Summary: Ms C complained about the temporary care her (late) father received in a nursing home, which was commissioned by the Council. The Ombudsman found there was fault with the care Mr F received, and the way in which the care provider responded to Ms C’s complaint. This resulted in distress for which the Council has agreed to apologise and pay a financial remedy.

The complaint

1. The complainant, whom I shall call Ms C, complained to us on behalf of her (late) father, whom I shall call Mr F. Ms C complained about the residential respite care the Council arranged for her father between 3 and 14 February 2018. She complains that:
• The home failed to provide the care her father needed for a pressure sore.
• The home failed to puree his food and did not provide him with ‘fork mashable’ food.
• The home failed to weigh her father and monitor his weight, as required.
• The home failed to empty her father’s catheter bag on time.
• The home failed to properly process / deal with her complaint
2. Furthermore, Ms C complains the Council failed to share the findings with her from its safeguarding investigation into the above concerns.

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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. 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. 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)

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How I considered this complaint

6. I considered the information the information I received from Ms C, the Council and the NHS Tissue Viability Nurse service. I shared a copy of my draft decision statement with Ms C and the Council and considered any comments I received, before I made my final decision.

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What I found

Mr F’s pressure sore care

7. Ms C says her father had a pressure sore, which did not improve at home. As such, the district nurses advised that he should temporarily go into a care home so he could be turned every two hours, throught the day and night. The stay would therefore hopefully improve his moisture lesion.
8. Mr F went into Greenacre Grange nursing home (run by Horizon Care (Greenacres) Limited) on 3 February 2018. On that day, the affected area was described in the home’s records as 3 by 1 cm. Ms C says she explained to the home at the pre-admission assessment, how his wound should be cared for. The home was supposed to treat the sore/wound twice a day and turn him every two hours. However, Ms C says the home failed to do either. Ms C told me the home failed to turn him every two hours, because family members were there for hours during which the home did not turn him. She also said that family members left a towel rolled up at the side of him at night and saw the next morning that it hadn't moved. She said the family did this to see if staff repositioned her father at night.
9. Ms C also told me that:
• Her father’s wound wasn't treated with cream for the first five days.
• The home did not use sterile water and washed the open wound with tap water and toilet paper instead. The family witnessed this on one occasion and the nurse told them the home did not have sterile water. When her father was at home, he was prescribed sterile water, which the nurses always used to wash him.
• Furthermore, the family noticed that her father’s air flow mattress was deflated on two occasions.
10. Ms C says that, as a result of the above failings, the moisture lesion deteriorated and became a level 3 or 4 pressure sore when the family took him back home after eleven days.
11. The home’s Risk Assessment (pressure sore) states:
• Risk of developing pressure sores due to Mr F’s poor condition, he is bed bound and unable to turn himself in bed.
• Medical Condition and Associated Risks:
1. Requires regular turns 2-hourly.
2. Ensure air mattress is in place.
3. Ensure air cushion is in place for the chair.
4. Check the skin integrity regularly and apply creams to sacrum and dry areas
5. Incontinent of faeces. Ensure skin is well cleaned and dried properly following episodes of faecal incontinence.
12. The home’s care plan “Skin Integrity” added that:
• Staff to check Mr F’s pressure areas at least daily and report any concerns to the Nurse on Duty
• Refer to Tissue Viability Service if needed
13. Ms C says:
• Her mother spoke to the care home’s nurse on 3 February 2018, the day of Mr F’s admission. The nurse said the home did not have ‘stuff to treat her father’s wound’. Her mother said the family would bring pro shields cream the next day.
• The family brought the cream the following day. She told the carers and put it in his room under the ‘medication cupboard’, so the nurse would see it when coming in; “you couldn't miss it”.
• Ms C says the family noticed on 5 February that the cream had not been moved. A nurse told her on 6 February that she had not seen the cream. By that time, his wound looked awful and had tripled in size. Ms C says it was washed and creamed three times a day at home.
14. The Council told me that a photo dated 5 February 2018, confirmed the wound was a moisture lesion. A record from 6 February said the home’s nurse reported that a District Nurse was continuing to visit to monitor the moisture lesion. However, the local NHS Trust told me that district nurses did not visit the home during Mr F’s stay, because he was in a nursing bed which meant the home’s own nurses could provide any care required.
15. At a joint meeting on 6 February 2018, when pro shields was discussed, the record states that Ms C reported that her father had used this previously and found it to be very good in treating the sore. The record does not mention that Ms C reported any concerns at the meeting to the home or the social worker about the way the home had managed the affected area so far.
16. On 7 February 2018, Ms C witnessed that a staff member cleaned her father’s affected area with normal water and toilet paper, rather than with sterile water. The District Nurse has since told the Council that if the wound was a moisture lesion, staff would not have had to use sterile water. At the meeting the previous day, the wound had been described as a moisture lesion.
17. The Council told me that the care home’s records showed there are regular recordings by the care and nursing staff, that show they attended to Mr F throughout the day and night. It said that whilst the records did not always state the support provided was for pressure care, they evidenced that staff attended to Mr F at least every two hours. The notes also include several recordings that suggested staff applied barrier cream and changed dressings.
18. The care home’s records state that:
• 4 February 2018
1. There is no record in the morning to show if/that night staff turned Mr F every two hours.
2. 4pm: “2 hourly positional changes performed”.
• 5 February
1. 6am: “Pressure area care was met by staff”.
2. There is no record in the afternoon / evening to show if/that day staff turned Mr F every two hours.
• 6 February
1. 5am: “Pressure area care was met by staff”.
2. 7pm: “Regular turn. Sacrum area grade 1 to 2. Medication given as prescribed”.
• 7 February
1. 5am: “Barrier cream applied. Pressure relief maintained”.
2. 4pm: “Seen by Practice Nurse. Continue with barrier cream. She will discuss with GP if dressings are needed”. No information about being turned by day staff regularly
• 8 February
1. 7am: “Pressure area care maintained”.
2. 8pm: observation about the status of the wound. No information about being turned by day staff regularly
• 9 February
1. 7am: “Pressure area care was met by staff, turns were maintained”.
2. 7pm: No information about being turned by day staff regularly. “Sacral wound photographed and sent to Tissue Viability Service. Wound redressed as per plan”. The TVN says it received a referral asking for treatment advice for category 2 pressure ulcer.
• 10 February: No records of what happened.
• 11 February
1. There is no record in the morning to show if/that night staff turned Mr F every two hours.
2. 2 pm: He remains in bed. Dressing renewed. Had all his medication. No information about being turned by day staff regularly.
• 12 February
1. 7am: Pressure area care was met by staff. Dressing intact and clean.
2. TVN responded to referral. Telephoned and spoke to the agency nurse in charge of the shift that day. The nurse advised that the patient had a category 2 pressure ulcer to the sacrum and assured RL that the patient as nursed on an alternating airflow mattress and was being repositioned on a 2-hourly basis. The nurse could not comment on the wound’s appearance. TVN arranged a joint appointment with the care home for 14 February 2018 and advised the agency nurse upon assessing the wound, if they felt the visit was more urgent to contact the Tissue Viability Service prior to the visit.
3. There is no record in the afternoon / evening to show if/that day staff turned Mr F every two hours.
• 13 February: No information about turning etc
• 14 February
1. 5am: “Turned two hourly last night and during the day”
2. The home did not provide a record that shows what was discussed during the TVN visit.
3. NHS record: Was informed on arrival that the patient was returning home. Patient’s wife was present during the visit and expressed her concerns about the care her husband received at the home and that she was taking him home earlier than originally planned as a result. TVN confirmed the wound was a category 2 pressure ulcer with a combination of moisture. The patient’s wife advised TVN, that the patient has an alternating airflow mattress and high-risk cushion at home and normally sits out. The patient’s wife advised TVN that she used Proshield Foam cleanser and proshield plus barrier cream at home with good effect. She expressed to TVN whilst in the home, the patient spent all his time in bed and proshield plus barrier cream had not been applied for several days. The recommendations provided by TVN was to continue with the proshield foam cleanser and pro-shield plus barrier cream. TVN asked the nurse at the care home to refer the patient to the Community Nursing Team for support at home and advised the patient’s wife that they will refer to the Tissue Viability Service again if they felt they required any further advice. Patient was then discharged from the Tissue Viability Service”.
19. Ms C says that, by the time the TVN checked her father’s sore on 14 February 2018, the wound had become a grade 3-4. After the visit, the family took Mr F out of the home. The care home told the Council the following day that the TVN confirmed that the pressure area had improved. However, there is no evidence that shows the TVN said this.
20. A District Nurse spoke to the Council on 2 March 2018. The record states the lesion was a grade 3 pressure sore now. The family had shown the nurse a photo of the area from the date he returned home and reported it had improved since then.
21. The care provider responded to Ms C’s complaint in June 2018. It said that:
• Assessments and plans of care were in place for Mr F’s pressure area care. The daily care records show the care to his pressure area has been documented. It also shows that appropriate steps were in place to care for his pressure area, including dressing changes, barrier creams and referrals to visiting professionals.
• Visiting professionals were involved with Mr F’s pressure sore care whilst he was at the home and made decisions about his treatment.
• Whilst there was a deterioration of the area, the home took appropriate action, including seeking (and acting on) advice from external specialists.
• The family did not raise any issues about Mr F’s mattress. However, it accepts the mattress was not fully inflated on two occasions. It appears this was because a tube was disconnected from the machine, for which the home would like to apologise.
22. The care provider has since said that, at the time of Mr F’s admission, it did not receive evidence that barrier cream had been prescribed to be used for Mr F.
23. The Council has since said that the care home’s pre-admission assessment should have discussed and highlighted, before Mr F’s admission, what medication and creams he needed. The home’s service user guide has been updated in the section on respite care.

Analysis

24. The only reason for Mr F’s stay at the home was to improve an affected skin area. He was also recorded as high risk for pressure sores developing. As such, I would have expected the care home to keep detailed records of the care it provided to Mr F’s affected area. Detailed records are also important to enable senior staff / managers at the home to monitor that staff are implementing the care as per the care plan and assessments. However, I found that:
• Although there were some records that described the affected area, overall there was a lack of detail in terms of describing how the affected area looked and changed (compared to the day before)
• There were some general references about pressure care “having been met”. However, there were many instances when there was no record at all as to what (if any) pressure care was provided.
• There is no actual evidence that shows at what times throughout the day or night Mr F was actually turned.
• The home’s risk assessment (pressure sores) says that staff should regularly apply creams to sacrum and dry areas. There is no evidence this was done during the first five days of his stay and/or that the nurse had decided this would not be necessary. Furthermore, there is insufficient evidence in the home’s records to conclude how often this was subsequently done throughout the day.
25. Ms C also mentioned the home kept Mr F in bed “all the time”, which increases the risk of deterioration, even though he would be taken regularly out of bed at home. She also said the family observed staff failing to turn Mr F during visits.
26. However, according to the records (including those from the NHS), the pressure sore was grade 2, not grade 3 or 4, when Mr F left the home.
27. As a result of the above, I am unable to conclude the care home managed Mr F’s affected area in line with its risk assessment and care plan. As such, I have found that the home failed to provide the pressure area support Mr F needed during his stay, which may have contributed to a deterioration of the affected area.
28. I have not seen evidence that shows that, considering the stage the affected area was at the time, that staff should have used sterile water.

Mr F’s dietary needs:

29. Ms C said that:
• When her father’s dementia deteriorated, he would constantly just chew his food without swallowing. The family therefore started to blend his food.
• Her father did not have capacity to make decisions about the texture of his food. As such, the family told the home at the pre-admission assessment that her father could only eat (swallow) fork-mashable food. The assessor told the family this would not be a problem.
• However, the home failed to do this. The family visited Mr F about two to three times a day, and especially at mealtimes. The family regularly raised a concern that Mr F did not receive this type of food, which the home ignored. This resulted in weight loss.
30. Ms C says the local NHS Trust completed an assessment at the home on 6 February 2018. The form completed said that: care home to take his weight and monitor. Ms C says the home received a copy of this form. However, the care home failed to do this. Her father lost nearly 6 kilograms in two weeks.
31. The nursing home’s Assessment Report said:
• Mr F has been assessed as not having capacity to make decisions relating to eating and drinking
• He has no difficulties eating - drinking - swallowing or chewing
• Mr F eats and drinks independently. He needs a fork mashable dysphagia diet (modified diet E).
• Mr F’s weight will be monitored weekly through the Weight (M.U.S.T) Chart. His food intake will be monitored through the Food chart.
32. The nursing home’s care plan “Eating and Drinking” said that:
• Mr F was unable to make choices about food and drink. He prefers to have a fork mashable diet, through choice rather than need. He needs his food cutting up.
• The home needs to initially weight Mr C weekly. If his weight has been maintained after four weeks, he can be weighed monthly.
33. I reviewed a print out of the care home’s electronic care records, which showed that Mr F did not receive fork-mashable food for lunch and dinner. However:
• He ate most of his breakfast most of the time.
• He ate half (or less) of his lunch on five occasions.
• He ate half (or less) of his dinner on six occasions.
• He had pureed food four times
34. Ms C told me the records are not true as he never ate his meals.
35. The care provider told Ms C in June 2018 that:
• The staff assessed that Mr F did not have any difficulty with swallowing or chewing. He did have difficulty in cutting up food, so staff recorded it would cut his food for him.
• A Texture Modified Diet is usually recommended by a professional (such as a Speech and Language Therapist), because providing one when there is no difficulty in swallowing can sometimes increase the risk of choking.
• The records show Mr F was able to eat a normal diet without difficulty and often ate everything (or at least a significant part of his meals). This did not cause any swallowing or choking issues. As such, it was safe to provide him with normal textured food.
• However, the staff team should have discussed this with the family before, or at the time of, Mr F’s admission, so his preferences as well as his safety could have been met. I apologise if this did not happen in your case.
36. Ms C told me that staff did not cut up her father’s meals.
37. The care provider also said that: There was no need to formally monitor Mr F’s weight, because he was a temporary respite client. As a result, it is not possible to verify if he lost weight during his short stay at the home. The provider considered the photos Ms C sent but could not conclude it showed significant weight loss.
38. The Council says:
• It has not been able to find any evidence in Mr F’s medical records that he should receive only pureed food or only mashable food, or that he had difficulty with swallowing.
• If a family says a resident needs a pureed diet, it would be normal process to follow this in cases of short periods of respite. If staff identify a problem, they should involve professionals (SALT etc).
• The home should have done more, on admission, to find out from the family why Mr F was on a pureed diet. This should have been discussed and dealt with at that time.
• Mr F’s weight should have been documented on admission. His weight should always have been reviewed one week later (as per plan) and documented.

Analysis

39. The care home has acknowledged it should have further discussed Mr F’s need for mashable food with the family, rather than making a decision not to provide mashable food to him. The care home has already apologised for this, which is a sufficient remedy.
40. However, the daily care records indicate that, although Mr F occasionally refused his food, he ate half or more of his meals, even when many meals were not mashable. The records did also not show there was a clear link between getting mashable food and eating more. It may therefore have been that, to some extent, he simply did not have a lot of appetite at times.
41. I agree with the Council’s view that “Mr F’s weight should have been documented on admission. His weight should always have been reviewed one week later (as per plan) and documented”.

The home’s alleged failure to empty Mr F’s catheter bag on time

42. Ms C says the home failed to empty her father’s catheter bag on two occasions, as a result of which they started to leak and burst. This resulted in her father’s clothes and bed becoming soaked with urine.
43. The care provider told Ms C in June 2018 that her photographs showed there was urine on the floor and bedding. It said the bedding should have been removed sooner and appropriate steps taken to deal with any spillage. The care home said it was sorry for the incident.

Analysis

44. Urine was spilled on two occasions due to an overfull catheter back, which is fault. The care home has already apologised for this, which is a sufficient remedy.

The way the care home dealt with Ms C’s complaint

45. Ms C says the care home failed to properly process / deal with the complaint she made. The family made a complaint on 20 March 2018 and was supposed to receive a response by 27 April 2018. Ms C says:
• The family did not receive a response and had to chase the care provider by telephone, and subsequently by email.
• The care provider suggested to meet on 18 May 2018. However, she didn't turn up.
• The care provider met Ms C on 25 May 2018 to discuss her complaint in more detail.
46. It took until 19 June 2018, before the care provider prepared a response. The provider says it sent this to Ms C and her solicitor. However, Ms C says they both did not receive it. I am unable to determine why this was the case. Ms C’s solicitor told the care provider on 14 August 2018 that Ms C had not received a response yet. This should have alerted the provider that she did not receive their letter.
47. The director of the care provider met with Ms C on 17 January 2019. After the meeting, the director sent a letter on 29 January 2019 and attached a copy of the June 2018 letter. The letter said that:
• The meeting on 25 May 2018 should have been carried out as a priority, which clearly did not happen in this case. I apologise for the delay in arranging this with you.
• The care provider’s response dated 19 June 2018 was sent to Ms C and her solicitor, but not received by either.

Analysis

48. It took two months before the care provider met with Ms C to discuss her complaint in more detail. This was an unreasonable delay.
49. Neither Ms C, nor her solicitor, received the complaint response letter dated 19 June 2018. As such I found that, on the balance of probabilities, this letter was produced but not sent out.
50. Even though Ms C’s solicitor told the care provider in August 2018 that Ms C had not received a response as yet to her complaint, there was a further unreasonable delay to respond to this.
51. As a result, it took a long time (10 months) before Ms C received a response to her complaint. The above delays are fault and resulted in distress and frustration to Ms C.

The Council’s safeguarding investigation

52. Ms C complains the Council failed to share the findings from its safeguarding investigation with the family, with regards to each of the concerns they had raised.
53. The Council wrote to Ms C on 26 November 2018. The letter referred to a meeting with Ms C on 21 November 2018, during which the Council had shared the findings from its safeguarding investigation with Ms C. The Council said that, at the meeting, the investigator described what she had done, who she had spoken to and the reasons for her conclusion. Some of the issues were difficult to investigate because several staff involved had since left the home. Ms C told the Council at the time that she was thankful for the visit.
54. A further meeting was held on 17 January 2019 between the Council’s Quality Management Team, the Care Home and Mr F’s relatives, because the family remained unhappy. At the meeting, all the issues were discussed. Since the events, a new management team had been put in place. There was also a clinical lead nurse now in all of the care provider’s care homes, so any problems can be looked at immediately.
55. The Council told Ms C on 28 June 2019 that:
• It is clear, from the care provider’s responses and the notes from the meeting (between the Council, the care provider and Mr F’s family), that some elements of the service were not up to the required standard. The provider has acknowledged and apologised for this. They also made a commitment to improving their practice and put measures in place to check this.
• The Council will continue to monitor the care home and ensure the improvements are sustained, so the home does not repeat the failings.
• The Council would like to offer a goodwill gesture of a £250 refund of the care home fees.
56. The Council says that:
• It is clear in the investigation report and running records that it investigated all the issues Ms C raised.
• The safeguarding investigator and manager provided feedback to the family with regards to all the issues raised. Further feedback was provided during the meeting in January 2019.
• The family did not raise any concerns with Mr F’s allocated social worker at the time Mr F was still in the home. There were several contacts with the family during this time but the family did not raise any issues other than that the wound had not healed as well as they would have liked. 

Analysis

57. I did not find fault with the Council, who ensured that Ms C and her family received a response with regards to each of the issues they had complained about.

Agreed action

58. When a council commissions a care home to provide services on its behalf, it remains responsible for those services and for the actions of the care home providing them. So, although I found fault with the actions of the care provider, I have made recommendations to the Council.
59. I recommended that, within four weeks of my decision, the Council should:
• Apologise to Ms C for the faults identified above and the distress these have caused Ms C.
• It should also pay Ms C £400 for the distress caused as a result of the deterioration in Mr F’s affected skin area, and the delays in receiving a response to her complaint.
• Assure itself, together with the care provider, that the care home has made the required changes to prevent a reoccurrence of the above failings.
60. The Council has told me it has accepted my recommendations.

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Final decision

61. For reasons explained above, I have upheld Ms C’s complaint. I am satisfied with the actions the Council will carry out to remedy this and have therefore decided to complete my investigation and close the case.
62. Under the terms of our Memorandum of Understanding with the Care Quality Commission (CQC), I have shared a copy of my final decision statement with the CQC.

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Investigator's decision on behalf of the Ombudsman