Summary: There is evidence of fault in this complaint Carers failed to check Mr X’s leg after he complained it was hurt during a hoist transfer from his bed. Carers also failed to record the incident. The Care Provider failed to deal with Mr X’s complaint about this properly.

The complaint

1. Mr X complains he suffered an injury to his leg on the last day of his stay at Manor Court Care Home.
2. Mr X says the Care Provider has failed to deal with his complaint about this properly.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers. 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)

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How I considered this complaint

4. I have:

• considered the complaint and discussed it with Mr & Mrs X;
• considered photographs of the injury;
• considered the correspondence between Mr X and the care provider, including its response to the complaint;
• made enquiries of the care provider and considered the responses;
• taken account of relevant legislation;
• offered Mr & Mrs X and the Care Provider an opportunity to comment on a draft of this statement.

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What I found

5. 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.
6. One of the fundamental standards (regulation 9 of the regulations for service providers and managers) is about person-centred care. Each person should receive person-centred care and treatment, based on their individual needs.
7. Standard (regulation 12) is about safety. Care providers should not put people receiving care at risk of harm that could be avoided. It says care providers should be able to show they have taken all reasonable steps to ensure the health and safety of those receiving care.
8. Standard (regulation 16) is about complaints. This says staff must know how to respond when they receive a complaint, and this can be verbal. Care providers must thoroughly investigate complaints. This includes keeping records of complaints and actions taken.
9. Standard (regulation 17) is about good governance. This includes keeping accurate, complete and detailed records about people receiving care, including records of care provided and decisions made relating to care.

Background

10. Mr X received five days respite care at a care home run by the Care Provider in August 2018. A pre-admission assessment was completed in July 2018, and a further admission assessment, including a body map were completed the day Mr X went into the care home. This noted Mr X’s feet were bandaged because of ‘old’ pressure sores. Some areas of skin were described as ‘red and soft’. The dressings were changed twice weekly by the district nurse.
11. The records show Mr X was immobile, but could weight bear, and that he needed a standing hoist for transfers.
12. Mr X says on the day he was discharged from the care home he hurt his leg on a wheelchair whilst being lifted out of bed in a full body sling. He recalls saying ‘ouch’ and telling the carers he had hurt his leg, but the carers did not check his leg. Mr X could not recall the names of the carers, but one could be easily identified because of her accent.
13. After Mr X arrived home Mrs X was helping him to wash when she noticed a bandage was stuck to his right leg. She discovered the skin was broken in two areas. Mrs X took photographs of the injuries.
14. Mr X says a district nurse visited numerous times to dress the wounds.
15. Mrs X complained to the Care Provider on 27 September 2018, 19 October 2018 & 19 December 2018. Mr X received only one response to his complaint on 21 November 2018. I have seen a copy of the letter which says the care home had no record of the incident, and staff at the care home had no recollection of it.
16. Mr X feels the complaint has been brushed aside and was not investigated properly. He says he expected an apology form the care home and a commitment to improving training on moving and handling.

What the care provider says

17. The Care Provider says it is unable to “locate any evidence or process being followed in the home around this complaint”.
18. The Care Provider is currently investigating a carer in relation to issues of moving and handling. I am unable to give any further details about this. This is because personnel matters are private.
19. The Care Provider says it’s response to Mr X’s complaint was not in line with its policy, no stage 1 response was issued, instead a stage 2 response was issued. It cannot explain why.
20. It says it is unable to locate the original complaint response as the letter attached shows a level two response was written and sent, although no signature is in place to identify the sender. It is currently investigating a senior staff member regarding the complaints process, again I am unable to disclose further details.

Analysis

21. The care home completed admission assessments of Mr X properly. This included a body map which noted existing skin issues and the vulnerability of Mr X’s skin. This was good practice.
22. It is often very difficult to determine the facts about an unrecorded injury sustained in a care home after the event. However, in this case, there is information available which gives weight to Mr X’s account.
23. Mr X made clear to care staff his leg had been hurt during the transfer from his bed. Care staff should have immediately checked his legs and recorded the incident, and whether there was any visible injury. It failed to do so and this is fault. The Care Provider should apologise for this.
24. Mr X is clear in his account of events and his description of one of the carers. The Care Provider is currently investigating a carer who meets Mr X’s description about issues of moving and handling. The Care Provider should have considered Mr X’s complaint in context of information it has about this carer. It should also have explained this to Mr X. It need not have gone into any detail other than to explain an investigation was underway. Mr X is not entitled to information about internal investigations or personnel matters.
25. The Care Provider acknowledges if failed to deal with Mr X’s complaint in line with its policy. This caused Mr & Mrs X some unnecessary frustration which it should apologise for.
26. It is currently investigating how complaints were dealt with at the care home.
27. To summarise, carers failed to check Mr X’s leg after he complained it was hurt during a transfer. Carers also failed to record the incident. The Care Provider failed to deal with Mr X’s complaint about this properly.
28. I cannot say with certainty that the injuries later discovered to Mr X’s leg were caused during the transfer.

Agreed action

29. The Care Provider, will within one month of the final decision:

• provide Mr X with a written apology for the failures set out above
• pay Mr X £150 to acknowledge its failure to deal with his complaint
• ensure care staff are trained and proficient in moving and handling
• consider staff training in relation to record keeping
• ensure complaints are dealt with in line with company policy.

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Final decision

30. There is evidence of fault in this complaint. The above recommendations are a suitable way to remedy the injustice caused to Mr X
31. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman