Summary: Mrs X complained Eothen Homes Ltd, acting on behalf of the Council, failed to care properly for her mother, Mrs M. As a result, she developed a serious pressure sore before it was noticed by carers. On the evidence so far, the care home failed to keep complete and detailed records of Mrs M’s care and on balance, it missed opportunities to notice the development of the pressure sore. It also failed to report this as a safeguarding matter in a timely manner to the Council. The Council was at fault in the way it carried out the safeguarding investigation. The Council has agreed to apologise to Mrs X for the distress and uncertainty it caused her, make her a financial payment and carry out procedural changes.

The complaint

1. Mrs X complained that Eothen Homes Limited’s failure to provide her mother, Mrs M, with appropriate care led to her developing a Grade 4 pressure sore. The care was provided on behalf of the Council.
2. As a result, Mrs X says Mrs M’s health was put at serious risk. The deterioration in her health also meant she had to move to a nursing home against her wishes. Mrs X said Mrs M was unable to get out of bed for more than two hours which resulted in her being unable to enjoy her previous social and leisure activities.
3. Mrs X also complains the care home delayed reporting the matter to the Council which delayed the start of a safeguarding investigation.

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The Ombudsman’s role and powers

4. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves, or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. In the case of this complaint, the Council arranged and paid for Mrs M’s care. Therefore, we will treat any actions by the care home as if they were the actions of the Council.
6. 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)
7. 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)
8. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

9. I spoke to Mrs X and considered the information she provided.
10. I made enquiries of the Council and considered the information it sent me. This included Mrs M’s care records, pressure sore risk assessments and her medication charts. I also considered information about the care home staff which had been on duty the week prior to Mrs M developing a pressure sore and the levels of training they had received in pressure sores.
11. I made enquiries of the relevant NHS Trust and considered the information it provided in response. This included details of the notes and photographs of Mrs M’s pressure sore made by the district nurse who visited Mrs M.
12. I have written to Mrs X and the Council with my draft decision and considered their comments before I made my final decision.

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What I found

13. 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.
14. Regulations 9 and 12 state people must receive appropriate and safe care and treatment.
15. Regulation 17 states care providers must securely maintain accurate, complete and detailed records in respect of each person using the service and records relating the employment of staff.
16. Regulation 18 states care providers must ensure staff receive the appropriate support and training to enable them to carry out the duties they are employed to perform.

Pressure sores

17. Pressure sores (also known as bedsores) are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time.
18. Under the European Pressure Ulcer Advisory Panel classification system, pressure sores are graded in severity from 1 to 4. A pressure sore is graded as 4 when there is a very deep wound that can reach the muscle and bone. These are the most serious type and can lead to life-threatening complications.
19. Pressure sores can be graded using the Bradon Risk Assessment Tool. This measures factors such as mobility, skin moisture, nutrition and levels of activity. A score of 16 or lower indicates the person is at risk of developing a pressure sore, with the lower the score, the higher the risk.

What happened

20. Mrs M who was in her 80s, had lived since 2015 in the care home. She had dementia and was incontinent of urine. She was also incontinent of faeces at times. She was generally confined to a wheelchair.
21. On 1 March 2018 the care records for Mrs M stated “[Mrs M] has a grade 4 pressure sore. D/N [District Nurse] has dressed it. [Mrs M] is to have bed rest and regular turns 2 hourly plus 2 hourly toileting”.
22. The 2 March care records recorded “I have asked the nurse if [the pressure sore] is something that could have appeared suddenly as [Mrs M] receives regular intimate care and a pressure sore of this degree and size I feel would have been noticed as do day and night staff. The nurse informed me that as [Mrs M] is unwell at present the sore could have presented at its current severity within as little as a day”.
23. The pressure sore was infected which meant the district nurse could not make a formal decision about its grading until 16 March, when the infection had reduced. The district nurse confirmed Mrs M had a Grade 4 pressure sore.
24. On 21 March, the care home contacted the Council’s safeguarding team. The care home said Mrs M was being turned every two hours and district nurses were attending each day. The care home said Mrs M was recovering well and was eating and drinking.
25. The Council telephoned the district nurse who had initially attended Mrs M. The Council’s notes record “DN [district nurse] stated she has no concerns about the pressure sore being as a result of organisational neglect by the care home and advised that she suspects the sore may have developed quickly as a result of [Mrs M’s] physical health. [The district nurse] advised staff at the care home are not trained and may not have known the early signs to look for”.
26. The Council closed the case.
27. Mrs X was unhappy with the actions of the care home and complained to the company which owned the care home (the Care Provider). The Care Provider responded and said “following a detailed investigation into the care provided I am satisfied the care was appropriate”. However, the Care Provider later stated in the same letter “I have been unable to determine if the sore could have been prevented”. The Care Provider apologised to Mrs X for the fact Mrs M developed a pressure sore in its care and also for not meeting her expectations for the care its care home had provided Mrs M.
28. The Care Provider also said it had made changes including a review of assessment documentation, training for all staff on preventing pressure sores, the purchase of pressure relieving mattresses and chairs and the recruitment of a training officer.
29. Mrs M’s health conditions deteriorated and the care home was no longer able to provide the care she needed. Mrs M moved to a nursing home where Mrs M says she slowly recovered some of her health. She said, however, that Mrs M was unable to leave her bed for more than two hours and so missed out on many social activities before her death at the end of 2018.

My findings

30. During my investigation I examined the care records for Mrs M from 1 January to 16 April 2018. These included her daily care notes, Bradon score charts, positional movement charts and her care plan.
31. I considered the notes and photographs taken by the district nurses who visited Mrs M after the care home found she had a pressure sore.
32. I also examined the training records for staff who may have cared for Mrs M shortly before her pressure sore was discovered.

Bradon risk assessments

33. These were carried out monthly by the care home. Until carers noticed the pressure sore, Mrs M scored above the 16 point threshold which therefore made her low risk. Based on the evidence I have seen, there is no fault in the way the care home reached its scores for Mrs M or in the frequency of its checks.

Development of pressure sore

34. Regulation 17 states care providers must securely maintain accurate, complete and detailed records in respect of each person using the service.
35. The records for the two month period January to March 2018, show that on 57% of days, the care home did not keep any records of Mrs M’s daily care. In particular, the care home failed to keep any daily notes on the four days prior to 1 March when Mrs M’s pressure sore was first noticed by a carer.
36. Where the care home did keep daily care records, they provide little detail and no useful information about how often Mrs M’s personal care needs were met.
37. The care home failed to keep accurate, detailed and complete records. This is in breach of Regulation 17 and is fault.
38. As a result of this fault, I do not have enough information to enable a conclusion to be reached on the adequacy of the care home’s care of Mrs M.
39. Where we have conflicting accounts or a lack of evidence, we can make decisions based on the balance of probability.
40. Mrs X believes that if the care home had monitored Mrs M properly, it would have identified the pressure sore before it progressed to Stage 4. She believes there is a strong link between failures in Mrs M’s care and her subsequent death.
41. The Care Provider told Mrs X it believed the care home had provided appropriate care, but also stated it had been unable to determine if the sore could have been prevented.
42. The nurse who treated Mrs M states she did not believe there had been any institutional neglect of Mrs M.
43. Mrs M’s Bradon score indicated she was at low risk of developing pressure sores. The district nurse is recorded as saying the pressure sore could have reached Grade 4 in “as little as a day”. But Mrs M was incontinent, so I would expect carers to have changed her pads several times each day. If carers had made a check of Mrs M’s skin when changing her pads, I would have expected them to notice as its integrity began to breakdown. But because there were no daily records on the four days prior to staff noticing the pressure sore, there is no evidence of what happened.
44. Looking at the staff who were on duty during these four days, all received training during induction on caring for pressure sores, although there is no evidence to indicate they received training on their prevention. 60% of carers also had either an NVQ or specific training in pressure sores. But without a record of Mrs M’s care, I cannot say whether she was looked after by staff with specific training in pressure sores.
45. In this case, I consider on the balance of probabilities the care home missed opportunities to identify and possibly prevent the pressure sore from developing. I therefore uphold this part of Mrs X’s complaint.
46. As a result of the faults identified, Mrs X has been left with distress and a sense of lost opportunity over whether changes in Mrs M’s skin integrity could have been noticed earlier by staff and whether the pressure sore could have been prevented or treated much earlier. This has caused her unnecessary and enduring uncertainty which warrants a symbolic payment.
47. The Care Provider has apologised to Mrs X and explained what procedural changes it has made since the incident. It should provide the Ombudsman with evidence it has carried out these changes.

Safeguarding

48. The records state the care home manager failed to report the pressure sore to the Council on 1 March when it was first noticed. She said this was because it was not possible to grade it at that stage because it was infected. Instead, she reported it on 20 March, 19 days later, once the district nurse had formally graded it as a Grade 4 sore.
49. However, the care home’s case notes for 1 March recorded Mrs M had a Grade 4 pressure sore. The photographs taken by the district nurse on 1 March showed a deep wound nearly 5cm in length which strongly indicated it was too serious to be graded as a 1 or 2.
50. Although it may not have been possible to definitively grade the pressure sore when it was first noticed, the care home should have alerted the Council immediately and then graded it later when the infection had improved. The Care Provider has already admitted it was at fault when the care home failed to do so.
51. When the Council was informed by the care home of the incident, it made enquiries to determine whether it should carry out a safeguarding investigation. On the 22 March, the Council’s notes record the district nurse stated she had no concerns that organisational neglect had taken place and that the pressure sore may have arisen because “staff at the care home are not trained and may not have known the early signs to look for”. As a result, the Council decided not to carry out a safeguarding investigation and closed the case.
52. Regulation 18 states care providers must ensure staff receive the appropriate support and training to enable them to carry out the duties they are employed to perform. The district nurse stated staff at the care home may not have had the training required to identify the early signs of pressure sores.
53. Following the conversation with the nurse, the Council should have taken action to check whether the staff at the care home had training appropriate to their roles. Its failure to do so is fault. Checks would have revealed the care home had failed to keep proper records of Mrs M’s care. Because the Council did not do so, there was a lost opportunity to learn from these events and address any shortcomings. Further, this fault exacerbated Mrs X’s distress as she had no reassurance these events were taken seriously. This is an injustice to her.

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Agreed actions

54. The service fell below the standard we would expect and that required by the fundamental standards.
55. Within one month of the date of the final decision, the Council has agreed to:
• apologise to Mrs X for the unnecessary distress and uncertainty she has been caused by the faults identified in this investigation; and
• pay Mrs X £300 as a symbolic token to acknowledge this unnecessary distress and uncertainty.
56. Within three months of the final decision the Council has agreed to:
• ensure staff at the care home are reminded of the need to maintain accurate and regular records. This should include clear reasons for any non-compliance with care plans and any actions needed to ensure residents’ needs are being met;
• ensure clear procedures are in place detailing when and what safeguarding actions the care home must take when pressure sores are detected; and
• ensure the care provider has carried out the actions it specified in its letter to Mrs X, namely a review of assessment documentation, training for all staff on preventing pressure sores, the purchase of pressure relieving mattresses and chairs and the recruitment of a training officer.
57. The Council will need to provide us with evidence it has completed these actions.

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Final decision

58. The Council has agreed to my recommendations. Therefore, I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman