Summary: The complaint is about the care Mr G’s mother received while in a care home. The Ombudsman has considered a council’s records of its safeguarding investigation. Our view is an investigation by us would be unlikely to add anything. So our view is we should discontinue our investigation.

The complaint

1. The complainant, whom I shall refer to as Mr G, complains about the care his late mother (Mrs H) received at the care provider’s Care Hub.

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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 provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• the action has not caused injustice to the person who complained, or
• the injustice is not significant enough to justify our involvement, or
• it is unlikely we could add to any previous investigation by the care provider, or other body, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants, or
• there is another body better placed to consider this complaint.

(Local Government Act 1974, sections 34B(8) and (9))

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How I considered this complaint

4. I have considered Mr G’s complaint and the documents he sent us. I have also considered the records of the local council, which carried out a safeguarding investigation about Mrs H’s stay at the Care Hub.
5. I have sent my draft decision to Mr G and the care provider and considered the responses I received.

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What I found

Legal and administrative background

6. 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

7. Mrs H had had dementia for several years. The Care Hub specialises as a dementia care provider. Mr G says Mrs H had spent time earlier in 2019 at the Care Hub, on a respite stay.
8. When Mrs H was at home, district nurses visited Mrs H once a week to monitor her skin. This was because someone of Mrs H’s age, with incontinence, was at increased risk of pressure sores. Mr G notes that this care meant Mrs H had not had any pressure sore problems for several years.
9. A district nurse told the council’s safeguarding investigation that she has found a mark on Mrs H’s right buttock before she went to the Care Hub. But her skin was intact.
10. On 8 August 2019 Mrs H began a planned 16-day respite stay at the Care Hub. It says, on Mrs H’s admission, it completed an assessment and a body map. Among other things, this noted some redness on Mrs H’s sacrum and two moisture lesions.
11. Mr G says he visited on 9 August. He was surprised to find Mrs H in her bed, with the blinds drawn at 3:30 pm.
12. Mr G and his family were away between 11 and 18 August.
13. On 15 and 16 August, district nurses who visited Mrs H at the Care Hub, noted multiple breaks to Mrs H’s skin and moisture lesions on her buttock. A nurse gave pressure ulcer prevention advice and prescribed a change in the creams that were used to treat Mrs H’s skin. The nurses planned to review the situation on a weekly basis (although Mrs H went home before they could visit again).
14. The Care Hub reviewed Mrs H’s care plan. It began two hourly pressure relief, on the advice of the district nurse.
15. Mr G’s wife and their son visited Mrs H on 20 August. Mr G says they found Mrs H dehydrated and in her nightie at 19:00. He says:

“My wife…asked staff to help my mother sit up in bed so that she could give a drink. The staff members then requested my wife leave the room, whilst they moved her. My mother cried out as she was being moved and my wife opened the bedroom door to see if everything was in order, She then saw one member of staff with her hands under my mother's legs and the second member of staff manoeuvring my mother under her arms. One member of staff then said she needed a slip sheet and went off for one. The search took around 10 minutes. Once obtained not only did the staff ask my wife to leave the room, but they also locked the door. I need to add that my mother's bed was placed against a wall and it would have needed to have be moved to move mother successfully. my wife was so aghast at what she saw that she telephoned me to say we needed to discharge mother.”

16. In its response to Mr G’s complaint, the care provider gave a different account of what happened:

“…our care staff are instructed to move and handle [Mrs H] with two trained carers present at all times which is why another member of staff was called in to assist. Both members of staff deny lifting [Mrs H] by her arms and legs and insist that a slide sheet was used immediately and appropriately. They also deny not knowing where the sheet was kept. They say that it was explained to you that the slide sheet was single use only for [Mrs H]. The staff also say that you left the room voluntarily because your son was running up and down the corridor and you went out to look at him. The door was then locked because we pride ourselves on putting the dignity of the resident first at all time and routinely lock the doors when personal care is in progress.”

17. The council spoke to both Mr G’s wife and staff as part of its investigation of what happened. It has a detailed record of what each of them said happened.
18. Mr G discharged Mrs H on 21 August. He says she had lost a significant amount of weight, was severely dehydrated and distressed.
19. District nurses visited Mrs H on 22 August. They found she had grade two pressure sores to her coccyx/sacrum and moisture lesions on both buttocks.
20. Mr G complained to the care provider. Its 23 August response noted:
• It had been monitoring Mrs H’s fluid and food intake. It also monitored her passing of urine.
• District nurses visited twice at its request.
• It had evidence in its logs that Mrs H participated in activities. It also had mood logs showing her at times happy and smiling. So it contested Mr G’s complaint she had no stimulation.
21. Mr G advises that on 26 August Mrs H was admitted to hospital and was severely dehydrated and very unwell. She passed away on 29 September.
22. On 16 September the local council started a safeguarding investigation about what happened during Mrs H’s stay at the Care Hub.
23. I can see from its records that, as part of its investigation, it spoke to several staff at the Care Hub, Mr G and his wife, Mrs H’s carers, district nurses and Mrs H’s usual GP. It also reviewed the Care Hub’s records and those of the district nurses.
24. Key findings from its investigation are:
• Fluid charts had daily records and the staff prompted Mrs H to take fluids every hour – two at most.
• Mrs H had incontinence of urine. She had regular bowel movements, one to four times a day.
• Mrs H’s diet was adequate.
• Records showed the Care Hub was monitoring personal hygiene and skin integrity regularly.
• The district nurses had no concerns about nutrition, hydration, urine or bowel movements.
• Mrs H’s red and blanching skin indicated she was hydrated (it would stay white if she was at a high risk of dehydration).
• Medical sources confirmed, due to Mrs H’s age and incontinence, she was prone to pressure sores.
• The Care Hub’s records have a risk assessment for moving and handling. This noted Mrs H found moving painful.
• It recorded that it used two trained staff to move Mrs H. The council’s officer had seen the carers’ moving and handling training certificates.
• The Care Hub said it was not told Mrs H used a pressure sore mattress at Hub. If it had known, it would not have accepted her for respite, as it would have needed to order a mattress. Mr G and Mrs H’s carer advised they had told the Care Hub about the mattress.
• The Care Hub’s view was that when Mrs H went home, she had the same moisture lesions as when admitted, but redder.
• A district nurse advised moisture lesions could develop into pressure sores overnight or within a day. But one nurse was surprised they developed so quickly in Mrs H’s case.
• Records indicated Mrs H watched tv on occasions, joined in activities, armchair exercises, coffee mornings, cinema/movie afternoons, engaging with other residents and attended summer camp. Staff reported it sometimes pulled the blinds down, when the sun was shining in Mrs H's eyes during bed rest periods.
25. The safeguarding report’s conclusion was that it had not found evidence to substantiate a claim of neglect or abuse. The Care Hub’s records indicated it provided “…appropriate, adequate and relevant care”.
26. The report says it had received advice that Mrs H was deteriorating before she was admitted to the Care Hub. And it had found no conclusive evidence the deterioration was the result of any neglect.
27. The report identified poor practice when one staff member had allowed Mr G’s wife to assist her with moving and handling. The Care Hub had addressed this issue. It also notes the accounts of what happened on 20 August differed.

Analysis

28. The council’s safeguarding team has carried out a detailed investigation. It has not found any evidence of poor care that caused Mrs H’s deterioration.
29. The council notes, as I do, that the accounts of what happened on 20 August differ and contradict each other. Mr G says the Care Hub and carers’ accounts of what happened are not an accurate record. But my view is there is insufficient evidence for me to uphold Mr G’s complaint about this. I cannot resolve the conflicting accounts of what happened. And further investigation would not likely change that, given the evidence I have already seen.
30. I know Mr G wants us to investigate, because of his strong belief the Care Hub provided poor care while Mrs H was there. But my view is its is unlikely that any investigation by the Ombudsman – that would look at the same documents the council has already considered – would lead to us making a different finding to the council safeguarding investigation’s conclusions.
31. So my view is that I should discontinue my investigation, as I do not believe our further investigation would add anything.

Final decision

32. I have discontinued my investigation. Further investigation by the Ombudsman would be unlikely to add anything to an investigation a council has already carried out.

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Investigator's decision on behalf of the Ombudsman