Summary: Ms C complains her mother experienced two incidents at the care home she lives, where she was injured during hoisting / transfers. The Ombudsman found that both incidents occurred due to fault by the care provider. However, they were not related to hoisting. The care provider has already taken appropriate action to remedy any injustice.

The complaint

1. The complainant, whom I shall call Ms C, complained to us on behalf of her mother, whom I shall call Ms M. Ms C complained about two incidents her mother experienced at her care home (Cherry Tree House in Stockport), which she believes are both linked to hoisting :
• Her mother suffered a friction burn to her neck in October 2018. Ms C says the care home failed to tell her when it happened and she does not believe the home has told her the truth about how it occurred.
• Her mother had a fall from her shower chair in January 2019, resulting in attendance to A&E for a head injury.

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The Ombudsman’s role and powers

2. 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 or others. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34H(3) and (4), as amended)
4. If we are satisfied with a care provider’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 considered the information I received from Ms C and the care provider. I also made enquiries with the GP. I shared a copy of my draft decision statement with Ms C and the care provider and considered any comments I received, before I made my final decision.

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What I found

The October 2018 incident

6. Ms C told me:
• She visited her mother on 4 October 2018 at 1pm, when she noticed a red mark on the right side of her mother’s neck. She also had red marks on her knuckles. She took some pictures of the marks and then asked a senior member of staff how the marks occurred. The staff member said she would speak to the members of staff involved with her mother’s care that day, to see if they could explain them.
• One of the care assistants told her the marks had not been visible when she provided personal care in the morning. The care assistant was certain the marks were caused by her mother’s head hanging over the bed rail later in the day. She said she noticed this at 10am.
• It was apparent the marks occurred because of friction.
7. Ms C complains that:
• The care home failed to tell her of this incident; she only found out when she visited the home and spotted the mark.
• The staff member(s) involved failed to report the incident immediately to a senior staff member and failed to record the incident. It was only recorded after she herself had alerted staff.
• She does not believe the care home has told her the truth about the way in which her mother suffered the friction burn to her neck. The care home has said it was caused by her mother’s neck hanging over the bedrail and the neck rubbing against a seam. However, she has shown the photos to colleagues in the NHS, who said the marks were more likely due to: misuse of equipment while hoisting, inappropriate moving and handling, or perhaps staff pulling her nighty off in a rough manner.
• She does not believe her mother was capable of moving herself in such a way, quickly enough, to result in friction burns.
8. The care home has said that:
• It interviewed staff, got statements from the relevant staff members, inspected Ms M's bed and bedrails, viewed her care documentation and gained the opinion of Ms M’s GP about the red marks to her neck and knuckles.
• The care assistant (CA1) said that, on the morning of the incident, she saw that Ms M’s head was hanging over the bedrail, between 11 and 11.30. She asked another care assistant (CA2) who was senior to her, to help her to reposition Ms M. She noted a small mark on Ms M’s neck, which was slightly red / pink. This mark had a similar pattern to that on the bed rail. She then put cushions in place to prevent a recurrence of the incident.
• CA2 said she did not immediately report the incident to the nurse in charge, because the nurse was attending to other matters. However, she did refer the matter to the nurse later that day.
9. The care home said in its complaint response to Ms C that:
• Following the incident, the home realigned the bed rail covers so the seam, which had been uppermost, was placed in a downward position.
• The GP’s opinion was the mark was consistent with Ms M rubbing it along the bed rail when the seam was uppermost.
• The movement that caused the friction mark did not need to be a quick movement. Her neck was on the bed rail and any slight movement would cause the friction type mark she sustained. This did not need to be a movement with force or speed, merely a slight movement to cause friction.
• The marks on her knuckles also appeared to have been caused by friction. However, it was not possible to be more specific on how they came about.
• It was regrettable and unacceptable that staff did not tell Ms C of the mark.
• CA2, as the more senior staff member, should have reported and recorded the incident at an earlier stage than she did. When the nurse was unavailable, she should have alerted a manager or other senior staff member.
• The staff member, and all other personnel at the home, would be reminded of the importance of reporting and recording such occurrences, as soon as reasonably practicable.
10. The care home told me that:
• Its records show that both care assistants received training in Moving and Handling in 2018 and had hoisted Ms M before. However, there is nothing to suggest Ms M was hoisted that morning.
• The maintenance person identified the bed rail bumper was fitted incorrectly. He immediately refitted them correctly. The maintenance person checks beds and bedrails every month, as part of routine monitoring.
• Following the incident, the home completed supervisions with housekeeping staff with instructions on how to correctly fit the bed bumpers.
• Although there was a delay in the matter being reported to the Unit Manager, this was because she was engaged in a meeting elsewhere. The care staff members involved made no attempt to conceal the incident from Ms C, and readily provided statements about what had happened. There was nothing to indicate the staff would not have reported or recorded the incident.
• The care home supervised staff during October and November 2018 with regards to: reporting accidents and incidents, completing related documents and informing families. The home has also revised the accident form to reflect Next of Kin being informed.
11. Ms C told me there is nothing to suggest / indicate the staff member(s):
• Would have reported the incident to a senior staff member. It was only reported after she became involved.
• Would have recorded the incident, if she had not alerted staff about her concerns.
12. The GP told me the care home asked her to look at photos of Ms M’s marks and look at the bed rail. The GP noticed the bedrail cover had a rough edge to it and advised this was a possible cause of Ms M’s injury.
13. The care home was unable to provide me with a copy of the daily care record for 4 October 2018. The care provider says it will introduce a new electronic indexing and archiving system to better track and quickly identify archived documents. Furthermore, all supervisory staff will be reminded of the importance of carefully filing residents’ records.

Assessment

14. The care home has said the marks were caused by the seam of the bed rails cover being incorrectly fitted. This was fault, for which the care home has already apologized to Ms C.
15. Although Ms C believes there may have been a different cause, there is insufficient evidence to support this.
16. The care home has already acknowledged to Ms C that there was a delay by staff in notifying her of the incident, reporting the incident to senior staff and recording the incident.
17. It is not possible to come to a view, on the balance of probabilities, whether CA2 would have reported and recorded the incident later that day, if Ms C had not visited her mother that day and raised her concern.
18. The care home has identified and carried out suitable steps to avoid a possible reoccurrence.
19. The care home was unable to provide a copy of Ms M’s daily care record to from 4 October 2018. This is fault. The care provider has identified appropriate actions to address this.

The January 2019 incident

20. The care home explained that:
• Two staff members hoisted Ms M out of her bed and into a shower chair. They then wheeled the shower chair into the bathroom so she could have a shower.
• However, carer 1 realised they forgot to get bath towels and asked carer 2 to get them. Carer 2 left the room to get the towels while carer one picked up a continence aid from the floor. At this point, Ms M fell to the floor, landing on her right side.
• Carer 1 raised the alarm and summoned the Nurse, who attended the shower room with the Senior Assistant Practitioner. The Nurse examined Ms M and applied pressure to a cut she had sustained to her right eyebrow. She instructed the Senior Assistant Practitioner to contact the paramedics who attended and transferred Ms M to Hospital
• This incident should not have happened. Both carers should have had all equipment and toiletries ready for the task they were about to carry out with Ms M. Both staff member should have stayed with Ms M to ensure her safety. The home has apologized.
• Both staff involved were visibly distressed and upset when making statements and when interviewed were extremely remorseful and concerned for the welfare of Ms M.
• The care home carried out reflective practice with both staff members and took appropriate action to minimise any further risk of this accident happening again. The home manager shared the accident with other staff members.
• The home reported the accident to the Council’s Safeguarding Team.
• The incident did not happen when Ms M was in a hoist or being hoisted.

Assessment

21. The care home has already acknowledged to Ms C that its staff was at fault. The incident did not happen during hoisting.
22. The care home has already apologized and has identified and carried out suitable steps to avoid a possible reoccurrence.

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Final decision

23. For reasons explained above, I found that while there was fault by the care home, it has already taken appropriate action to remedy this.
24. I am satisfied with the actions the care provider has carried out in response to the faults, and have therefore decided to complete my investigation and close the case.
25. Under the terms of our Memorandum of Understanding with the Care Quality Commission, I will send it a copy of my final decision statement.

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Investigator's decision on behalf of the Ombudsman