Summary: Mrs X complained the Care Provider failed to provide the necessary wound care for her mother, Mrs Y, during her respite stay. We find the Care Provider’s actions caused an injustice. We make several recommendations to address this injustice.

The complaint

1. Mrs X complains the Care Provider failed to provide the necessary wound care for her mother, Mrs Y while she was in its care home. She says Mrs Y’s wounds became worse and infected during her stay at the home and the Care Provider failed to take the necessary steps to deal with this.
2. She says this impacted her mother’s recovery from her fall and caused her distress.

Back to top

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 an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
6. If we are satisfied with an organisation’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)
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.

Back to top

How I considered this complaint

8. I have considered:
• The information provided by Mrs X and discussed the complaint with her;
• The Care Provider’s comments on the complaint and the supporting information it provided; and
• Relevant law and guidance.
9. Mrs X and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

Law and guidance

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards below which care must never fall. The standards include:
• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Assessments should be reviewed regularly and whenever needed throughout the person’s care and treatment.
• Dignity and respect (Regulation 10): Service users must be treated with dignity and respect and in a caring and compassionate way.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user. This includes systems to assess, monitor and mitigate risk relating to health, safety and welfare of service users.

What happened

11. Mrs Y lived at home alone. In July 2022 she had a fall. Her GP recommended respite to help her recover. She went to stay at Ditton Priors Care Centre run by St. Philips Care Limited for two weeks.
12. The Care Provider carried out an assessment when Mrs Y arrived. It recorded Mrs Y as having several bruises on her arms, legs and head, four skin tears which already had dressing in place and a pressure sore.
13. The Care Provider created a care plan for Mrs Y in mid-July following a visit from the district nurse. It recorded that skin tears to her left arm and a pressure sore would be reviewed in one week and the skin tears to her right arm would be reviewed in three days. It recorded that staff would be guided by a district nurse and would monitor the wounds. It noted that Mrs Y had a specialist cushion and mattress to relieve the pressure on this area and that she needed to stand regularly.
14. The district nurse attended a week later to clean and redress the wounds. Following this visit the Care Provider updated Mrs Y’s care plan to include getting barrier cream to apply to her pressure sore daily.
15. Photographs were taken on the district nurses first visit and again when they visited a week later.
16. Mrs Y’s son and a private carer collected her in late July 2022. The Care Provider noted Mrs Y had substantial difficulties getting into the car due to the height of the car and needed lifting.
17. Mrs X says that when Mrs Y arrived home they removed her cardigan, and raised concerns about her right arm. It was swollen red, itchy, painful and smelt. They contacted a doctor who attended Mrs Y that day.
18. Mrs X says the doctor was concerned about the wound and Mrs Y was close to being taken to hospital because of the poor condition.

Findings

The skin tears

19. When Mrs Y arrived at the care home in mid-July, she had four recorded skin tears. The worst of which was on her right arm. Mrs X believes the lack of care resulted in this arm suffering from cellulitis.
20. The Care Provider’s care plan for Mrs Y noted the wound had been dressed and recorded it should be reviewed in three days’ time. The Care Provider has not been able to provide any daily care notes for Mrs Y’s visit. It can only document the visit from the district nurse a week later. As such there is no evidence the Care Provider reviewed this wound in accordance with the care plan. This is not in line with the fundamental standards.
21. Although I cannot say with any certainty that Mrs Y’s wound deteriorated because of a lack of care, the lack of notes and Mrs Y’s condition on discharge has caused uncertainty for her and her family about whether or not she was provided the care she needed. The failure to provide the recommended wound care would have put Mrs Y at risk of increased harm. The failure to follow the care plan and keep care notes has caused an injustice.

The pressure sore

22. Mrs Y had a pressure sore on arrival at the care home. The Care Provider recorded at the start of Mrs Y’s stay that she needed to be mobilised regularly and has specialised cushions. It hasn’t provided evidence to show it regularly mobilised Mrs Y or used her cushions at any time during her stay.
23. The Care Provider updated the care plan a week into Mrs Y’s stay after the district nurse had been to visit. The notes recommended applying a barrier cream to the pressure sore daily. The Care Provider says it got the cream recommended but there is no evidence showing it followed the care plan and applied the cream.
24. Further, there is no evidence the care home monitored Mrs Y pressure areas during the time she was at the home.
25. Again, I cannot say whether Mrs Y’s pressure sore deteriorated because of the Care Provider’s failure to follow the care plan or whether there were other causes. However, the failure to provide the recommended pressure sore care would have put Mrs Y at risk of increased harm. The failure to keep notes has caused uncertainty for Mrs Y and her family about whether she was provided the care she needed to prevent her pressure sore deteriorating. The failure to follow the care standards has caused an injustice.

Back to top

Recommended action

26. The Care Provider within one month should:
• Apologise to Mrs X and Mrs Y for the injustice caused.
• Pay Mrs Y £300 for the injustice caused.
• Waive £1,100 from the outstanding bill.
27. The Care Provider within two months should:
• Provide training to all care staff on the importance of record keeping, to ensure the records kept are fit for purpose and in line with fundamental standards.
28. The Care Provider should provide us with evidence it has complied with the above actions.

Back to top

Final decision

29. I have completed my investigation. I have found injustice and have recommended action to remedy the injustice caused and prevent reoccurrence.

Back to top

Investigator's decision on behalf of the Ombudsman