Summary: We have found fault in the way the care home provided care to Mrs D, particularly in relation to personal hygiene, provision of stimulating activities and moving and handling. This has caused distress to Mrs D’s daughter and we recommend that the care home apologises, pays a financial remedy and carries out a service improvement.

The complaint

1. Mrs C complains on behalf of her mother, Mrs D who has died. Mrs C complains about the care provided to her mother at Chatsworth Grange Nursing Home in Sheffield.

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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. If they have caused a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
3. 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)
4. 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)

5. 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)

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What I have and have not investigated

6. The Ombudsman does not normally investigate complaints about events that have taken place more than a year ago. I have exercised some discretion to look back more than a year, particularly in relation to the complaint about the care relating to the contracture and bathing. However, generally speaking I have focussed my investigation on recent events.
7. Mrs C also complained that the Home would not share Mrs D’s care and health records with her. I have not investigated this complaint as the Information Commissioner’s Office (ICO) is better placed to do so.

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How I considered this complaint

8. I have discussed the complaint with Mrs C. I have considered the information that she and the Home have sent, the relevant law, guidance and policies and both sides’ comments on the draft decision.

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What I found

Law, guidance and policies

9. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards which says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

What happened

11. Mrs D was an older woman who had dementia. Mrs D had been living in residential care since 2018. She moved to the Home in June 2021 as she was assessed as needing nursing care which the care home where she had been living did not provide. Contact restrictions were in place at the time of Mrs D’s move because of the COVID-19 pandemic.
12. The Council’s assessment of Mrs D, in June 2021, said Mrs D was unable to mobilise or adjust her position following a right sided stroke in 2017. Mrs D’s left leg was ‘flexed’ and two care workers had to use a hoist for all transfers.
13. Mrs C complained to the Home and made safeguarding referrals and complaints to the Council. I have summarised the complaints insofar as they are relevant to the investigation.

Complaint – 1 March 2023

14. Mrs C complained on 1 March 2023 and said:
• She had concerns about the discomfort caused by Mrs D’s leg contracture. Mrs C suggested that a warm bath may assist and the manager said they would ask for a physiotherapist’s assessment to decide whether it would be safe for Mrs D to have a bath.
• Mrs C noticed during visits that Mrs D’s nails were long, sharp and dirty with faeces.
• On 17 February 2023 Mrs C visited Mrs D and noticed that Mrs D was pulling her tooth out and her cheek was red and swollen. She had dried food on her cheek, neck and chest. Mrs D then pulled the tooth out later that day.

The Home’s response – 23 March 2023

15. The Home replied and said:
• In terms of the leg contracture, the manager said a bath may put Mrs D at risk of falls and pain, but Mrs D’s hygiene needs were met in different ways.
• The GP reviewed Mrs D in August 2022 and they prescribed a muscle relaxant but this was discontinued as it made Mrs D sleepy.
• The physiotherapist reviewed Mrs D on 13 October 2022 and fully assessed her contracture and said that they were satisfied that the Home had tried everything and advised the Home to continue to provide care as it had done.
• The manager discussed the contracture with the GP on 22 March 2023 and the GP said there was no prevention for contractures and that reasonable follow-ups to the relevant members of the multi-disciplinary team had been made.
• The Home accepted that Mrs D had dirty nails with faeces on one occasion.
• Mrs D’s skin was like tissue paper so it was at greater risk of damage. The Home’s care was appropriate and any skin tears had been properly documented and treated.
• Mrs C noticed on 17 February 2023 that Mrs D had a painful tooth. Pain medication was given and the tooth fell out later that day.

Complaint to the Council – 29 August 2023

16. Mrs C complained to the Council and said:
• The Home did not always inform of her of bruises or cuts to Mrs D’s skin and its communication was often poor.
• The Home did not provide proper care in terms of moving and handling, particularly in relation to the contracture.
• Mrs D spent most of her time in bed and was not taken out on her chair. She received no stimulation.
• The Home had never given Mrs D a bath, only bed baths.
• Mrs D had a bruise on 13 March 2023 on her hand and her leg was in an uncomfortable position under her bottom. Mrs D had a bruise on 5 April 2023. On 20 March 2023 Mrs D’s leg was trapped under her and the foot was in the crease of the mattress.
• Mrs C spoke to the nurse on 14 March 2023 and said Mrs D was much better when she was not in bed and asked whether she could be taken out of bed every day. The nurse told her Mrs D shared a wheelchair with another resident and said: ‘You get her a wheelchair and we will get her up.’ Mrs C said the Home should have told her earlier that she had to buy a wheelchair.
• Mrs D often had dirty and long fingernails. As Mrs D held her contracted leg tightly and her fingernails were long, there was an increased risk of skin tears.

Council’s response – 4 December 2023

17. The Council responded on 4 December 2023 and said:

Communication

• In terms of communication, the Council said that the Home’s manager acknowledged that although ‘she felt she and her team had been open and available, she had asked the team to reflect on communication with relatives’. This then became part of a ‘lessons learned’ exercise recorded on 14 August 2023 – see below.

Activities

• The Council upheld the complaint that there was a lack of activity and stimulation for Mrs D. The records showed 17 entries tagged as ‘activities’ between January and July 2023, a period of 7 months. The Council said it would have expected to see more records of activity.
• To address this fault, the Council had requested that the Home’s manager enhanced the daily checks and undertook a monthly audit of the daily records to ensure that activities were offered and recorded for residents who were nursed in bed.

Mrs D’s moving and handling care plan and the management of the contracture

• Professionals involved were satisfied with the Home’s management of the contracture.
• Mrs D’s mobility care plan did not provide detail on contracture management, but one of the care staff who was the Home’s moving and handling trainer had trained other staff in how to support Mrs D with repositioning.
• There was a discussion on 9 June 2023 with Mrs C and the occupational therapist and it was decided that Mrs D should be cared for in bed from that date.
• The Council concluded that ‘the records could have contained more detail about how to support [Mrs D] with her contracted leg.’
• To address this, the Council said the Home would work with a nurse from the NHS quality team to on how to provide more effective support to people who are nursed in bed and increase mobility and to increase the amount of detail in the care plan.

Skin integrity and fingernails

• The care plan said Mrs D’s fingernails should be checked every day and the nails trimmed and filed where necessary.
• The Council sample checked June and July 2023 and checks were done on most days except for a five-day gap. The Council’s action plan for the Home included checks to be undertaken to ensure personalisation of records in line with care plans.
• In response to the bruises on 5 April 2023 and 8 June, the Council said there was appropriate recording and tracking of bruises and skin tears.

Personal care

• The Council referred to the bath risk assessment from June 2021 which said Mrs D was supported to have a bath. This was reviewed monthly. The most recent assessment dated 28 July 2023 said it was now unsafe for Mrs D to be washed in the bath or shower.
• The Council asked the Home whether there were any records of Mrs D having a bath in 2022 but the Home was unable to find any references in their care records.
• To address this, the Council said that to aim for best practice that was person-centred, the nurse in the NHS quality team had given the Home an improvement action to support residents who were nursed in bed or less mobile to take baths and showers in line with their preferences.
12. The Home’s ‘lessons learned’ from the complaint document dated 14 August 2023 said:
• Staff were reminded to prioritise communication to with next of kin regarding incidents and changes in care needs.
• Management would review records to ensure that nail care had been undertaken.

Further information

Photos

19. Mrs C sent photos dated 14 December 2022, 17 February 2023, 20 March 2023, 3 July 2023 showing Mrs D had long and dirty fingernails. I looked at the daily records for December 2022 and February and March 2023 and they said Mrs D’s fingernails were checked on the days that Mrs C took the photos.

Home’s records and responses

20. I have considered the Home’s records which are relevant to the complaints. The Home was not able to send me Mrs D’s initial care plan as the plan was continuously updated.

Communication

21. I asked the Home to send me its policy on how it informs the family and friends of residents when there has been an incident such as a fall or a discovery of an injury. The Home said it did not have a policy but this information was contained in the care plan.

Moving and handling review

22. The moving and handling reviews said two care workers used a hoist for all transfers. Mrs D sat in a small recliner and needed support and travelled in a supportive chair.
23. The chronology regarding the leg contracture is as follows:
• 4 July 2022. Mrs C complained about a bruise on Mrs D’s leg. She said Mrs D may require specialist input because of the leg contracture.
• 3 August 2022. The Home asked the GP to assess Mrs D. The GP prescribed medication which may support Mrs D with her contracture.
• 7 September 2022. The GP reviewed Mrs D and advised the Home to continue with the medication. (The medication was later stopped as it made Mrs D drowsy).
• 13 October 2022. A physiotherapist and an occupational therapist visited Mrs D for advice regarding the contracture. They said the Home should maintain the care it had been providing and they were satisfied that the Home had ‘tried everything possible.’
• 22 March 2023. The GP reviewed Mrs D’s leg contracture and Mrs C was present. The notes said they had a lengthy conversation about the nature of contracture, the limitations of what could be done and what had been tried.
• The record of 22 March said: ‘[Mrs C] said she wasn’t aware she had to purchase own chair for mum to sit out every day despite us having several conversations to this effect. The chair [Mrs D] is currently using is a donation and is shared. Would need own bespoke chair to enable sitting out every day…specialist chairs are not provided by the Home. To refer to OT to advise on safe seating, possible suitable chairs.'
• 9 June 2023. An occupational therapist reviewed Mrs D and said it may be best if she was nursed in bed.
24. I asked the Home whether Mrs D had a suitable wheelchair during her stay at the Home and, if not, why Mrs C was not informed of this earlier. The Home responded and said Mrs D had access to a tilt and space chair. However, it was felt that this no longer met her needs. Therefore, the Home made a referral to an occupational therapist on 23 March 2023 and a physiotherapist on 16 May 2023.

Skin integrity / personal care

25. The care plan noted that Mrs D’s skin was paper thin and bruised easily. She had to be repositioned every four hours. Staff had to ensure that bedrails and bumpers were used when Mrs D was in bed.
26. On 21 July 2022 the Home added that bed wedges should be used to reduce the risk of Mrs D putting her arm down the side of the bed as she was prone to bruising. Great care had to be taken when moving Mrs D because of her contracture and fragile skin. She had large items such as a teddy or snake which she could hold to distract her from holding her limbs.
27. Mrs D’s hands and nails could sometimes be covered with faeces and so her nails had to be checked every day and kept short. Nails should be trimmed and filed when necessary.

Bathing records

28. The Home’s records showed that Mrs D had a bed-bath between 4 to 6 times a month in 2022.

Daily records

29. From the records I looked at, Mrs D was more often nursed in bed rather than transferred to her chair. For example, in December 2022, Mrs D was nursed in bed 22 days and in March 2023, 19 days.
30. The daily record for 17 February 2023 showed Mrs D was washed at 07:38. Mrs C visited at 10:06 and Mrs C gave Mrs D a nutrition shake. Mrs D had breakfast (porridge) at 10:06. At 12:01, Mrs D’s fingernails were checked , she was washed and dressed and her teeth were cleaned and her mouth was washed. Mrs D was washed and dressed at 17:21 and the record noted that Mrs D had a toothache and Mrs C had also reported this. Mrs D was given regular paracetamol and the dentist was to be contacted. The tooth fell out at 17:54.
31. Mrs C sent photos dated 20 and 22 March 2023 and she said these showed Mrs D’s leg was in an uncomfortable position. I have checked the records for those dates.
32. On 20 March 2023 Mrs D was washed and dressed at 07:57, repositioned at 11:02, provided a nutrition shake at 13:43, repositioned at 14:10, lunch at 14:11, checked and repositioned at 15:05. Repositioned at 17:17 and 17:39. Mrs C visited at 17:17. On 22 March 2023, Mrs C was repositioned frequently and moved into her chair at 11:13 until 15:45 when she was seen by the GP.

Skin management records

33. I have looked at the skin management records from April to June 2023 and there were detailed records of any bruises or tears, including photos and plans to manage the care. The bruises or tears were monitored frequently.

Analysis

Stimulating activities

34. The Council has already upheld the complaint that the Home failed to give Mrs D enough stimulating activities so I have not investigated this further. But I agree it was fault and 17 activities in 7 months was not sufficient.

Moving and handling

35. In terms of the leg contracture, I note, as the Council did, that there was little information in the earlier versions of the mobility plan that told the care workers what they should do to support Mrs D with the leg contracture. The Home said staff had been trained by the Home’s moving and handling trainer. That may be the case but this should have been clearly documented in the care plan from the outset so that all staff were aware. The failure to do so was fault.
36. I note the Home did not obtain professional advice from medical or other professionals about the contracture until August 2022, after Mrs C raised concerns in July 2022. However, it is impossible to say whether earlier input from outside professionals would have made any difference. I note that the GP, the physiotherapist and the occupational therapist were all satisfied with the care provided by the Home in terms of the contracture once they reviewed the contracture.
37. Mrs C said the Home often left Mrs D in bed all day. The Home blamed this on a lack of a suitable chair, but if that were the case, then the Home should have raised this as soon as it became a problem. The Home took no action in relation to the lack of a suitable chair until Mrs C raised it as a problem on 14 March 2023. This was fault. The Home had a duty to provide the care set out in the care plan. If the Home lacked equipment to do so, it should have raised this with Mrs C.
38. I note that in the records I checked that Mrs D was nursed in her bed far more than she was transferred to her chair. It is impossible to say whether this was what Mrs D wanted or whether this decision was made by the Home’s staff or whether it was linked to the lack of a suitable chair.

Skin integrity / personal care

39. I uphold the complaint that the Home failed to follow Mrs D’s care plan in terms of providing her with a bath. The bath risk assessment from June 2021 said Mrs D should be offered a bath. The Home only gave her bed baths from June 2021 and throughout 2022. The plan did not change until March 2023. No explanation was given in the notes why the care workers did not follow the care plan in 2021 and 2022.
40. When Mrs C questioned the lack of bathing in March 2023, the manager said the Home would require a physiotherapist’s assessment to decide whether it was safe to bathe Mrs D in a bath. I do not understand why, if that was the case, the Home did not address this risk earlier by asking for the risk assessment and changing the care plan. Either way, there was fault.
41. I also uphold the complaint that there were occasions when the Home did not provide appropriate personal care, particularly in relation to Mrs D’s nails. The care plan said Mrs D’s nails should be checked daily and cleaned and trimmed as necessary. Mrs C has sent photos showing the dirty long nails on 4 occasions so the Home failed to properly check the nails on those occasions. Also, as nails grow only 3 mm a month, it appears to me that the problem had been allowed to go on for more than one day.
42. This was concerning as the care plan noted that Mrs D scratched her skin and had paper thin skin. Therefore it was important that her nails were kept short and clean as failure to do this may contribute to a higher risk of skin tears.
43. In terms of the bruises and the occasions where Mrs C said Mrs D’s leg was positioned wrongly, I have considered the records for the bruises for 3 months in 2023 and note that the Home had a detailed plan for staff to manage the bruises and the Home regularly monitored the bruises and kept a record of this. I have also considered the records for some of the days when Mrs C says Mrs D’s leg was positioned wrongly. The Home checked and repositioned Mrs D frequently on those days.
44. I have also considered the records of 17 February 2023, but there is nothing in the records that adds any further information in terms of the complaint. Mrs D was checked and repositioned regularly and she was washed several times that day.

Remedy

45. Mrs D is the person who has potentially suffered most of the injustice as the result of the fault that I have identified. Sadly, as Mrs D has died, I cannot remedy any injustice that she has suffered.
46. However, I accept that Mrs C has also suffered an injustice as she felt that Mrs D was not receiving the care that she needed and this caused her distress. She also suffered directly from the poor communication. In a complaint such as this one, where the main injustice is distress, we can sometimes recommend a symbolic payment to acknowledge the distress. I recommend the Home pays Mrs C £500.
47. I note that the Council has already made recommendations for service improvement recommendations to the Home in terms of the monitoring of activities for residents, its care planning for people who are nursed in bed, provision of baths and showers to residents who are less mobile so I do not recommend any further improvements.
48. However, in terms of some of the improvements the Home made (lessons learned) after the complaint, I question whether they fully addressed the problem. In terms of communication, although staff were reminded to communicate with next of kin, I note that there was still no policy regarding this and no clear explanation about which incidents or injuries should trigger communication with relatives.
49. Similarly, I agree it was a good idea for managers to check the records relating to nail care but this was not enough. The records I looked at said that Mrs D’s nails had been checked on the days Mrs C sent photos of long and dirty nails. Therefore, the nail checks may have happened but they were not done properly. It may be that actual physical spot checks of the care provided, rather than checking the records may be necessary.
50. I have therefore made some service improvement recommendations relating to these concerns.
51. The Care Quality Commission (CQC) is best placed to deal with any other service improvements that the Home may require. Under our information sharing agreement, I will share this decision with the CQC.

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Recommended action

52. I recommend the Home takes the following actions within one month of the final decision. It should:
• Apologise in writing to Mrs C for the fault that I have identified and acknowledge the fault in its apology letter.
• Pay Mrs C £500.
• Consider whether further practice improvements or policies are required in relation to communication with next of kin and checking whether staff have carried out the tasks certified in the records.

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Final decision

I have completed my investigation and have found that the Home’s actions have caused an injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman