Summary: Miss X complains Hanford Manor failed to look after her late father, Mr Y, properly when he stayed there in February 2021. She says this resulted in a rapid decline in his condition and poor infection control, which resulted in him catching COVID-19 from which he died. Hanford Manor failed to produce care plans for meeting Mr Y’s needs. Although this did not cause injustice to Mr Y, Hanford Manor needs to improve its working practices.

The complaint

1. The complainant, whom I shall refer to as Miss X, complains Hanford Manor failed to look after her late father, Mr Y, properly when he stayed there in February 2021. She says this resulted in a rapid decline in his condition. She also says poor infection control resulted in him catching COVID-19, from which he died.

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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. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. 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”.

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Miss X;
• discussed the complaint with Miss X;
• considered the documents Hanford Manor has provided;
• shared a draft of this statement with Miss X and Hanford Manor, and taken account of the comments received.

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What I found

Key facts

6. Mr Y had dementia. His family looked for a care home while Mrs Y had tests done.
7. Miss X visited Hanford Manor, a residential care home, on 4 February 2021. She says she was allowed in without taking a lateral flow test or having her temperature checked. Hanford Manor disputes this, saying her temperature was 36.4 C and the lateral flow test result on her phone said she was negative.
8. Miss X took Mr Y went to stay at Hanford Manor on 7 February. She says she offered to provide evidence of a negative lateral flow test on her phone but Hanford Manor said it did not need to see this as it trusted her. Hanford Manor says Miss X provided photographic evidence of the test results. Hanford Manor completed a body map which identified swollen ankles, discoloured skin on his calves, and swollen and discoloured fingers. It also started producing a personal profile to identify Mr Y’s care needs. This covered: health needs; mental health needs; breathing difficulties; emotional needs; physical needs (sight, speech, continence, nutrition, personal hygiene, mobility, lifting/moving, foot care); falls; sleeping; social needs; spiritual needs; and medication. The personal profile reflects input from Mr Y’s family but is incomplete. Hanford Manor did not produce care plans for Mr Y.
9. Miss X went to visit her father on 8 February. She says he had been left in a soiled continence pad and a care worker soiled his trousers when changing the pad. Hanford Manor says Miss X could not have known when her father had defecated but accepts the care worker soiled his clothing. It puts this down to Mr Y being a new resident and his family remaining in the room while his pad was being changed. Miss X says the care worker failed to follow her advice on how best to help her father. Hanford Manor gave Miss X a document to complete to provide information to help it understand Mr Y’s needs better. Miss X told Hanford Manor the room was “quite cold” and suggested providing a blanket at night. She later said the room was “ice cold” but Hanford Manor never corrected this. It has denied there was a problem with the heating.
10. Hanford Manor moved the furniture around in her father’s room. Miss X says it did this despite advising it would disorientate him. When responding to an e-mail from Miss X, the Manager said she assumed the family had rearranged the furniture but she would have it moved back as that was not the case. However, other records say it moved the furniture round so Mr Y could see his bathroom from his bed, as it understood that may make him feel more at ease.
11. Miss X says a care worker shouted at her father when assisting him in the bathroom. She also says the care worker spoke too quietly for her father. Hanford Manor says this was early in Mr Y’s stay and the best way of communicating with him had not yet been determined.
12. Miss X says at the first window visit her father was on the other side of the room, so he could not see her or understand what was going on. She says he was very lethargic. According to Hanford Manor’s records, Mr Y had been unsettled throughout the night, spending much of it in the lounge.
13. On 12 February Hanford Manor e-mailed a GP raising concerns that Mr Y may have Parkinson’s disease. It said he was very stiff, did not bend and hesitated when walking. It said his family reported a paramedic raising similar concerns following a fall. The GP said they could discuss this on the next visit, noting there was around a six-month wait to get a diagnosis from the hospital.
14. Hanford Manor also e-mailed Miss X saying it would not break protocol and had not said she could visit every day. It said Mr Y should be at home with Miss X and suggested collecting him on 14 February. Miss X e-mailed Hanford Manor, acknowledging that she was finding it difficult adapting to her father being in the home while visits were restricted, but asked if he could stay. She spoke to the Manager who explained about the concerns that Mr Y may have Parkinson’s disease. In an e-mail Miss X said she had not realised her dad was “as bad as he is” and they would not have known were it not for Hanford Manor. It agreed Mr Y could stay another week to see if he settled. Miss X says they had already started looking for another care home, as they were not happy with Mr Y’s care.
15. Mr Y had a fall when his right knee buckled while using his walking frame. Staff tried to use a hoist to lift him from the floor but he refused to cooperate. However, he followed instructions on getting himself up. He had no apparent injury.
16. On 13 February Mr Y grazed and cut the back of his right hand on his wheeled walker. Hanford Manor completed a body map and an incident form, which says he grazed his hand after becoming aggressive and distressed when staff attempted to deliver continence care.
17. Miss X says when she visited on 14 February her father had purple swollen feet and did not have his walking frame. Hanford Manor accepts Mr Y’s feet were swollen. It says he:
• was unsettled;
• slept in a chair, as his family said he had never used a recliner (in which his feet would have been raised) and would not use one;
• would not rest in bed or use a foot stool, which would also have enabled his feet to be raised; and
• always had his frame close by, unless using a wheelchair.
18. According to Hanford Manor’s records for 14 February, Mr Y’s mobility was very poor so staff used a wheelchair to transfer him. Miss X e-mailed Hanford Manor asking staff to leave Mr Y with his walking frame. She noted her father liked to wander, could not do this without his walking frame and his mobility would decline if he did not walk.
19. On 15 February Hanford Manor told Mr Y’s family it was not the correct setting for him. It said:
• his mobility was very poor;
• he would often try walking without his walking frame and was aggressive to staff (hitting and spitting) if they encouraged him to use it;
• he would refuse to sit down or would sit on the floor, making it difficult to keep him safe; and
• he refused help with personal care after soiling himself.
20. According to Hanford Manor’s records, it took four members of staff to assist Mr Y with personal care and he started hitting out at them. He was taken to the lounge in a wheelchair. He kept trying to get up. Staff asked him “several times to sit and be safe”.
21. On 16 February Miss X had a window visit with her father. He was very lethargic and still had purple swollen feet. He was not wearing his glasses, so a care worker fetched them. Miss X says the care worker did not put them on properly. She asked about the bruise on her father’s hand. A care worker said he had knocked his hand on the drawers by his bed. Miss X asked to speak to a Manager but someone in charge of entertainment came to speak to her.
22. On 17 February Mr Y tested negative for COVID-19. He had spent the night in the lounge since 01.45. Hanford Manor told Miss X her father would be on bed rest after dinner as he was very lethargic, so it was not a good day to visit. Mr Y did not want to get out of bed for his tea. When Miss X called her father at 21.00, he said he wanted to get up but she advised him not to.
23. On 18 February when Miss X visited, Mr Y was sat in the window with no socks but wearing a pyjama top. He was unshaven and his eyes had not been wiped. He was in a wheelchair with no walking equipment. Hanford Manor’s records say Mr Y did not want to stand using his frame. He was physically and verbally aggressive towards its staff, and refused help with shaving and brushing his teeth. He accepted some help with personal care later in the day.
24. Mr Y left Hanford Manor on 19 February. Before leaving staff helped him shower and “did the best they could with a shave due to his behaviour”. His family took him to a nursing home. Miss X says:
• he was sleepy and lethargic on 20 February;
• on 21 February staff could not wake him so he was taken to hospital where he tested positive for COVID-19 and later died;
• on 23 February Miss X and Mrs Y received negative test results for COVID-19.

Did the care provider’s actions cause injustice?

25. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations. We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet them. They need to do this for all residents.
26. When someone moves to a care home it takes time to develop care plans for meeting their needs because it takes time to get to know someone properly. Also, people’s needs can change when they are in a new environment. Hanford Manor started assessing Mr Y’s needs but did not complete the task. Nor did it produce any care plans for meeting his needs. It seems likely this was because it quickly decided Mr Y would be better placed elsewhere. It suggested he return home, because Miss X found it difficult to deal with the restrictions on visiting, but agreed he could stay longer to see if he settled.
27. But Mr Y did not settle. It appears the move to residential accommodation resulted in a disturbed sleep pattern. This in turn resulted in him being tired during the days, some challenging behaviour and a reluctance to mobilise with his walking frame. If Hanford Manor had produced care plans it could have considered ways to address these issues. While that was fault, given the short time Mr Y was there, there is not enough evidence to say the outcome would have been different. Nevertheless, Hanford Manor needs to improve its working practices.
28. It is not possible for me to say when or how Mr Y contracted COVID-19. It is possible he contracted it while at Hanford Manor. But it does not necessarily follow from that that it was due to poor infection control. The information on the CQC’s website says there were three deaths from COVID-19 during 2020/21 at Hanford Manor, all in April to June 2020. That does not suggest significant lapses in infection control.

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Recommended action

29. I recommend Hanford Manor within six weeks takes action to improve its working practices by introducing timescales for the completion of care plans, to make sure they are produced along with needs assessments.
30. Under the terms of our Memorandum of Understanding and information sharing protocol with CQC, I will send it a copy of my final decision statement.

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Final decision

31. I have completed my investigation on the basis that Hanford Manor will take the action I have recommended to improve its working practices.

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Investigator's decision on behalf of the Ombudsman