Mr John Graham Haslam & Mrs Jennifer Mary Bailey (19 003 763)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 12 Feb 2020

The Ombudsman's final decision:

Summary: The care provider failed to provide safe and appropriate care which met Mrs X’s needs. As a result she suffered pressure sores and a loss of dignity as well as delay in obtaining medical attention. The care provider will offer a payment to Mrs X in recognition of the distress caused by its failures.

The complaint

  1. Mrs A (as I shall call the complainant) say the care provider failed to seek medical attention promptly for her mother Mrs X when she fell, and then did not follow the doctor’s advice. She says the care provider failed to move Mrs X as stipulated and so Mrs X suffered pressure sores.

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The Ombudsman’s role and powers

  1. 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)
  2. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

  1. I considered the information provided by Mrs A and by the care provider. I spoke to Mrs A. Both the care provider and Mrs A had the opportunity to comment on an earlier draft of this statement before I reached a final decision.

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What I found

Relevant law and guidance

  1. 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.
  2. Regulation 9 says care and treatment must be appropriate and meet service-users’ needs.
  3. Regulation 13 says that care and treatment must not be provided in a way that significantly disregards the needs of the service user for care and treatment.
  4. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be in that person’s best interests.
  5. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)

What happened

  1. Mrs X is a very elderly lady with dementia. She had been resident in Across the Bay care home for some time. Her care plan (dated June 2017) noted that her skin integrity was at very high risk. A note on the plan adds, ‘Due to (Mrs X) being mobile staff will only monitor for any redness or skin breaks when assisting (Mrs X) with her personal care’. An update in September 2018 noted that Distrcit Nurses were going to assess Mrs X for a hospital-type bed as she was spending more time in bed.
  2. In January 2019 Mrs X fell twice within the space of three days: once on 15 January when she had an altercation with another resident, and again on 18 January when she was found by staff to have fallen out of bed. (Mrs A says the alarm in her mother’s room never worked properly, and the care provider fitted a stairgate at the top of the stairs.) The care notes record Mrs X complained of pain in her back after the second fall and was given pain relief. She continued to complain of pain, or was recorded as being ‘in great pain’, over the next few days.
  3. On 16 January the care home manager made a Best Interests decision that Mrs X should spend most of her time in her room, as the records showed that mixing with other residents increased her agitation and aggression.
  4. On 22 January the care provider asked the GP to visit Mrs X. The care home manager says she attended his visit too and says, “we discussed that (Mrs X) was very challenging when we tried to get her out of bed which the GP witnessed in part, on the day. I discussed with the GP how difficult she was to get her out of bed due to her challenging behaviour, he said in an ideal world we would send her for an x-ray, the GP then left. When GP ask us to take people for a x-ray they give us a form that tell the X Ray department why they are being sent and that it is authorised without this slip we are unable to send anyone, I took this and the lack of direct advise to take her, to mean she did not need to go.” The GP prescribed more painkillers for Mrs X.
  5. The care home records show Mrs X fell out of bed three times in the next few days. Mrs A says the sensor mat net to Mrs X’s bed was not secured and slipped away when she put her feet on it. The records continue to say that she was complaining of severe pain in her back. She spent most of the time in bed and frequently refused care (when out of bed she was able to be supported to the commode).
  6. On 9 February carers giving personal care noticed a sore area on Mrs X’s bottom and telephoned the District Nurses (DN) to visit. A DN came out the same day and dressed the pressure sore. She recommended a two-hourly turning routine and a hospital bed for Mrs X. She asked why Mrs X had not been taken to hospital after her fall and said she might have damaged something as she was still complaining of pain. The care home records show that staff commenced the two-hourly turning regime straight away.
  7. The DN also spoke to the out-of-hours GP service. A GP called the care provider to ask the staff to arrange an emergency ambulance to take Mrs X to hospital for x-rays. Mrs A accompanied Mrs X. She later telephoned the care provider to say there was no sign of fractures on the x-ray but Mrs X was staying in hospital.
  8. The care home manager visited Mrs X in hospital to assess whether she could return to the care home. Following a discussion with the ward staff she told Mrs A that the home could no longer meet Mrs X’s needs as she now required nursing care. Mrs X was discharged to a nursing home.
  9. Mrs A complained to the care provider about the care and treatment of her mother. She said when she asked why her mother had not been sent for an x-ray after her fall she was told it was too difficult as her room was on an upper floor and it would be difficult to get her downstairs. She said a soiled incontinence pad had been left in her mother’s room after personal care. She complained that Mrs X had been allowed to develop a pressure sore, had been left in bed for three days, and she had sometimes gone unchecked for hours.
  10. The care provider responded. They said Mrs X displayed challenging behaviour and sometimes refused to get up. They said as Mrs X was continent and could move about freely in her bed, it was agreed not to wake her when she was sleeping peacefully. They said there was no indication from the care reports on the days before the pressure sore was noted that there was any redness of her skin.
  11. The care provider acknowledged there had been an occasion (Mrs A says it happened more than once) when an incontinence pad had been inadvertently left in the room and staff had been reminded to clear them away immediately. They said regular checks were made but staff did not always note them at the time.
  12. In respect of a failure to act on the GP’s advice to take Mrs X for an x-ray, the care provider said ‘the GP said ideally he would like Mrs X to have an x-ray. (The manager) agreed but stated that it would be difficult due to (her) challenging behaviour. The GP agreed this would be difficult and did not insist on an x-ray and therefore (the manager) felt it would be in (Mrs X’s) best interests to remain in the home’.
  13. The local council also conducted a safeguarding investigation into the allegation of neglect on the part of the care provider after the DN raised an alert. It found that the allegation was substantiated; its report said, “the carers were advised that (Mrs X) should attend hospital by the GP, this had been ignored”. It recommended the home should follow the council’s falls prevention guidance. It said, “when a reported difficult service user is required to attend the hospital then the care home has a duty of care for this person to attend and an ambulance crew can be called to assist”.
  14. Mrs A complained to the Ombudsman. She said several senior members of staff had left the care home at the same time. She said Mrs X’s condition had deteriorated both physically and mentally for several weeks before her hospital admission.
  15. The care provider says Mrs X was not sent for X-Ray after the GP visit as “staff did not think that the GP had directly informed them to but had said ideally she should. No documentation to organise an X-Ray was given to staff therefore this did not take place. In hindsight this was an error which has been highlighted for future procedure within the home”.
  16. The care provider also says that staff had not been concerned about Mrs X’s ski integrity as they observed her being able to reposition herself in bed. However, “on Saturday the 9th February staff were concerned that (Mrs X) had refused to get up washed and dressed for several days and felt that she should now be coaxed out of bed. Having found that (Mrs X) had developed a grade 2 pressure sore, they immediately rang the district nurses who came to the home some seven hours later to examine her.”
  17. The care provider accepts that on some occasions the staff did not follow the correct procedures: Mrs X’s call bell was left out of her reach and incontinence pads were left in her room.
  18. The care provider does not agree that its actions caused any injustice to Mrs X.
  19. The care home manager says the staff at the home needed “extra training in Challenging Behaviour due to (Mrs X’s) deteriorating health, staff found it hard to deal with her when she was shouting and threatening to hit them, the training was put in place and staff followed it as best they can”. She says she has followed all the advice given subsequently by the council safeguarding team and the CQC.


  1. There is no evidence the care provider put in place a recognised falls procedure on the several occasions Mrs X fell.
  2. Despite the very high risk rating for Mrs X’s skin integrity, the care provider did not adhere to its plan to check her skin for redness or soreness at personal care interventions when she was immobile in bed resisting care for several days at a time: as a result, she developed a pressure sore.
  3. The records suggest the care home manager argued against the GP’s advice to take Mrs X to hospital for an x-ray. The GP could have overridden that argument. However, as the safeguarding investigation noted, the care provider had a duty of care towards Mrs X, however difficult her behaviour.
  4. There were other acknowledged complaints (the soiled incontinence pads left in the room, the failure to ensure the call buzzer was always in reach) which add to the impression of poor care.
  5. Mrs X did suffer injustice as a result of the care provider’s actions: she was given substandard care. Mrs A also suffered injustice; the anxiety caused by seeing the conditions in which her mother was being cared for and the knowledge that the care provider as doing less than it could have done to ensure Mrs X was well treated.

Recommended action

  1. The safeguarding investigation recommended specific actions: within one month of my final decision, the care provider will let me have details of how it has complied with those recommendations;
  2. The care provider will ensure its care plans are implemented robustly and within one month of my final decision, let me have details of how it reviews compliance;
  3. The care provider will, within one month of my final decision, let me have details of the training in challenging behaviour which staff are given;
  4. The care provider will, within one month of my final decision, offer a payment to Mrs X of £500 in recognition of the poor care and treatment she experienced;
  5. The care provider will also, within one month of my final decision, offer a payment of £500 to Mrs A in recognition of the distress and anxiety she was caused because of her mother’s poor care.

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Final decision

  1. The actions of the care provider caused injustice to Mrs X and Mrs A.

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Investigator's decision on behalf of the Ombudsman

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