Summary: Mrs A complains about the care of her mother, Mrs B at a care home. She has also complained about a council’s safeguarding enquiries. We found fault in relation to the Home’s lack of mask wearing. We did not find fault with the other issues in this complaint.

The complaint

1. Mrs A complains about the care of her mother, Mrs B, at the Old Hall Care Home (the Home) from July to August 2020. Mrs B’s care was partially funded by the Council and then by the NHS during the last three weeks of her life. Mrs A has specifically complained:

the Home did not manage her mother's falls risk resulting in several falls;

the Home did not inform the GP or district nurse of injuries from a fall;

her mother's leg and shoulder were allowed to deteriorate;

the Home did not properly manage her mother's pressure areas;

her mother's room was not cleaned properly;

the Home did not manage her mother's hygiene needs;

staff did not follow infection control guidelines;

the Home did not properly manage her mother's pain relief towards the end of her life; and

Mrs A is unhappy with the conclusions of the Council's safeguarding enquiries.

2. Mrs A said these faults left her mother in pain, contributed to her death and were distressing for Mrs A to witness. Mrs A wants compensation as a remedy for this. In addition, she would like training for staff to improve the care they provide.

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The Ombudsmen’s role and powers

3. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)

4. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
5. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
6. The Ombudsmen 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, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
7. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

8. I have considered evidence from Mrs A, the Council and the Home. I have also considered the guidance in place at the time. Mrs A, the Council and the Home had an opportunity to comment on my first draft decision statement before I issued a second draft decision. I gave them the opportunity to comment on the second draft before making this final decision.

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What I found

Government guidance

9. There were two versions of the same guidance document in place during the period concerned in this complaint. The name of the guidance was ‘Personal protective equipment (PPE) - resource for care workers working in care homes during sustained COVID-19 transmission in England’ and it was published by Public Health England. The first version concerned with this complaint was in place from 15 June 2020 to 19 July 2020. On 20 July 2020 the guidance was updated. This guidance described the scenarios when PPE should be worn and which items of PPE were appropriate for each scenario.

Background

10. Mrs B moved into the Home in 2019. In July 2020 she was in her 80s and had heart problems and Chronic Obstructive Pulmonary Disease (COPD). COPD describes a group of lung conditions that make it difficult to empty air out of the lungs because the airways have become narrowed.
11. In July 2020 Mrs B was coming towards the end of her life. She deteriorated and died in August 2020. The coroner carried out a post-mortem at the family’s request and recorded the primary cause of death as acute heart failure as a consequence of heart disease.
12. Mrs A raised several safeguarding concerns and made a complaint to the Home and the Council. They responded before Mrs A approached us in December 2020.

Falls

13. Mrs A complained the Home did not manage her mother’s falls risk. She said this resulted in five falls in ten days. Mrs A feels these falls contributed to her mother’s death and caused her significant pain and distress.
14. Furthermore, Mrs A complained that following these falls, the Home did not seek medical attention or ask Mrs B’s GP to examine her. Mrs A feels her mother could have had a catastrophic injury from these falls that went unnoticed and led to her death.
15. The Home said Mrs B had several falls when she attempted to get out of bed unaided. It said it considered bed rails but felt at the time the risk could be greater as she could try and climb over them meaning she would fall from a greater height.
16. The Home said it put a sensor mat in place to alert staff if Mrs B did attempt to get out of bed. In addition, it carried out several falls risk assessments.

Analysis

17. Mrs B had five falls altogether in a ten day period between July and August. During this period, Mrs B was funded by the NHS so the Home was acting as a health provider. She had a falls risk assessment in place before her first fall. This assessment stated Mrs B was bed bound and required the support of two care workers for repositioning. It said she was becoming more mobile and was making attempts to get out of bed despite not being strong enough to stand unsupported. For this reason, a sensor mat was in place.
18. The Home put appropriate measures in place to try and reduce the risk of Mrs B falling and it has given a reasonable explanation of why it did not use bed rails. The Home also put a crash mat in place to cushion Mrs B’s impact if she did fall out of bed.
19. After each fall staff found Mrs B on the floor having tried to get out of bed. Staff recorded they checked her for any injuries, and none were found apart from on one occasion when she had a graze on her head and nose. On each occasion they asked if she was in pain and then settled her back in bed.
20. The Home has subsequently put a post falls protocol in place.
21. As the Home assessed Mrs B after each fall, the postmortem found no injuries, she was examined by a GP and district nurse some days later, and the Home has now put in place a post falls protocol, I have not found fault in this aspect of the complaint.

Mrs B’s leg and shoulder

22. Mrs A said that her mother’s right leg became injured and discoloured. She said it had no pulse. She felt that her mother had suffered injuries to both her leg and shoulder in her falls and that these were allowed to deteriorate.
23. The Home said this discolouration and lack of pulse was due to circulation issues as Mrs B was nearing the end of her life. The GP was performing a video round of the Home’s residents the afternoon Mrs B died.
24. From the records the issue of the discolouration of Mrs B’s leg was raised by Mrs A on the morning of her mother’s death. She suggested ringing NHS 111. A district nurse attended and examined Mrs B. The opinion was the discoloration was due to a lack of circulation as she was towards the end of her life.
25. Therefore, there is insufficient evidence Mrs B had a leg injury that was not given proper attention. Mrs A raised the issue and the Home sought expert advice from the district nurse on the same day. The district nurse found no injury. The GP did not have the opportunity to examine Mrs B’s leg before her death and there is insufficient evidence there was a leg injury.
26. Mrs A also raised the issue of bruises to Mrs B’s arm and shoulder, she raised this with the police and coroner as well. There was a bruise found by the district nurse but no serious injury. In addition, the post-mortem found no fractures.
27. Therefore, we have found insufficient evidence Mrs B suffered injuries to her right leg and shoulder which were not given proper attention.

Pressure areas

28. Mrs A complained her mother’s pressure areas were not looked after to prevent her from being at risk of pressure sores. Pressure ulcers (also known as pressure sores or bedsores) are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time. Pressure areas are those areas of the body that may be susceptible to developing pressure sores. People at risk of pressure sores are encouraged to reposition themselves at regular intervals to relieve pressure on vulnerable areas.
29. The Home said Mrs B was regularly repositioned during this period to prevent the development of pressure sores. It said the only time this did not occur was in the last days of her life as the family asked that she was not disturbed. Despite this, following her death, Mrs B did not have any skin breakdown on her pressure areas.
30. There is evidence in the records Mrs B was regularly repositioned and moisturising cream applied to any areas when needed. In addition, there is insufficient evidence that Mrs B developed any pressure sores during this period. Therefore, I have not found fault with the Home in managing Mrs B’s pressure areas.

Cleanliness of Mrs B’s room

31. Mrs A said her mother’s room was frequently dirty and was not cleaned regularly. She took photos of the room as evidence of the lack of cleanliness.
32. The Home said it did regularly clean Mrs B’s room. However, in the last days of her life her daughters were in her room for long periods and it was difficult to clean at this time.
33. I have seen the cleaning schedules for the Home for this period. These show that staff regularly cleaned Mrs B’s room apart from the final days of her life. The Home has given a reasonable explanation for why staff struggled to clean Mrs B’s room in the final days of her life. Therefore, I have not found fault with the Home in this aspect of the complaint.

Mrs B’s hygiene needs

34. Mrs A felt her mother’s hygiene needs were not always met with her having dirty fingernails and not being washed regularly.
35. The Home said until the last days of Mrs B’s life when her daughters moved into the Home, staff provided regular hygiene care. In the last days her daughters provided it themselves.
36. There is sufficient evidence in the records that Mrs B was given regular personal care in relation to changing her clothes and washing her. She did sometimes refuse personal care but was offered it at regular intervals. Therefore, I have not found fault with the Home meeting Mrs B’s hygiene needs.

Infection control

37. Mrs A raised examples of staff not wearing PPE and on 19 July 2020 a member of staff kissing her mother. She said there was evidence staff had not worn masks when it was required. The incident with her mother made her extremely worried not just for her mother’s health but also her own and her family’s.
38. The Home said prior to guidance changing on 20 July 2020 staff had been following guidance that PPE was not required at all times. When new guidance came in on 20 July 2020 the Home said staff followed this guidance in wearing PPE including a mask when providing care or when within two metres of a resident who was coughing.
39. It said before this it had taken advice from the local Clinical Commissioning Group (CCG) who said masks were not required. CCGs fund health care providers for the NHS. The Home carried out a risk assessment and decided it was better not to wear masks as it affected communication with residents and the residents were confused and distressed when staff wore masks.
40. With regard to the staff member kissing Mrs B, the Home said the staff member was leaving after her shift and thought it may be the last time she saw Mrs B who was coming to the end of her life. The Home apologised and reminded staff of the need to keep their distance from residents unless necessary.

Analysis

41. The guidance in place on 19 July 2020, the date Mrs A referenced, was the guidance introduced by Public Health England on 15 June 2020. It stated that masks should be worn

“when providing close personal care in direct contact with the resident(s) (e.g. touching) OR within 2 metres of any resident who is coughing; and

when within 2 metres of a resident but not delivering personal care or needing to touch them, and there is no one within 2 metres who has a cough”

42. This guidance also stated that PPE was recommended even if no one in the Home had COVID-19 symptoms.
43. The guidance the Home has referred to, which was instituted on 20 July 2020, had essentially the same requirements and the Home is not correct in stating that this was when masks were first required in care homes.
44. Therefore, although I do take into account the reasons the Home had for not wearing masks, it was not, as it thought, following the guidance in place at the time and so was at fault. I have also considered that the Home said it was advised by the CCG it was not required to wear masks. However I have not seen evidence of this or when this advice was given. Furthermore the advice was changing regularly during this time and so may have been out of date even though the Home felt it was following it correctly.
45. The fault in not wearing masks in the Home, although there is no evidence it led to any cases of COVID-19, caused distress to Mrs A who was worried for her mother and her other family members. In addition, it put Mrs B at risk during a period of pandemic.
46. It was fault of the staff member to kiss Mrs B and it would have been distressing for Mrs A to witness. However, the Home has apologised and taken action so we would not recommend further action on this issue.

Pain relief

47. Mrs A said her mother’s pain was not managed properly towards the end of her life which caused her a great deal of distress. It was also distressing for Mrs A to witness.
48. The Home outlined the pain relief provided. She started being given oramorph orally. Oramorph is a liquid version of morphine which is a strong painkiller. It is used to treat severe pain, for example after an operation or a serious injury, or pain from cancer or a heart attack. It is also used for other types of long-standing pain when weaker painkillers no longer work. Mrs A had breathing difficulties for which oramorph also helped.
49. When Mrs B found it hard to swallow and her pain increased district nurses put in place a syringe driver so she could have pain relief medication without needing to swallow tablets. A syringe driver (or syringe pump) is a small battery-powered pump. It delivers a steady stream of medication through a small plastic tube into the patient’s arm. The Home felt Mrs B was comfortable most of the time and when she was not it requested extra pain relief from Marie Curie or the district nurses. Marie Curie is a charity that provides care and support for terminally ill people.

Analysis

50. In July and early August 2020 Mrs B was having oramorph and lorazepam for pain relief, breathing difficulties and agitation. Lorazepam is used to treat severe agitation.
51. The evidence in the records shows that oramorph was to be given when needed, at four hourly intervals and that this worked in providing Mrs B with pain relief.
52. Towards the end of Mrs B’s life she became agitated one morning and oramorph and lorazepam were not working. The Home asked Marie Curie to help and it sent a district nurse who attended a couple of hours later. The district nurse administered injections of Midazolam. This is short-acting sedative and sleep-inducing drug. This settled Mrs B.
53. Later this day there was a period of six hours when Mrs B was agitated either due to anxiety or being in pain. The Home promptly contacted Marie Curie and then had to wait for a district nurse to give the injections. Home staff could not do this themselves and so I do not find fault with the Home in relation to this episode.
54. Later that evening Mrs B became agitated again and staff called for a nurse. Again there was a delay of approximately four hours before a nurse could administer midazolam and morphine. This settled Mrs B. I have not found fault with the Home in this episode as it contacted the nurses promptly and then had to wait for them to come and administer the injection.
55. The following morning district nurses put in a syringe driver.
56. From the evidence in the records Mrs B did experience episodes of pain in her final days and the Home was prompt in requesting nurses to come out to administer pain relief. Therefore, I have not found fault in how the Home managed Mrs B’s pain relief.

Council safeguarding enquiries

57. Mrs A made a safeguarding concern on 20 July 2020 that staff at the Home were not wearing correct PPE and so putting her mother at risk. She also used the example of a staff member kissing her mother.
58. Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. The Care Act requires that each local authority must make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by who.
59. The Council took evidence from Mrs A and the Home. The Council concluded that there was no immediate concern about staff not wearing PPE as it had adopted the guidance issued on 20 July 2020. However, it did find that there was an act of neglect in the staff member kissing Mrs B. It took the view that this had been dealt with by the explanation from the staff member and apology and staff being informed no more contact of this type to be made with Mrs B or any other residents.
60. I have not found fault with how the Council considered the matter of the staff member kissing Mrs B. It took on board the Home’s explanation and the action it took to reduce the risk to other residents.
61. Regarding the mask issue, the Council’s role under section 42 of the Care Act was to establish if there was an ongoing risk to Mrs B and other residents. In this case the Home provided evidence it had adopted the guidance on 20 July 2020 and staff were now wearing masks at the appropriate times.
62. Therefore, by the time the Council carried out its enquiry there was not a risk to other residents as the Home had on 20 July 2020 started wearing masks in line with the guidance. The Council took into account evidence from Mrs A and the Home and I have not found fault with this aspect of the safeguarding enquiry.
63. Mrs A raised another safeguarding concern in August 2020 relating to pressure area care, pain relief, cleanliness and falls management. The Council consulted with the Home, Mrs A and took advice from the local Community Health Services (in relation to pressure care and pain relief).
64. The Council also took into account the evidence from the coroner’s post-mortem. It also considered photos Mrs A had taken of Mrs B and her room. The Council concluded that Mrs B’s pressure area care and pain relief was managed appropriately. I have not found fault with the process the Council followed when coming to these conclusions as they consulted with the correct experts in the community health services and considered the appropriate evidence.
65. The Council concluded Mrs B’s room was in a poor state of cleanliness. It informed the Care Quality Commission who carried out an inspection and it did not find fault with the cleanliness of the Home. In addition, the Home had explained how it monitored cleanliness in the Home. Therefore, the Council decided that although Mrs B’s room had been in a poor state of cleanliness, there were no further concerns for other residents as action had been taken to ensure the Home was of the required standard of cleanliness.
66. With regard to the issue of falls, the Council said the purpose of the enquiry was partly to see if there was a potential risk to remaining residents. It looked at the care notes and at the post-mortem and concluded that the falls did not cause an injury which led to Mrs B’s death and that there was no risk to other residents.
67. I have not found fault with the Home’s handling of these falls and the Council properly considered the issue in its safeguarding enquiry.

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Recommendations

68. I found fault with how the Home dealt with the issue of mask wearing and this caused Mrs A distress in feeling her mother and other residents were at risk.
69. Therefore, I recommend that, by 15 June 2022, the Home write to Mrs A acknowledging the fault of not wearing masks and apologising for the distress this has caused Mrs A. The Home should send the Ombudsmen a copy of this apology.

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Final decision

70. I found fault with the Home in relation to infection control. I did not find fault with the other issues in this complaint.

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Investigator's decision on behalf of the Ombudsman