Summary: Mrs X complained the Care Provider failed to provide her mother, Mrs Y, with an acceptable level of care when she stayed at the care home for respite. The Care Provider failed to provide personal care and pressure care during Mrs Y’s stay. It delayed getting medical attention when her health declined and failed to provide the necessary information to emergency services. The Care Provider will apologise, pay for the injustice caused and provide evidence of the training given to staff to prevent reoccurrence of the failures.

The complaint

1. Mrs X complained the Care Provider failed to provide her mother, Mrs Y, with an acceptable level of care when she stayed at the care home for respite. She says the Care Provider failed to provide the necessary support and cushioning her mother needed and failed to recognise when her health was worsening. She also says there was poor personal care and a failure to provide the correct information to the emergency services.
2. She says this resulted in Mrs Y becoming ill and suffering from a severe pressure sore which took months to recover from.

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 our information sharing agreement, we will share this decision with the Care Quality Commission (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.
• 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.
• Duty to notify (Regulation 18) Care Providers must notify the CQC of all incidents that affect the health, safety and welfare of people who use services.

Pressure sores

11. Pressure sores (also called pressure ulcers or bed sores) are wounds caused by pressure on part of the body interrupting the blood supply to the skin. People with mobility difficulties and who are over 70 are more at risk.
12. Under the European Pressure Ulcer Advisory Panel classification system, pressure sores are graded in severity from 1 to 4. Grade 1 indicates the first signs of pressure damage; including redness, discolouration, swelling or heat but with intact skin. Grade 2 is usually an abrasion or blister and involves a partial thinning of the skin. Grade 3 involves full loss of skin thickness with damage to, or death of, the underlying tissue. Grade 4 indicates severe pressure damage, usually a deep wound that may go down to the bone and involve the death of underlying tissue.
13. Pressure sores can develop over a short period of time when a large amount of pressure is applied to a skin area or over a long period of time when less pressure is applied.

Key events

14. Mrs Y suffers from dementia. She was living at home with her husband and received domiciliary care three times a day.
15. In July 2022 Mrs X arranged respite for Mrs Y at Mockley Manor run by Coate Water Care Company Limited. She was due to stay at the home for around two weeks from late July 2022.
16. One week before the visit the Care Provider carried out an assessment of Mrs Y’s needs. It identified that Mrs Y was immobile and sits in a recliner chair during the day and a hospital bed with safety rails at night. It recorded that Mrs Y needed help with personal care and had incontinence meaning she needed pads. Mrs Y had a history of pressure damage, but her skin was intact on assessment.
17. The Care Provider created a care plan for Mrs Y. Under the care plan Mrs Y needed help with all personal care and changing her pads at least every four hours. The Care Provider needed to help her out of bed and into her chair daily and with repositioning every four hours to prevent pressure sores. Mrs Y skin was to be checked regularly for skin breakdown with concerns reported. It also noted in food preferences that Mrs Y struggled to tolerate acidic foods.
18. The Care Provider carried out a body map assessment when Mrs X arrived at the care home. It took photographs of any areas of concern.
19. Mrs Y needed a special pressure mattress at home. Mrs X enquired whether the Care Provider would provide this. She also moved Mrs Y’s specialist chair from home into her room.
20. The records show that during Mrs Y stay staff repositioned her and moved her from her bed to the chair in her room and to the lounge. On seven occasions the Care Provider left Mrs Y for around six hours without repositioning and on three occasions it left her for around five hours.
21. The daily care records show the Care Provider changed Mrs Y’s pad three times a day for the first couple of days and then five times a day. It also shows it applied barrier cream in the morning and in the evening. Except for her last day when the Care Provider applied it four times.
22. Several days after her arrival the Care Provider found Mrs Y’s health to be declining and she became unresponsive. It called the ambulance around 03:00. It said the patient was unresponsive and had irregular breathing. The Care Provider confirmed there was a do not resuscitate order in place. When asked, it explained it was not undertaking resuscitation. The ambulance summarised the call noting that this was an unexpected death, and that Mrs Y was not breathing. It warned the Care Provider the ambulance could take up to three hours to arrive because of the limited assistance it could provide with the order in place. The Care Provider made no correction to the statement that Mrs Y was not breathing.
23. When the ambulance crews arrived at 03:19 Mrs Y was in her room with four members of staff and breathing. The Care Provider told the ambulance crew that Mrs Y had normal temperature readings. The crew found Mrs Y was red flag septic and had a national early warning score (NEWS) of four out of 16. It raised concerns about the Care Provider’s actions. Mrs Y was taken to hospital, but care staff could not provide any patient history, paperwork or a red bag.
24. On admittance, the hospital found Mrs Y had sepsis and pneumonia. It identified and recorded a pressure sore at 05:20 and 05:30. The rating for the pressure sore was not noted down.
25. The hospital recorded at 14:22 that it had yet to order a pressure relieving mattress. It said it would arrange this after Mrs Y was transferred.
26. In an email to the hospital the Care Provider accepted there had been an error in the thermometer readings it had taken for Mrs Y. It explained this was because of a fault with the thermometer. It said it had been on memory mode. It stated it would remind staff of the importance of checking thermometers, the red bag scheme and providing the hospital pack.
27. Mrs X raised a complaint to the Care Provider in November 2022. She raised concerns that it had:
• Failed to provide basic hygiene and care.
• Failed to provide medication.
• Failed to provide a patient history to ambulance crew.
• Falsely reported Mrs Y as not breathing to the emergency services.
• Left Mrs Y in either her wheelchair or other chair for a long time.
• Failed to call emergency services at an appropriate time.
• Failed to record personal information correctly.
28. The Care Provide responded in March 2023. It admitted that it had not provided pressure relief to Mrs Y on the day she arrived, two days into her stay and for several hours the day she started to become unwell. It also accepted it had not provided incontinence care two days into her stay. That it only provided barrier cream twice a day during Mrs Y’s stay. It accepted it had not provided the hospital with her patient history or medication in a red bag. It explained this was due to the red bags not being returned previously and none being available. It accepted that when Mrs Y first showed signs of being unwell it did not carry out a NEWS assessment.
29. The Care Provider agreed to carry out training around the red bag scheme, its record system, the NEWS monitoring system and nutrition and hydration. It stated it had introduced a system to check equipment, to deal with admissions and to oversee pressure care.
30. Mrs X was unhappy with the response and raised questions. The Care Provider issued a further complaint response in April 2023. It retrospectively calculated Mrs Y’s NEWS rating based on the notes taken. It accepted that it should have called the emergency services several hours earlier than it did. It accepted it had recorded personal information wrongly in the pre-admission documentation. It noted that as Mrs X had spotted this the error had had no impact on Mrs Y or Mrs X. It denied it had placed Mrs Y in an unsuitable chair when she was in the lounge. It explained the care home had reclining chairs which Mrs Y had been placed in.
31. The Care Provider says following the complaint it has reviewed and amended the training it provides on pressure relief. It says staff have undertaken the new training in place and it has introduced an electronic reporting system to record how skin is presenting. It says it has carried out training for staff to build confidence in making calls to emergency services.

Findings

Provision of hygiene care

32. The Care Provider recorded that Mrs Y suffered from incontinence. The care plan created stated that she needed her pads changing every four hours. It also needed to apply barrier cream three to four times a day.
33. The Care Provider has accepted it failed to provide continence care for Mrs Y. Its records show Mrs Y was not provided continence care every four hours. During the first three days it only changed her pads three times a day. It has also accepted it failed to apply barrier cream in line with the care plan. Staff applied cream in the morning and evening only.
34. The lack of personal care and hygiene caused Mrs Y discomfort. Mrs X believes it has also affected her health. I cannot say whether this led to a decline of her health or the time she spent recovering in hospital. It has, though, caused Mrs X uncertainty about her mother’s health and whether this could have been prevented. This is an injustice.

Pressure sore care

35. When Mrs Y arrived at the care home in late July the Care Provider created a care plan for her. This noted that she was at high risk of pressure sores. To prevent these from occurring the Care Provider needed to reposition Mrs Y every four hours and sit her in a reclining chair.
36. Mrs X raised concerns the bed provided was not suitable for people with a high risk of getting pressure sores. The Care Provider has some hybrid mattresses which are suitable for people with high risk of pressure sores. There are no records which show the Care Provider considered the type of mattress Mrs Y wanted or the provision on this. This lack of record keeping has left Mrs X with uncertainty around whether this need was met or not.
37. Mrs X also raised concerns that Mrs Y was not placed in a reclining chair when she was moved into the lounge as needed in her care plan. I cannot say for certain where Mrs Y was placed. However, the care home does have reclining chairs in its lounge and the staff statements confirm they put Mrs Y into the reclining chairs.
38. The care notes for Mrs Y show the Care Provider did not move Mrs Y every four hours as needed under her care plan. This is not in line with the fundamental standards.
39. The hospital identified a pressure sore within an hour of Mrs Y arriving. The pressure sore was not graded or described at this time. As pressure sores can develop over a short period of time, I cannot say whether it occurred because of the Care Provider’s failure to repositioned Mrs Y every four hours.
40. However, the failure to provide the agreed pressure relief could have caused Mrs Y to develop a pressure sore. It would have put her at increased risk of harm. It has also left Mrs X with the uncertainty as to whether the care provider’s actions cause the pressure sore to arise. The Care Provider’s failure to follow the care standards has caused an injustice.

The hospital admission

41. The Care Provider has accepted on review of the notes that it should have called the emergency services earlier at around 23:00. I appreciate Mrs X feels the emergency services should have been called earlier than this. I cannot say at what point the Care Provider should have called the ambulance. I am, though, satisfied there was a delay in Mrs Y receiving the medical care she needed.
42. The Care Provider accepted staff had used a thermometer set on memory mode resulting in inaccurate readings when reviewing Mrs Y’s health. It also said in response to the complaint that it would be introducing a hospital check list. The Care Provider’s actions have affected when it called the emergency services. This caused Mrs Y’s condition to worsen further before she received the treatment she needed. This is an injustice.
43. When the Care Provider contacted the emergency services it told them that Mrs Y was breathing but it was abnormal. It confirmed Mrs Y had a do not resuscitate in place. At the end of the call the emergency service staff asked questions about whether Mrs Y’s death was expected and summarised Mrs Y as being unresponsive and not breathing. The Care Provider did not correct this misunderstanding to confirm that Mrs Y was alive. The emergency services arrived within 30 minutes and not the three hours suggested on the call. As such this error did not result in a delay in Mrs Y receiving the treatment she needed. It has though left Mrs X concerned about the treatment Mrs Y received and whether this could have been better.
44. The Care Provider has accepted it did not provide the hospital with a patient history and sent medication in a plastic bag. This is not the Care Provider’s agreed process. It says this occurred because the printer had run out of ink and the red bags had not been returned from previous transfers. The Care Provider should have ensured staff were aware of the transfer process and had enough red bags. The Care Providers actions placed Mrs Y at risk of harm because the ambulance crew did not have a patient history.

Back to top

Agreed action

45. Within one month of the final decision the Care Provider will:
• Apologise to Mrs X and Mrs Y for its failure to provide personal care, hygiene care and pressure sore care during Mrs Y time at the care home and the injustice caused. It should also apologise for its failure to correct the misunderstanding with emergency services and provide a patient history and the injustice caused.
• Pay Mrs Y £400 in recognition of the distress caused and the risk of harm.
• Pay Mrs X £100 in recognition of the uncertainty caused.
• Refund £1,450 of Mrs Y’s bill.
• Provide evidence that all staff have undertaken its skin integrity and pressure damage training.
46. The Care Provider should provide us with evidence it has complied with the above actions.

Back to top

Final decision

47. I have completed my investigation. The Care Provider is at fault causing injustice. The Care Provider will take action to address the injustice and prevent recurrence.

Back to top

Investigator's decision on behalf of the Ombudsman