Summary: Mrs X complains Chaseview Nursing Home failed to look after her father properly when the Council placed him there for two weeks of respite care. There was confusion over when her father would arrive and Chaseview failed to produce a person centred care plan for him. This resulted in it failing to meet all his needs. The Council has agreed to apologise and pay financial redress.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains Chaseview Nursing Home (“Chaseview”) failed to look after her father properly when the Council placed him there for two weeks of respite care.

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The Ombudsman’s role and powers

2. 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)
3. 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, sections 30(1B) and 34H(i), 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)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries; and
• invited comments on a draft of this statement with Mrs X, the Council and HC One Limited (via the Council), for me to consider before making my final decision.

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What I found

What happened

6. Mrs X’s father, Mr Y, has early stage vascular dementia, impaired mobility and other age-related health problems. He has a catheter, which a District Nurse changes each week. He lives at home with his wife who is his full-time carer. They pay a care agency to help shower Mr Y three times a week.
7. In August 2019 a Community Mental Health Nurse recommended a respite placement in a “residential dementia setting where staff would have the clinical knowledge to maintain his catheter whilst he is there”. This was so Mrs Y could have a break from caring for her husband. The Council assessed Mr Y’s needs and produced a care and support plan. It agreed to arrange a two-week respite stay in a care home. It also agreed to consider further respite breaks to help Mrs Y continue with her caring role.
8. The assessment says Mr Y:
• needs help cleaning himself after going to the toilet;
• needs prompting to reposition and mobilise, otherwise he would remain in the same position all day;
• is at risk of skin breakdown;
• had a sore on his back and weeping legs. District Nurses visited twice a week (more often if needed) to check skin integrity and redress wounds when required;
• likes to sleep in his reclining chair;
• has swollen feet, so cannot wear shoes.
9. The Council identified Chaseview as a placement which could meet Mr Y’s needs for a two-week respite stay. It sent Chaseview a copy of its assessment. It has no records of the contact with Chaseview about the placement. But Chaseview has provided copies of its e-mails with the Council.
10. Chaseview visited Mr Y at his home in the afternoon of 2 September and filled in a pre-admission assessment with him and his wife. This says:
• the possible date of admission was 4-18 September;
• bottom sore at times and very swollen lower legs and feet;
• does not mobilise much without prompting;
• mobilises with a frame and one person;
• sleeps in a chair, more comfortable.
11. On 3 September Chaseview told the Council it could accept Mr Y on 4 September. The Council said it had not been able to contact Mrs Y about the respite but would let Chaseview know when it had. Chaseview asked the Council to let it know about the proposed admission date as soon as it was known. On 4 September Chaseview told the Council it could accept Mr Y on 5 September.
12. Mrs Y took her husband to Chaseview on 4 September. Chaseview was not expecting him to arrive until 5 September, so nothing was ready for his arrival.
13. Chaseview completed a seven-day care plan for Mr Y. Although dated 4 September, it appears to have completed it between 00.15 and 00.24 on 5 September. It says Mr Y:
• will not stay in his bed all night but will sleep in his chair;
• has very swollen feet and can change his own position;
• apart from his swollen feet his skin seems intact.
14. Chaseview started completing a safer people handling risk assessment and care plan but most of the document is blank, including the section on tissue viability.
15. Chaseview kept records of the care provided for Mr Y. There are too many to list here, so I refer to the key contents.
16. The hygiene records say:
• Mr Y had a shower and catheter bag change on 7, 10, 13 and 16 September, and staff helped him wash on the other days;
• staff checked skin integrity on 7 September and then each day from 10 September;
• Mr Y received help changing his clothes each day.
17. The daily records say Mr Y got into bed for a bit on the first night but decided to sleep in his chair because his back was hurting. Although not always mentioned in the records, Mr Y continued to sleep in the chair each night using a foot rest. The records say he slept well.
18. Other records say:
• Mr Y had swollen legs and a red sacrum when he arrived;
• he had a blister on his leg on 12 September;
• a District Nurse said there was no need to visit if the blister was not broken;
• the blister broke on 13 September;
• a District Nurse visited to dress the blister;
• Mr Y also had small break on his sacrum;
• on 14 September the blister was oozing, causing the dressing to come off;
• Chaseview asked a District Nurse to visit but when one did not arrive asked a Nurse from upstairs to have a look, who was concerned the wound may be infected;
• Mr Y’s legs were dressed and a District Nurse would return on 16 September.
19. The fluid charts show Mr Y drank on average (excluding the day he arrived and the day he left) over two litres a day. The food charts show he ate all his food.
20. On 30 September the Council registered a safeguarding concern from Mrs X about the care her father received at Chaseview. She said it had not looked after him properly, resulting in him developing pressure sores, and his legs becoming swollen and blistered, affecting his mobility. He spent two weeks sitting in low chairs which did not recline to raise his swollen legs. She said Chaseview had not been expecting him when he arrived and thought he was leaving two days earlier than agreed.
21. Mrs X also complained to HC One Limited, which owns Chaseview, about the care provided for her father and:
• not accepting a verbal complaint from her mother;
• telling her parents they were a day early when they arrived and leaving them for an hour in Mr Y’s unprepared room;
• not asking Mrs Y to explain her husband’s needs;
• although swollen his feet and legs were in good condition when he arrived but were swollen and bandaged due to burst blisters when he left, and he had painful sores on his bottom;
• when he left he also had dried excrement on his bottom and down his legs, and the dressing covering his sores was semi-detached, bloody and soiled, and the sores were weeping and painful;
• her father said staff wiped his bottom but did not wash him and gave him soap and a sponge to clean his front;
• Mrs Y packed enough clothing for a daily change but he had only worn half of them;
• his breathing and bloating were due to a lack of liquid intake as he only had drinks at meal-times or when a trolley came round and there was no water in his room;
• Mr Y wanted to sleep in the chair but the bed was not made so he could not have used it even if he wanted to;
• no one told her mother he was sleeping in a chair or that his legs had swelled up but she was told his catheter had been changed the day before because the tap had broken, but it should have been changed every week.
22. When Chaseview responded to Mrs X’s complaint on 16 October it said:
• it apologised for not expecting Mr Y when he arrived on 4 September but said this was because the Council’s Brokerage Team had said he would arrive at 11.20 on 5 September;
• when Mr Y arrived staff had been busy as it was lunchtime and it apologised if they had appeared brusque;
• it had contacted the District Nurses on 12 September when Mr Y developed a blister on his leg;
• the District Nurses said Mr Y did not always follow advice to keep his feet and legs elevated while sitting in his chair;
• a District Nurse visited on 13 September and applied a dressing to the blister on Mr Y’s leg and to a sore on his sacrum;
• a District Nurse visited again on 14 September, as the dressing was oozing, and redressed the wound;
• it had told the family about the District Nurse’s visit but not about the dressings, for which it apologised;
• it understood Mr Y slept in a chair at home and he chose to do that at Chaseview (which provided a footrest), despite being encouraged to sleep in bed;
• staff helped Mr Y dress and undress each day;
• most of his clothes were unworn as it had been washing the clothes he wore and apologised for not explain this to Mrs Y;
• it had helped Mr Y shower on 7, 10, 13 and 16 September and to wash on other days;
• it had recorded changing Mr Y’s catheter on 17 September but had not recorded doing this on 10 September, although a senior carer confirmed this had happened;
• it apologised Mrs Y had to wait when she went to pick her husband up;
• it apologised for not taking a verbal complaint from Mrs Y;
• the concerns raised had helped Chaseview improve its practices.
23. On 23 October, the Council decided not to make enquiries into the safeguarding concern as Mr Y was no longer at risk (having left Chaseview). It decided the care provider should continue with its internal investigations into the complaint. It passed the safeguarding concerns to its Quality Assurance Team and the Care Quality Commission, to consider inspecting Chaseview.
24. In December, the Council’s Quality Assurance Team asked Chaseview to respond to the issues. Chaseview sent the Council a copy of its letter to Mrs X (see paragraph 21 above).

Is there evidence of fault by the Council which caused injustice?

25. There was some confusion over when Mr Y would arrive at Chaseview. It appears this was because the Council could not get hold of Mrs Y to confirm the dates with her. However, Mrs Y had discussed dates with Chaseview, which recorded them in the pre-admission assessment. There was therefore no need for any confusion. That was fault for which the Council is accountable.
26. Chaseview was not expecting Mr Y when he arrived. It seems likely this contributed to Chaseview failing to complete a care plan with Mr Y while Mrs Y was there. Had it done this when Mr Y arrived it would have better understood his care needs. This resulted in Chaseview failing to meet all his needs. In particular, there is no evidence it encouraged Mr Y to move regularly to promote skin integrity. This is likely to have contributed to the decline in Mr Y’s skin integrity. That is fault causing injustice for which the Council is accountable.
27. There is no dispute over the fact Mr Y’s condition declined while he was at Chaseview. It was his choice to sleep in the chair. This reflected his practice at home, albeit that he has a reclining chair there. However, Chaseview was not at fault as it could not make Mr Y sleep in a bed if he did not want to. The decision to sleep in the chair is also likely to have contributed to the decline in Mr Y’s skin integrity.

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Agreed action

28. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions Chaseview, I have made recommendations to the Council.
29. I recommended the Council:
• within four weeks, writes to Mr & Mrs Y apologising for the problems they experienced and pays them £300;
• within eight weeks identifies the action it needs to take to ensure Chaseview produces a person-centred care plan for each resident, involving their carer where relevant.

The Council has agreed to do this.

30. Under the terms of our Memorandum of Understanding and information sharing protocol, I am sending the Care Quality Commission a copy of this statement.

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Final decision

31. I have completed my investigation as the Council has agreed to take the action I recommended.

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Investigator's decision on behalf of the Ombudsman