Summary: Mr X complained about the care provided to his late grandfather, Mr Y at the Council commissioned care home. The care home was at fault for not properly recording communication with relatives, for not completing an accident report and for when a staff member was rude to Mr Y. The Council has agreed to apologise to Mr X and make a symbolic payment to acknowledge the distress and uncertainty caused. The Council has already taken appropriate action to prevent a recurrence of the faults.

The complaint

1. Mr X complained about the quality of care provided to his late grandfather, Mr Y, at the Council commissioned care home. In particular, he complained the care home:
1. Ignored Mr Y’s and the family’s requests for a GP to be called when Mr Y felt unwell and later tested positive for COVID.
2. Ignored Mr Y’s concerns about a headache and not being able to move his left arm, which it was later established were signs Mr Y had a stroke.
3. Failed to supervise and assist Mr Y with meals following his stroke.
4. Handled Mr Y inappropriately which led to bruising on his arms and staff spoke to Mr Y inappropriately.
5. Failed to appropriately treat a bed sore.
6. Failed to properly administer Mr Y’s diabetes medication.
2. Mr X said the poor care impacted Mr Y’s health and led to a deterioration in his condition and caused the family significant distress.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended). In this case the Council commissioned the care home so we consider the care home was acting on the Council’s behalf.
5. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended). In this case I have not named the care home to protect Mr Y’s anonymity.
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

What I have not investigated

8. I have not investigated item f) above. This is because decisions on whether or not to continue Mr Y’s diabetes medication were made by the GP not the care home. We cannot investigate the GP’s actions.

Back to top

How I considered this complaint

9. I considered information provided by Mr X and discussed the complaint with him on the telephone. I have considered the Council’s response to our enquiries and records from the care home.
10. I gave Mr X and the Council the opportunity to comment on a draft of this decision. I considered any comments I received in reaching a final decision.

Back to top

What I found

Relevant law and guidance

11. 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. The standards include:
• Providers must make sure that people who use their services have adequate nutrition and hydration to aid good health. People must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition (regulation 14).
• Providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).
• Providers must treat those using their service with dignity and respect at all times when they are receiving care and treatment (regulation 10).
12. 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. Under the European Pressure Ulcer Advisory Panel classification system, pressure sores are graded in severity from 1 to 4.
13. 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. 

Key events

14. In March 2022 Mr Y was admitted to the care home after a hospital stay. He had multiple health conditions and had capacity to make his own decisions about his care. His hospital discharge records showed Mr Y had restriction in the range of movement of his upper and lower limbs and required a soft diet.
15. The Council’s ‘urgent service request’ document completed in February 2022 set out that Mr Y needed support from one member of staff with all his care needs. He had a grade two pressure sore and was discharged to a care home to support pressure care and other needs.
16. The care home completed care plans. The wound care plan noted Mr Y had a previous pressure sore at the base of his spine which was healed. Mr Y’s pressure care plan noted he was at high risk of pressure sores. He was given a pressure relieving mattress and pressure cushion for use in a chair. He was prescribed a barrier cream. Staff were to encourage him to lie on his side from time to time throughout the day.
17. Mr Y’s nutrition and hydration care plan noted Mr Y required a soft diet but could eat and drink independently.
18. The care home updated the wound care plan each month. The plans noted a pressure sore in August 2022 which healed within two weeks. Mr Y developed a further pressure sore on his sacral area in December 2022 which the care plan noted should be dressed every three days or when necessary.
19. The positional change records show staff repositioned Mr Y regularly but there were occasions when Mr Y refused to lie on his side. The care home weighed Mr Y monthly. The records showed Mr Y had a healthy weight to height ratio.
20. In late February 2023 the GP visited Mr Y following concerns about loose stools. The GP referred Mr Y for further tests. Mr Y and his family later decided they did not want any further tests carried out. Two days later the care home did routine COVID testing and Mr Y tested negative.
21. The following day the care home called 999 as Mr Y was unwell with symptoms of a chest infection. Mr Y tested positive for COVID. The notes record Mr Y did not want to go to hospital. The care home updated Mr Y’s relatives. Mr Y was prescribed an inhaler to help relieve his symptoms. The care home’s daily notes of the following five days record Mr Y’s vital signs were monitored. Staff assisted him to use his prescribed inhaler during the night and he was compliant with taking his medications. In early March staff noted Mr Y was slightly confused in the night. The GP visited the following day and prescribed antibiotics for a chest infection. Mr Y tested negative for COVID the following day. Two days later the record noted Mr Y had visitors.
22. A week after their previous visit to Mr Y, the GP visited. The notes record Mr Y was referred to the GP as he was unable to move his left arm or leg. He was not complaining of pain. Mr Y was transferred to hospital with a suspected stroke. Mr Y’s relatives were updated.
23. Two days later the hospital discharged Mr Y. It had diagnosed a stroke and prescribed antibiotics for Mr Y. It referred Mr Y for input from the speech and language therapist (SALT). The care home completed a body map on his return and noted redness at the base of Mr Y’s spine and an old bruise on both arms.
24. The SALT visited Mr Y. They gave advice on Mr Y’s diet and fluid intake and recommended Mr Y be supervised by one staff member during mealtimes. He needed support moving his plate. The care home noted this in Mr Y’s nutrition and hydration care plan. The care home started completing food and fluid charts for Mr Y. The GP visited Mr Y twice that month and increased his painkillers.
25. From late March 2023 onwards Mr Y often refused to be repositioned, although this was offered every two hours. A body map completed in April noted old bruises on his arms. The daily food charts showed Mr Y’s food intake had decreased and he was generally eating less. Mr Y met his fluid target on most days. From April 2023 it added thickener to his fluids as Mr Y was coughing when drinking.
26. The care home continued to monitor Mr Y’s pressure sore and by April 2023 noted it was much improved.
27. In April 2023 Mr Y was unwell and complaining of pain. A GP prescribed antibiotics for a urine infection. Around this time the care home requested anticipatory medications for Mr Y as the GP considered he was approaching end of life. The care home also stopped weighing Mr Y regularly. The GP reviewed Mr Y twice more in April 2023.
28. Mr Y developed a further pressure sore in May 2023. In May 2023 the GP changed Mr Y’s medication to liquid as he had difficulty swallowing tablets. They advised the care home to keep Mr Y comfortable and to encourage his fluid intake.
29. Mr Y died in May 2023.
30. In June 2023 the care home considered a complaint by a family member about Mr Y’s care which included that Mr Y had a bruise on his hand and concerns about a delay in getting a GP when Mr Y complained of left hand weakness. The care home said the bruise was caused by a cannula fitted when Mr Y went into hospital. It said the GP had regularly reviewed Mr Y.
31. In November 2023 Mr X complained to the care home. He said Mr Y complained of feeling unwell and he and other relatives asked the care home to call the GP but were ignored and it was a week before the care home tested him for COVID. Mr X said Mr Y complained of having a headache and that he could not feel his arm and the care provider took too long to assess him. Mr Y was later found to have had a stroke. He complained that after the stroke the care home failed to provide him with the care he needed. He said it failed to support him with eating or to wake him to assist with eating if he was asleep. Mr X said a carer would grip Mr Y by the arms to change him causing bruises. He also said that Mr Y had a bruise on his hand and a carer had spoken inappropriately to Mr Y. Mr X also said Mr Y had a grade 4 pressure sore which got worse and was not properly cared for.
32. The care home responded to Mr X’s complaint in January 2024. It set out what had happened based on Mr Y’s care notes. It said Mr Y was frequently seen by the GP and transferred to hospital for further treatment as necessary. It noted Mr Y was frequently reluctant to accept staff assistance with eating and drinking but it acknowledged Mr Y’s concerns and apologised that Mr Y was not supported in the way family wished.
33. It noted when Mr Y returned from hospital following his stroke he was in a weak condition with minimal appetite. It said the care home had made the family aware of how ill Mr Y was but noted it had spoken with the manager about the need to document conversations with family. It referred to Mr Y receiving a skin tear when he trapped his hand between the bed and bumpers and that the nurse had completed an accident report at that time. It noted actions including the need to document conversations with families and to understand the importance of good communication and sensitivity to a family whose loved one is approaching end of life.
34. Mr X remained unhappy and complained to the Council. The care provider investigated at the second stage of its complaints procedure. The Council wrote to Mr X in mid February 2024. It said:
• The records showed the care provider contacted the family when Mr Y tested COVID positive and regarding his admission to hospital. However, it was not clear from the records when Mr X or the family raised concerns about the numbness in Mr Y’s arm. It considered the care home’s records were not an accurate account of the concerns raised by the family. It recommended the relatives communication records should also include records of conversations started by the family.
• The care home had said the bruise on Mr Y’s hand was caused by a canula inserted in the hospital. The care home also told it the skin tear was caused by Mr Y trapping his hand beside the bed but provided no accident log evidencing this. It said it would follow this up with the home as all accidents should be properly recorded.
• Its Care Quality Team had visited the care home in November 2023 and found no serious concerns with the service but made some recommendations for improvements.
• The care home had apologised for the way Mr Y was spoken to by a carer and said staff would attend additional training sessions on effective communication. The Council would check the training had been carried out.
35. The care home later confirmed to the Council it had held a team meeting about the importance of recording discussions with relatives especially where relatives expressed dissatisfaction. It was planning a further meeting to discuss the accurate completion of body maps and incident recording. It confirmed relevant staff had supervision and dignity training which had then been made available to all staff.

Findings

Delayed contacting GP

36. The records show the GP saw Mr Y three days before he was diagnosed with COVID and again five days after, and the care staff called an ambulance when Mr Y’s blood oxygen was low. The notes record the GP visited regularly. I have seen no evidence of delay in the care home getting medical treatment for Mr Y when he was diagnosed with COVID. The GP prescribed antibiotics when Mr Y developed a chest infection and the records show these were administered.

Ignored Mr Y’s concerns which were found to be a stroke

37. Mr Y had COVID symptoms and his vital signs were monitored by the care home. Mr X says Mr Y complained to care staff of numbness in his arm staff and the family also raised their concerns. There is no record of this within the care notes. The records show family visited three days before Mr Y went to hospital and it is possible they raised concerns at that point.
38. The Council identified that while the care provider recorded when it contacted relatives, it failed to record when relatives contacted the care home to raise concerns. This was fault. Even on balance I cannot say when Mr Y first developed stroke symptoms and what, if any, difference it would have made had Mr Y received medical attention sooner. However, this leaves Mr X with an enduring sense of uncertainty over whether things may have been different.
39. The Council recommended improvements in the way the care home recorded communication with relatives. It then followed this up with the care home and found the care home held a team meeting regarding this issue. The Council has already ensured the care home has taken action to address the fault so I have made no further recommendation.

Supervising and assisting Mr Y with meals following his stroke.

40. The care plan noted Mr Y could eat independently but following his stroke required supervision and assistance to move his plate. The care provider started food and fluid charts which showed Mr Y’s intake decreasing.
41. Mr X said staff did not assist Mr Y with eating or encourage him as much as they should. I cannot now know the extent to which staff supported Mr Y or whether further support would have increased his intake. It is possible staff assumed family would support Mr Y when visiting when it was actually the staff’s responsibility to ensure Mr Y received support. But I cannot now say whether there was fault. In its complaint response the care provider apologised that the care home had not supported him in the way family wished. There is nothing more I could achieve through further investigation of this issue.

Handled Mr Y inappropriately which led to bruising on his arms and staff spoke to Mr Y inappropriately.

42. The care home regularly completed body maps. A body map completed after Mr Y had been in hospital noted bruising on his arms. I cannot establish when this happened or what caused it. The care home acted appropriately in noting this in a body map.
43. Mr X also expressed concern about a bruise on Mr Y’s hand. The care home reported this was due to a cannula inserted in Mr Y’s hand at the hospital but also referred to a skin tear when Mr Y trapped his hand beside the bed. In its complaint response the Council found the care home at fault for not completing an accident record or body map when Mr Y trapped his hand. The failure to keep an accurate record is fault and not in line with the CQC fundamental standards. The Council followed this up with the care home which confirmed it was meeting with staff to discuss the completion of body maps and accident reports. The Council has already taken action to prevent a recurrence of the care home’s fault. This was appropriate and there is nothing more I could achieve by investigating this issue further.
44. The care home accepted a member of staff had spoken inappropriately to Mr Y. This was not in line with the CQC fundamental standards and was fault. This caused Mr Y and the family distress. The care home apologised for this. The Council followed this up with the care home and found the care home had since provided appropriate training and supervision to the staff member concerned and that the training was made available to all staff which will help prevent a recurrence of the fault.

Treatment of a bed sore.

45. Mr Y had a bed sore prior to entering the care home. The Council completed a care plan which showed he was at very high risk of pressure sores. It provided appropriate equipment to support Mr Y, regularly monitored Mr Y’s skin and reviewed and updated the care plan. When Mr Y developed a pressure sore the care home completed an appropriate care plan and a turning chart. It sought to regularly reposition Mr Y but Mr Y sometimes refused. Mr Y had capacity and so the care home could not make him reposition if he chose not to. The records show the care home provided appropriate pressure care and was not at fault.

Injustice

46. The Council’s quality monitoring team has monitored the care home and it has taken action to ensure the recommendations it made following the complaint were implemented. This was appropriate and therefore I have made no further recommendations for service improvements.
47. I cannot say the deterioration in Mr Y’s health was as a result of the care home’s faults. In addition, Mr Y has died and so we cannot remedy any injustice caused to him by the care home’s actions. However, the faults by the care home caused Mr X distress and uncertainty about whether there could have been a better outcome for Mr Y.

Back to top

Agreed action

48. When a council commissions or arranges for another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation undertaking them. So although I found fault with the actions of the care home, the following recommendation is made to the Council.
49. Within one month of the final decision the Council has agreed to apologise to Mr X and make a symbolic payment of £300 to acknowledge the distress and uncertainty caused by the faults identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended.
50. The Council should provide us with evidence it has complied with the above actions.

Back to top

Final decision

51. I have completed my investigation. There was fault causing injustice which the council has agreed to remedy.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman