Bupa Care Homes (CFC Homes) Limited (19 011 992)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 16 Feb 2021

The Ombudsman's final decision:

Summary: Mrs Y complains about the care provided to her late mother, Mrs X, in a nursing home in the way she was moved and handled during an assessment. Mrs Y says this caused Mrs X and the family distress. The Ombudsman finds fault in the Care Provider’s actions which caused injustice. The Care Home has agreed to apologise to Mrs Y, make a payment to her to acknowledge the impact of its fault, share this statement with its complaints team for learning, and arrange up-to-date manual handling training for staff.

The complaint

  1. Mrs Y says her late mother, Mrs X, received poor care at Heathbrook House Nursing Home (the Home), operated by Bupa Care Homes Ltd (the Care Provider). She says the Care Provider attempted an unsafe ‘practice assessment’ injuring Mrs X’s leg, but no risk assessment was conducted before attempting the ‘practice assessment’. She says this directly resulted in Mrs X being admitted to hospital nine days later with broken bones in her lower leg.
  2. Mrs Y says this caused distress to Mrs X and the family. She says after Mrs X left hospital they had to move Mrs X to a different home.

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The Ombudsman’s role and powers

  1. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34H(3) and (4), as amended)
  2. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
  3. 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)
  4. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

  1. I have considered the complaint and information provided by Mrs Y and the Care Provider. I have discussed the complaint with Mrs Y. I have considered the relevant care records, and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations). Mrs Y and the Care Provider had an opportunity to comment on an earlier draft of this statement. I considered all comments received before I reached a final decision.

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What I found

Legal and administrative background

The fundamental standards

  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. The standards include:
    • Safe care and treatment (Regulation 12): The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people’s health and safety during any care.
    • Complaints investigation (Regulation 16): “Any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation”.

Moving and handling risk assessments

  1. The Care Quality Commission (CQC) provides guidance on its website for ‘Moving and handling in social care (Health and Safety Executive)’. This specific HSE guidance, HSG220 Health and Safety in Care Homes, says employers (in this case care homes) must reduce the risk of injury to staff and people using care services by:
    • assessing the risks from specific risks, such as moving and handling, that cannot be avoided;
    • putting measures in place to reduce the risk, where reasonably practicable;
    • doing a person-centred risk assessment, and, where possible, involving the service user or their family in decisions about how their needs are met. This can reassure them about the safety and comfort of the equipment, and how it and the methods used will ensure their safety and the safety of staff;
    • showing awareness that an individual’s needs and abilities can change over the course of a day. Staff should understand the impact this may have on moving and handling practices; and,
    • being aware that individuals may become upset or agitated when being moved. Others, though willing to assist at the start of a manoeuvre, may find themselves unable to continue.
  1. This guidance says equipment - such as slide sheets - “should only be introduced following an assessment and should be used in conjunction with the care plan and the manufacturer’s instructions”.

Slide Sheets

  1. Slide Sheets are used to move and reposition people up and down a bed as well as between two surfaces (bed to bed, bed to trolley). The 2018 NHS Clinical Review on the use of Slide Sheets says:

“Prior to the use of a Slide Sheet a thorough risk assessment in line with local policy should be undertaken to identify and mitigate against potential risks.”

  1. Manual Handling Nursing Practice guidance from the Nursing Times (13 January 2009) says “slide sheets are often made of slippery material and can be hazardous”. It details the “preparations that should be carried out before undertaking any manual handling” including:

“Perform a risk assessment. Assess the patient for sliding up the bed; check their mobility care plan and consult colleagues…”

Mental capacity and making decisions

  1. A person must be presumed to have capacity to make a decision unless it is established that they lack capacity. A person should not be treated as unable to make a decision:
  • because they make an unwise decision;
  • based simply on their age, their appearance, assumptions about their condition, or any aspect of their behaviour; or,
  • before all practicable steps to help the person to do so have been taken without success.

Key events

  1. Mrs X had various medical conditions one of which (lymphoedema) required extra care and attention to her legs.
  2. The Home’s pre-admission assessment recorded that Mrs X had limited mobility, used a walking frame sometimes, and needed specialist equipment (bed, chair, and commode). It says she needed the help of two care workers with washing and dressing, and a care worker was needed to help her move her legs in bed. It also recorded that she was at “risk of falls”.
  3. The records show no concerns about Mrs X’s mental capacity. There is a note stating Mrs X has “excellent communication skills both verbal and written”.
  4. A note in the records said Mrs X preferred not to be taken to hospital “unless it is something very serious” as “she wants to stay in the home to be treated in the home”.
  5. Mrs X received specialist clinical care from a community team of nurses and doctors visiting often to check her legs. From the records it seems Home staff had been trained in compression bandaging of Mrs X’s legs by a specialist nurse.
  6. In early September, the daily care notes record staff finding that, it was “hurting” Mrs X in her stomach when staff helped her in to bed.
  7. The care plan records that, with Mrs Y and Mrs X’s consent, staff wanted to assess a different way of moving Mrs X’s legs in and out of bed using a “slide sheet”, as apparently some staff had trouble with moving Mrs X into her bed due to the condition of her legs. The records go on to note a discussion with Mrs X and Mrs Y about “alternate” ways of moving Mrs X on to the bed and while in bed using slide sheets. Staff found both Mrs X and Mrs Y were “reluctant” to try different ways of moving Mrs X as they said they had tried unsuccessfully at home before. Staff telephoned a specialist moving and handling team for further advice who recommended the use of slide sheets.
  8. According to the notes, three members of staff then went to Mrs X’s room to try “alternate methods of moving” via a “practice assessment”. The record says Mrs X was “very reluctant to try anything. Slide sheet used to lift legs but legs slipped and (Mrs X’s) foot slipped on floor’”. The assessment stopped and Mrs X was helped back into her chair.
  9. A senior member of the Home staff recorded in Mrs X’s notes that she visited Mrs X later that day to check up on her. She informed Mrs X about a referral to occupational therapy plus the clinical team that looked after Mrs X’s legs. She wrote that Mrs X told her that her legs kept “giving way”. Mrs X also said her knees were “dislocating”. The member of staff told Mrs X that the Home had to keep her safe and also their staff safe. So the Home would need to consider the safe moving and handling of Mrs X further. She noted that Mrs X reported a pain in her heel. Mrs X was provided with her usual pain medication on the day. No other concerns are recorded as raised on the day either by Mrs X or Mrs Y.
  10. A little later on the same day Mrs X was checked by a different care worker who wrote: “Been to see (Mrs X) to see if she needed any assistance with anything but she has declined at this time. She is bright in mood and enjoying a cup of tea with her daughter and son-in-law. No concerns to report.”
  11. The next day the records show the Home made a referral to the community occupational therapy team for assistance and equipment when getting Mrs X’s legs in and out of bed. The referral said Mrs X was “becoming difficult to manage from a moving and handling perspective … (Mrs X) is not open to new ideas, and suggestions re sliding sheets, she will not compromise on, convinced she is going to fall. Any help and advice would be most appropriate as it is becoming difficult to lift her legs into bed.”
  12. A few days later Mrs Y changed her mother’s support stockings and reported a skin wound in Mrs X’s right foot had healed. There is no record of any other concerns being raised.
  13. The next day, Mrs X is recorded as complaining of knee pain and asking to see a GP. A nurse in the Home told Mrs X that an ‘out-of-hours GP’ could be called, or paramedics, to take her to hospital. Mrs X is noted as replying “it was not a lot of pain” and she would wait to see the GP tomorrow. The notes say Mrs Y was present and witnessed this.
  14. While a GP visited the following day to see Mrs X, the GP did not take any action. Mrs X is noted to say her leg was “less painful”.
  15. A different GP visited a few days later to check Mrs X’s legs for a different issue. Mrs X did not raise any concerns.
  16. About a week later, the Home completed a ‘moving and handling risk assessment’. It noted Mrs X was unable to bear weight and would remain in bed.
  17. Another GP visited after Mrs X said she was “unwell” around this time. The GP wanted to look at Mrs X’s legs under the stockings. The notes say Mrs X refused to remove her stockings and said she was “feeling better”.
  18. A few days later, in the afternoon, Mrs Y raised her concerns about Mrs X’s health to Home staff. A nurse took Mrs X’s observations resulting in the nurse calling 999. Mrs X was admitted to hospital.
  19. Just over a week later Mrs Y complained to Home. In short, she said her mother received poor care resulting in a hospital admission. She said Mrs X had broken bones in her lower leg and was suffering from ‘neglect’.
  20. Mrs Y said they had both objected to the Home’s intention to use a slide sheet to move Mrs X onto the bed and then use two carers to lift her legs together. Mrs Y said she informed staff that, due to the condition of Mrs X’s legs, Mrs X would not be able to sit as far back on the bed as the manoeuvre required, and there was a risk of her falling.
  21. Mrs Y complained that staff in the Home appeared to be more interested in staff welfare. She described how staff rolled a slide sheet under Mrs X’s ankles and then two members of staff lifted her legs up. But the slide sheet slipped from under Mrs X's ankles and “her feet crashed to the floor”.
  22. When the Home replied to Mrs Y’s complaint it said it had:
    • followed guidance from its senior staff as well as its specialist moving and handling equipment providers;
    • sought Mrs X’s consent as well as her family members’, and had arranged to carry out the manoeuvre while all the family were present in Mrs X’s room;
    • arranged for a nurse to be present in the room;
    • confirmed that during the attempt Mrs X’s left leg slipped down from the slide sheet “approx. 6 inches to the floor”;
    • moved Mrs X to her chair and she reported pain in her heel;
    • arranged for Mrs X to be visited by staff at 3pm, 4.20pm and 11pm;
    • administered Mrs X’s usual pain medication after she raised no further concerns; and,
    • noted that no concerns were raised by family members who had been present in the daytime.
  23. When the Home replied to the Ombudsman’s enquiries it said “the (practical) assessment was within the deputy manager and registered nurse’s scope of practice and were competent to complete a practice assessment”.

Did the Care Provider’s actions cause injustice?

  1. The evidence shows Heathbrook House (‘the Home’) failed to carry out an essential risk assessment prior to attempting the manual handling ‘practice assessment’. Irrespective of whether this was allowed under clinical practice - as stated by the Home - this may be a breach of the fundamental standards, as the Home cannot adequately document that it took action to mitigate risk to Mrs X. This is evidence of fault.
  2. However, I cannot speculate that a risk assessment would have prevented Mrs X’s leg slipping to the floor. Nor is there evidence showing a direct causal link between this incident and Mrs X’s later hospital admission. This is because Mrs X’s comments to staff and GPs after her leg slipped do not show she was consistently complaining of pain or requesting medical assistance as would usually be expected if she had sustained an injury. The records also show Mrs X turned down a nurse offering to call out paramedics, and later refusing a GP request to inspect her legs. Mrs X was perfectly entitled to make these decisions and staff had to respect them as there were no concerns about her mental capacity.
  3. Otherwise the Home seems to have responded as well as it could have done, by taking advice from specialist moving and handling professionals, having the Home manager attending together with family, and the Home nurse also being present in Mrs X’s room during the ‘practice assessment’. The notes also show the actions taken after the incident such as the Home arranging regular visits from clinical professionals and providing pain relief, equipment and an occupational therapy referral.
  4. With respect to the Home’s response to the complaint, I consider the failure to carry out a risk assessment should have been picked up in the Home’s complaints investigation. So, there is an injustice to Mrs Y as she has been put to avoidable time and trouble in pursuing her complaint to the Ombudsman. We cannot adequately assess the impact to Mrs X as she has since passed away.

Agreed action

  1. Within four weeks of this decision, the Home will apologise to Mrs Y and make a payment to her of £250 to reflect the injustice referred to in paragraph 40. This is in line with the Ombudsman’s published guidance on remedies.
  2. Within four weeks of this decision, the Home will remind its staff of the importance of carrying out risk assessments.
  3. Within four weeks of this decision, the Home will share a copy of this decision with its complaints team to reflect on any learning from this investigation.
  4. Within three months of this decision, the Home will arrange to provide training to its staff on up-to-date manual handling, including the use of slide sheets.
  5. The Ombudsman will need to see evidence that these actions have been completed.

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Final decision

  1. I have completed my investigation and found fault causing injustice. The Care Provider has agreed to take action to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman

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