Summary: Ms X complains Meavy View Retirement Home (run by MTCARE Property Limited) failed to look after her mother properly while she was living there during the COVID-19 pandemic in 2020. Meavy View did not keep proper records of the care provided for Mrs Y, which may have put her and others at risk of harm. MTCARE Property Limited needs to apologise and pay financial redress for the distress caused.

The complaint

1. The complainant, whom I shall refer to as Ms X, complains Meavy View Retirement Home (Meavy View) failed to look after her mother properly while she was living there during the COVID-19 pandemic in 2020. She says this resulted in a decline on her mother’s condition.

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What I have investigated

2. I have investigated Ms X’s complaint about the care her mother, Mrs Y, received at Meavy View. I explain at the end of this statement why I have not investigated other matters.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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”.
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)

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How I considered this complaint

7. I have:
• considered the complaint and the documents provided by Ms X;
• discussed the complaint with Ms X;
• considered the comments and documents the care provider has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Ms X and the care provider, and taken account of the comments received.

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What I found

8. Meavy View run by MTCARE Property Ltd (the Care Provider). Mrs Y funded her own placement at Meavy View. She has dementia and is at risk of falls.
9. On 2 April 2020 the Government issued guidance on Admission and Care of Residents during COVID-19 Incident in a Care Home. This said to:
• follow social distancing measures for everyone in a care home, wherever possible, and the shielding guidance for the extremely vulnerable;
• implement daily monitoring of COVID-19 symptoms among residents and care home staff twice daily, including temperature checks for a fever;
• isolate anyone with symptoms in a single room with a separate bathroom, where possible; and
• contact a GP if symptoms worsen or do not improve after seven days.

Key facts

10. Meavy View closed to visitors from 14 March 2020 because of COVID-19. Ms X could no longer visit her mother inside the home but had some window visits. Sometimes she was also able to speak to her mother over the telephone. She called frequently to check on her mother’s condition. Ms X says for the window visits her mother would sit on a chair by a window which was sometimes closed and sometimes ajar. She says on one occasion she had to hold her mother to prevent her from falling when she tried to reach her out of the window.
11. On 4 May, 18 out of 25 staff at Meavy View tested positive for COVID-19. Rochdale Borough Council provided staff to cover for those who were off sick or self-isolating. However, the Care Provider remained accountable for what went on at Meavy View.
12. Meavy View’s records for the following week are very brief. There is no record of checking Mrs Y for symptoms of COVID-19.
13. On 13 May Mrs Y was not well. A District Nurse visited and advised returning her to her room. Meavy View sent the NHS a list of residents who needed testing for COVID-19. This included Mrs Y whose symptom was a bad cough.
14. On 14 May Meavy View told Ms X her mother was “under weather” and waiting for a COVID-19 test result.
15. On 17 May Mrs Y tested positive for COVID-19. Ms X rang for an ambulance but Mrs Y did not need to go to hospital.
16. On 18 May Ms X told Meavy View she wanted her mother to be treated in hospital. However, its records say the paramedics and a GP did not agree to this as she was “well at the moment”. Her observations were normal and she was eating and drinking normally. A GP agreed to call Ms X to discuss her concerns.
17. On 19 May Mrs Y was “fine” but “washed out”. She had good oxygen levels and pulse. She was isolated in a lounge because of the risk of falls.
18. On 21 May Mrs Y was “looking well” and her observations were normal. It appears she recovered quickly from COVID-19.
19. Towards the end of May the passenger lift broke and was not repaired until after Mrs Y had left. After the lift broke, Mrs Y spent most of her time in her room upstairs. She sat in her chair watching TV. Ms X says staff were reluctant to take the phone up to her mother’s room after the lift broke.
20. By 3 June Meavy View was free from COVID-19. Seven residents had died from COVID-19.
21. On 12 June a stair-lift was installed at Meavy View.
22. On 15 June Meavy View updated Mrs Y’s moving and handling assessment. This says she:
• could mobilise independently using a wheeled walker; and
• needed help from one person to use the stair-lift, until the passenger lift was repaired.
23. Mrs Y spent time in the lounge on 19, 22, 25, 29 and 30 June. On other days she preferred to remain in her room.
24. On 5 July Mrs Y had three sachets of laxative to help her go to the toilet. Around 16.30, after having her tea, she vomited. At 17.17 Meavy View asked for a District Nurse to check Mrs Y over. A District Nurse visited at 18.55 and requested a visit by a GP, who could prescribe enemas. Meavy View told the out of hours GP service Mrs Y had not opened her bowels “for a few days at least” and possibly a week. Later, during a telephone call, a GP diagnosed constipation and referred Mrs Y for a face-to-face assessment.
25. On 6 July a GP visited at 20.26 and prescribed enemas for constipation and impacted stools, noting she may need more than one enema. The GP advised Meavy View to ask for a District Nurse to visit when the enemas arrived, and to call for an ambulance if the enemas did not work. Meavy View asked for a District Nurse to visit at 20.58 to administer an enema.
26. At 17.19 on 7 July Meavy View asked a District Nurse to visit to administer another enema.
27. A District Nurse visited at 09.48 on 8 July and administered another enema, after examining Mrs Y’s bowels.
28. On 9 July a District Nurse visited at 08.53 to administer the fourth enema. Mrs Y had not yet had a proper bowel movement, despite also taking oral medication to ease constipation. The District Nurse asked for a GP to review Mrs Y, as she may need to go to hospital. A GP visited and prescribed suppositories.
29. A Community Staff Nurse visited at 09.25 on 10 July to administer a suppository. A Nurse administered a second suppository at 16.15.
30. At 10.55 on 11 July a Community Staff Nurse administered another suppository. Mrs Y had had a small bowel movement. Another suppository was administered at 16.46. Mrs Y was not in pain and was not nauseous, but her abdomen was hard and distended.
31. On 12 July paramedics took Mrs Y to hospital.
32. When Mrs Y left hospital on 7 August she moved to another care home.
33. The Care Quality Commission inspected Meavy View in September and published a report in November. This says Meavy View required improvement to make it safe and well-led. With regard to infection prevention and control, CQC was “assured” in most areas but only “somewhat assured” over the arrangements for visitors, use of personal protective equipment and its policies.
34. Ms X complained to the Care Provider on 14 September. When the Care Provider replied on 11 November it said:
• Ms X had been able to have window visits with her mother and speak to her over the telephone;
• Mrs Y had not needed hospitalising when she had COVID-19;
• there was no evidence of a significant deterioration in Mrs Y’s health after she recovered from COVID-19; and
• Mrs Y weighed 50kg in January, 47.5kg in June and 48.1kg before she went to hospital and never lost her appetite.

Did the care provider’s actions cause injustice?

35. Meavy View was badly affected by COVID-19, which resulted in most of its staff being away from work and the deaths of seven residents.
36. Our guidance on Good administrative practice during the response to COVID-19 emphasises the need for basic record keeping during a crisis. Meavy View’s records did not meet this requirement. It failed to evidence monitoring Mrs Y for symptoms of COVID-19. This could have put her and others at risk of harm.
37. Meavy View also failed to monitor Mrs Y’s bowel movements. This meant it was unable to say how long it was since she had opened her bowels in July and may have resulted in a delay in seeking medical attention.
38. As is often the case when records are inadequate, it is difficult to be precise about the impact and the injustice this has caused. Nevertheless, the Care Provider needs to apologise and pay financial redress. I will not make specific recommendations for service improvements as I am aware that both CQC and Rochdale Borough Council have already been working with Meavy View to improve its working practices.

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Recommended action

39. I recommend the Care Provider within four weeks:
• writes to Ms X apologising for the distress it has caused her and her mother, and the time and trouble it has put her to in pursing the complaint; and
• pays Mrs Y £500 and Ms X £250.
40. 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

41. I have completed my investigation on the basis that the Care Provider’s actions have caused injustice and it will take the action I have recommended to remedy that injustice.

Parts of the complaint that I did not investigate

42. I have not investigated Ms X’s complaint about the loss of some of her mother’s possessions. Ms X replaced them and was repaid by her mother’s Court appointed Deputy for property and affairs. Ms X has therefore suffered no injustice herself. It would be for the Deputy to complain on behalf of Mrs Y. Ms X cannot do this, as she has no responsibility for her mother’s property and affairs.
43. I have also not investigated Ms X’s complaint that Meavy View failed to follow a recommendation in a 2018 deprivation of liberty safeguard for Mrs Y to move to a more suitable room when one became available. This is because of the restriction in paragraph 6 above. This is a late complaint and there are no grounds to investigate it now, not least because the 2019 deprivation of liberty safeguard did not make the same recommendation.

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Investigator's decision on behalf of the Ombudsman