Summary: There was fault as staff at a care home made a medication error and failed to ensure that a resident had routine foot care. The medication error did not cause injustice to the resident, but the Council’s waiving of a final invoice and improved footcare procedures remedy the injustice caused from the failure to provide routine footcare for 5 months.

The complaint

1. The complainant, who I shall call Mr X, complains a care home (Delph House Care Home) did not adequately monitor and arrange treatment for his mothers overgrown toenails or pressure sores.
2. He also complains the care home did not respond to concerns about his mother’s susceptibility to mini-strokes and gave his mother’s medication early which resulted in her admission to hospital.

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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 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)
5. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

8. I read the papers put in by Mr X and discussed the complaint with him.
9. I considered the Council’s comments about the complaint and any supporting documents it provided.
10. Mr X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Fundamental Standards of Care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
12. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.

Key facts

13. Mrs Y (Mr X’s mother) received care at home from 4 visits by carers per day. After respite care at a care home in December 2018, this became a permanent stay in January 2019. Mrs Y had two hospital admissions, one in November 2019 and one in February 2020. The hospital discharged Mrs Y to a different care home in February 2020 and she died shortly afterwards.
14. Mr X complains about his mother’s care in the care home. After his mothers death, Mr X received an invoice for outstanding care fees. The Council waived these fees after the reviewing the complaint it received from the Ombudsman in April 2021.

Medication error

15. A care giver gave Mrs Y medication a day too early in February 2020. I have seen the medication error report from the care home, which records the staff member did not read the instructions correctly.
16. Mrs Y had a fever the next day, the paramedics came and Mrs Y went to hospital. The care home told her family. The hospital treated Mrs Y for sepsis and all the medical evidence shows that this was not related to the medication error.
17. The care home reported the incident to the Council safeguarding team the next day. The home says the staff member involved stopped medication administration, would need to complete medication training, supervision when administrating, training and have their medication competency assessed by a manager.
18. The Council received the safeguarding referral and a social worker visited Mrs Y in hospital, to ensure the hospital were aware. The Council got an opinion from doctors that Mrs Y’s liver damage was unrelated to the medication error. The Council closed the safeguarding enquiry as it did not need to further investigate.
19. The care home staff made a medication error. This was fault. However, both the care home and the Council responded responsibly to the error. The care home promptly reported the error and took steps to retrain the staff member. The Council spoke to all involved and closed the enquiry when it was clear the medication error was not related to Mrs Y’s sepsis and advanced liver damage.

Footcare

20. When Mrs Y went into hospital in November 2019, Mr X says that her toenails were badly overgrown. He complains the care home did not arrange visits by the chiropodist.
21. In November 2019 the social worker talked to the diabetic nurse, who noted Mrs Y had some long toenails but some that had been cut recently, possibly if Mrs Y refused full treatment. The nurse said there were pressure sores on both heels, with no open wounds.
22. The care home said that its chiropodist cared for Mrs Y’s feet in September 2019 (7 weeks ago), for which there is a report. Mrs Y’s feet had also been seen by the district nurse at the end of October. The social worker was of the view that Mrs Y’s feet were adequately cared for but the care plan should ensure the frequency the chiropodist saw her was in the plan.
23. A further safeguarding referral was made about footcare when Mrs Y went into hospital in February 2020.
24. The Council investigated Mr X’s complaint as part of the safeguarding referral. The hospital duty social workers notes say that ‘the diabetes podiatrist has seen Mrs Y and documented that both feet nails are very long, estimated to be 6 months growth, they were cut and filed. They document the right posterior heel had an almost healed ulcer with granulating tissue present, no necrotic tissue and the left heel was intact’.
25. The Council’s notes show the social worker spoke to Mr X and requested foot care records from the care home. The social worker had to request the records from the care home a number of times, although this was in March/ April 2020 during the initial COVID-19 lockdown when access to records may have been difficult.
26. The records showed that the chiropodist visited the home in November when Mrs Y was in hospital and Mrs Y’s feet were seen weekly by the district nurses from November to February to dress pressure sores. The care home said that as Mrs Y had dressings on her feet she wouldn’t have been able to have a chiropody appointment.
27. The social worker closed the safeguarding referral without further investigation as Mrs Y’s pressure sores on her feet were being seen weekly by the district nurses. And, the care home recorded the chiropodist visiting patients every two months but unfortunately Mrs Y missed that visit in November 2019. The care home has said that Mrs Y’s care plan said her feet were to be attended to every 12 weeks.
28. There is evidence the care home and district nurses were attending to Mrs Y’s pressure sores so I can find no fault on this point.
29. I have looked at all the information and can understand Mr X’s concerns about his mothers footcare. Mrs Y missed her chiropodist appointment in November 2019 and unless her toenails were cut in hospital, did not receive further chiropody until February 2020. Her care plan recommends her feet were attended to every 12 weeks so she waited from September to February, about 5 months, between appointments. This is about 20 weeks which fits with the diabetic nurse’s opinion that Mrs Y’s toenails had about 6 months growth.
30. The safeguarding referral made in November 2019 meant the care home was aware of concerns about Mrs Y’s toenails. Mrs Y missed the routine chiropody visit in November 2019 because of her hospital stay and I can see no evidence the care home rearranged this.
31. Mrs Y’s care plan said that chiropody appointments should be every 12 weeks. There is evidence to support that she had no chiropody care for 20 weeks, which was only provided when she went into hospital. I do not consider the fact that her pressure sores were being dressed by the district nurse was a reason not to schedule chiropody appointments. As the district nurse commented, they could have visited to redress her feet if needed.
32. My view is the care home was at fault in not arranging regular foot care appointments for Mrs Y and rearranging them when appointments were missed or she refused care. The Council has said that its footcare policy says that it will endeavour to rearrange missed appointments. This did not happen, so Mrs Y went without routine nail care for 20 weeks. This was fault and is potentially a breach of the Fundamental Standards of providing person centred care and dignity and respect.
33. The nurse cut Mrs Y’s toenails in hospital and as she sadly died soon after, the injustice to her directly is difficult to determine. But, I can see this caused more worry and stress for her son. The Council has waived the final invoice for Mrs Y’s care and while I appreciate that money will not make up for the worry, I do consider this provides a personal remedy to Mr X for his complaint. This is along with a recommendation that the Council ensures the care home establishes a foot care procedure so appointments are rearranged if residents have dressings on their feet.

Concerns about mini-strokes

34. Mr X says the care home did not monitor Mrs Y for mini-strokes. The care home has said Mrs Y’s GP did not tell them to do this. In the absence of any further evidence, there is nothing further I can investigate on this point.

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Agreed action

35. The Council waives the cost of the final invoice for Mrs Y’s care. This part of the remedy has already been carried out.
36. The Council ensures the care home updates its footcare policy to ensure that appointments can be rearranged if residents have dressings on their feet within two months of the date of the decision on this complaint.

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Final decision

37. I have completed my investigation of this complaint. This complaint is upheld as I have found evidence of fault. The actions above remedy the injustice to Mr X.

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Investigator's decision on behalf of the Ombudsman