Summary: The care home commissioned by the Council failed to keep proper records and failed to carry out a thorough assessment before Mr B was admitted. As a result, it did not identify that Mr B had difficulty using his hands, and he sustained a burn to his leg when he spilled a cup of hot tea. The Council has agreed to apologise and make a payment to Mr B. It will also ensure the care home makes service improvements.

The complaint

1. Miss X is complaining on behalf of her mother and step-father, Mr and Mrs B. She says that Mr B received poor care during a respite stay in a care home. In particular, she says that the care home failed to take appropriate action when Mr B burned himself which meant that the injury took longer to heal. Miss X says that Mr B is reluctant to have further respite stays, which impacts Mrs B who is his main carer.

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The Ombudsman’s role and powers

2. 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)
3. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
4. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
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)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

7. I have:
• considered the complaint and the documents provided by Miss X;
• discussed the issues with Miss X;
• made enquiries of the Council and considered the comments and documents the Council has provided; and
• given the Council and Miss X the opportunity to comment on my draft decision.

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What I found

Fundamental Standards of Care

8. 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.

Key events and analysis

9. Mr B lives at home with his wife, Mrs B. He has care and support needs and carers visit four times a day. Mrs B also assists Mr B between care visits.
10. To provide Mrs B with some respite from caring for Mr B, the Council arranged for Mr B to stay in a care home for three weeks. He was admitted on 15 September 2023.

Painkillers

11. Miss X says that one morning, Mr B told a member of staff that he had experienced chest pains during the night and he asked for paracetamol. According to Mr B, his request was refused and he was not asked any further questions about the pain.
12. The care home says that if a resident reported chest pains, staff would call 999. It also confirmed that while it does have paracetamol, it can only be administered with permission from a GP.
13. There is no mention of Mr B asking for painkillers in the care home’s records. However, it seems likely that Mr B did ask for paracetamol, considering he knew that the care home would not provide him with any. On the balance of probabilities, I consider staff failed to take appropriate action when Mr B requested painkillers.
14. Mr B arranged for Mrs B to bring him some paracetamol later that day. I consider it unlikely that he would have received painkillers sooner if care home staff had taken appropriate action and sought medical advice.

Temperature

15. Miss X says that Mr B’s room was cold and he requested another blanket, but one was not provided. The care home records confirm that Mr B complained that his room was cold on 24 September. The records do not indicate whether staff took any further action to ensure he was warm enough.
16. Care home staff have since stated that Mr B did ask for another blanket, and one was provided. They report that the extra blanket was left on the bed when he was discharged.
17. Given the conflicting accounts and lack of clear documentation, I do not consider it possible to determine whether there was any fault on the part of the care home here.

Emergency call

18. On 4 October, Mr B sustained a burn to his leg when he spilled a cup of hot tea. He says that he pressed the emergency assistance call button six times but received no response. He says that no one came until he called reception using his mobile phone.
19. I have reviewed the call system records. The alarm was activated at around 5:20pm, but it is unclear whether this was due to Mr B pressing the emergency assistance call button or because the sensor mat in his room was unplugged or moved. The alarm was reset immediately, which the Council interprets as evidence that staff were already present when the alarm was triggered.
20. I have seen no evidence of a telephone call being made by Mr B to reception for assistance. Staff witness statements indicate that Mr B did not alert staff to the injury, and it was only discovered when he was being given personal care at approximately 6pm.
21. Based on the available evidence, I am unable to conclude that staff failed to respond to a call for assistance from Mr B.

Treatment

22. Miss X believes that the care home should have applied cream and dressed the wound immediately. She states that the wound was not treated until after Mr B returned home, when Mrs B contacted his GP directly.
23. The care home’s records indicate that when the burn was first discovered, Mr B had a blister the size of a 10 pence coin, which was still intact. The senior carer contacted the clinical lead, who determined that immediate treatment was not required. The senior carer also completed an incident form, an Abbey Pain Scale assessment, and a body map.
24. The clinical lead assessed the wound the next morning and did not believe it required dressing. However, she contacted the GP, who later prescribed an ointment and a breathable dressing, in case the blister ruptured. The GP sent the prescription to a local pharmacy. The clinical lead emailed the pharmacy, requesting prompt provision of the prescribed items.
25. The following day, the pharmacy informed the clinical lead that it needed to order the ointment, and it would not be available until the next day, a Saturday, when they did not offer deliveries. Since Mr B was due to return home that day, the clinical lead reached out to a nearby pharmacy close to his home. This pharmacy agreed to order the ointment and deliver it to Mr B's home on Monday.
26. Based on this information, I am satisfied that staff sought medical advice and adhered to the guidance they were given. I believe they took appropriate steps to ensure that Mr B would receive the prescribed items in a timely manner. I have found no evidence of fault here.

Assessment

27. Care providers are required to carry out an assessment of the service user’s needs and preferences and to assess risks to their health and safety.
28. Miss X believes that Mr B should have been provided with an appropriate cup with a lid because he has arthritis in his hands.
29. The care home states that it carried out an assessment before Mr B’s admission and noted that he was independent with meals. It also says that it does have different drinking aids available such as two handled cups and cups with lids, but staff are not allowed to provide these unless they are specifically requested. It considers it to be inappropriate for staff to assume someone is unable to drink from a normal cup and give aids that could potentially deskill them.
30. While the care home did conduct an assessment before Mr B was admitted, it was not fully completed. When the Council investigated Miss X’s complaint, it accepted that the care home had failed to carry out a thorough pre-admission assessment. It asked the care home to put an action plan in place to ensure all new assessments are completed and they do not solely rely on the care plan supplied by the social worker.
31. Given Mr B's arthritis, I believe staff should have specifically confirmed whether he required a special cup or any other adjustments to support his independence and prevent potential risks. I consider the care home failed to carry out a proper assessment.
32. If a proper assessment had been carried out before Mr B’s admission, it is likely that care home staff would have recognised that Mr B should not be given a full cup of hot tea in a standard cup. Had this been identified, it is unlikely that Mr B would have sustained the burn. I consider the care home’s failings resulted in Mr B experiencing mild pain and discomfort until the wound healed.
33. The Council's records do not indicate that Mr B has shown any reluctance to enter a care home for respite following this incident. When Mr and Mrs B have requested respite care, the Council has arranged for respite to be provided and Mr B has stayed in a different care home without issue.

Record keeping

34. Care homes are required to maintain an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.
35. The care home records for Mr B show two entries per day, which provide minimal detail and do not adequately document the care and treatment Mr B received. As such, I consider the care home has failed to maintain proper records in accordance with the required standards.

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Agreed action

36. When a council commissions or arranges for another organisation to provide services, we treat actions taken by that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of the care provider and make the following recommendations to the Council:
37. Within four weeks, the Council will ensure Mr B receives an apology for the failings identified in this case. It will also make a symbolic payment of £150 to Mr B to recognise the pain and discomfort he experienced.
38. Within eight weeks, the Council will take the following actions:
• Ensure the care home is carrying out thorough assessments before admitting new residents.
• Require the care home to establish clear procedures for documenting all aspects of care and treatment provided to residents. This should include specific guidelines for the level of detail required in daily records, such as documenting observations, treatments, care decisions, and any concerns raised.
• Ensure care home staff are reminded of the correct process to follow when a resident says they are experiencing pain.
39. The Council should provide us with evidence it has complied with the above actions.

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Final decision

40. I have completed my investigation and uphold the complaint. There was fault by the Council which caused injustice. The action the Council has agreed to take is sufficient to remedy that injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman