Summary: Mrs X complains Tendercare Home Ltd failed to meet Mrs Y’s assessed care needs and placed her at considerable risk. She also complains the Council failed to keep her informed of the outcome of a safeguarding investigation. The failings in the care and services provided by Tendercare Home Ltd and in the Council’s safeguarding investigation amount to fault. This fault has caused Mrs Y and Mrs X an injustice.

The complaint

1. The complainant, whom I shall refer to as Mrs X complains Tendercare Home Ltd failed to meet Mrs Y, her mother’s assessed care needs and placed her at considerable risk. Mrs X believes that failings in Mrs Y’s care contributed to a deterioration in her health and well-being and led to Mrs Y’s admission to hospital with a severe pressure sore and scabies.
2. Mrs X also complains the Council failed to keep her informed of the outcome of a safeguarding investigation.

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The Ombudsman’s role and powers

3. 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)
4. 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)

We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

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. As part of the investigation, I have:
• considered the complaint and the documents provided by Mrs X;
• made enquiries of the Council and considered the comments and documents the Council provided;
• sent a statement setting out my draft decision to Mrs X and the Council and invited their comments. I have considered Mrs X, the Council and Tendercare Home Ltd’s comments.

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What I found

Key facts

8. Mrs Y moved to the Tendercare Home in 2016. She had a diagnosis of dementia and needed full assistance with her personal care. Mrs X was initially happy with the care Mrs Y received at the home. Mrs X’s complaint is about the standard of care her mother received at the home in the Spring of 2018.
9. Mrs X asserts that if the home had been meeting Mrs Y’s care needs, particularly her personal hygiene needs it would have noticed Mrs Y’s pressure sore and scabies much sooner. Mrs X says the home should have sought medical attention sooner and the lack of urgency contributed towards the deterioration in Mrs Y’s health. Mrs X has also raised concerns about the communication she received from the home. She says it did not keep her properly informed about her mother’s medical condition.
10. According to the home’s records, staff arranged for Mrs Y to see the GP on 7 March 2018 as she had a rash. The GP diagnosed this as dermatitis eczema and prescribed a cream. The home then completed a body map on 1 April 2018 which notes:

“Skin intact. Has rash. Seen by GP. Dry skin. Dermatitis/ eczema”

11. On 6 April 2018 the home contacted the district nurse service as carers noticed a wound on Mrs Y’s bottom. The home’s records state the district nurse said this was a burst abscess and applied a dressing. The district nurse arranged to visit again on 9 April 2018 to change the dressing.
12. The care notes for 7 April 2018 state Mrs Y had been fine that day and there were no concerns. They state Mrs Y ate and drank well and slept well that night. There is no reference to Mrs Y’s personal care. The care notes for 8 April 2018 also state Mrs Y appeared fine. She needed encouragement to eat but had drank well. The notes state Mrs Y was assisted with her personal care and there were no concerns.
13. But on 9 April 2018, the care notes state Mrs Y did not appear well. The home states it attempted to call the GP. When the district nurse arrived, they were concerned Mrs Y may have sepsis and advised the home to call an ambulance. Mrs Y was admitted to hospital with a sacral pressure sore and scabies.
14. When Mrs Y was discharged from hospital a couple of weeks later, she did not return to Tendercare Home, but moved to a different care home. Mrs Y lived there until her death in March 2019.
15. While Mrs Y was in hospital Mrs X’s son made a complaint to the home on Mrs X’s behalf about the care Mrs Y had received prior to her admission to hospital. He noted the pressure sore was not an acute condition and could take weeks or months to develop. Also, Mrs Y had an extensive widespread case of scabies to her hands, arms, abdomen, groin, feet and legs. He questioned why the home had not noticed earlier and why it had not informed Mrs Y’s family. He also raised several questions about the home’s practices and procedures.
16. The home’s response sets out the action it takes to prevent the occurrence of pressure sores and how it assesses and manages any suspected areas or pressure sores. It also sets out the action it took to check other residents when it found out Mrs Y had scabies.
17. Mrs X did not complain to the Council at this stage, but the Council received a safeguarding referral raising concerns about Mrs Y’s pressure sore and scabies on 12 April 2018. As part of their enquiries an officer contacted Mrs X on 19 April 2018 to discuss her concerns, and then visited Mrs Y in hospital. The officer did not speak with Mrs Y as she was sleeping but read her notes. The notes stated Mrs Y had been admitted for a peri-anal abscess. The pressure sore was in the sacral area and had necrotic skin. Mrs Y also had scabies on admission.
18. The officer then contacted the manager of the home who said Mrs Y had gone to hospital as she had an abscess that had popped. The home had first noticed the abscess on 6 April 2018 and had contacted the district nurses. The manager stated the district nurse had told them it was not a pressure sore. The manager also stated they had not informed Mrs X of Mrs Y’s abscess as Mrs X was unwell. The home was unaware Mrs Y had scabies until her son told them on 15 April 2018.
19. The home manager confirmed it had since checked all residents for a rash. The home had also contacted the Health Protection Agency for advice, and all residents and staff had been treated for scabies.
20. The officer also made enquiries of Mrs Y’s GP surgery, the district nurse service, the adult safeguarding nurse at the hospital, and a tissue viability nurse.
21. The officer concluded that the safeguarding allegations were partially substantiated. They found staff should have informed Mrs X of Mrs Y’s condition and sought urgent medical attention without being prompted by the district nurse.
22. In reaching this conclusion the officer noted the home had contacted Mrs Y’s GP when she had a rash and that Mrs Y was treated for dermatitis eczema. Mrs Y still had this rash when the home completed the body map on 1 April 2018 and the home did not realise it was scabies. In relation to the pressure sore, the home had contacted the district nurses when they saw a break in Mrs Y’s skin and the district nurse identified this as an abscess rather than a pressure area. The officer noted the tissue viability nurse had advised that the skin can look normal until the abscess comes to the surface. The tissue viability nurse had also advised that pressure damage can develop very quickly, particularly when there are other risk factors.
23. The officer also noted the district nurses were concerned about the number of visits they were making to the home for residents with pressure ulcers and skin tears. This had increased since the home had expanded. The district nurses had arranged for tissue viability nurses to provide the home staff with training on pressure areas and wound care.
24. Mrs X states she repeatedly chased the Council for written confirmation of the outcome of the safeguarding investigation, and only received this after making a formal complaint.
25. The officer wrote to Mrs X in July 2018 setting out their findings and conclusions. The officer acknowledged that the home and other professionals had failed to identify Mrs Y had scabies. But stated there was no evidence that any persons had been negligent in respect of their duty of care to either seek medical attention or to assess. In relation to the pressure sore the officer noted there was no evidence to dispute the home’s claim that it contacted the district nurses as soon as they noticed the break in Mrs Y’s skin. The district nurses had recorded they had seen an abscess rather than a pressure wound.
26. Mrs X disputes the Council’s findings and has asked the Ombudsman to investigate her complaint. She maintains the home should have sought medical attention when Mrs Y’s rash did not improve. Mrs X also asserts the home should have been aware of the wound sooner. She disputes that Mrs Y’s skin could have been intact on 1 April 2018, given the necrotic condition of the wound on 9 April 2018. Mrs X has provided photographs she took of Mrs Y hands and arms, and the pressure sore when Mrs Y was admitted to hospital.
27. The Council commissioned Mrs Y’s place at Tendercare Home Ltd. It is therefore responsible for the home’s acts and omissions. In response to my enquiries the Council has set out its monitoring arrangements with the care homes it commissions. It monitors care and support services according to risk, and where there are declining standards it manages them through the Council’s safeguarding process. The Council states that in 2018 it strengthened its monitoring resource to include a pharmacist, nurse, and health and safety officer. It states this enables more specialist monitoring and has enabled key risks to be targeted and escalated, which helps improve standards.
28. However, the Council has not provided any details of how its procedures were applied in relation to Tendercare Home Ltd. It has not confirmed the home’s assessed risk level or provided details of the most recent monitoring or whether/ when further monitoring will take place.

Analysis

29. Based on the information available I consider there were failings in the care and services provided by Tendercare Home Ltd. The records show that Mrs Y had a rash in early March 2018. Despite being prescribed cream by the GP, this rash had not cleared up by 1 April 2018, when the home completed a body map. Yet the home did not ask the GP or another medical professional to review it.
30. Based on the photographs of the rash and sores on Mrs Y’s hands and arms taken on /around 9 April 2018 I would have expected the home to seek further medical attention. Particularly in relation to the sores on Mrs Y’s hands, which Mrs X states were crusted or Norwegian scabies. The failure to do so amounts to fault.
31. Mrs X disputes that Mrs Y’s skin was intact on 1 April 2018. She states she was told by hospital staff that given the necrotic nature of the pressure sore it had been present for some time. It is not now possible to determine when Mrs Y first developed the pressure sore, or whether the home should have noticed it and sought medical attention sooner.
32. It is unclear why the district nurse considered Mrs Y’s wound was an abscess, when the hospital later confirmed it was a pressure wound. But I would not criticise the home for relying on the district nurse’s diagnosis or plans for treatment. I would however have expected the home to inform Mrs Y’s family of her condition. I would also have expected the home to proactively seek medical attention when Mrs Y’s condition deteriorated. The district nurse should not have had to prompt staff to call for an ambulance. These failures amount to fault.
33. I also consider there were failings in the Council’s safeguarding investigation. Given the dispute about how long Mrs Y had had scabies, and when the pressure sore first developed, I do not consider the investigation was sufficiently robust.
34. The investigating officer visited Mrs Y in hospital but was unable to speak to her. The officer did not return when Mrs Y was awake or speak to the nursing staff about her condition. Mrs X states the doctor who treated Mrs Y ordered medical photographs, but there is no evidence the officer asked for copies of these. Nor did the officer speak to the doctor or seek their views about Mrs Y’s pressure sore or scabies.
35. I recognise the officer spoke to a tissue viability nurse, but the notes record that they could only give general advice. The tissue viability nurse could not comment on Mrs Y’s particular case without seeing the pressure sore.
36. The failure to obtain detailed information from the hospital staff about Mrs Y’s pressure sore and scabies, and their views on how long she had had them is fault. This information should have been a fundamental consideration in investigating the allegations against the home. It is not sufficient or appropriate to conclude there is no evidence to dispute that the care home contacted the district nurses as soon as they noticed the break in Mrs Y’s skin, when no evidence has been sought.
37. Having identified fault, I must consider whether this has caused a significant injustice. The main injustice of the home’s neglect and acts of omission would be to Mrs Y. Unfortunately, as Mrs Y died earlier this year, I am unable to recommend a remedy for any injustice caused to her. We do not normally seek a substantive remedy in the same way as we might for someone who is still living.
38. I consider the fault identified above had also caused Mrs X an injustice. Mrs X has experienced distress and uncertainty in relation to the failings in Mrs Y’s care and in the safeguarding investigation; and has been put to unnecessary time and trouble to trying to resolve the matter.

Agreed action

39. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Tendercare Home Ltd I have made recommendations to the Council.
40. The Council has agreed to
• apologise to Mrs X for the failings in Tendercare Home Ltd’s care and in the safeguarding investigation; and
• pay Mrs X £300 in recognition of the distress and uncertainty she experienced and the time and trouble she was put to as a result of the failings in Tendercare Home Ltd’s care and in the safeguarding investigation.
41. The Council should take this action within one month of the final decision on this complaint.
42. The Council has also agreed to review training on / remind officers of the need to ensure that conclusions and decisions in safeguarding investigations are clearly evidenced and defensible. The failure in this case to obtain evidence to corroborate events or establish how long Mrs Y had had scabies and a pressure sore should be used to improve practice.
43. The Council should take this action within two months of the final decision on this complaint.

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Final decision

44. The failings in the care and services provided by Tendercare Home Ltd and in the Council’s safeguarding investigation amount to fault. This fault has caused Mrs Y and Mrs X an injustice.

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Investigator's decision on behalf of the Ombudsman