Summary: Ms X complained that her father, Mr Y, received inadequate care during a respite placement. We found the care provider failed to provide an adequate service to Mr Y causing him avoidable harm and distress. This also caused his family avoidable distress. In addition, the care provider failed to keep full and accurate records about Mr Y. In recognition of the injustice caused, the care provider has agreed to refund half of the fees Mr Y paid and make a payment to his family.

The complaint

1. Ms X complains on behalf of her father, Mr Y, that the care provided to him during his respite stay was poor and unacceptable causing him to lose mobility and develop pressure sores, both of which required medical treatment. This also caused the family distress and anxiety.

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The Ombudsman’s role and powers

2. 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)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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)
5. 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

6. I have considered all the information provided by Ms X, made enquiries of Littlecombe Park Limited (‘the care provider’) and considered its comments and the documents it provided.
7. Ms X and the care provider 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

8. 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.
9. Regulation 9 states that the care and treatment of service users must: be appropriate; meet their needs; and reflect their preferences.
10. Regulation 12 states providers must assess the risks to people’s health and safety during any care or treatment and make sure staff have the qualifications, confidence, skills and experience to keep people safe. The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm.
11. Regulation 17 states that care providers must keep accurate, complete and detailed records for each person using the service.

Key facts

12. Mr Y has arthritis and suffers from poor mobility and balance. He lives with his wife, Mrs Y, who is his main carer. In February 2022 Mr Y’s daughter, Ms X, arranged respite care for him at the Hollies Care Home (‘the Home’) to give her mother a break from her caring role.
13. The care provider completed a pre-admission assessment which noted that Mr Y had a right foot oedema (swelling), a rash on his back and a sore area on his shoulder which was being dressed by the community district nurse. He also had a catheter. It was discussed that Mr Y would need an air mattress and a profiling cushion for his chair. Mr Y explained he had previously had a sore on his sacrum requiring treatment from the district nurse and, although the area was now healed, scar tissue was present. Mr Y said he needed a recliner chair in his room. The care provider said they would try to provide this, but all the recliners may already be in use. If so, they would provide a high backed, well-supporting chair and source riser feet if necessary.
14. Mr Y was admitted to the Home on 9 March 2022. The care provider completed a care plan and falls and mobility assessments. Mr Y was assessed as being at high risk of falls. A full skin inspection was also completed and Mr Y was assessed as being at low risk of pressure sores. The skin inspection identified six areas of blemished or dry skin requiring cream and a healed sacrum pressure sore.
15. On 17 March 2022 Mr Y’s other daughter, Ms Z, sent an email to the Home’s manager saying Ms X had spoken to Mr Y the previous day and was concerned about what he was saying about his care. She discussed the concerns with the manager. The manager sent an email to Ms Z the same day saying she had spoken to the nurse and she was going to check Mr Y’s sacral area, encourage a walk and mention about teeth at night to the night staff.
16. Mr Y was discharged home on 23 March 2022.
17. On 28 March 2022 Ms X complained to the care provider. She said the basic care Mr Y had received was “dreadfully poor and in some ways appalling”.
18. Ms X said the benefits the respite stay had given her mother vanished within hours of Mr Y returning home and she suffered much anxiety, sadness and anger. She said she had planned to stay with her parents from 22 to 26 March to help settle Mr Y back home but had to take a further week off work due to the condition in which Mr Y returned.
19. On 24 April 2022 the Head of Care responded to the complaint saying a full investigation had been completed and she had spoken to and received statements from several staff involved in Mr Y’s care. She accepted there had been a lack of care and apologised for this. She also accepted there were failings in relation to lack of documentation. She also found that Mr Y declined to mobilise daily and should have had more encouragement to do so.
20. The Head of Care said the care provider had adapted its practice to ensure this situation did not recur in future. This included:
• Discussion with the care team about the failings identified;
• a change to documentation to require daily pressure area checks;
• the nurse in charge to identify all residents to be visually checked;
• staff training to increase awareness of the need for pressure area care;
• the agenda for all quarterly team meetings to include discussions on: mobilising and the link with pressure area care; the correct devices to aid comfort; and the importance of routine oral hygiene.
21. The care provider has provided evidence that, following its investigation into Ms X’s complaint, it added skin inspections to the daily care records. It has also provided notes of a team meeting confirming staff were notified that: pressure sore areas had been added to the charts and these should be completed for every resident; mouth care charts should be completed when mouth care was performed; training packages were available for staff to complete including ‘accountability and documentation’ and ‘pressure ulcer prevention’.

Analysis

Mobility

22. In her complaint to the care provider, Ms X said that, prior to his stay at the Home, Mr Y had been walking four times a day with a frame and the help of one person but he hardly walked when he was in the Home. She said Mr Y told her he often asked if someone would walk with him but this rarely happened. However, he also said that sometimes when the carers did suggest a walk he declined due to tiredness or being frightened of falling and injuring them. Ms X said a gentle reminder of the importance of mobilisation might have been all that he needed to give him confidence.
23. Ms X said that, during the second week of Mr Y’s stay, after the family had raised concerns, he told them he had walked 41 steps. She said this was too far for him to walk having hardly walked in the first week. Consequently, he arrived home with immobility, poor balance, weak legs and no confidence and the family had to involve a physiotherapist.
24. Ms X was also concerned that Mr Y had had two falls whilst in the Home when he had only had two falls in the last five years.
25. The mobility/moving and handling plan completed on admission states that Mr Y has reduced mobility because of his age and arthritis and that he mobilises using a Zimmer frame and help from one person. It states that he may need prompting to stand and mobilise.
26. A note added to the mobility/moving and handling plan on 16 March 2022 (several days after admission) states that the care provider had discussed with Ms X about helping Mr Y to walk and had agreed to help him walk at least twice a day at 11.30 am and 2.30 pm.
27. The care provider says Mr Y had full mental capacity and was able to inform carers what he wanted and when. It also says the family was aware throughout Mr Y’s stay of its concerns regarding his reluctance to mobilise. It says that, when carers did mobilise Mr Y, the family advised they had mobilised him too much.
28. The care provider says that some mornings Mr Y was very agile and able to transfer and walk with his frame to his chair from his bed. But some mornings he was assisted because of his poor balance and high risk of falls.
29. The records show as follows:
• On 9 March 2022 Mr Y walked with assistance down to the lounge for lunch.
• On 14 March a stand aid was used to transfer Mr Y into bed.
• On 15 March Mr Y chose to spend the day relaxing in his room. However, an accident report form was completed which shows he had a fall. It states he was walking with his frame and staff assistance from his ensuite into his bedroom. He leaned to the side and, due to his physical size, the carer was unable to assist him to rebalance. No injuries were evident and Mr Y said he was not in pain.
• On 16 March Mr Y declined to leave his room. The manager of the Home sent an email to Ms Z saying “we are trying to encourage mobility, but your father is adamant sometimes that he does not want to go for a walk. He is slowly mobilising in his room when assistance required for the toilet”.
• On 18 March the daily notes state that Mr Y’s mobility was not very good. The afternoon entry states that he walked the length of the corridor with the assistance of two carers and a note was made that carers should continue to encourage and monitor him.
• On 19 March 2022 Mr Y required the use of a stand aid. But a later note states that he “had been assisted to walk with Zimmer frame from the room to room 38 and back to room thereafter”.
• On 20 March Mr Y was unable to raise from the chair and a stand aid was used.
• On 21 March Mr Y was able to stand and transfer to his bed with only carer assistance and his frame. He walked in the morning in his room and a longer distance in the afternoon.
• On 22 March Mr Y declined assistance to have a walk in the morning as he was waiting for a telephone call. A statement provided by the registered nurse as part of the care provider’s investigation confirmed this. She also stated that later that day Mr Y went out for a trip on the minibus and so missed his afternoon walk.
30. I find that, as mobility was a significant issue for Mr Y and the care provider had specifically been asked to mobilise him, the carers should have recorded in the daily care records when Mr Y managed to mobilise and, if not, whether efforts were made to encourage him to do so. At the very least, carers should have assisted Mr Y to stand regularly. The care provider has been unable to provide evidence that Mr Y was mobilised regularly or that he was encouraged to do so. Although Mr Y has capacity to reach his own decisions, staff should have encouraged him to mobilise for his own welfare. The care provider accepted this in response to Ms X’s complaint. Failure to do this caused Mr Y significant injustice as he had lost mobility by the time he arrived home.

Pressure area care

31. Ms X says that Mr Y told her during a telephone conversation on the eighth day of his stay that, whilst having a bed bath that morning, a carer had told him that his “bottom looks sore” and put cream on the area. The following day Ms Z raised concerns with the care provider. She said that, when Mr Y returned home, he had multiple grade 2-3 sacral pressure sores. A district nurse was having to visit to dress them. The care provider says it received no contact from the district nurse with any concerns after Mr Y’s discharge.
32. The pre-admission assessment stated that Mr Y was at low risk of pressure sores. The skin inspection completed on admission shows that he had a dressing to his left shoulder and scabs and dry skin on his legs and a healed sacral pressure sore.
33. The skin integrity plan completed on 10 March 2022 conflicts with the preadmission assessment as this stated that Mr Y was at risk of skin breakdown due to his advanced age, lack of mobility and occasional incontinence. It stated that staff should inspect Mr Y’s skin daily during personal care and report any changes/concerns. It stated that carers should apply creams as directed and document this. It also stated that carers should encourage Mr Y to stand and walk short distances regularly to relieve pressure. Ms X provided information to the home before Mr Y’s admission which stated that he had had a previous sacral pressure sore and had poor mobility so the care provider should have been aware that he was at risk of pressure sores.
34. The care provider says tissue viability is checked daily when assisting a resident with personal care and no change in skin integrity was found. It says Mr Y did mention on one occasion during personal care that his sacrum was sore. The carer did not see any form of soreness but applied cream at Mr Y’s request.
35. The daily care records show no reference to any pressure sores. However, following concerns raised by the family, the manager sent an email on 17 March saying she had spoken to the nurse and she was going to check Mr Y’s sacral area and encourage him to walk.
36. As part of the care provider’s investigation, one of the carers stated that on 17 March 2022 she and another carer showered Mr Y and “his skin on his bottom looked fine and not red and he did not mention that his bottom fell sore in any way”. Ms X says Mr Y had lost sensation in that area and so feels no pain. She says the care provider was made aware of that at the pre-admission meeting.
37. Mr Y was visited by the community district nurse on 15 March to review his back wound. She visited again on 20 March and change the dressing on his shoulder. She raised no concerns.
38. The Home’s registered nurse provided the following statement as part of the care provider’s investigation: “at no time did the care staff report to me that [Mr Y’s] pressure areas were broken or that they were concerned”.
39. Although carers did not notice any issues, Mr Y returned home with pressure sores. I find that, on the balance of probability, this was caused by the failure to mobilise him regularly during his stay at the home. This caused Mr Y injustice as he suffered pain and discomfort and required medical care.

Elevation of legs/height of chair

40. Ms X says that, although it was documented in the care plan that Mr Y needed to elevate his legs when sitting because of his swollen ankle, a footstool was not provided until the ninth day after the family raised concerns on the sixth day. As a result, Mr Y arrived home with severe swelling in both legs from his groin to his toes. This did not help his mobilisation and rehabilitation at home and his GP had to put him on medication.
41. Ms X also says Mr Y is tall and the armchair in his room was too low. When he arrived at the Home the family asked the carer to get a frame to raise the chair but this did not happen until the ninth day after they raised the issue again. This would have affected Mr Y’s ability to get out of the chair, even with the assistance of carers.
42. The care provider says Mr Y refused a profiling cushion in his chair so they raised the chair with feet. Although this helped, Mr Y did not like this. It says it also tried a recliner chair to raise his feet and a footstool after Ms X requested this. However, it accepts this was not done in a timely fashion.
43. The records show that on 17 March 2022 the care provider sent an email to the family saying they had found a footstool and put it in Mr Y’s room. This was eight days after he arrived at the Home.
44. The failure to elevate Mr Y’s legs within a reasonable time caused Mr Y a significant injustice. He returned home with swelling to both legs requiring medical treatment.

Oral hygiene

45. Ms X said that on the eighth day Mr Y informed her during a telephone call that he had only brushed his teeth two or three times during the first week and was never offered assistance with this.
46. The care plan states under the heading “personal care, oral care and foot care” that Mr Y required assistance to meet all personal care needs. It states that he could brush his teeth, shave and wash his hands and face independently but needed assistance with showering and dressing. However, it stated under the heading “nutrition/hydration plan” that Mr Y may need assistance with cleaning his teeth.
47. Ms Z sent an email to the care provider the day before Mr Y’s admission to the Home explaining that he was suffering pain with his shoulder and was having difficulty shaving as a result and his carer had been doing this for him. She said, “I believe he told you he could manage his shaving-this no longer seems to be the case. I’m not sure about the teeth brushing”. This should have alerted the care provided to encouraging and/or assisting Mr Y with his teeth brushing.
48. There are references in the daily care notes to carers assisting Mr Y with personal care but there is only one reference to him cleaning his teeth, in the entry dated 10 March 2022.
49. On 17 March 2022 Ms Z raised concerns with the care provider about teeth cleaning and the manager sent an email saying she had spoken to the nurse who was going to mention teeth cleaning at night to the night staff. Despite this, there were no references in the notes to teeth cleaning.
50. As oral hygiene had been raised as an issue, carers should have documented in the daily care notes whether Mr Y brushed his teeth or was assisted to do so.

Conclusions

51. I find the care provider failed to provide the level of care Mr Y and his family had the right to expect. The failures identified caused Mr Y harm. He suffered pressure sores and swelling to both legs and difficulties mobilising and required medical intervention on returning home.
52. Mrs Y, Ms X and Ms Z also experienced avoidable distress and anxiety because of the poor care Mr Y received. The purpose of the period of respite care was for Mrs Y to rest. But any benefit was negated by the anxiety caused when Mr Y returned home in the condition that he did.
53. Under Regulation 17, the care provider is required to maintain accurate, complete and detailed records. Failure to fully record information relating to Mr Y’s daily care causes the family uncertainty about the care he received.
54. The care provider has apologised for the poor care and has put in place service improvements. These actions go some way to remedying the injustice suffered by Mr Y and his family.

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Agreed action

55. In addition to its apology and the service improvements it has put in place, the care provider has agreed that, within one month, it will:
• refund half of the fees Mr Y paid for his respite placement in recognition of the poor care he received; and
• pay the family £500 in acknowledgement of the distress and anxiety they suffered because of Mr Y’s poor care.

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Final decision

56. I find the care provider’s actions have caused Mr Y and his family an injustice.
57. I have completed my investigation on the basis that the care provider has agreed to implement the recommended remedy.

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Investigator's decision on behalf of the Ombudsman