Summary: The care provider failed to take action which could have prevented Mrs M from sustaining an injury to her leg, and then following the incident, it failed to take a witness statement from Mrs M. It also failed to contact Mrs M’s GP after it said it would and failed to properly follow its procedures in relation to personal protective equipment, moving and handling and complaints. The care provider has agreed to apologise and make a payment to Mrs D and take action to prevent similar failings in future.

The complaint

1. Mrs D complains about the lack of care her late mother, Mrs M, received from her care provider, ExtraCare. In particular, Mrs D complains that her mother sustained an injury to her leg because of ExtraCare’s actions, which resulted in her hospital admission and subsequent death.
2. Mrs D considers ExtraCare should reimburse the fees her mother paid. She says its actions have caused her significant distress and put her to avoidable time and trouble.

Back to top

What I have investigated

3. I have investigated the matters Mrs D raised in her formal complaints to ExtraCare and in her complaint to the Ombudsman. I have not investigated some matters which Mrs D raised in response to my draft decision on her complaint for the reasons explained in the last section of this statement.

Back to top

The Ombudsman’s role and powers

4. 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)
5. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:
• their personal representative (if they have one), or
• someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
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 care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
7. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
8. 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.
9. 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)

Back to top

How I considered this complaint

10. I have:
• considered the complaint and the documents provided by Mrs D;
• discussed the issues with Mrs D;
• made enquiries of the care provider and considered the comments and documents it has provided; and
• given the care provider and the complainant the opportunity to comment on my draft decision.

Back to top

What I found

Overview

11. Mrs M lived at home until she was admitted to hospital in March 2018. She was discharged from hospital on 4 May 2018 and moved into Brunswick Gardens Village, a retirement village. Services at the village are managed by ExtraCare Charitable Trust. Residents own or rent apartments and ExtraCare provides a domiciliary care service. ExtraCare provided Mrs M with a level 5 care package, which consisted of nine care visits each day at scheduled times.
12. On 10 May, while carers were supporting Mrs M with personal care in bed, Mrs M sustained an injury to her leg which required nine stitches.
13. Mrs M was re-admitted to hospital on 15 May and passed away on 3 June.
14. Mrs D considers ExtraCare failed to provide the care which Mrs M needed and sustained the leg injury because of its actions, which led to her hospital admission and subsequent death. She also considers Mrs M developed pressure sores due to ExtraCare’s failure to provide appropriate care and equipment.

Analysis

Late complaint

15. As explained in paragraph six, we will usually only consider complaints about matters that a complainant has become aware of in the last 12 months. In this case I have exercised discretion to investigate earlier events. This is because Mrs M’s death was the subject of a Coroner’s Inquest and Mrs D felt she could not complain until the coroner’s verdict was given, which was in September 2019. Mrs D did not then delay complaining to ExtraCare or to us.

Hospital Discharge to Brunswick Gardens

16. Mrs D considers the family were misled by ExtraCare and wrongly led to believe that it could provide the care and equipment that Mrs M needed at Brunswick Gardens.
17. When Mrs M was discharged from hospital, all parties would have been aware that Brunswick Gardens is not a care home providing 24-hour care, and of the package of care that ExtraCare had agreed to provide. The records show that everyone who attended the discharge meeting was happy with the discharge plans and no concerns were raised during the meeting about Mrs M moving to Brunswick Gardens.
18. An ExtraCare manager carried out an assessment of Mrs M’s needs while she was still in hospital and discussed her needs with a hospital Occupational Therapist (OT). The OT recorded that Mrs M could complete transfers with the aid of a rotunda and knee block, and she arranged for this equipment to be provided. The manager says the OT advised that Mrs M would only need to be cared for in bed on Fridays when she was fatigued after receiving chemotherapy treatment.
19. After Mrs M moved into Brunswick Gardens, carers found that Mrs M was regularly fatigued and transfers were difficult. ExtraCare asked the Community OT for a hoist to assist with transfers but the OT did not consider it would be appropriate. Instead, the OT ordered an electric standing aid and said that she could arrange a hoist in future if Mrs M deteriorated.
20. I do not consider there was any fault by ExtraCare here. The information the hospital provided did not suggest Mrs M would need any other equipment to assist with transfers. Once ExtraCare was aware that further equipment was needed, it took appropriate steps to obtain it. I do not consider ExtraCare was provided with any information to suggest that it would not be able to provide the care and support Mrs M needed when she was discharged from hospital.
21. An ExtraCare manager told family members that if Mrs M moved into Brunswick Gardens, she would not need to move again if her health deteriorated, unless she got dementia and needed 24-hour care. I consider this was misleading as dementia is not the only reason why a person may need to move somewhere which provides 24-hour care. On the balance of probabilities, I consider it likely that Mrs M would still have moved into Brunswick Gardens, even if family members had known that it may not be possible to stay if her health deteriorated.

Leg injury

22. The records show that Mrs M sustained a leg injury when carers were providing personal care to Mrs M in bed and her leg slipped and caught the bed remote, which had been hung on the lowered bed rail.
23. ExtraCare says it does not consider the accident was foreseeable and therefore not preventable. However, a risk assessment carried out when Mrs M moved into Brunswick Gardens stated that the bed remote must not be hung on the bed rail. After the incident, the risk assessment was updated and this instruction was repeated. Carers failed to ensure the remote was stored correctly. This was fault and led to Mrs M sustaining the leg injury.
24. The carers present at the time of the incident provided witness statements but a statement was not taken from Mrs M. This was fault. It may also have been helpful to take a statement from Mrs D although she did not witness the incident as she was in the next room. ExtraCare has apologised for not taking statements from Mrs M and Mrs D. It says that staff have since received more training on how to complete accident/incident forms and the importance of obtaining any witness statements.
25. Mrs D says the carers failed to provide appropriate first aid after the incident. She says that the manager had to tell carers to stop using tissues to try and stop the bleeding. There is some disparity in the evidence provided. One of the carers said that she applied a wet flannel and then called the manager. But the manager says that she applied a wet flannel when she arrived. On the balance of probabilities, I consider it likely that carers were inappropriately using tissues on the wound until the manager arrived and provided appropriate first aid. However, I do not consider it caused Mrs M any significant injustice.
26. The coroner’s inquest concluded that Mrs M died of natural causes. I have seen no evidence to suggest the leg injury contributed to her death. I note that the District Nursing team records show that on the day of Mrs M’s re-admission to hospital, her leg was healing well and there were no signs of infection.

Moisture damage

27. When Mrs M was being discharged from hospital to Brunswick Gardens, hospital staff said that Mrs M’s skin was sore due to moisture damage from diarrhoea, which was a side effect of antibiotics she was taking. The hospital made a referral to the District Nursing team who visited Mrs M regularly to treat the moisture damage.
28. Mrs M had also been prescribed laxatives when she was discharged from hospital. The family were concerned that the laxatives were contributing to the problem and raised this with a district nurse on 12 May and Mrs M’s GP on 14 May. The GP then stopped the laxatives.
29. I do not consider ExtraCare was wrong to continue to give Mrs M the laxatives which had been prescribed by the hospital. It was also reasonable to expect the District Nursing team to raise any concerns about this with Mrs M’s GP. However, an ExtraCare manager told a District Nurse on 11 May that she would contact Mrs M’s GP about the matter, and there is no evidence that she then did so. This was fault. If the manager had contacted Mrs M’s GP, I consider it likely that Mrs M would have stopped taking laxatives three days earlier, which is likely to have reduced her discomfort.

Missed Call

30. Carers did not carry out a care visit scheduled for 10.15pm on 6 May. This was fault. Carers visited at 11.40pm shortly after Mrs D told the carers that Mrs M was waiting to be helped into bed. There were then difficulties transferring Mrs M into bed because she was very tired. The lateness of the call would have contributed to this, and the failure to carry out the call without prompting will have contributed to the family’s view that a family member should stay with Mrs M at all times.

Moving and handling

31. Mrs D says that on one occasion, carers failed to treat Mrs M with dignity by accepting a member of the family’s offer to help support Mrs M while they were carrying out personal care.
32. ExtraCare disputes this and it has provided evidence to show that it refused the family member’s offer to help on another occasion. However, on the balance of probabilities, and after considering the family’s records, I consider it likely that the family member did help to support Mrs M on one occasion while carers were carrying out personal care. This was fault and would likely have compromised Mrs M's dignity and caused her distress.
33. ExtraCare’s records also show that on another occasion, carers allowed Mrs D to help with transferring Mrs M to bed. ExtraCare’s moving and handling policy says that non care staff are not to move and handle customers unless appropriately trained. I do not consider Mrs D helping to transfer Mrs M caused her any significant injustice.

Personal Protective Equipment (PPE)

34. Mrs D says that carers did not always wear PPE and this exposed Mrs M to infection. The contract between Mrs M and ExtraCare states that carers are required to wear PPE. The evidence shows that on at least one occasion, a carer was not wearing PPE while carrying out a care visit. This was fault. There is no evidence to suggest Mrs M suffered any infection as a result of staff not wearing PPE. However, it is likely that Mrs M suffered some embarrassment when a carer had to remove some of her own clothing after it got soiled while giving Mrs M personal care.

Care plan

35. Mrs D says that Mrs M’s care plan was not always in her apartment so carers did not know what they needed to do during each visit. The evidence suggests the care plan was removed on 10 May to be updated and had not been returned by 14 May. This was fault. The District Nursing team’s records suggest that a carer used wet wipes after the care plan should have been updated to show that wet wipes should not be used. As the carers had no instructions to refer to, it is likely that some of the care specified in the care plan was not properly provided, and family members had to remind carers about what was required. This should not have been necessary. I consider ExtraCare’s failure to promptly return the care plan will have contributed to the family’s view that a family member should stay with Mrs M at all times.

Re-admission to hospital

36. On 11 May, an ExtraCare manager made a safeguarding referral to the Council. She considered the hospital had failed to provide ExtraCare with the full facts about the amount of care and support Mrs M needed. She said that she felt Mrs M needed 24-hour nursing care.
37. ExtraCare should have told the family that it considered Mrs M needed 24-hour nursing care so they had the opportunity to try and find a suitable care home or nursing home. This was fault. However, it is very unlikely that a suitable placement would have been found quickly and so even if the family had been told, Mrs M would likely have remained at Brunswick Gardens until she was re-admitted to hospital on 15 May.

Complaint responses

38. ExtraCare accepts that there were some deficiencies in its responses to Mrs D’s complaints. It did not address all the issues she raised and did not process her complaint in accordance with its complaints policy. This was fault. ExtraCare has apologised to Mrs D for the distress this is likely to have caused.

Injustice

39. An autopsy was carried out and the pathologist’s opinion was that the cause of death was chest infection, multiple myeloma and liver cirrhosis. The coroner concluded that Mrs M died of natural causes.
40. Mrs M did not die as a result of the failings identified in this case. But they will have caused Mrs M distress, and the injury to Mrs M’s leg and the failure to contact Mrs M’s GP sooner will have resulted in Mrs M suffering pain and discomfort. As Mrs M has since died, it is no longer possible to remedy that injustice. I do not consider ExtraCare should reimburse Mrs M’s estate for the cost of her care.
41. I consider the failings in this case have also caused Mrs D distress and she has been put to avoidable time and trouble pursuing her complaint.

Back to top

Agreed action

42. Within four weeks, ExtraCare will make a payment of £250 to Mrs D and apologise for any failings identified in this case for which it has not already apologised, and for the time and trouble she has been put to pursuing her complaint.
43. Within eight weeks, ExtraCare will:
• Speak to relevant staff about the importance of providing accurate information to the family of prospective residents.
• Review its procedures for updating care plans to ensure carers always have access to them when carrying out care visits.
• Explore why Mrs M’s GP was not contacted on 11 May 2018 and take action to prevent similar failings in future.
• Review its procedures to prevent care calls from being missed.
• Provide written guidance to its carers to ensure they are each aware that non carers are not to move and handle residents unless appropriately trained, they must wear PPE, and must protect the dignity of residents while carrying out personal care.
• Provide evidence that it has reworded the risk assessments in relation to the storage of bed remotes.
• Remind carers not to hang bed remotes on bed rails.
• Provide evidence to show that carers are required to have first aid training.
• Provide evidence that staff have received more training on how to complete accident/incident forms and the importance of obtaining statements from all witnesses.
• Remind relevant staff that the complaints process must be followed properly and complainants signposted to us without delay.

Back to top

Final decision

44. I have completed my investigation and uphold Mrs D’s complaint. There was fault. The action ExtraCare has agreed to take is sufficient to remedy the remaining injustice.

Back to top

Parts of the complaint that I did not investigate

45. In response to my draft decision, Mrs D raised two new complaints which were not included in her formal complaints to ExtraCare, or to the Ombudsman. Mrs D complained about an incident when Mrs M first arrived at Brunswick Gardens and was taken to the wrong room, and that ExtraCare has not refunded an overpayment made by Mrs M.
46. As explained in paragraph six above, we cannot investigate late complaints unless we consider there are good reasons why the complaint was not made to us sooner. I do not consider there are grounds to exercise discretion to investigate these matters because I consider it would have been reasonable for Mrs D to have complained to us sooner.

Back to top

Investigator's decision on behalf of the Ombudsman