Summary: Ms B complains about the care her father received at Foxholes Care Home and says she witnessed an incident where the care staff handled her father in a rough manner. The Ombudsman cannot say there was evidence of fault in the way the staff handled Ms B’s father but there was fault in the provision of the care and the record keeping. The Ombudsman recommends the Home apologises to Ms B and pays her £150.

The complaint

1. Ms B complains on behalf of her father Mr C who has passed away. Mr C was living at Foxholes Care Home in Hitchin. Ms B says she observed poor care and she says she observed an incident where Mr C sustained bruising because of the staff’s rough handling.

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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. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

How I considered this complaint

5. I have discussed the complaint with Ms B. I have considered the documents that she and the Council have sent, the relevant guidance and policies and Ms B’s comments on the draft decision.

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What I found

Fundamental standards

6. 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) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.

7. The CQC has provided guidance on the regulations. This says that:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. (regulation 12).
• The nutritional and hydration needs of the service user must be met. (regulation 14).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).

The Home’s policy

9. The Home has a policy on what should happen if there is an incident involving a resident. This says that:
• Any skin tears, lacerations or bruising must be photographed and recorded on a body map detailing the size and location.
• The manual handling risk assessment may need to be updated if there is an injury as a result of a fall.
• The risk integrity assessment will need to be updated.

What happened

10. Mr C moved into the Home in November 2018.
11. His care plan dated 27 November 2018 said:
• He could communicate his needs to staff.
• Staff should ensure that Mr C had his call bell pendant with him. He could not always use his call bell independently so staff should check upon him regularly.
• He was incontinent and often needed assistance with his toileting. Staff should check his pad regularly.
• Staff should monitor his weight and ensure that he had eaten and drunk a sufficient amount.
• He needed oxygen when he mobilised.
• His skin was like tissue paper. He was very frail and had fragile skin. He bruised very easily.
12. His care plan, in terms of mobility, said that Mr C was able to walk very slowly using a walking frame, but needed a wheelchair for long distances. He may need a rotary stand when transferring. It said he was able to bear his own weight but as he was losing strength, he would need the support of staff to ensure his safety. It said staff should assess his mobility at the time of each move and use the rotary stand if necessary.
13. Mr C was seen by the respiratory nurse on 3 December 2018. She said Mr C should use oxygen when walking around with the carer supporting. She said he did not need to use the oxygen at any time unless he was walking.
14. The Home monitored Mr C’s weight on a weekly basis. It noted his weight was low on 11 December 2018 and the frailty nurse went to see him on 17 December 2018. The advice at that stage was to encourage him to drink plenty of fluids. After 1 January 2019, the plan was to assist him with eating and drinking.
15. The Home reviewed Mr C’s care plan on 17 December 2018. Most of the care plan remained the same. In terms of mobility, the plan that Mr C could walk short distances with the use of a zimmer frame and the support of 1 care staff.
16. On 30 December 2018, Ms B noticed a bruise on Mr C’s hand. She raised it with the GP and the GP started to speak to Mr C about this. Ms B says Mr C kept looking at the carer when the GP was asking questions. She says the GP asked Mr C whether Ms B or the carer should leave and Mr C said the carer should leave.
17. There is a brief note of the visit written by the GP in the records but it does not give any detail of the visit apart from an adjustment in Mr C’s medication.
18. Ms B observed the carers providing care later that day (30 December 2018) She says the carers started to assist Mr C up from his chair, but Mr C said: ‘My legs have gone’ and was unable to stand. She says the carers struggled to hold Mr C up and had not planned the move well. Ms B says she then moved his bed out of the way and moved the wheelchair to Mr C so the carers could allow Mr C to sit in his wheelchair.
19. Ms B says she then left the room, while one of the carers (carer D) undressed Mr C. She says she heard Mr C call out: ‘Stop, you’re hurting me’. She says she came back in the room and the carer had tried to pull Mr C’s arm though his vest, and he was lying on the arm. She says Mr C asked the carer to leave and Ms B cut the vest off Mr C.
20. There is a record for 31 December 2018 (01:26) which says: ‘[Mr C] knocked his jelly over into his bed covers and pendant and over floor. Cleaned everything up. Bed covers in wash. Had to mop floor as was sticky. Was awake, was content.’
21. Ms B went to see Mr C on 31 December 2018 and discovered Mr C had bruises on his arm. Ms B took a photo of the arm and spoke to the Home’s manager. According to Ms B, the manager said the bruises may have been caused by Mr C banging his arm as he bruised very easily.
22. Ms B made a formal complaint during the meeting and said:
• The carer left a dirty glass of water on a table across the room, outside of Mr C’s reach.
• Mr C’s pad was not changed for seven hours while Ms B visited.
• There was spilt jelly on his table since yesterday.
• Mr C had bruising to his right hand and arm. The bruises on the arm were done by the carer when she was putting a vest on Mr C.
• Mr C was intimidated by one of the carers.
• Staff were not planning the transfers of Mr C properly and did not properly communicate before a transfer. She witnessed a transfer yesterday that was not properly planned.
• Mr C should be given oxygen whenever he was moved. This had not happened.
• Staff told him to use his call bell for assistance, but he was unable to do this independently. She had found his call bell inside his clothing when she visited him.
23. The manager said she would investigate the complaint.
24. Mr C called Ms B in the evening. Ms B said he sounded distressed. He had tried to speak to Ms B’s mother and sister who lived closer but they had not answered the phone. Mr C said his legs were trapped. Ms B called the police.
25. The police attended the next day and spoke to Mr C. The police had no concerns about the Home or the care Mr C received and closed the case.
26. Ms B called the Council on 1 January 2019 and made a safeguarding referral about the Home. Her concerns were:
• The rough handling on 30 December 2018 which she said resulted in finger-tip bruising on Mr C’s arm.
• Failure to change his continence pad for seven hours on 27 December 2018.
• She observed Mr C being transferred without being given oxygen.
27. The Council started a section 42 safeguarding investigation.
28. The Home’s manager discussed the complaint with the carer who had been involved in the incident on 1 January 2019. The carer said she did not struggle to dress Mr C but had been told by the family to put a vest on him. Mr C had not wanted this and had created a fuss as a result.
29. The manager and the carer also discussed the transfer. They agreed that Mr C was sometimes able to transfer but his mobility was very unreliable. They discussed how transfers could be managed better as Ms B felt that the move she witnessed was not well planned.
30. The Council’s social worker spoke to the Home’s manager on the same day. The manager said Mr C had been prone to bruising since he arrived and his skin integrity had deteriorated further. She said the carer told her the bruises had been there for a while. The social worker asked whether there was a body map of the bruises and the manager said there was not. She had spoken to the carer to remind her they should do a body map whenever they discovered bruising.
31. The manager also said that Mr C did not need oxygen when he was being moved, only when he was mobilising. She said the pad was not changed as he did not need changing.
32. The Council asked for the Home’s records relating to the concerns. The Council said the GP should visit Mr C and give an opinion on the bruises and the oxygen. The Council also asked an occupational therapist to give her opinion on the bruises and the Home’s moving and handling of Mr C. It was agreed that carer D would not provide any care to Mr C while the Council’s investigation was ongoing.
33. The Home carried out a review of the care plan on 1 and 2 January 2019 and changed the following:
• It changed the moving and handling section and said Mr C needed the assistance of 2 staff and a rotary stand for any transfers in and out of bed. He needed the assistance of two staff for transfers from bed/chair to wheelchair/commode and for bathing and showering. It said Mr C used a wheelchair.
• It said, in the skin integrity section, that staff should record any bruising that appears anywhere on Mr C's body.
34. The GP visited Mr C on 2 January 2019. This was a different GP from the GP who visited Mr C on 30 December 2018.
35. The GP saw the bruises on Mr C’s forearms. He said he could not say whether these were the result of poor moving and handling, but said that, given Mr C’s thin skin and use of aspirin, Mr C was likely to bruise easily. He said he therefore had ‘no reason to suspect that the bruises were caused by anything other than senile purpura from my examination, but I cannot conclusively say that there was no other cause.’
36. It is my understanding that senile purpura is a condition that sometimes affects older people. It is characterised by oddly shaped discoloured areas on skin, usually the arms and hands. Aging skin is the most common cause of senile purpura.
37. An occupational therapist visited Mr C on 3 January 2019 to review Mr C’s moving and handling and the techniques in place. She said the bruising was not consistent with poor moving and handling. She looked at the bruises and said Mr C had a bruise to the right forearm and a bruise to the back of the right elbow.
38. She said: ‘Due to the size and the location of the bruises these, in my opinion, do not look like they are caused by holding of the arm but more likely from the arm being knocked. Other small bruises were observed to the arm and [Mr C] told me that he bruises easily.’
39. The occupational therapist asked Mr C how he sustained the bruises and he said: ‘The nurse got hold of me.’ He said it happened about a week or 10 days ago and said: ‘She was holding my arm, doing various actions they do to turn you over.’ Mr C told the OT he was happy in the Home and wanted to remain living there.
40. The Home responded to Ms B’s complaint on 4 January 2019. It listed ‘follow-up actions’ to each of the complaint. The Home said:
• The manager spoke to the carer about the glass of water not being left within Mr C’s reach. The carer said she was still in the room as she had been providing care to Mr C and this is why the table with the water was across the room.
• His continence pad was changed regularly but staff allowed Mr C privacy when he had guests. Staff felt uncomfortable going into Mr C’s room when his family was there.
• In relation to the spilt jelly which had been there for two days, the Home said staff were aware they should clean up after residents in a timely manner. It could not say why this was not done on this occasion.
• Carer D said she did not struggle to dress Mr C on 30 December 2018. She said the family told her to put a vest on Mr C, Mr C did not want this and created a fuss as a result.
• Mr C was at risk of bruising from even the slightest touch. He also took medication which increased the risk of bruising.
• Staff were trained in moving and handling and were shown the best way to handle someone.
• The Home’s manager discussed the transfer which happened on 30 December 2018 with the carer. They agreed that Mr C’s mobility was unreliable and discussed how transfers could be managed better. They would assess Mr C for a rotary stand and staff would plan any move before executing it.
• The Home was of the view that Mr C could use his call bell to ask for assistance. Staff would continue to visit him regularly.
41. The Council wrote to the GP on 9 January 2019 and asked him to confirm his diagnosis of purpura and his previous analysis as Ms B questioned the outcome. The GP did so in April 2019.
42. Ms B rang the Council on 26 February 2019 as she wanted an update on the safeguarding investigation.
43. The OT gave an overview of her visit and said that in her opinion, the bruising was not the result of poor moving and handling. Ms B explained her concerns which had been outlined in the complaint.
44. Mr C moved to a different care home in January 2019. Sadly, he passed away on 2 March 2019.
45. The Council closed its safeguarding investigation on 19 March 2019 and said there was not sufficient evidence to support the allegation that Mr C had been physically abused. The safeguarding allegation was closed as unsubstantiated.
46. Ms B has made further comments on the Home’s response to the complaint and the draft decision. She said:
• The carer was leaving the room when Ms B alerted her to the glass of dirty water which was left across the room.
• Ms B did not notice the bruising before 31 December 2018. She had checked Mr C’s arm for bruising after she saw the bruise on 30 December 2018 and the GP did so as well. There was no bruising on the arm. There was no bruising on the arm when she saw Mr C in his vest on the evening of 30 December 2018. Therefore, she questioned the Home’s statement that the bruises had been there a long time.
• The Home’s manager admitted during the meeting on 31 December 2018 that staff did not always follow the moving and handling plan. The Home’s manager later denied admitting this.
• During the meeting on 31 December 2018, the manager checked the notes and there were other occasions when the pad had not been changed for a long time and the manager was surprised at this.
• There were 11 times in the records for December where Mr C was walking using his zimmer frame and there was no record that he was offered oxygen.

• Mr C lost weight when he was at the Home. The records show the intake of food and liquid was low on certain days.

47. I checked Mr C’s records from 20 December 2018 until 31 December 2018 to check the gaps between pad changes. I noted gaps of 7 hours or more on several days, even when the family was not visiting.
48. The Home has said there were problems with its electronic recording system so it was sometimes difficult to see when actions took place. The Home is in the process of changing to a different recording system.

Analysis

49. Ms B’s main complaint relates to the incident on 30 December 2018 and the care Mr C received around that time.
50. In terms of the hygiene in the room and the spilled jelly, there was fault and the Home admitted this.
51. The Home has explained why the water was across the room from Mr C and said the carer had completed her care of Mr C but was still in the room. Ms B says the carer was in the process of leaving the room and would have left the water where it was. I cannot add anything to that except that Mr C did not suffer any injustice.
52. In terms of the change of the continence pad, the Home accepts there were long gaps when Mr C’s continence pad was not changed but said the gaps occurred because the carers did not want to disturb Mr C while he had visitors.
53. I have checked some of the records for the days when Mr C did not have visitors and found similar long gaps. I appreciate that this may be because the carer may have made a record after the event. It may also be that the carer checked and noted that the pad did not need changing but did not record this. Either way, there was fault. The Home had a duty to properly record the care it was giving. The times on the record should be correct and, if the carer checked the pad, that should be recorded. So either the carer did not check Mr C’s pad frequently enough or the carers did not properly record their actions.
54. There was fault in the administration or the recording of the oxygen as there were incidents when Mr C walked and there is no record that he was given oxygen.
55. The Home monitored Mr C’s weight and recorded Mr C’s food and fluid intake but there were times when the intake was low. I note the Home obtained the advice from the frailty nurse and changed the care plan. I cannot see any evidence that the Home checked what the daily intake was which would have been good practice.
56. There was fault in relation to the incident which happened on 31 December 2018. The Home’s policy said that whenever there was bruising, this should be recorded on a body map detailing the size and location. The risk integrity assessment should also to be updated.
57. The Home failed to do this on two occasions and this is fault. Mr C had a bruise on the back of his hand on 30 December 2018 but there was no record of when or how this bruise occurred. He then had further bruises on his arm on 31 December 2018 which the Home said had occurred earlier, but there was also no record of these bruises until Ms B raised the issue.
58. A record is vital in cases such as this, both to understand the cause and then to carry out a risk assessment and, if necessary, a change in the care plan to minimise the chance of a further occurrence. The Home’s failure to record the bruises properly was fault.
59. The Home’s communication about the bruises also added to the confusion. The Home initially said the bruises may have been caused by Mr C banging his arm, but then later said that according to the carer, the bruises had been there for a long time.
60. This was not recorded in the carer’s statement and it should have been as it was important information. The Home also failed to check with any other staff when they noticed the bruising first and why the bruises had not been recorded by any of the staff.
61. In relation to the transfer on 30 December 2018, the manager discussed the transfer with the carer and they discussed how transfers could be managed better. I note the Home re-assessed Mr C’s moving and handling on 2 January 2019 and changed his care plan as a result.
62. Ms B says the carer handled Mr C roughly when she dressed him and the rough handling caused the bruises. The carer denies this.
63. Ms B says she did not see the bruises until the morning of 31 December 2018. I believe Ms B as I am of the view that, if she had seen the bruises earlier, she would have brought them to the immediate attention of the staff.
64. However, the GP diagnosed Mr C with senile purpura which meant he bruised very easily. The OT said the bruising was not the result of poor moving and handling. Therefore, the bruising does not mean that Mr C was abused or handled roughly. In the absence of any other evidence, I cannot say therefore that there is enough evidence to say that the carer handled Mr C roughly on 30 December 2018.
65. I have considered the injustice that Mrs C has suffered of the fault. The records suggest that there have been times when the care provided to Mr C was not in line with his care plan or that the carers had not properly recorded the care. Either way, Mr C suffered an injustice as the provision of care and proper record keeping were important to ensure that the care met his needs. The failure to properly record the bruising meant the Home did not update the risk assessment which put Mr C at risk. It also meant that it was more difficult to determine what happened as there was no time-line.

Recommended/ agreed action

66. The Home is in the process of changing its recording system so I have not made a service improvement in relation to this.
67. The Care Quality Commission is best placed to address any concerns that have been raised about the care or the records and I will send a copy of this decision to them.
68. I recommend the Home takes the following actions within one month of the final decision. It should:
• Apologise in writing to Ms B.
• Pay her £150 for the distress caused.
• Remind staff of the importance of good record keeping.
• Ensure staff are reminded to provide care in line with the care plan.

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Final decision

69. I have completed the investigation and I have found the Home’s actions have caused injustice.

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Investigator's decision on behalf of the Ombudsman