Summary: Mr B has complained about the care of his parents in a care home. We found fault in aspects of facilities and sensitivity shown around family bereavement which caused distress to Mr B and the Home has agreed to make apologies.

The complaint

1. Mr B complains about the care of his mother and father, Mr and Mrs C, at Middleton Grove Nursing Home in February 2021. Mr C funded his own care and the NHS funded Mrs C’s. Specifically, Mr B complains:

• his parents' bedding was poor quality;
• his parents were left in a water damaged room;
• his parents' room was not clean;
• his parents contracted COVID-19 despite measures in place at the Home;
• Home staff did not tell his mother her husband had died and let her sleep in the same room;
• when undertakers were removing his father's body staff did not put a screen up to shield his mother from this scene;
• the nurse in charge prolonged the episode by not giving the undertakers the code for the door to leave or letting them out;
• the nurse in charge asked how much longer he would be; and
• staff left his father's notes in full view of his mother

2. Mr B also complains:

• items in quarantine were not given to his parents;
• the family paid extra for items which the Home did not give to his parents;
• his mother’s wheelchair was lost; and
• his parents’ bedding was lost

3. Mr B believes the faults of the Home caused his father's death and led to distress for both him and his mother. He believes the Home should be held accountable for allowing COVID-19 to enter the Home. In addition, the Home should carry out essential maintenance works to improve services for residents.

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What I have investigated

4. I have investigated:

• his parents' bedding was poor quality;
• his parents were left in a water damaged room;
• his parents' room was not clean;
• his parents contracted COVID-19 despite measures in place at the Home;
• Home staff did not tell his mother her husband had died and let her sleep in the same room;
• when undertakers were removing his father's body staff did not put a screen up to shield his mother from this scene;
• the nurse in charge prolonged the episode by not giving the undertakers the code for the door to leave or letting them out;
• the nurse in charge asked how much longer he would be; and
• staff left his father's notes in full view of his mother

but not:

• items in quarantine were not given to his parents;

• the family paid extra for items which the Home did not give to his parents;

• his mother’s wheelchair was lost; and

• his parents’ bedding was lost

5. I will explain later in this statement why I have not investigated these issues.

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The Ombudsmen’s role and powers

6. The Ombudsman investigates complaints about adult social care providers and decides 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)
7. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen 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).
8. If it has, they 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. 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 ‘Principles of Good Administrative Practice during COVID-19’.

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How I considered this complaint

11. I have considered information from the Home and Mr B when investigating this complaint. I have also considered the relevant policies and guidance in place at this time. I considered comments from the Home and Mr B on my draft decision before making this final decision.

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What I found

Background

12. Mr B’s parents (Mr and Mrs C) moved into the Home in a shared double room in 2020. Mrs C had Parkinson’s disease and Mr C had dementia. Both were elderly.
13. Mr C died of COVID-19 in February 2021 and Mr B made a complaint in April 2021. He had a period of correspondence with the Home before approaching the Ombudsmen in September 2021.
14. The relevant government guidance I have used on in this case is ‘COVID-19: management of staff and exposed patients or residents in health and social care settings’.
15. I also used the Home’s policy ‘COVID-19 Contingency Plan’.
16. In addition I used the Care Quality Commission Fundamental Standards of Care which are based on Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Living conditions

17. Mr B said the mattress and pillow on his father’s bed was at least 20 years old and extremely thin.
18. Mr B also complained that water had leaked into his parents’ room and stained the wall and ceiling.
19. Furthermore, Mr B said he observed his parents’ room was not clean and it was obvious had not been cleaned regularly. He felt these conditions unsatisfactory and unsafe for his parents.
20. In response to our enquiries the Home said its bedding was of a high quality. However, it explained that as it had to be washed at high temperatures for infection control it was not the same as “contemporary” or household bedding.
21. The Home went on to say although Mr B did bring in bedding for his parents it became damaged during washing so the Home went back to using its bedding with the offer of extra pillows.
22. Regarding water damage the Home said heavy rain caused a water leak and it informed its maintenance team. However because the Home was in a COVID-19 outbreak situation entry to residents’ rooms was restricted and so non-essential maintenance put on hold. In addition, moving to another room was not possible due to Mr C’s declining health and lack of availability of other rooms.
23. The Home said rooms were cleaned daily and a full deep clean was provided every three days during the outbreak situation. It provided a copy of the deep clean record.

Analysis

24. The Home’s explanation relating to bedding is reasonable and I have not found fault in relation to this part of the complaint. It has explained why the bedding was different and changed it to the bedding Mr B brought in.
25. The Home provided evidence that the leak was fixed at the time and was no longer leaking into the room. This meant that the room did not remain damp. Therefore I have not found fault in this aspect of the complaint.
26. I have seen the deep cleaning rota and it illustrates that regular cleaning was going on in Mr and Mrs C’s room. Therefore, although I do not doubt Mr B’s account, I am satisfied that any dirt he witnessed was cleaned within a reasonable timeframe thus not posing a serious risk to his parents’ health.

Mr and Mrs C contracted COVID-19

27. Mr B said that one of the causes of death listed on his father’s death certificate was COVID-19. His mother also contracted COVID-19. He asked the Home how both his parents managed to contract COVID-19 despite the supposedly stringent measures in place such as the wearing of PPE, staff being tested daily, and items brought into the Home being quarantined for 72 hours.
28. Mr B said that as it was not a family member who had visited as they were not allowed to, his only conclusion was that his father caught COVID-19 from a member of staff and it contributed towards his father’s death. He said that through the incompetence of staff his father contracted COVID-19 and this left him susceptible to his underlying illnesses which accelerated his deterioration and death. Mr B said he was aware several staff members had tested positive for COVID-19 and he was angry about what had happened to his parents.
29. The Home said residents at the time when Mr C had tested positive were being isolated in their bedrooms. Whilst others remained in their rooms, Mr C who had been diagnosed with advanced dementia and who was still able to mobilise, was leaving his room and travelling to other parts of the home including other residents’ bedrooms. The Home said staff were unable to restrain him due to his behaviour.
30. In addition, the Home said unfortunately, as with other cases throughout the pandemic, it is impossible to say how one person has contracted the virus.
31. The guidance the Home has provided which it was adhering to at the time Mr B is complaining about was in line with the government advice. This included taking precautions such as handwashing, wearing PPE when required and isolating residents who had tested positive. The Home was also using barrier nursing to care for residents. In addition, staff were taking temperature tests twice daily in line with its guidance.

Analysis

32. I am unable to say how Mr C contracted COVID-19. However, I am satisfied the Home had appropriate measures in place to protect residents from COVID-19, albeit these were not successful for Mr and Mrs C.

Events following Mr C’s death

33. Mr B said the Home contacted him in the early hours to tell him his father had died. He went to the Home where staff let him in and he donned PPE. He said staff then informed him that no one had told his mother her husband had died in the same room that evening and she was still there.
34. Mr C said he woke his mother and told her the news. Shortly afterwards the undertakers arrived and, when it was time to remove Mr C’s body, Mr B complained no one offered to move Mrs C or put up a screen.
35. Mr C was put in a body bag and on a stretcher and manoeuvred out of the room in view of his wife. Mr B said this was disgusting and disrespectful. There was also a delay as the nurse in charge left and the undertakers did not have a code for the door.
36. Mr B said the nurse in charge then asked him if he would be much longer when he was trying to comfort his mother which he found insensitive.
37. Furthermore, Mr B said that he noticed his father’s notes were left out in full view of his mother before he had a nurse take them away. He said that his mother does not have advanced dementia and could have read and understood the notes.
38. In its complaint response the Home admitted these events could have been handled better and with more compassion. It said Mrs C was fast asleep throughout the night and was woken shortly after her husband died. It was not possible to move her from her bedroom as there were no other rooms available at that time.
39. The Home said staff may have decided not to wake and tell her immediately to avoid distress whilst they carried out the necessary verification of death procedures for her husband.
40. The Home went on to say Mrs C suffers from Parkinson’s Disease, dementia and has a diagnosis of long and short-term memory loss which can lead to difficulty in retaining information.
41. The Home agreed that staff should have put up a screen and may have not done so during the incident. It said it had offered its apologies for this.
42. Regarding the undertakers, the Home said the undertakers who attended that morning were the Home’s usual service providers and were fully aware of the exit code. In addition, the Home said the exit code was clearly marked on the keypad. However, it apologised for the delay in letting the undertakers out.
43. Regarding the nurse in charge asking Mr B how long he would be, the Home said it was under lockdown and all visits were cancelled. However, time limited visits on compassionate grounds where a resident is at the end of their life or who has just died were facilitated under strict control procedures.
44. The Home said its COVID-19 visiting policy, which Mr B was aware of, these visits were to be limited to one hour. The Home said therefore the nurse in charge was right to enquire how long Mr B was intending to stay however it said this may have come across as inconsiderate at that time.
45. Regarding the notes being in view of Mrs C the Home said she was Mr C’s next of kin and due to her advanced dementia would not have been able to understand his records.

Analysis

46. Regarding staff not telling Mrs C her husband had died this was a difficult situation.
47. However, if staff had placed a screen around Mr C this may have been less distressing for Mrs C. In addition the Home did place a member of staff with Mrs C to comfort her while Mr C was being removed from the room so it should have done this while staff were checking if Mr C had died rather than leaving her on her own until Mr B arrived. A screen would have also protected Mr C’s dignity.
48. Regulation 10 of the Health and Social Care Act Regulations deals with privacy and dignity. It states:

“Service users must be treated with dignity and respect.

Without limiting paragraph (1), the things which a registered person is required to do to comply with paragraph (1) include in particular—

ensuring the privacy of the service user;”

49. The guidance to this Regulation states:

“Each person's privacy must be maintained at all times including when they are asleep, unconscious or lack capacity.”

And

“People using the service must not be neglected or left in undignified situations”

50. Therefore, I have found fault in this aspect of the complaint in the lack of dignity and privacy observed by not putting a screen around Mr C after he had died.
51. Regarding Mrs C being in the same room as the undertakers removed Mr C’s body, I can understand that there were no other rooms available to place Mrs C while this was taking place. The Home had a COVID-19 outbreak and this meant that residents could not be moved to different rooms. However a screen could have been put around Mrs C’s bed so she did not have to witness it. Mr B could then have chosen whether he also wanted to stay behind the screen rather than having to witness the traumatic events. Therefore, I find fault with the Home in this aspect of the complaint in not adhering to Regulation 10 in respecting privacy and dignity.
52. I do not find fault with the Home in relation to the delay of the code as the delay was a matter of a few minutes although I understand in view of the prior events it was still distressing for Mr B.
53. The Home have accepted that it may have been insensitive in asking how long Mr C was likely to take. I agree that it was insensitive even taking into account the reasons behind the question. It is understandable this insensitivity caused Mr B frustration during a distressing time.
54. Regarding Mr C’s notes there is no indication that Mrs C read the notes which were not left out for a long period of time. In addition they were removed at Mr B’s request. Therefore, I have not found fault in this matter.

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Recommendations

55. Due to the faults and impact to Mr B which I have outlined, the Home has agreed to carry out recommendations to help address the matter.
56. By 30 April 2022 the Home has agreed to write to Mr B acknowledging and apologising for the distress and frustration caused by the faults I have outlined in relation to:

• the lack of privacy and dignity offered to Mr and Mrs C after he died; and
• the insensitivity displayed by staff to Mr B when asking him how long he would be at the Home.

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Final decision

57. I have found fault in some aspects of the care provided to Mr and Mrs C, causing injustice to Mr B. The Home has agreed to acknowledge and apologise to Mr B for the distress and frustration these faults caused him.

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Parts of the complaint that I did not investigate

58. I have not investigated:

• items in quarantine were not given to his parents;

• the family paid extra for items which the Home did not give to his parents;

• his mother’s wheelchair was lost; and

• his parents’ bedding was lost

59. This is because the Home has already offered apologies and where appropriate given refunds in these matters which are appropriate remedies for the injustice caused and so I would not recommend it carry out any further action.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman