Summary: Mrs X complained about the actions taken by Seacroft Grange Care Village to protect her mother, Mrs M, during the COVID-19 pandemic and the actions and care prior to her death. I have not reinvestigated most of Mrs X’s complaints because the Council carried out a robust and thorough investigation which identified some areas of fault, and I could achieve nothing further. However, the Council should provide evidence the Care Home has carried out the recommendations it made. Where I have investigated, there was no fault.

The complaint

1. Mrs X complained about the steps taken by Seacroft Grange Care Village to protect her mother, Mrs M, during the COVID-19 pandemic and the actions taken and care it provided leading up to Mrs M’s death.
2. Mrs X said this has caused her enduring distress and left her traumatised.

Back to top

The Ombudsman’s role and powers

3. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where councils provide services themselves, or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases.
4. In this case, the Council arranged and commissioned Mrs M’s care. Therefore, we have treated the actions of the Care Provider, including any fault identified, as those of the Council.
5. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
7. If we are satisfied with a council’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)
8. 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 Council and Care Provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.

Back to top

How I considered this complaint

9. I spoke to Mrs X and considered her view of her complaint and the information she submitted. This included Mrs M’s daily care records and communication sheets and other documentation relating to her care.
10. I spoke to a Council officer and made enquiries. I considered the information it provided. This included the safeguarding documentation and complaints correspondence.
11. I wrote to Mrs X and the Council with my draft decision and considered their comments before I made my final decision.

Back to top

What I found

Background

12. Mrs M, who had dementia and diabetes, had been a resident at Seacroft Grange Care Village (the Care Home) since 2014.
13. In March 2020, the Care Home went into lockdown because of the COVID-19 pandemic.
14. At the beginning of April, there was an outbreak of COVID-19 at the Care Home.
15. On 17 April Mrs M died without her family present. The cause of death was COVID-19 related pneumonia.

Complaint to the Care Provider

16. Mrs X made a formal complaint to the Care Provider which owned the Care Home and said that it:
1. failed to take adequate steps to protect residents from contracting COVID-19, resulting in an outbreak and its spread between residents. This included a failure to always wear appropriate Personal Protective Equipment (PPE);
2. failed to inform her of the COVID-19 outbreak;
3. failed to inform her of the deterioration in Mrs M’s health which began on 13 April and did not mention Mrs M may have COVID-19;
4. behaved in an abrupt and unempathetic manner when a Care Home nurse informed her on 16 April that Mrs M had now gone onto end-of-life care and spoke to her brusquely about whether Mrs M had a Do Not Attempt Cardio-Pulmonary Resuscitation (DNAR) form in place;
5. called an ambulance even though Mrs M’s care plan said she should not be taken to hospital at end of life but should remain in the Care Home;
6. delayed in organising oxygen for Mrs M;
7. delayed in telephoning her so she was too late to be with Mrs M when she died;
8. had no one to let her in when she arrived to be with her mother on the morning she died;
9. lied to her and falsified documents because there were discrepancies over the timing of events on the day Mrs M died; and
10. failed to give Mrs M her diabetes medication between November – December 2019 which might be a factor in why she was unable to fight of the COVID-19 infection.

Care Provider response to Mrs X

17. The Care Provider replied to Mrs X about her complaints. In summary it said:
• the Care Home had written to families on 8 April to say there was a COVID-19 outbreak in the Care Home. It could not explain why Mrs X had not received the letter;
• the notes recorded Mrs M became increasingly sleepy and tired from 10 April, although there were periods when her health improved. The GP was called on 13 April. Mrs M’s vital signs were recorded and the GP advised staff to continue to monitor Mrs M. Staff spoke to Mrs X three times on 14 April to update her. The GP reviewed Mrs M again via telephone on 15 April and no changes were made;
• the notes recorded a significant change was observed on the morning of 16 April in Mrs M’s breathing. The GP reviewed Mrs M virtually and a discussion took place with Mrs X. The Care Home made the decision to call for an ambulance. The paramedics administered oxygen and the GP prescribed antibiotics, paracetamol and oxygen;
• there was evidence of communications with Mrs X throughout the night of 16/17 April;
• the notes for the morning of 17 April were disorganised but this was not an attempt to falsify records. After talking to the staff delivering care to Mrs M, the Care Provider found the notes were written around four hours after Mrs M’s death as at the time the staff were delivering care to her. The Care Provider said improvements would be made to the Care Home’s record-keeping to ensure more accurate notes were maintained;
• it sincerely apologised that Mrs X was not with Mrs M when she died. Staff did not expect her to die so quickly. The Care Provider noted Mrs X’s comments that the time she was called was later than the time recorded in the notes and said this was because the notes were written after the events had occurred. The Care Provider stated it did not believe there was any unjustified delay in calling her;
• the Care Provider and the Care Home had spoken to the nurse Mrs X said had been abrupt to her. The Care Provider apologised Mrs X felt there had been a lack of compassion and said the nurse “has reflected on this, understands the need to show empathy towards others at all times and especially when dealing with distressing, difficult conversations”; and
• it apologised no one was on reception to let Mrs X in immediately she arrived.

Council safeguarding investigation

18. Mrs X also made a safeguarding referral to the Council about issues relating to the actions of the Care Home during the pandemic and her belief the Care Home had lied to her over various issues and communicated poorly.
19. The investigator contacted the Care Provider to ask for a response to the issues raised by Mrs X. The Care Provider responded with the following key points:
• it had followed government guidance in relation to Personal Protective Equipment (PPE) and social distancing and could evidence this through emails, staff briefings, training sessions and other resources. The management team carried out a daily walk to monitor whether the guidance was being followed and although social distancing could not be adhered to at all times staff did their best where they could;
• the Care Home had been split into two zones – Red and Green. Staff did not mix across the two zones but did mix within a zone. When using agency staff, the Care Home tried to use the same staff to reduce any risk. Before resuming work after a long period off, staff had to test negative for COVID-19;
• staff would move between different care homes owned by the Care Provider but were tested beforehand. If staff had to go to more than one home in a day they avoided contact with residents in the second home and had a full change of clothes;
• without specific instances, the Care Home could not respond to Mrs X’s complaint it had lied to her. It stated Mrs M’s health had deteriorated quickly which may have led Mrs X to believing the Care Home had not relayed information accurately or promptly; and
• there were no apparent inaccurate or falsified records. The Care Provider agreed the Care Home had not communicated sufficiently with Mrs X in relation to changes in Mrs M’s condition prior to her death which may have led Mrs X to believe the records were inaccurate.
20. The investigator stated they had received a copy of Mrs M’s care notes and discussed these with Mrs X. The investigation recorded Mrs X was unable to be date specific and “reflected that she did not have concerns about how staff delivered care to her mother and reiterated that her concerns were lack of communication with management and Covid compliance issues”.
21. The investigator recorded they had examined the care and medication administration records and was satisfied there were no safeguarding concerns or further enquiries to make about them. They said the Care Home had “acknowledged that the quality could have been better and have made improvements in these processes for future practices".

Complaint to the Council

22. As well as raising a safeguarding alert, Mrs X also made a complaint to the Council. This detailed specific incidents when Mrs X believed staff at the Care Provider’s care homes, including the one where Mrs M had been resident, had breached COVID-19 regulations.
23. The Council made enquiries of the Care Provider. It examined the relevant case notes and staff rotas and spoke to the Care Home manager.
24. The Council wrote to Mrs X and provided a detailed response to each of her complaints. Its conclusions included:
• the investigation of staff moving between different floors, zones and homes was inconclusive, but in any case the practice of working in different zones on different days was not considered poor practice at that time of the pandemic as long as correct PPE was worn. Therefore, the Care Provider was compliant with government guidance at that time;
• staff had no recollection of some of the events Mrs X complained were increasing the risk of spreading COVID-19, for example, one staff member telling her she took her mask off because some residents were scared by them and another telling her Mrs M had just kissed her. The Council said it would not investigate these issues further;
• in relation to the incident on 10 April when Mrs X considered Mrs M had collapsed, the case records did not support this interpretation. The evidence led the Council to the conclusion the Care Home felt there were no medical concerns that required the GP becoming involved;
• the case notes evidenced Mrs M’s health began deteriorating on 13 April and the Care Home should have informed Mrs X at that time;
• the investigator had seen email correspondence between the Care Home and the nurse who spoke to Mrs X about signing a DNAR form. This demonstrated a ‘reflective’ discussion had taken place. The nurse had apologised for anything she said or how it was said;
• when Mrs X asked the Care Home to provide Mrs M with oxygen on 16 April, it did so;
• the Care Home’s notes were written up four hours after Mrs M died. The Council had examined the phone records and the time of the call to Mrs X was 20 minutes later than the time recorded in the notes;
• record-keeping needed to improve and the Council would monitor this;
• in relation to the administration of some medications to Mrs X in November 2019, the Care Home and the agency which employed the nurse had both investigated and suspended the nurse from working at the Care Home during the investigations. The Council had seen records of actions and discussions with the nurse which showed a thorough investigation had been carried out. The Nursing Agency had also communicated with the Nursing and Midwifery Council (NMC) about the investigation. The Council had informed the CQC and safeguarding of this;
• the Council investigator had examined the medication administration records (MAR) charts for that period and found significant issues with them. The Council had recommended actions the Care Home should take.
25. Mrs X remained unhappy and complained to the Ombudsman.

My findings

26. The Ombudsman provides a free service but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• there is not enough evidence of fault to justify investigating, or
• any injustice is not significant enough to justify our involvement, or
• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome, or
• there is another body better placed to consider this complaint.

(Local Government Act 1974, section 24A(6))

27. In relation to Mrs X’s complaints, which are detailed in paragraph 16 above, I will not investigate points a) – d), g) and i) – j). This is because the Council carried out a robust, evidence-based investigation into these matters. It then made a finding of fault or no fault or stated it was unable to come to a finding on the evidence available. Where the Council found fault, it made suitable and appropriate recommendations to help prevent a re-occurrence of the same faults at the Care Home. The Nursing Agency informed the NMC and the Care Home informed the CQC where appropriate. It is unlikely we could add anything further to these investigations. However, the Council should provide us with evidence that the Care Home has carried out the Council’s recommendations and the Council has undertaken the appropriate monitoring.

Complaint 15e) - the Care Home called an ambulance even though Mrs M’s plan stated she should remain at the Care Home at end of life

28. This specific complaint was not considered either by the Council’s safeguarding investigation nor in its complaint response. However, I will not investigate this matter because I do not consider any injustice is significant enough to justify our involvement. This is because Mrs M was not admitted to hospital and when her oxygen levels dropped, the paramedics called by the Care Home administered oxygen.

Complaint 15f) – delivery of oxygen

29. The Council’s complaint investigation did not consider whether there were any delays in the delivery of oxygen to Mrs M. Therefore, I have investigated this complaint.
30. The communication records note the Care Home called the GP on 15 April at 3pm. The GP made no recommendations for any changes in Mrs M’s care.
31. The record at 18:40 on the evening of 15 April recorded Mrs M was comfortable. At 05:10am on 16 April, the notes recorded she appeared wheezy and chesty. At 08:30am the notes recorded Mrs M was struggling to breathe. The notes do not record when the Care Home called the ambulance but Mrs X believes it was around 9-10am. Mrs M received oxygen whilst the paramedics were there and then later once the oxygen ordered by the GP arrived.
32. The Care Home called an ambulance promptly when it found Mrs M was struggling to breathe. It called the GP without delay who ordered oxygen. There is no evidence of a delay in the Care Home’s actions.

Complaint 15h) – there was no one to let Mrs X in when she arrived at the Care Home

33. This was investigated by the Care Provider but not the Council. The Care Provider apologised there was no one on reception to let Mrs X in as soon as she arrived.
34. I will not investigate this matter further. Even if I was to find fault, I would recommend an apology and this has already been provided to Mrs X. Therefore, an investigation would be unlikely to achieve anything meaningful at this stage.

Back to top

Agreed actions

35. Within three months of the date of the final decision, the Council has agreed to provide evidence that the Care Home has carried out the actions recommended in its complaint investigation and evidence that it has monitored these actions.

Back to top

Final decision

36. I have not investigated most of Mrs X’s complaints because it is unlikely we could add anything further to the Council’s investigation. Where I have investigated, I did not find fault. The Council has agreed to my recommendations. Therefore, I have completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman