Derbyshire County Council (17 013 650)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 19 Dec 2018

The Ombudsman's final decision:

Summary: The complaint is about Ms B’s care in a nursing home. There was fault in the nursing home’s care planning and record keeping, but we do not conclude this caused either of her falls or the infection following the first fall. The Council delayed in responding to the complaint and this is fault. The nursing home has already refunded notice payments which is a partial remedy. The Council accepts our recommendation to apologise for the delay in responding to the complaint and to visit the nursing home to check the care records of those residents it funds.

The complaint

  1. Ms A complains about her late mother Ms B’s poor care in Oakford Manor Nursing Home, Glossop (the Nursing Home). Derbyshire County Council (the Council) arranged and funded Ms B’s care. In particular, Ms A complains:
      1. About a fall leading to a head wound which Ms A thinks may have become infected due to Ms B receiving poor care and support around hand hygiene
      2. About a second fall resulting in a broken hip which Ms A says was due to a lack of supervision when Ms B went to the toilet independently in the night and staff did not respond to her pressure alarm
      3. Ms B became dehydrated and had to go into hospital in August 2016. She had gastroenteritis (a viral or bacterial infection causing sickness and diarrhoea)
  2. Ms A considers these incidents led to an avoidable decline in Ms B’s health and independence. She would like a refund of half the charge Ms B paid for the placement and a refund of fees after she gave notice.

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What I have investigated

  1. I have investigated Ms A’s complaints about two falls. My reasons for not investigating the complaint at paragraph 1 (c) is at the end of this statement.

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The Ombudsman’s role and powers

  1. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company, such as a nursing home, is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
  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 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 council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
  4. We provide a free service, but must use public money carefully. We may decide not to start, or discontinue an investigation if we believe it is unlikely we would find fault or if we consider there is no injustice. (Local Government Act 1974, section 24A(6), as amended)
  5. 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

  1. I considered Ms A’s complaint to us, the Council and Nursing Home’s responses to her complaint, the Council’s responses to my enquiries and safeguarding records and care records described later in this statement. A colleague discussed the complaint with Ms A and I considered the parties’ comments on a draft of this statement.

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What I found

  1. 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. These enquiries are known as safeguarding investigations. (Care Act 2014, section 42)
  2. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care. When investigating complaints about council-funded care placements, we consider the 2014 Regulations. Those relevant to this complaint are:
    • Regulation 9: requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
    • Regulation 12(i): says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
    • Regulation 17: requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

Key facts

  1. The Council arranged Ms B’s care in the Nursing Home, where she lived from 2015. Ms B was frail and had dementia. She could walk. The Council’s care and support plan for Ms B said she needed assistance after going to the toilet as she was not washing her hands properly and faeces collected under her nails. The care and support plan said staff should keep her nails short and support her with hand hygiene.
  2. At the end of May 2017, Ms A called the Council’s social care team with concerns about Ms B. She reported Ms B had fallen twice, once in April and a second time in May. The first fall resulted in a head wound which became infected and the second a broken hip.
  3. The Council carried out a safeguarding investigation into Ms A’s concerns. As part of the investigation, the Nursing Home completed a chronology of key events in relation to the complaints. I have summarised this in the following two paragraphs.
  4. In relation to the fall leading to a head wound: in April 2017, Ms B was found by a carer in the bathroom. She was bleeding from an injury on the right side of her face. A nurse stemmed the bleeding and called the paramedics. ( Ms B told me the bleeding was very heavy.) Ms B went to hospital and returned to the Nursing Home the next day. The following day, the Nursing Home referred Ms A to the district nurses and completed a wound map. The district nurses visited Ms B to dress the wound. Ms B removed the dressing and carers contacted the district nurse. Despite chasing, the district nurse did not visit for 2 days. About 4 weeks later, a care services manager visited the Nursing Home and told the nurse in charge to call Ms B’s GP as it looked like Ms B had cellulitis (a bacterial skin infection) in her head wound. The GP visited the same day and prescribed antibiotics. Ms A told us she had told carers to call the GP the same day as the care services manager as she thought the wound looked inflammed. Ms A told me it was her intervention that prompted the Nursing Home to seek medical assistance, and not the care services manager. Ms A said she had to insist staff called the GP.
  5. In relation to the fall and broken hip. Ms B fell at 1.05 am and staff called an ambulance at 1.20.
  6. Social care officers and senior staff from the Nursing Home held a second safeguarding meeting to review all the information. I summarise the minutes below:
    • Ms B was cleaning the commode herself after use and she got dirty hands as a result. The commode was supposed to be removed in the day and put in her room at night, depending on how much she had been wandering in the day. If she had been wandering a lot, staff did not put the commode in her room at night as there was a risk of her falling over it. They would do a risk assessment on the day
    • Staff were supposed to clean Ms B’s hands and check the sink was clean twice a day
    • District nurses cared for the head wound
    • Inflammation in the head wound was noticed and Ms B saw the GP on the same day
    • Council officers asked the Nursing Home’s manager some questions and the plan was for the manager to prepare a report and then there would be a further meeting to discuss the evidence.
  7. The Nursing Home completed a report for the safeguarding investigation. This said:
    • There should have been care plans in place for when Ms B removed her dressings. Care plans were not specific enough and needed more detail about how to manage Ms B’s care. The care plan did not mention nail care, or that Ms B used a commode at night.
    • The daily notes suggested Ms B had a commode in her room at night (two entries referred to carers giving support to use the commode at night in April)
    • Staff recorded in the daily notes when Ms B removed her dressing and when they contacted health professionals
    • Staff needed further training in care planning and improvements were required in record keeping.
  8. The minutes of a second safeguarding meeting to review the evidence found:
    • The district nurses visited to check and dress the head wound following the first fall. They did not raise any concerns about dirty nails or poor personal care. There was no evidence of neglect in relation to wound care
    • In relation to personal care, the Nursing Home accepted its care plans were not robust and council officers were going to review the new paperwork it had recently introduced
    • In relation to the second fall, the injury appeared superficial initially. The fall coincided with the Manchester bombings and so there was a delay in an ambulance attending. There was no evidence of neglect by the Nursing Home, but better recording and care planning was needed
    • Ms A was consulted, given feedback and was satisfied with the outcome of the safeguarding investigation
    • The Nursing Home would use new care plan records and would not use standard forms as there was not enough detail on them.
  9. Ms A complained to the Nursing Home in October 2017. The Nursing Home responded, but Ms A did not receive its letter until July 2018 because the letter was sent to the wrong address. The Nursing Home said:
    • Ms B’s dementia had worsened. Staff could not prevent falls, only put in place measures to reduce the risk
    • Its records showed Ms B was assisted to use the toilet at night or a commode was put in her room. She was ‘restive’ at night (slept well) and so staff were likely to assist her to the nearest toilet
    • Care staff could not respond to calls straight away if they were using a hoist to move another resident as they could not leave that person. This was the case when Ms A’s alarm went off before the second fall
    • A manager had already spotted the signs of cellulitis and asked the district nurse to review Ms B. This was shortly before Ms A visited
    • It would refund Ms B’s contribution for the notice period.
  10. Ms B died in October 2017.
  11. Ms A complained to us in November 2017. We asked the Council to investigate and respond to her complaint and told Ms A she could ask us to investigate if she was unhappy with the Council’s response to her complaint. Ms A contacted us again in May 2018 saying she had not received a response from the Council.
  12. The Council responded to Ms A’s complaint only when we prompted it to do so. Its complaint response said:
    • It completed a safeguarding investigation; Ms A gave her views to the social worker and she said she was satisfied with the outcome of the investigation (Ms A told me she was not satisfied with the outcome, only that she was satisfied that new measures agreed as a result of the investigation would minimise the risk of recurrence)
    • It would not reinvestigate the same issues through the complaints procedure because her concerns had already been looked into through safeguarding
    • If she was unhappy with the safeguarding investigation, or she had further concerns, the Council would consider these.
  13. A director of the Nursing Home, manager from the Council and Ms A met at the end of July 2018. The director apologised for Ms A’s distress and for the company’s complaint response of October 2017 being posted to the wrong address.
  14. The Nursing Home has evidenced it refunded Ms B’s charge from 21 June 2017 (the date Ms A gave notice.)

Was there fault and if so did this cause injustice requiring a remedy?

Complaint a: Ms B fell and injured her head. Ms A thinks the wound may have become infected due to Ms B receiving poor care and support around hand hygiene

  1. Nursing homes cannot eliminate the risk of a mobile resident falling and can only put in place measures to minimise risk. The care arrangements for Ms A included a pressure mat which sounded when she left her room and I am satisfied this arrangement was an appropriate way to reduce the risk of falls.
  2. I note Ms A and a manager both spotted redness to Ms B’s head on the same day and raised concerns. I am unable to confirm from the documents which person did so first. But I do not regard there to be an injustice to Ms B in any event because she received prompt treatment from her GP and in line with the Nursing Home’s duty to work with health professionals under Regulation 12(i) of the 2014 Regulations. So there is no need for me to pursue this point further.
  3. The safeguarding investigation noted the Nursing Home’s records for Ms B did not include a care plan setting out what staff were to do when Ms B removed the dressing, or about the circumstances when she should have a commode or about her nail care. This was particularly important given it was known Ms B had poor hand hygiene, had a habit of cleaning the commode herself and needed support for this. The care plans for Ms B were faulty as they were not in line with Regulations 9 or 17 of the 2014 Regulations.
  4. It is not possible for me to conclude on a balance of probability that the wound became infected because of poor hand hygiene. There is no direct causal link between the failures in record keeping and care planning and the infection. However, there is a risk of similar concerns about care planning and record keeping arising for other residents in the Nursing Home and so I have made a recommendation about this later in this statement.

Complaint b: A second fall resulted in a broken hip which Ms A says was due to a lack of supervision when Ms B went to the toilet in the night and staff did not respond to her pressure alarm.

  1. My view is there is no fault in the failure to respond to the pressure alarm sooner. I have taken into account that:
    • Ms B was not assessed as requiring, nor did the Council fund one to one care for her.
    • There may be times when care staff cannot respond to an alarm straight away because of the needs and safety of other residents, for example, if two staff are hoisting another resident when a pressure alarm goes off.
  2. Even if I did conclude there had been an unacceptable delay in responding, it does not follow that the fall would have been prevented by a quicker response. Ms B may have fallen in any event.
  3. There is no complaint that the Nursing Home failed to seek timely medical assistance after the fall and documents suggest an ambulance was called within 15 minutes of carers discovering Ms B which is not fault. There appears to have been delay by the ambulance service attending, but this is not an issue we can consider as we have no power to investigate complaints about the NHS.

Other issues

  1. There was a delay in the Council responding to Ms A’s complaint as this did not happen until we prompted it to reply. This is fault.

Agreed action

  1. When a council commissions another organisation to provide services on its behalf, it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the Nursing Home, I have made recommendations to the Council.
  2. The Council, will, within one month of my final decision:
    • Apologise to Ms A for the delay in responding to her complaint
    • Visit the Nursing Home (through its contractual/commissioning process) to check the care plans of all the residents whose care it funds to ensure the care plans are appropriate to meet each resident’s needs
    • Provide me with a written report of its visit.
  3. Ms A was caused avoidable distress because of the faults described in this statement. The Nursing Home has already refunded £600 (which Ms B was due to pay as it was her client contribution during the notice period) and this is an appropriate reflection of her avoidable distress at the fault I have identified and so I make no recommendation for further refunds of care contributions.

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Final decision

  1. The complaint is about Ms B’s care in a nursing home. There was fault in the nursing home’s care planning and record keeping, but this did not cause either of her falls or the infection that arose after the first fall. The Council delayed in responding to the complaint and this is fault. The Nursing Home has already refunded notice payments and this is a partial remedy. The Council will also apologise for the delay in responding to the complaint and visit the Nursing Home to check the care plans of those residents it funds.

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Parts of the complaint that I did not investigate

  1. I did not investigate the complaint about Ms A becoming dehydrated and going into hospital in August 2016. This is because:
    • it is a late complaint as Ms A complained to us in November 2017 and there is no reason for the delay and
    • it is unlikely I would uphold the complaint as dehydration is a common consequence of diarrhoea and vomiting and does not in itself suggest fault.

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Investigator's decision on behalf of the Ombudsman

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