Summary: Mr and Mrs A complain about their late relative Mr B’s care in a nursing home. There was poor record keeping by the Care Provider and so we uphold this part of the complaint. The Care Provider has already remedied any injustice. We are satisfied wound care was appropriate and in line with Regulation 17 of the 2014 Regulations and so do not uphold this part of Mr and Mrs A’s complaint.

The complaint

1. Mr and Mrs A complain about their relative the late Mr B’s nursing care at Ashley Lodge Care Home (the Nursing Home) owned and managed by BUPA Care Homes (CFC Homes Ltd) (the Care Provider). They say the Nursing Home provided inadequate pressure sore care and did not keep adequate records.
2. Mr and Mrs A want the Ombudsman to identify and poor practice and if so, to make recommendations to ensure it is not repeated.

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The Ombudsman’s role and powers

3. 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. (Local Government Act 1974, sections 34B and 34C)
4. 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)
5. If we are satisfied with a care provider’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 complaint to the Ombudsman, the Care Provider’s responses to the complaint and documents described in this statement. I discussed the complaint with Mr A. The parties received a draft of this statement and I took into account their comments.

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What I found

What should have happened?

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
8. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
9. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

What happened

10. Mr B was a self-funder (he paid for his care privately). He lived in the Nursing Home from December 2017 until he went into hospital in the middle of June 2019 and died shortly after. Mr B had heart failure, diabetes, short term memory loss and a skin condition causing blisters.
11. Mr B’s health was deteriorating in May/June 2019. He was less mobile and needed more support with moving around. Mr A told me he and Mrs A went to a meeting at the Nursing Home with the GP and the GP instructed staff to turn him regularly. There is a record of this meeting in the Nursing Home’s notes on Mr B.
12. The Nursing Home completed a review of Mr B’s assessment and rewrote his care plans. The review said his mobility had deteriorated and was variable. It noted there was a wound on his spine and heel. He required Band 4 nursing care. The Care Provider describes Band 4 as:
• High or more complex needs
• Requires up to 3 hours of care a day and one hour of nursing care
• Unstable and unpredictable
• Requires additional equipment such as wound dressing.
13. Mr B’s mobility care plan said he had lipoma (a soft fatty, harmless lump) on his back and he preferred to sleep on his back. His heels were noted to be vulnerable to pressure. He slept on a pressure mattress which was checked weekly. Staff used slide sheets to move him in bed.
14. Staff completed a monthly skin integrity risk assessment (called a Waterlow assessment). He was at high or very high risk of skin break down in the last three months of his life.
15. Nursing staff kept skin care plans for Mr B. These noted:
• He used a pressure mattress
• He needed help to reposition in bed every four hours
• He used a special cream on his skin
• He had wounds (a diabetic skin tear and a lipoma on his spine)
• The aim was to promote healing and reduce further skin break down.
• He had a history of skin blisters which staff should monitor
• Staff should check his hands and feet.
• Staff were to check pressure areas, apply cream, document any changes and liaise with doctors and the family to report changes.
16. Staff photographed wounds to Mr B’s heel and spine in May and June 2019. Staff completed wound care charts documenting and describing the progress of the wounds and when they changed the dressing. It appears from the photographs that the blister to the spine had burst. The records indicate the wounds got no worse.
17. The Nursing Home documented when staff reviewed Mr B’s skin care plan:
• In April 2019: the lipoma on Mr B’s spine was at risk of skin damage due to friction and pressure. Mr B was not compliant with repositioning. He slept on a pressure mattress
• 11 May 2019: the pressure area was intact. He was at very high risk of skin break down to the back.
18. The Care Provider kept charts to record each time staff helped Mr B to change position in bed (from May 2019). This was done at least every four hours. There are a few gaps in the charts.
19. The podiatrist visited Mr B on 3 June. The nurse on duty noted the podiatrist said the wound on the heel was linked to Mr B’s diabetes and was not a pressure sore. The podiatrist also wrote in Mr B’s notes that the heel was dry and intact and it had been a skin tear due to dry feet and was not pressure related. No dressing was needed.
20. Mr B’s condition declined and he went into hospital in the middle of June.
21. Nursing staff from the Nursing Home noted a social worker from the hospital telephoned to ask about Mr B’s heel and spine. The nurse told the social worker the sore to the heel was a diabetic skin split that bled and clotted. The nurse also explained the wound to the spine was a long-term lipoma and Mr B had been nursed on a pressure mattress for that after it started showing signs of bruising after Mr B lost weight.
22. Mr and Mrs A complained to the Care Provider about the issues raised with us and about other issues. They said hospital staff told them Mr B had grade four pressure sores on admission. The Care Provider’s responses said:
• There were some gaps in the turning charts and at times staff failed to record when they moved Mr B back to bed from his chair. One day was because Mr B was in hospital and so he was not repositioned by staff). This meant its records were not up to standard. It was sorry for this.
• The wounds were not pressure wounds: one was a diabetic skin split that had clotted and the other was a known lipoma and was longstanding. Staff took photographs and completed wound care plans. It was redressed on 14 June and there was no change from the photo on 9 June. Mr B was on a pressure mattress
• Staff at the Nursing Home spoke to the social worker and explained the nature of the wounds. The Nursing Home received no further contact from the authorities about any safeguarding issues.
23. The Care Provider’s final response to the complaint accepted Mr B’s care did not meet expected standards and offered a reduction of £3500 on the outstanding fees as a goodwill gesture.
24. Unhappy with the final response to the complaint, Mr and Mrs A complained to us

Findings

25. I am satisfied the Care Provider’s wound care was appropriate and in line with Regulation 9 of the 2014 Regulations. In particular:
• It drew up skin care plans for Mr B noted the risks of skin breakdown and included steps to minimise the risks (a pressure mattress, cream)
• It reviewed and updated the care plans as Mr B’s health declined
• Wounds were identified, photographed, treated and reviewed.
26. I note the hospital’s comments about grading the wounds and the suggestion they may be pressure sores. It is possible that the wounds deteriorated rapidly as Mr B was nursed in bed the last weeks of his life. But this does not necessarily indicate any failings in Mr B’s care.
27. The Care Provider noted and acknowledged in its complaint response that there were gaps in the turning charts. It apologised and waived part of the fee. The failings in record keeping meant Mr B’s care was not in line with Regulation 17 of the 2015 Regulations. The Care Provider has already taken appropriate action to remedy the injustice. No further recommendations are needed.

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Final decision

28. Mr and Mrs A complain about their late relative Mr B’s care in a nursing home. There was poor record keeping by the Care Provider and so I uphold this part of the complaint. The Care Provider has already remedied any injustice. I am satisfied wound care was appropriate and in line with Regulation 17 of the 2014 Regulations and so do not uphold this part of Mr and Mrs A’s complaint.
29. I have completed my investigation and shared a copy of this statement with the CCQ in line with our information sharing agreement.

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Investigator's decision on behalf of the Ombudsman