Summary: Mr X complained the Council commissioned care provider failed to take action when his mother got a pressure sore. The care provider was at fault as it failed to follow its procedures. There was no fault in the way the Council carried out a safeguarding investigation into Mr X’s concerns although there was an error in the letter it sent to Mr X and it delayed responding to Mr X’s complaint. The remedy the Council has offered Mrs Y and Mr X through its complaints’ procedure is appropriate. In addition, it has agreed to pay Mr X £100 to acknowledge the frustration caused by the delay in its complaints process.

The complaint

1. Mr X complained the Council commissioned care provider, Homecare for You, failed to take action when his mother Mrs Y got a pressure sore on her back, causing her pain and discomfort. He says it then lied and provided falsified documents to the safeguarding enquiry, blaming him by claiming it had advised Mr X of the pressure sore a week earlier than it had. This has left Mr X angry and distressed.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
4. If we are satisfied with a council’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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How I considered this complaint

5. I have considered the information provided by Mr X and have discussed the complaint with him on the telephone. I have considered the Council’s response to my enquiries, including case records from the care provider. I have considered our Guidance on Remedies.
6. I gave Mr X and the Council the opportunity to comment on a draft of this decision and I considered the comments I received in reaching a final decision.
7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share the final decision with CQC.

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What I found

8. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)
9. 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.
10. 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. 

What happened

11. Mrs Y lived in her own home. She had Alzheimer’s disease and poor mobility. She used a walking frame to get around. Mr X visited Mrs Y every day to provide support. In December 2019 Mr X requested assistance from the Council in supporting his mother. After completing an initial screening tool, the Council arranged a package of care for three visits a day for Mrs Y:
• 1 hour in the morning to assist with personal care, and to provide breakfast.
• 30 minutes lunch time to assist with continence care and provide lunch.
• 30 minutes in the evening to assist with continence care, provided food if needed and to get Mrs Y ready for bed.
12. The needs assessment completed by the care provider noted Mrs Y needed prompting with medication, support with personal care and dressing from care staff and with continence care as she had episodes of incontinence. It noted that carers should make observations about Mrs Y’s health and well-being and report any changes to the manager. Mrs Y also needed all meals preparing and prompting and encouraging to eat as she had a poor appetite.
13. The care provider also completed a moving and handling risk assessment. This noted ‘Carers to supervise mobility during care visits also need to monitor general health and wellbeing. Any concerns must be reported and logged via careplan entries and handsets’. A pressure sore assessment recorded Mrs Y was at medium risk of pressure sores and the body map completed at that time recorded no issues.
14. Mrs Y’s care package was delivered by three main carers.
15. The Council completed a needs assessment in February 2020 which confirmed the package of care was working well.
16. In May 2020 Mrs Y developed a pressure sore on her back. In late May Mr X reported this to the GP who prescribed antibiotics. Following this the District Nurse visited three times a week and then daily to dress the sore. In early June the Tissue Viability Nurse assessed the pressure sore as a minimum of grade 3.
17. In June 2020 Mrs Y had a fall which resulted in a hospital admission. During her stay the sore became infected and Mrs Y was later discharged to long term care in a care home.

The safeguarding Investigation

18. On 4 June 2020 Mr X raised a safeguarding alert with the Council. He said he was told by the care provider on 21 May about the wound on his mother’s back. He believed the wound had been there longer than a week and was concerned he was not made aware of it sooner. He asked to change care agencies. The Council asked the care provider to undertake an internal investigation.
19. On 8 June the care provider confirmed it would undertake an internal enquiry. The Council requested a response within 28 days. The investigating officer also spoke to the District Nurse. They advised Mrs Y had protruding bones in her spine which was where the sore was. They said if Mrs Y had sat for long periods of time this may have caused the pressure sore to become worse.
20. The care provider provided the investigator officer with the outcome of the internal investigation on 5 August 2020. As part of the investigation the care provider spoke to Mrs Y’s three carers. In the report they stated:
• Carer 1 noted a spot on Mrs Y’s back during the morning visit of 14 May. Carer 1 mentioned this to carer 2 who spoke to Mr X. Carer 1 stated the sore appeared to have slight redness. Carer 1 said they wrote a detailed record on 21 May.
• Carer 2 said they had spoken to Mr Y around 14 May to inform him of the wound. Carer 2 said they mentioned it to him every day after that. Carer 2 said they mentioned it to Mr X verbally and did not write a detailed log that day. They said on 21 May they sent a text message to Mr X and raised concerns it was getting worse. The text message stated ‘Plz can u make [Mrs Y] drs appnmt I think she had infection on back u can see discharge mark on night dress’. They said Mr X acknowledged this and agreed to make a Doctor’s appointment. Carer 2 said Mr X had already been dressing Mrs Y’s wound himself for a number of days prior to them asking him to contact the Doctor.
• Carer 3 said they told Mr X about the pressure sore and was sure they had written it in the visit record. Carer 3 said when she told Mr X he said carer 2 had already informed him.
21. The care provider concluded the staff had reported the issue to Mr X. However, carer 2 had not put anything in the log when they first noted the pressure sore. None of the staff had completed a pressure sore chart which formed part of the care plan packs that remain in service users’ homes.
22. The investigating officer discussed the internal investigation with the care provider in September 2020. They were concerned the carers had not raised the issue with their management. The care provider responded they did but did not provide evidence of this. The investigating officer highlighted the need for carers to complete pressure area forms so management could follow it up with the family.
23. The care provider’s daily visit records say:
• carer 1 noted on 13 May they had noticed a pressure sore on Mrs Y’s back and they informed carer 2.
• At the lunchtime visit carer 3 noted they spoke with Mr X about the pressure sore. They noted he had brought some dressings to apply.
• At the teatime visit carer 2 noted a pressure sore on Mrs Y’s back. Mr X was there. They mentioned it to him and told him to make a Doctor’s appointment.
• In the visit records of the following days the carers noted the dressing on Mrs Y’s back and that Mrs Y’s back was causing her pain.
• On 19 May carer 2 noted they had talked to Mr X about Mrs Y’s back getting worse.
• On 21 May in the daily notes carer 2 recorded ‘wound/abscess on her back, discharge from back, dressing stuck with back of top. Stuck back on and informed son by text message’.
24. In September 2020 the investigating officer discussed the safeguarding investigation with Mr X. They explained the care provider said it told Mr X about the sore on 13 May and carers said he was dressing the wound. Mr X believed the care records were forged. He said he did not know about the pressure sore until 21 May. The investigating officer suggested Mr X discuss this with the care provider and if he remained unhappy he could complain.
25. At the end of September the Council concluded the safeguarding enquiry. It found it partially substantiated. In a letter to Mr X it set out the evidence stated the carers told Mr X about the pressure sore on 14 May. However, Mr X refuted knowing about it until 21 May. It concluded this part of the enquiry as inconclusive as it could not evidence either way when the carers actually told Mr X about the pressure sore. However, it partially substantiated the enquiry as it considered neglect did occur. The carers failed to inform the office or complete a pressure sore chart. It found no remaining risk to Mrs Y as she received the required care when the District Nurses became involved and she now lived in residential care.
26. The Council made a number of recommendations to the care provider. These included:
• Management receiving training in safeguarding
• Care staff training in accurate record keeping
• Ensure a skin integrity plan was in place
• Ensure staff complete regular skin integrity checks and document at least weekly on a body map
• Ensure staff are familiar with pressure sore protocols, complete pressure sore charts and inform the office of all pressure sores identified
• Consider disciplinary action against staff who failed to share the pressure sore concerns with the agency

Mr X’s complaint to the Council

27. Mr X complained to the Council in early October 2020. He complained the care provider neglected his mother and there was an inconsistency in the safeguarding investigation about when he was told about the pressure sore. He was told it was 13 May but the safeguarding document referred to 14 May. This mattered as he was with his mother on 13 May but was at work on 14 May so could not have been told then. He considered the care provider was blaming him. He requested compensation.
28. The Council responded to Mr X’s complaint in late January 2021. It accepted the safeguarding partially upheld the allegation of neglect. It said it had reviewed the care package in March 2020 at which point it was working well. It offered to refund Mrs Y’s client contribution (the amount she paid towards her care package) from March 2020 to when the care package ended in June 2020 to acknowledge the concern and stress caused to Mrs Y.
29. It accepted there was an administrative error which meant the date in the letter to Mr X was wrong. However verbally the investigating officer had provided Mr X with the correct date of 13 May for when the carers said they told Mr X about the sore. The Council apologised for this administrative error and offered him £200 to acknowledge the distress this caused.
30. The Council said it was continuing to monitor the care provider through its Quality and Contracts Service.

Findings

31. The care provider was at fault as it failed to complete a pressure sore chart when it identified Mrs Y had a pressure sore. There is no evidence it completed weekly body maps to assess Mrs Y’s skin condition and when a pressure sore developed it failed to update her pressure sore assessment. The carers also failed to report the sore to the management. This was fault.
32. When Mr X raised a safeguarding alert the Council carried out a safeguarding enquiry. It considered the evidence from the care provider’s internal investigation, from the care records available and from Mr X. It partially substantiated the enquiry but could not reach a conclusive finding on when the care provider notified Mr X of Mrs Y's pressure sore. The investigating officer set out their reasoning and made a number of recommendations to the care provider to improve its service. There was no fault in the way the Council carried out the safeguarding investigation.
33. Mr X believes the care provider falsified the daily records and these are forged. I have seen the records and they are consistent with records completed by the care provider before and after the events complained about. There is a discrepancy between the internal investigation and the daily records as the internal investigation refers to carers raising it with Mr X on 14 May and the care records refer to 13 May. However, in line with the Council’s safeguarding investigation, I cannot establish when exactly the carers told Mr X about the pressure sore and whether or not the records were falsified. I cannot see that further investigation would reach a different conclusion. In any case, the purpose of safeguarding is to prevent harm or risk of harm. Mrs Y is now living in a care home so the risk to her is removed. The Council also made a number of recommendations to the care provider to improve its service.
34. In response to my enquiries the care provider has confirmed it has complied with the recommendations made by the Council. In the Council’s response to Mr X’s complaint, the Council also confirmed that its Quality and Contracts Service was continuing to monitor the care provider to ensure that standards were improved to support vulnerable people. I am satisfied this is appropriate to prevent a repeat of the faults identified.
35. In response to Mr X’s complaint the Council accepted the care provider was at fault. It also accepted it made an administrative error in the letter sent to him with the safeguarding outcome. To acknowledge the stress caused to Mrs Y and to Mr X the Council offered to refund Mrs Y her financial contribution to her care costs from March to June and to pay Mr X £200. This is an appropriate remedy.
36. In addition, the Council delayed responding to Mr X’s complaint. Mr X complained in early October 2020 and did not receive a response until late January 2021. This delay was fault and caused Mr X frustration.

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Agreed action

37. Within one month of the final decision on this complaint, the Council has agreed to pay Mr X £100 in addition to the £200 it has already offered him to acknowledge the frustration caused by the delay in responding to his complaint.

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Final decision

38. I have completed my investigation. There was evidence of fault causing injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman