Summary: Mrs C complains about the care provided to her mother, who developed a pressure sore while in residential care. The Ombudsman finds the actions of the provider fell short of what was required and that this caused injustice, for which a remedy has been agreed.

The complaint

1. The complainant, whom I shall call Mrs C, complains on behalf of her late mother Mrs D about the care provided to her at Goldendale House. In addition, she complains the care provider refused to respond to her correspondence and complaint about the matter following Mrs D’s death.

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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. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (Local Government Act 1974, section 26A or 34C)
5. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

7. I considered all the information provided by Mrs C in support of the complaint. I made written enquiries of the care provider and took account of the information it provided in response. I also made enquiries of the local authority, which was responsible for considering safeguarding. I provided Mrs C and the care provider with a draft of this decision, and considered all comments received in response.

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What I found

8. At the time of the events complained of, Mrs D was living in a privately commissioned care placement at Goldendale House, which is run by Lovett Care Limited. She was self-funding. She lived at Goldendale House from September 2017 until the end of June 2018 when she moved to a nursing home. She died on 15 August 2018, aged 98 years.
9. While at Goldendale House Mrs D developed a pressure sore. Mrs C believes her mother’s death was due to ineffective care.

Information about pressure sores

10. Pressure sores (also called pressure ulcers) are wounds caused by pressure on parts 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.
11. 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.
12. Treatment options for pressure sores typically include regular changes of position, using special mattresses or other equipment to reduce or relieve pressure, and dressings to help heal the sore.

The care home’s pressure sore management policy and procedure

13. The home’s policy and procedure in respect of pressure sore management includes the following:

• that those at risk of developing pressure ulcers must have a detailed plan of care and staff will be trained in supporting reducing risk of an manage of pressure sore damage;
• that skin condition will be assessed during every care intervention and concerns will immediately be communicated to the senior support worker;
• that pressure ulcer prevention care plans will be in place for residents, which will detail specific risk management strategies including repositioning regimes and use of therapeutic equipment; support and assistance must be provided to those who cannot easily change their position;
• that a specific wound care plan will be implemented;
• that in addition to maintaining a care plan and pressure prevention risk assessment, for residents nursed in bed repositioning charts should be used and these must clearly state the frequency of repositioning and clearly document when this is undertaken;
• that pressure sores at Grade 3 & 4 will be reported to local safeguarding teams and that to support learning the home will complete a root cause analysis investigation for any home-acquired pressure sores. The policy also says grade 2 and above must be reported as a ‘local clinical incident’.

What happened in this case

14. The care home’s records for Mrs D include care plans, daily care records, risk assessments, multidisciplinary notes including records of action and advice from district nursing staff, body map and records in respect of dependency scoring and manual handling. The records show the following sequence of events.
15. In October 2017 Mrs D had a profiling bed and pressure-relieving cushion. Staff were to monitor pressure areas so that district nurses could be informed of any concerns. A risk assessment in respect of tissue viability in January 2018 noted that Mrs D was at risk of tissue breakdown and staff were to ensure she mobilised and changed position wherever possible to relieve pressure areas.

Action after a pressure mark was noted

16. Carers assisting Mrs D with personal care first noticed a pressure mark to her left heel in the evening of 22 April 2018. The records from the next day show a district nurse attended and dressed the area. The dressing would be changed twice a week and pressure-relieving boots ordered. The body map diagram in Mrs D’s records was updated the same day to show ‘large blister (pressure) noted to left heel. Action taken: Senior informed’.
17. On 26 April 2018 the records note the advice given by the district nurse who had been asked about whether Mrs D should continue to wear her stockings, given the blister to her heel.
18. Between 5 and 12 May 2018 Mrs D was in hospital. The admission was not related to the pressure sore.
19. Between 15 and 28 May the home’s records noted the district nurse’s attendance to re-dress the heel and that she gave advice that ‘negative pressure’ should be ensured, with Mrs D’s feet being elevated.

The first reference to a Grade 3 pressure sore

20. The first reference to Grade 3 pressure sore appears in the home’s records of 11 June 2018, with entries on the notes in respect of district nursing action, the risk assessment in respect of tissue viability, and care plan notes in respect of moving and handling and personal care. Entries record that the district nurse advised care staff that Mrs D’s pressure sore to her heel was now at Grade 3, having been assessed by the NHS tissue viability service from photographs. Advice given was that she should use a wheelchair for transfers and be turned in bed every three hours. Other records such as the emergency evacuation chart, manual handling chart and care plan in respect of sleeping were updated to reflect the advice received as appropriate the following day. The care plan monthly review chart and the dependency profile score chart were all appropriately completed at the June review.
21. The home’s records for 12 June 2018 also note that tissue viability staff had visited and carried out a doppler test, which had shown an issue with the circulation to the affected area. It noted Mrs D was to remain on bed rest until a dressing boot was in place. A pressure ulcer calculator checklist completed on this date noted the existing pressure ulcer and scored risk accordingly.

The home’s records in respect of three-hourly repositioning

22. The daily care records between 12 June and 20 June 2018, which are handwritten notes, include the following specific references to three-hourly repositioning:

• 13 June at 5pm “[Mrs D] was repositioned after receiving
  “[Mrs D] remains on bed rest; 3 hourly turns”;
• 14 June at 2.10am “3-hour repo”.
• 16 June at 1.35am “3-hour repositioning’.

23. In addition to these entries, there are others which indicate there would have been a repositioning even when Mrs D was confined to bed, such as assistance with personal care and feeding. Mrs D was not confined to bed for the whole of this period.
24. The daily care records between 21 June and 2 July 2018 are electronic notes. For the most part, these do record repositioning approximately every three hours, and as above there are sometimes other actions such as personal care recorded which would suggest a probable position change, although not always in the three-hour window. There are however occasions where the time between recorded repositioning appears more significant:

• On 24 June, a four-hour gap between 10pm and 2am;
• On 26 June, a six-hour gap between 4.05am and 10.06am;
• On 27 June, a gap in excess of six hours between repositioning at 1.56am and dressing at 8.29am, and almost four hours between the likely repositioning for a drink at 1.32pm and food at 5.15pm;
• On 28 June, specific reference to repositioning is made at 4.26am but then no reference to activity to move Mrs D until a drink was given at 11am (a gap of more than six hours); and
• No repositioning at all is recorded between 8.32pm on 29 June and 5.09am the following morning.

25. Because of the gaps in the records, identified above, it is not possible to say whether there was a failure by care staff to carry out some of the required repositioning in line with the district nurses’ advice, or whether there was simply a failure to record that it had been done. I shall address the impact of this later in this statement.

Reporting of a safeguarding concern

26. The home’s senior carer reported the Grade 3 pressure sore a safeguarding concern to the safeguarding team at the local authority on 12 June 2018, the day after the district nurse advised care home staff that this classification now applied. That was in accordance with the home’s policy and procedure.

Mrs C’s correspondence with the home

27. Under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, care providers have a duty of candour which means that providers should be open and transparent with people who use services in general in relation to care and treatment. The relevant regulation also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.
28. In Mrs D’s case, a duty of candour review was commenced by the health trust, and evidence indicates that associated with this the home wrote to Mrs C’s sister in mid-June 2016 and that Mrs C chased the care provider for an update or response on 18 July 2018.
29. On 23 July, the care provider wrote back to Mrs C. In the letter, headed ‘Notification under the duty of candour regulations’, the provider referred to the pressure damage to Mrs D’s heel and said as part of the investigation the incident had been discussed with senior staff, and the investigation had concluded the pressure damage was unavoidable; and that all necessary procedures were followed. It apologised for any distress caused.
30. Mrs C wrote back to the care provider on 30 July expressing her dissatisfaction with the letter which fell short of setting out the facts. She asked questions about the care Mrs D had received. The provider then said it could not comment while the review by the health trust was ongoing.
31. Responding to my enquiries on the complaint, the care provider has said that in hindsight it should have awaited the outcome of the health trust’s investigation before writing to Mrs D in the terms it did on 23 July. The safeguarding investigation was also still underway. I agree that the response provided in July was not appropriate at this time, while investigations were on-going. It led Mrs D to feel the outcome of any investigation had been pre-judged. A better approach would have been for the provider to set out the relevant facts from its records about the pressure sore and the care given to Mrs D, and advising that it was aware of the investigation by the health trust the outcome of which was awaited.
32. The outcome of the health trust’s review of the nursing care Mrs D had received was not completed until September 2018, and the findings were notified to Mrs C on 19 October 2018. The review determined that the care given by the nursing team was in accordance with national guidance and best practice.
33. In December 2018 and January 2019 Mrs C corresponded again with the care provider seeking responses to the questions she had asked in July. The provider responded saying the complaint had been closed following the outcome of the health trust’s investigation. Mrs C then submitted a formal complaint letter, repeating her questions. The care provider advised that the questions related to the nursing service and so if she wished to complain she should contact the risk management team.
34. Mrs C was entitled to raise a complaint with the care provider about its actions in respect of her mother’s care, separate from any concerns about matters which were the responsibility of the health trust’s staff. The care provider’s response to her complaint did not properly address this.

Injustice to Mrs C

35. The actions of the care provider led to injustice to Mrs C.
36. As set out at paragraph 25 above, the available records mean there is uncertainty about whether care staff provided appropriate care for Mrs D by completing three-hourly repositioning as advised by the district nursing staff whenever this was appropriate. That uncertainty causes avoidable distress for Mrs C.
37. Mrs C was caused frustration and was put to some time and trouble in pursuing correspondence with the care provider which on balance could have been avoided if the provider had given more considered responses to her letters, questions and complaint.

Agreed action

38. In recognition of the injustice identified above, I recommended that within four weeks of the date of the decision on this complaint, the care provider:

• Issues Mrs C with a formal written apology; and
• Pays her £350.

39. In addition, I recommended that within three months of the date of the decision on this complaint, the care provider:

• Reviews lessons learned from this complaint;
• Reminds all staff of the importance of full record keeping; and
• Ensures information for residents and their representatives about how to make a complaint is clear and easily available, including on the provider’s website, and that relevant staff are reminded of the importance of good complaint handling and effective communications.

40. The care provider has agreed to my recommendations.

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Final decision

41. I have completed my investigation on the basis set out above.

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Investigator's decision on behalf of the Ombudsman