Summary: Mrs X complained about events leading up to her husband, Mr X, contracting COVID-19 and being admitted to hospital. These matters have already been investigated by the Care Provider and the Council has also carried out a safeguarding investigation. Both identified fault and the Care Provider has taken suitable actions to help prevent a reoccurrence. The findings of my investigation are in line with these two investigations and I can add nothing further.

The complaint

1. Mrs X complained Banstead Manor Care Home failed to:
• test Mr X for COVID-19 after he displayed symptoms and then failed to carry out observations after he tested positive;
• follow the correct COVID-19 prevention and control policies, including failing to test often enough;
• call Mrs X when Mr X fell on the night of 5 January;
• involve external professionals in Mr X’s care and failed to take appropriate action when Mr X’s health deteriorated on 5 and 6 January;
• have a senior person in charge at the Care Home on the evening of 5/6 January; and
• inform the family of contacts with the emergency services on 6 January.
2. Mrs X says that as a result, Mr X caught COVID-19 and when he was admitted to hospital he had a severe lung infection. Mrs X also said she and the family have been caused distress by the Care Home’s actions.

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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. (Local Government Act 1974, sections 34B and 34C)
4. 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

5. I spoke to Mrs X and considered her view of her complaint.
6. I made enquiries of the Care Provider and considered the information it provided. This included the infection control policies in place at the time events took place, Mr X’s care notes, records of testing of Mr X and staff and all complaints correspondence. I have also considered the Council’s safeguarding investigation, its findings and the Care Provider’s response, together with the agreed actions.
7. I wrote to Mrs X and the Care Provider with my draft decision and considered their comments before I made my final decision.

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What I found

Background

8. The following section provide a brief description of events in December 2020 and January 2021. Because these events were the subject of two investigations by the Care Provider and a safeguarding investigation by the Council, more detail is provided later in this decision statement about each of Mrs X’s complaints.
9. Mr X was admitted as a resident to Banstead Manor Care Home in 2020 following a fall at home. Banstead Manor is owned by Hallmark Care Homes (the Care Provider).
10. Mr X had a number of health conditions, including epilepsy and a condition which meant he had no feeling in his feet, which affected his mobility and increased his risk of falls.
11. In December 2020, Mrs X said she suspected Mr X had COVID-19 after a phone call. She alerted staff at the Care Home and asked them to test Mr X. He tested positive.
12. On 5 and 6 January 2021, Mr X had two unwitnessed falls and a possible seizure, again unwitnessed. As a result, he was admitted to hospital where he was diagnosed with a severe lung infection.
13. Mrs X complained to the Care Provider. Her complaints are listed in paragraph 1 of this decision statement and discussed in more detail below.
14. Surrey County Council also carried out a safeguarding investigation into some of Mrs X’s complaints and issued its findings towards the end of 2021. The Council found evidence of neglect and omission. These findings have been included where relevant. The actions of the Council are not part of this complaint.

Complaint 1 a) the Care Home failed to test Mr X for COVID-19 after he displayed symptoms and then failed to carry out observations after he tested positive

Mrs X’s complaint

15. Mrs X said that she and two other family members spoke to Mr X on 28 December in separate phone calls. All heard him coughing and Mrs X said it was so bad, she had to end the call because Mr X could not speak.
16. Mrs X called the Care Home and explained what had happened. She asked staff to give Mr X a COVID-19 test which they did. Mr X tested positive.
17. Mrs X complained she should not have had to instigate the test and the Care Home should have been aware Mr X was displaying signs of COVID-19 earlier.

The Care Provider’s findings

18. The Care Provider’s Management of COVID-19 policy stated residents who had not tested positive should have their temperature, oxygen saturation levels and visible symptoms of COVID-19 monitored twice daily.
19. The Care Provider found that on 28 December, Mr X’s case notes recorded his temperature alone was checked, and only once. As a result, the Care Provider partially upheld this complaint because it had not followed its own policy.
20. The Management of COVID-19 policy goes on to state that staff should only carry out observations of COVID-19 positive residents if there is a clinical need.
21. Once testing positive, the Care Provider noted staff monitored Mr X at least daily and more frequently when his oxygen levels fell outside acceptable levels. It found the Care Home had monitored Mr X in accordance with his clinical need and did not uphold Mrs X’s complaint.

Complaint 1b) the Care Home failed to follow the correct COVID-19 prevention and control policies, including failing to test often enough

Mrs X’s complaint

22. Mrs X was unhappy the Care Home only tested residents for COVID-19 once a month. She also questioned the Care Home’s infection control procedures because 14 members of staff tested positive.

Care Provider’s response

23. The Care Provider stated that at the beginning of December 2020, the CQC inspected the Care Home as a result of receiving concerns about its management of infection prevention and control (IPC). The CQC examined all aspects of the Home’s IPC practices and rated it as ‘good’.
24. The requirements of Care Provider’s Management of COVID-19 policy in place at the time Mr X tested positive included the following:
• the Home should test residents in line with the testing arrangements in its local area;
• covert handwashing spot checks should be made weekly;
• staff should have their temperatures taken at the start of each shift; and
• the Home should develop a care plan for COVID-19 positive residents, detailing the care to be delivered to the resident in isolation and the precautions to be taken.
25. The Care Provider stated the Care Home’s General Manager confirmed residents were tested monthly in December 2020. Team members were tested weekly.
26. The Care Provider found covert hand washing spot checks were carried out and no team member failed them. In addition, between 14 December 2020 and 3 January 2021, temperature checks were carried out in line with the policy and no staff member’s temperature was too high.
27. However, it also found:
• not all residents were checked twice daily in line with the policy; and
• the Care Home failed to draw up an acute care plan for Mr X once he tested positive.
28. As a result of the above findings, the Care Provider partially upheld Mrs X’s complaint.

Complaint 1c) when Mr X fell on the night of 5 January, the Care Home failed to call Mrs X

Mrs X’s complaint

29. Mrs X was unhappy because the Care Home failed to call her when Mr X fell late on the evening of 5 January. She only became aware when the Care Home told her daughter who phoned after midnight for an update on Mr X.

Care Provider’s response

30. The Care Provider upheld this complaint because Mr X’s care plan stated he wished Mrs X to be informed if he fell and the Care Home failed to do this.

Complaint 1d) on 5 and 6 January, the Care Home failed to involve external professionals in Mr X’s care and failed to take appropriate action when Mr X’s health deteriorated

Mrs X’s complaint

31. Mrs X said that when Mr X was found after a suspected fall on 6 January the Care Home was reluctant to call 111 for medical assistance and only did so when she insisted. She said Mr X’s observations should have been taken more often as he was on the highly vulnerable list for COVID-19.

Care Provider’s response

32. The Care Provider found Mr X’s care notes recorded he was very confused at the handover on the evening of 5 January and his oxygen saturation levels were lower than normal for him.
33. Mr X had a fall at 10:30pm. The notes recorded he was able to explain what happened and only had a superficial injury. Mr X said he did not hit his head. By then, his oxygen levels were satisfactory. Therefore, the Care Home did not feel it necessary to call 111.
34. On the morning of 6 January, a staff member was concerned Mr X had had an unwitnessed fit because he had blood on his lip, he was more confused than normal and was slurring his speech. They called 111 at 9am. The 111 operator called back around midday and agreed to send paramedics to the Care Home.
35. The Home monitored Mr X’s oxygen levels at 2pm and found they were outside acceptable levels. Staff called 999 for emergency help and at 3pm an ambulance arrived. The Care Provider interviewed a senior Care Home staff member who was present. They recalled the paramedics were reluctant to take Mr X to hospital because of the risk of COVID-19 and also because Mr X did not wish to go. Mr X’s oxygen levels were at an acceptable level so the paramedics agreed he should remain at the Care Home and staff should monitor him.
36. Mr X was found in his room following a fall at 6:30pm that evening. The Care Home staff called 111 at 7:25pm and the care notes said staff were waiting for advice from paramedics about Mr X’s fluctuating oxygen levels. A conversation took place around 8pm with paramedics who decided to send an ambulance and take Mr X to hospital.
37. The Care Provider concluded the Care Home had acted appropriately and did not uphold Mrs X’s complaint.

Complaint 1e) on the evening of 5/6 January 2021, there was no senior person in charge at the Care Home

Mrs X’s complaint

38. Mrs X was unhappy because she felt no senior management staff were on site on the night of 5/6 January 2021.

Care Provider’s response

39. The Care Provider examined the rotas and found the manager was not on site but was on call for advice and support. There were three team managers present as well as a clinical staff member. It did not uphold Mrs X’s complaint.

Complaint 1f) the Care Home failed to inform the family of contacts with the emergency services on 6 January

Mrs X’s complaint

40. Mrs X was unhappy because the Care Home failed to inform her that it called emergency services on the afternoon of 6 January.

Care Provider’s response

41. The Care Provider stated the Care Home’s Community Lead commented in their interview that they updated the family after each contact with the emergency services. However, one contact on the afternoon of 6 January had not been recorded in Mr X’s notes. The Care Provider decided therefore that because it was not possible to evidence the family had been updated at that time, the complaint should be partially upheld.

Outcome of the Care Provider’s investigation

42. Where the Care Provider found it had acted with fault, it apologised to Mrs X for the distress it had caused her and the family. It also stated it would take cation in any areas where fault had been found to ensure the same things did not happen again.

Council safeguarding investigation

43. Surrey County Council carried out a safeguarding investigation and found there was evidence of neglect and omission by the Care Home. The report noted it failed to:
• identify signs Mr X was developing COVID-19 symptoms due to its failure to carry out sufficient observations as well as non-compliance with its COVID-19 policy;
• create an acute care plan once Mr X tested positive, particularly as it was known that Mr X’s epilepsy could be triggered by infections;
• update Mr X’s falls plan because COVID-19 could increase people’s risk of falls or appropriately manage Mr X’s risk of falls;
• inform the safeguarding authority (the Council) when Mr X had two unwitnessed falls; and
• include detailed instructions in Mr X’s care plan on when to seek medical advice or to contact emergency services which the Council found to be a significant short-coming. The investigation acknowledged however, that the Care Home acted appropriately when staff suspected Mr X had had a seizure on the morning of 6 January.
44. The Council stated the Care Home had failed to “join the dots between infection, increased risk of seizures and increased risk of falls, and to activate the epilepsy plan to be more vigilant when an infection is identified”.
45. The Council also stated it was not clear whether Mr X should have been placed on the nursing floor instead of the non-nursing floor. However, given his health conditions and the link between infection and his epilepsy, the investigator considered Mr X should have been assessed previously for Continuing Health Care (CHC). (CHC is awarded by the NHS when a person’s need is primarily for health care. If a person has CHC, the NHS will also pay for all their care needs). In addition, the investigator stated “It is clear that when [Mr X] became unwell he did need nursing and clinical input, and the absence of an acute care plan at this point was critical”.
46. The safeguarding investigation asked the Care Provider to specify what actions it had taken, or planned to take, to address the issues raised in the investigation.

Care Provider’s response to the safeguarding investigation

47. The Care Provider raised some issues about the findings of the Council safeguarding investigation and made the following comments:
• although Mr X did not have an acute care plan his care records detailed numerous times when staff either supported him or offered to do so. And when Mr X’s condition changed on the 5/6 January, external medical support was sought appropriately;
• it had not been shown clinically that infection triggered Mr X’s epilepsy, it was only considered as a possibility;
• until the CQC inspection in June 2021, it was unaware that all unwitnessed falls had to be reported to the CQC; and
• Mrs X did not raise any concerns about Mr X being on the non-nursing floor. Mr X liked to be as independent as possible in meeting his own care needs, administered his own medication and was assessed as low dependency. It was not aware of Mr X having any seizures between 2017 and 2020. The Care Provider stated none of these facts suggested Mr X needed the support of a nurse 24 hours a day.
48. Although the Care Provider did not agree with all the findings of the safeguarding investigation, it drew up a schedule of actions to help prevent a reoccurrence of the same issues. I have seen these actions and they are suitable and appropriate.
49. Mrs X raised issues in relation to the Care Provider’s response during my investigation. She stated the matter of whether Mr X should be on the nursing floor was raised during his initial assessment and also at one stage during his stay. Mrs X also said Mr X had a fall in November 2020 and his previous falls were discussed at the initial assessment.

My findings

50. In considering the matters under investigation, I have spoken to Mrs X, considered the infection control policies in place at the time events took place, Mr X’s care notes, records of testing of Mr X and staff and all complaints correspondence. I have also considered the Council’s safeguarding investigation, its findings and the Care Provider’s response, together with its apology to Mrs X and the agreed actions as well as Mrs X’s views on the Care Provider’s response. I can add nothing further, or meaningful, to these investigations.
51. The Care Provider, particularly at stage 2 of its complaints procedures, carried out a robust evidence-based investigation. The Council also carried out a safeguarding investigation into Mrs X’s concerns. Both investigations came to conclusions based on the information available. The issues Mrs X raised in paragraph 49 are noted but do not affect the substantive findings of the safeguarding investigation or the Care Provider’s response.
52. The Care Provider disagrees with some of the conclusions of the Council’s safeguarding investigation, but this is something it is entitled to do, and it provides cogent and defensible reasons to support its views. And notwithstanding these differences of opinion, the Care Provider has accepted the findings and drawn up a schedule of appropriate actions to meet the safeguarding findings. It has provided examples of how it is meeting those actions.

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Final decision

53. There was fault leading to injustice. The Care Provider has already taken the appropriate steps to minimise a reoccurrence of events. Therefore, I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman