Summary: Mrs D complains about the Care Provider's actions during the COVID-19 pandemic while her late mother was a resident at St Mary's Care Centre. We have found it was fault for the Care Provider not to facilitate an indoor end of life visit for Mrs D and her brother. This has caused significant injustice to them as they missed an opportunity to spend time with their mother before she died. The Care Provider has agreed to apologise to them.

The complaint

1. Mrs D complains about the Care Provider's actions during the COVID-19 pandemic while her mother, Mrs F, was a resident at St Mary's Care Centre. In particular she complains it:
1. Did not follow guidance and took an inconsistent approach to allowing visits to her mother who was at the end of her life. Mrs D says she was wrongly only allowed to see her mother through the window or outside, depriving them of precious time together in her final days.
2. Abruptly closed the window during one of her visits, causing distress.
3. Cancelled one of her brother's visits, but then asked where he was, and only allowed the re-arranged visit to last for 15 minutes.
4. Delayed advising the family that if Mrs F deteriorated, they could sit with her for an hour, preventing her brother from seeing his mother again in the days before she died.
5. Failed to label her mother's personal belongings, causing them to go missing after she passed away adding further distress when they were grieving.
6. Failed to offer condolences despite there being opportunities to do so and failed to show compassion or empathy in their communications with the family, causing them to feel upset and distressed.

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The Ombudsman’s role and powers

2. 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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

4. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
5. We may investigate matters coming to our attention during an investigation, if we consider that a member of the public who has not complained may have suffered an injustice as a result. (Local Government Act 1974, section 26D and 34E, as amended)
6. 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 “Good Administrative Practice during the response to COVID-19”.
7. 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.
8. 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

9. I spoke to Mrs D about her complaint and considered the Care Provider’s response to my enquiries and:
• Guidance: Admission and care of residents in a care home during the COVID-19 pandemic, Public Health England, 2 April 2020
• Guidance: Update on policies for visiting arrangements in care homes, Public Health England, 22 July 2020
10. Mrs D and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Visiting arrangements in care homes during the COVID-19 pandemic

11. Guidance on care home visiting arrangements changed throughout the period covered by this complaint. The April 2020 Guidance said family and friends should be advised not to visit care homes, except next of kin in exceptional situations such as end of life. Visitors should be limited to one at a time to preserve physical distancing and alternatives to in-person visiting should be explored.
12. Further guidance was issued in July 2020, which set out the broad principles on which local policies should be based. Among other things, it advised:
• taking into account the extent of the harm that will be experienced by the resident from a lack of visitation or whether the individual is at the end of their life
• balancing the benefits to residents against the risk of visitors introducing infection;
• limiting visitors to a single constant visitor per resident, wherever possible;
• reducing risks via visits to communal gardens, window visits and/or drive through visits;
• encouraging visitors to keep personal interaction with the resident to a minimum.
13. In response to our enquiries, the Care Provider says it did not have a specific visiting policy and its care homes were advised to follow local policy due to regional variations and as guidance changed frequently.
14. The relevant local authority guidance issued in June 2020 says care homes could only allow two visitors outside "unless it is to see someone who is at the end of their life”. Indoor visits should be restricted to one person.

What happened

15. Mrs F had been a resident of St Mary's Care Centre (“the Home”), operated by Private Medicare Ltd (the “Care Provider”) since 2019. She had a daughter, Mrs D, who lived nearby and a son, Mr M, who lived about a five-hour drive away.
16. In March 2020, in response to the developing COVID-19 pandemic, the Home’s manager decided to stop all indoor visits by friends and family to manage the risk of infection. Visitors were able to talk to residents through the windows.
17. In July 2020 Mrs F had a stroke and went into hospital. She was discharged on 31 July. The records show that on her return she received personal care and medication, was re-positioned and was eating and had thickened fluids. Mrs F’s daughter, Mrs D, would visit to see Mrs F through the window.
18. The Home says all staff had been advised at an 8am handover not to take any windows off the restrictors that limited opening when family visited. One member of staff did not arrive until 9.30am and this message was not passed on to her.
19. On 9 August, a nurse asked Mrs D not to open the window wide and lean in. Mrs D said she had been allowed to do this previously and complained about the nurse’s abrupt attitude.
20. A few days later, Mrs D advised the Home that Mr M had travelled up hoping to see his mother. It was agreed he could visit her outside on 17 August. On 16 August, the Home rang to cancel this visit as it said Mrs F was too ill.
21. The care records show the Home told a stroke nurse on 16 August that Mrs F had deteriorated and was declining food. The nurse advised Mrs F’s medications should be reviewed.
22. On 17 August the Home’s manager called Mrs D asking where Mr M was, as Mrs F had been got ready for his visit. It was agreed he could visit outside for 30 minutes the following morning. The Home spoke to the pharmacist about Mrs F’s medication review. The pharmacist said he would ask the GP about the possibility of end of life care. The Doctor later advised the Home “not to worry if Mrs F won’t take her meds” and to await a call from the palliative care team.
23. The Home says the next day Mrs F was poorly but was brought outside to see her son. Mr M arrived ten minutes late and the Home only allowed him to see Mrs F for 15 minutes before taking her back inside.
24. The Home contacted Mrs F’s GP on 19 August about her deterioration, very poor diet and fluid intake, and to seek advice about end of life care. The Doctor called that afternoon. She said to stop all oral medication and she would arrange for end of life medication. The Home told Mrs D what the Doctor had advised. The GP reviewed Mrs F by video call on the morning of 20 August and was assured that she appeared comfortable and in no pain.
25. Mr M decided to travel back to his home on 21 August as he believed he would not be allowed to visit Mrs F again. Mrs D visited that afternoon and saw Mrs F through the window. She says the Home told her then that if Mrs F deteriorated further she and Mr M could visit her inside. This was distressing as Mr M had already left and was unable to travel back. Mrs F passed away at about 6am on the following morning without having had a visitor as the Home did not consider Mrs F had deteriorated.
26. Mrs D collected Mrs F’s belongings a few days later, but her handbag containing some valuables was missing. It had not been labelled and had been given to the family of another resident. It was later returned to Mrs D.

Mrs D’s complaint

27. Mrs D made a formal complaint on 30 August. The Care Provider replied on 17 September. It offered condolences and apologised for the poor communications in relation to Mrs D’s window visit and the initial cancellation of Mr M’s visit. The Home had carried out a “lessons learned” session and would improve practice by:
• Making all staff aware of the need to tie named labels on all items brought to the office for safekeeping and to hand them in person to either the Manager or Administrator.
• Recording all staff briefings on a daily “flash meeting” document
• All nursing and senior care staff speaking to any visitor observed trying to gain access to their relative through the window.
• Having better communication with relatives at the end of the resident's life.
• Discussing final arrangements with families at admission, especially if end of life care is to be provided.
• Documenting discussions in the care folder.
28. The letter said the Care Provider had introduced guidance in relation to visits at the end of life and had followed the national Guidance. It had asked that the number of visitors at any person’s bedside should be limited to one close family contact. Mrs D then raised concerns with the Care Provider about inconsistent policies across its homes and complained to the Ombudsman. Mrs D told us she was concerned the Home would not implement improvements to practice.
29. The Care Provider wrote to Mrs D on 25 November. It said its home managers had made decisions on an individual basis regarding families visiting during end of life care. It apologised this resulted in inconsistency but said each home followed different local guidance.

My findings

30. There is no fault by the Care Provider in having different visiting policies in place across its care homes. The Guidance says local policies should be developed and these should be based on balancing the benefits to residents against the risk of visitors introducing infection. Home managers are entitled to make these risk assessments and reach different conclusions based on the circumstances in their home, including for different residents at different times. Our guidance on good administrative practice during the response to COVID-19 says individual circumstances should be considered and clear audit trails kept of how and why such decisions are made.
31. The Care Provider has accepted it mislaid Mrs F’s handbag. It also accepted there was poor communication with Mrs D and Mr M in relation to their visits. It has already apologised for these issues.
32. The Home’s lessons learned review said that it had decided it was not in Mrs F’s best interests to stay outside for a prolonged period of time when Mr M visited. On reflection, the Care Provider considered he should have been allowed to come inside and have his final visit.
33. In response to Mrs D’s complaint, the Home said Mrs F’s final deterioration was rapid which meant Mrs D was not able to have her final visit indoors. In response to our enquiries, the Home’s manager said Mrs F did not display any signs that her death was imminent and that if she had realised that Mrs F only had a short time left to live, she would have permitted an end of life visit of two people for an hour indoors.
34. However, the records show that on 17 August the pharmacist had referred to seeking advice from the GP about end of life care. The Home was aware Mrs F was at the end of her life from 19 August, following discussion with the GP who clearly stated this.
35. I therefore find it was fault for the Care Provider not to facilitate an indoor end of life visit for Mrs D and Mr M at some point from 19 to 21 August. This has caused significant injustice to them as they missed an opportunity to spend time with Mrs F before she died.
36. In my draft decision statement, I recommended the Care Provider send evidence to the Ombudsman that it had made the changes it agreed at the lessons learned review. In response it said:
• Anything brought into the office is now labelled with the residents name, date and the time and handed directly to the administrator or manager. There have been no further reports of items going missing.
• The manager now attends shift handovers every morning. This is also attended by domestic staff, care staff and nurses.
• Communication regarding residents at end of life had improved and there have been no further formal concerns raised. The manager now telephones families once a person has passed away to offer her condolences and allow them the opportunity to discuss any concerns they may have.
• Families were sometimes reluctant to discuss final arrangements on admission, but the Home will continue to approach the subject during the initial assessment or on admission.
• Recording of discussions with families has improved. The Home is to go onto an electronic system that will provide the home manager and company greater oversight of the services and make it easier for staff to record conversations with relatives.

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Agreed action

37. Within a month of my final decision, the Care Provider has agreed to apologise to Mrs D and Mr M for the injustice caused to them by its failure to allow indoor end of life visits for them both.

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Final decision

38. There was fault by the Care Provider. The actions it has agreed to take remedy the injustice caused. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman