Revitalise Respite Holidays (18 002 187)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 07 Jan 2019

The Ombudsman's final decision:

Summary: The care provider failed to provide proper care to Mr X, who returned home from respite with a serious pressure sore. There was also a failure to understand and implement the requirements of the Mental Health Act. The care provider will now put in place further staff training about mental capacity. In addition to the refund of fees already provided the care provider will offer an additional £500 to Mr and Mrs X to recognise the significant distress they suffered.

The complaint

  1. The complainant (whom I shall call Mrs X) complains that the care provider failed to look after her husband’s hygiene and skin integrity to the extent that he suffered a serious pressure sore on his ankle when he left the care home after only two weeks. She says she herself suffered an angina attack as a result of the shock and distress and Mr X has been left with a deep mistrust of other carers.

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The Ombudsman’s role and powers

  1. 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. (Local Government Act 1974, sections 34B and 34C)
  2. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

  1. I considered the written information provided by Mrs X and by the care provider. I spoke to Mrs X. Both Mrs X and the care provider had an opportunity to consider and comment on an earlier version of this statement before I reached a final decision.

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What I found

  1. 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.
  2. The guidance says that providers must make sure that they provide appropriate care and treatment that meets people’s needs, but this does not mean that care and treatment should be given if it would act against the consent of the person using the service.
  3. The guidance also says that where people’s wishes for their care and treatment do not meet their needs, and they lack capacity, then providers must act according to the Mental Capacity Act. It says where people lack capacity to make their own decisions, their best interests must be established and acted on in accordance with the Mental Capacity Act.

What happened

  1. Revitalise provides respite holidays for disabled people and their carers. In 2016 both Mr and Mrs X had stayed at the care home for a short break which they enjoyed. Mr X suffers from Huntington’s Disease and Mrs X is his principal carer.
  2. When Mrs X suffered a cardiac arrest in 2017 and required surgery, she arranged at short notice for Mr X to stay at the care home again for two weeks, from 14 September. The care provider’s pre-admission assessment noted that Mr X “does not have capacity to make many decision…ongoing assessment and B.I. [best interests] needed”. It noted that he may resist help with personal care, that he needed help with hygiene and that carers would have to make best interests decisions. The summary care plan created for Mr X on admission stipulated he should have a body-map taken within 24 hours of admission, and that carers should “check pressure areas at each intervention and report any red or broken skin to nurse”.
  3. The care provider’s records include the body-map which was taken on the first day of Mr X’s stay. There is a note that his skin was “intact”. His Waterlow score (a system devised to assess the risk to skin integrity) was 8, which was not within a risk category.
  4. Mrs X says when she telephoned to speak to Mr X during his stay she was often told that he was “agitated”. Mrs X says she hardly recognised Mr X when she went to collect him at the end of the stay on 30 September. She says he was dirty, unshaven and he smelled. When she unpacked his suitcase, she describes a smell of “rotting flesh” and says his sock was stuck to his foot with pus. Mrs X took Mr X to the emergency GP who diagnosed a grade 4 pressure sore on his ankle.
  5. Mrs X telephoned the care provider. The care provider’s note of the conversation says Mrs X had said Mr X had a septic abscess to the sole of his foot: “she stated the clothes in his suitcase were all unwashed and smelling badly in particular three pairs of socks, which were described as being ‘heavily stained with pus and smelling badly’”. Mrs X suffered an angina attack that evening (which she believes was caused by the upset) for which she attended hospital. District nurses were required to dress Mr X’s ankle daily.
  6. Mrs X met the head of nursing care at the care home the following week and showed her the photos of the sore on her husband’s ankle. She says the head of nursing care acknowledged they had failed Mr X badly. A note on file of the conversation by the head of nursing care states “We were unaware (Mr X) had left NWH (the home) with a stage 3 pressure ulcer and investigation procedures have commenced”. The file note concludes with a list of actions to be implemented, including “each member of staff must read each care plan that are already placed in guests’ rooms. Why this is important to be communicated to staff so that we can ensure information is shared and quality care is given. There is a signature sheet at the front of each guests care plan for assurance that it is being read at the point of delivery.”
  7. Mrs X also raised concerns that Mr X had not had a shower while he was staying at the home.
  8. The care provider’s handover sheet shows that Mr X was showered on 21 September. The carer who completed the record noted that he was “very reluctant” to agree to a shower. She noted that he insisted on putting on his dirty and soiled clothes after the shower. The record concludes, “nurse was informed, no concerns”. There is a record for 25 September that “(Mr X) was awake and having a shower when checked”. The handover note for 27 September stated that Mr X was “up and dressed to his own standards” and that staff intended to offer him a shower that afternoon (but there is no record of a shower).
  9. The GP raised a safeguarding alert with the local council about the sore on Mr X’s ankle. The care provider also referred itself to the council’s safeguarding department on 31 October.
  10. The report which the care provider completed for the safeguarding enquiry said that Mr X declined personal care and was often already dressed when day staff arrived. In addition to the details provided on the handover sheet the report said Mr X had also been showered on 17 September according to the ‘bath list’.
  11. The care provider’s head of nursing provided further information to the safeguarding enquiry in November 2017. She said “We are mindful that guests maintain their independence and allow them dignity and choice for themselves.”
  12. In May 2018 the care provider’s director wrote to Mrs X. She said she was aware Mrs X had not wanted contact but she hoped Mrs X would now accept an apology from the organisation, as well as the full refund for the fees which the care provider had already made. She said the organisation had made some changes as a result of the complaint. She offered Mr X a short break free of charge so that the couple could regain confidence in the organisation.
  13. Mrs X complained to the Ombudsman in July 2018. She said Mr X had been withdrawn and unsettled since he returned from the care home, and had made her promise he would not have to go there again. She said even though the care provider had explained how practices had changed, she and her husband were finding it difficult to come to terms with what had happened.
  14. The care provider has detailed the measures put in place to respond to the complaint. These include improving the pre-assessment process; carrying out a daily audit of the care plan checks and collecting dirty laundry every day; including an action plan when follow-ups are needed; improving staff written communication; completing a departure checklist with each service user.


  1. Mr X’s care plan very clearly states that “pressure areas should be checked at each intervention” but there is simply no evidence that was done. If it had been, it is inconceivable that carers could have missed the very obvious pressure sores (of which Mrs X has provided photographic evidence to the Ombudsman). That was the principal failure of basic care which led to the injustice caused to Mr X.
  2. The care provider says it seeks to allow “dignity and choice” for its guests but to allow such sores to develop within the space of 14 days in the name of choice shows a failure to understand the need for the “best interests” decisions which the care provider’s own assessment said were necessary.
  3. Mr X’s reluctance to shower was documented but there is little evidence of attempts made by care staff to find ways of assisting his personal hygiene. On one occasion when the carer reported to the nurse that Mr X had chosen to put back on his soiled pants after a shower, the nurse was said to have had “no concerns”. That was a failure to treat Mr X with dignity.
  4. To its credit the care provider has given a full refund, offered a stay free of charge, referred its own actions as a safeguarding alert and put in place a number of measures designed to avoid a recurrence.

Agreed action

  1. In addition to the actions already taken, the care provider will (within one month of my final decision) put in place additional training for staff on the Mental Capacity Act and let me have details;
  2. The care provider will also within one month of my decision offer Mr and Mrs X a further payment of £500 in recognition of the considerable distress caused to them both by the failure of care.

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Final decision

  1. There was fault on the part of the care provider which caused injustice to Mr and Mrs X.

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Investigator's decision on behalf of the Ombudsman

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