified first aider on duty was at any particular time.

61. The policy defined a first aider as someone who had completed an Emergency First Aid at Work (EFAW) qualification which enabled a first aider to give basic life-saving first aid to someone who became ill, or a First Aid at Work (FAW) qualification which included the same content as the EFAW and additional training.

My analysis - was there fault by the care provider causing injustice?

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

Measures taken by the care provider to protect Ms X from Covid-19

63. In my view, the care provider had put appropriate policies and procedures in place to protect service users, including Ms X, from Covid-19. But there is a dispute between Mrs Y and the care provider as to whether these procedures were properly followed by staff all times.

Complaint a) on 5 August 2021 staff did not wear PPE when in Ms X’s home

64. The care provider said there was no report of staff not wearing PPE. But there was – Mrs Y reported this to manager C on 16 August.
65. I consider Mrs Y’s evidence is more likely to be accurate. The visit to her sister was very important to her and she has given a clear account of what happened on that day. And on balance I consider it unlikely staff would have recorded in notes they were not wearing PPE.
66. I accept Mrs Y’s evidence staff did not ask whether she had any Covid-19 symptoms or offer her any PPE, and that none of the staff in Ms X’s home were wearing PPE.
67. In my view, the failure of its staff to take appropriate measures to protect Ms X that day, in accordance with its policies, was fault by the care provider.

Complaint b) on 5 August 2021 three or four members staff went into Ms X’s home to do Covid tests even though they were not caring for her

68. I don’t consider I have sufficient evidence to make a finding on whether staff who were not working with Ms X were tested in the staff room at her home that day.
69. But, for the reasons set out in paragraph 65, I accept Mrs Y’s evidence a staff member who was not one of the care workers supporting Ms X at the time, came into Ms X’s living room, staff members being tested were not wearing PPE and the staff room door was open while tests were being carried out.
70. In my view, the failure of its staff to take appropriate measures to protect Ms X that day, in accordance with its policies, was fault by the care provider.

Complaint c) a care worker allocated to Ms X continued to work after she had symptoms of Covid and believed she had it

71. Mrs Y says Ms X’s key care worker told her on 7 August she was unwell but still working with Ms X, as cover had not yet been arranged. The daily case notes confirm this care worker was working that day.
72. But the care provider has provided conflicting information about staff testing in the period from 5 August to 8 August. Its evidence has been that (a) staff including the key care worker took positive LFT tests on 5 August, (b) the key care worker took a PCR test on 5 August, with a positive result received on 7 August, and (c) this care worker took a positive LFT test at work on 8 August.
73. My view is the care provider’s information about staff testing around 5 August is unreliable. Because of this I do not consider I have sufficient evidence to make a finding a care worker continued to care for Ms X, after testing positive for Covid-19.
74. But I consider the care provider failed to keep accurate records of staff testing during this period and this was fault.

Complaint d) staff failed to dispose of used PPE appropriately and, instead, placed them in a normal waste bin in Ms X’s home

75. Mrs Y said used PPE had been placed in a bin kept in the staff room at Ms X’s accommodation. On the basis of the evidence seen, I do not consider there was a failure to dispose of used PPE correctly and I do not propose finding fault by the care provider for this part of Mrs Y’s complaint.

Complaint e) when Mrs Y went into Ms X’s isolation area on 18 August, staff failed to ensure she was wearing PPE (which she did have but had forgotten to put on in her distress)

76. The care provider has accepted its staff did not offer Mrs Y PPE on that occasion.
77. I consider this failure to follow appropriate Covid-19 safety measures was fault. Fortunately, Mrs Y did not suffer any physical harm. As the care provider has already apologised for its oversight, I do not propose to recommend any further action for this aspect of Mrs Y’s complaint.
78. And, although not part of Mrs Y’s complaint, I have noted that it was the care provider’s policy and a requirement of Ms X’s care plan that staff attend the office each week for PCR testing. The provider has confirmed it did not carry out PCR tests on staff working with Ms X during the period from 26 July to 5 August. I consider this was fault by the care provider.

Impact of the failures to take adequate measures to protect Ms X from Covid-19

79. Ms X was tested for Covid-19 on 5 August. As the result was confirmed as positive on 7 August, this means Ms X had already contracted Covid-19 as at the day of Mrs Y’s visit. So, I do not consider I can say the specific failures on and around 5 August identified above had an impact on Ms X.
80. But in my view, they show a lack of consideration of Ms X’s particular vulnerability to the effects of Covid-19 as a diabetic. And they also raise a concern that these were not “one-off” events and may indicate an ongoing failure by the care provider to ensure its procedures were being properly followed by all staff at all times at all of its sites.
81. I consider these failures have caused Mrs Y significant upset and uncertainty about whether the appropriate measures to protect Ms X from Covid-19 were taken by staff working with her before 5 August. And while we cannot say one way or another, this in turn has left Mrs Y with understandable uncertainty about whether, if staff had acted without fault, Ms X would not have contracted Covid-19.

Ms X’s care from 5 August to 17 August

82. Mrs Y’s complaint (f) was that on 17 August 2021 staff left Ms X to sleep for six hours without food or drink during the day – despite Ms X being diabetic and this being out of character for her.
83. Based on the evidence seen, my view is there were significant failures in the care provided to Ms X, not only on 17 August, but throughout the period from 5 August. I consider the care provider failed to:

• carry out an assessment of risk when Ms X tested positive for Covid-19. It knew Covid-19 posed an increased risk to health for people with diabetes. I have seen no evidence staff were given guidance about the possible impact of Covid-19 on Ms X, as a diabetic or about monitoring her condition;
• monitor Ms X’s blood sugar levels in the period from 6 August to 9 August;
• ensure it had adequate supplies of blood sugar testing strips; and
• implement regular and appropriate testing of Ms X’s blood sugar levels. The frequency of this testing was inconsistent, varying between once, twice or four times a day. I have not seen any evidence of guidance to staff about the timing and frequency of testing. There is no evidence staff sought any advice about the variations in Ms X’s blood sugar levels, as told to do in the care plan.

84. I consider the care provider also failed to:

• assess the risk to Ms X’s health from 14 August, when staff had noted she appeared unwell, was sleeping for unusually long periods of time and refusing food and drink;
• assess the risk to Ms X’s health of the very significant reduction over a number of her days in her fluid and nutrition intake;
• assess the risk for Ms X as a diabetic, of not having regular nutrition and fluid intake;
• monitor the information recorded about Ms X’s health and her fluid and nutrition intake in its daily charts and logs; and
• seek medical advice or intervention when it noted Ms X’s health was significantly deteriorating.

85. In my view, the care provider failed to provide Ms X with an adequate level of care in the period from 5 August to 17 August. This was fault.

Impact of the failures to provide Ms X with adequate care from 5 August to 17 August

86. I consider there were many times, in this period, when but for these failures, the care provider would have obtained medical advice and intervention about the deterioration in Ms X’s condition. In my view they also indicate a real lack of concern and consideration by the care provider about Ms X’s well-being. Sadly, we can’t put this right for Ms X.
87. Because of Ms X’s overall health and the number of variables, I cannot say whether, with appropriate care, her condition would have significantly improved. But I consider the failures have caused Mrs Y upset about the standard of care provided to Ms X in the days before her death. They have also left her with uncertainty about whether, if staff had acted without fault, there would have been a different outcome for Ms X.

Ms X’s care on 18 August

88. Mrs Y’s complaint (g) was that care staff failed to carry out first aid measures in a timely manner after Ms X became unwell. From the point of staff finding Ms X was not breathing, it took six minutes until they called 999 and 11 minutes until they started resuscitation efforts.
89. Based on the evidence seen, my view is there were significant failures in the care provided to Ms X on 18 August. I consider the care provider failed to:

• assess the seriousness of Ms X’s condition on the morning of 18 August and seek urgent medical advice. It knew Ms X had had nothing to eat or drink between 3pm the previous day and 5.30am that morning and been asleep for unusually long periods;
• take appropriate action and follow proper procedures when it found Ms X unresponsive;
• immediately call 999; and
• ensure staff knew who to call, as the on-duty qualified first aider, to provide immediate basic life-saving first aid to Ms X. There is no evidence care workers A and B knew who the on-duty qualified first aider was that morning.

90. In my view, the care provider failed to provide Ms X with an adequate level of care on 18 August. This was fault.

Impact of the failures to provide Ms X with adequate care on 18 August

91. I consider because of these failures, the opportunity to seek urgent medical advice and intervention for Ms X earlier that morning was missed. They also caused a delay of some possibly significant minutes in calling for an ambulance and giving Ms X basic life-saving first aid.
92. But for these failures, it is possible there might have been a different outcome for Ms X. There is no way for us to say, even on balance, it is more likely than not there would have been a different outcome and it is too late to put this right for Ms X now. However, in my view, the possibility that the outcome may have been different, but for the care provider’s fault, has caused Mrs Y significant distress.

Response to Mrs Y’s concerns

93. Mrs Y’s complaint (h) was that a report produced by the care provider and shared with her was unacceptable and inappropriate, for reasons including a lack of professionalism and an adequate level of detail.
94. The care provider shared its report of what happened on 18 August with Mrs Y on 19 August. Clearly, this was an extremely distressing time for Mrs Y and I appreciate her upset at reading its contents. But it appears to have been intended as an immediate account of the events that day, as requested by Mrs Y, and not a comprehensive report. On that basis I do not consider there was fault in the way the care provider provided Mrs Y with its initial account of Ms X’s care that day.
95. But, in my view, the care provider failed to respond properly to the complaints Mrs Y raised with it on 27 August.
96. It had told Mrs Y, once the external investigation had been completed, it would provide a full written outcome of the investigation and action taken.
97. However, although the external investigator issued a detailed report on 15 September, the care provider did not provide Mrs Y with its response until 30 November. This response simply said it had held disciplinary hearings and taken appropriate action in line with its policy and procedures. In my view, it did not properly address Mrs Y’s specific concerns.
98. I consider this was an inadequate response to Mrs Y’s complaints and fault by the care provider. Because of this, Mrs Y was left uncertain about what had happened in the period leading up to Ms X’s death, causing her additional distress and put her to the time and trouble of bringing the complaint to us for a detailed investigation.

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Agreed Action

99. I have found fault with the care provider’s actions. I acknowledge that the Council and the ICB did not have any day-to-day involvement with Ms X’s care. But because of their overall responsibility for Ms X’s care, we are finding them at fault also.
100. To remedy the injustice caused by the above faults, and within four weeks from the date of our final decision, the care provider has agreed to:
1. apologise to Mrs Y for the distress and uncertainty caused by its failures to: take adequate measures to protect Ms X from Covid-19; provide Ms X with adequate care from 5 August to 17 August and on 18 August; and provide Mrs Y with a proper response to her complaint. The apology should reflect the principles about making an effective apology set out here Guidance on remedies - Local Government and Social Care Ombudsman in in our published Guidance on Remedies; and
2. pay Mrs Y £500 to acknowledge the distress and uncertainty caused by these failures and the time and trouble of bringing her complaint to her. This figure is a symbolic amount based on our published Guidance on Remedies.
101. And within three months from the date of our final decision, the care provider has agreed to review with its senior managers:

• its systems for monitoring compliance of all staff with its policies and procedures;
• its policies and procedures for first aid training and checking staff competency in first aid and emergency procedures, and its system for ensuring all staff know at all times who to call, as the on-duty qualified first aider, to provide immediate basic life-saving first aid;
• its procedures, guidance and training for staff about monitoring, and testing, blood sugar levels of service users with diabetes and when to seek medical intervention;
• its policies and procedures for management oversight of the day-to day care of individual service users and monitoring of daily logs and care records; and
• its policies and procedures for training and guidance to staff about the assessment of risk to service users’ health and well-being, responsibility for the escalation of concerns and seeking medical intervention.

102. The care provider should provide us with evidence it has done this.
103. And within three months of our final decision the Council and the ICB have agreed to:

• make its quality monitoring teams aware of this decision;
• if it has any service users at the care provider, take appropriate steps to satisfy itself the provider is providing a suitable level of care; and
• monitor the care provider’s response to our recommendations.

104. The Council and the ICB should provide us with evidence they have done this.

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Final decision

105. I have found fault, as set out above, by the care provider, the Council and the ICB, causing injustice. I have completed my investigation on the basis they will carry out the above actions as a suitable way to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman