Derbyshire County Council (19 013 433)

Category : Adult care services > Residential care

Decision : Not upheld

Decision date : 18 Nov 2020

The Ombudsman's final decision:

Summary: Mrs Y complains on behalf of Mr X about the standard of care provided. Mrs Y has raised concerns about five separate matters and there is no evidence to suggest fault causing an injustice in relation to these issues.

The complaint

  1. Mrs Y, on behalf of Mr X, complains about the care provided to Mr X at 24-hour care accommodation where they both live. In particular she says:
  1. Poor care in March 2018 resulted in Mr X being taken to hospital with large pressure sores;
  1. Poor care in late 2018 meant Mr X was left to lie in diarrhoea for hours and the carer said this was acceptable;
  1. A call from Mr X at night for an ear spray was ignored:
  1. On repeated occasions the catheter valve was not opened and put Mr X at risk of urinary tract infections; and
  1. An incident on 4 October 2019 resulted in Mr X injuring himself after being trapped in a door and the carer was aggressive and shouted at him.
  1. Mrs Y says Mr X suffered pain and indignity as well as being at risk of harm.

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The Ombudsman’s role and powers

  1. 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)
  2. 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

  1. As part of the investigation, I have:
    • considered the complaint and the documents provided by the complainant’s representative;
    • made enquiries of the Council and considered the comments and documents the Council provided;
    • discussed the issues with the complainant’s representative;
    • sent my draft decision to both the Council and the complainant’s representative and invited their comments.

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What I found

  1. Mr X has multiple sclerosis (MS) and requires help with his personal care. He lives in a flat within an extra care scheme. This is an independent living facility which is staffed 24 hours a day. Residents are provided with a package of care in the same way as they would if they lived in the community.
  2. Mr X receives four care calls per day with two carers attending. There is also a call system which can be used for additional help outside of the agreed care package times. However, staff are not always immediately available as they may be assisting other residents.
  3. Mrs Y also lives within the scheme and is a close friend and carer for Mr X. She has made the complaints on behalf of Mr X as she sees him everyday and so understands his situation.

Poor care in March 2018 resulted in Mr X being taken to hospital with large pressure sores

  1. Mr X was admitted to hospital on 20 March. Paramedics attended his home after he was unable to get up off the toilet. The care notes say he was confused, was being sick and was unable to bear weight and so the paramedics felt he should go to hospital. There is nothing to suggest a pressure sore was noticed at this time.
  2. Mr X was in hospital for a for three months. He was treated in hospital for a de-roofed blister and was seen by the tissue viability nurse. The hospital discharge notes mention this but it does not mention when it developed. In response to my enquiries the Council has provided case notes of incidents prior to the hospital admittance when Mr X fell and required help. There is no mention of pressure sores. The Council has also provided the daily record sheets which show carers attending to Mr X and helping him to the toilet and with washing. There is no mention of a pressure sore in these notes.
  3. The complaint implies the pressure sore developed prior to Mr X being admitted to hospital and is as the result of poor care. On the basis of the information I have seen, I cannot say with any certainty when the pressure sore developed. There is nothing to suggest Mr X or Mrs Y raised this issue with the carers prior to 20 March. There is also nothing to suggest the paramedics saw it as they did not report it or make a safeguarding referral. As Mr X was helped by the paramedics because he was unable to get off the toilet, it would have been visible to the paramedics.
  4. It is my understanding that pressures sores can develop quickly. Mr X was left on the hard toilet surface for a period of time as he could not get up until the paramedics arrived. Information I have seen on the internet also suggests that even when a pressure sore develops quickly it can be advanced in nature.
  5. On the basis of the information I have seen, I cannot conclude that the pressure sore identified during Mr X’s stay in hospital was as a result of poor care provided in his home.

Poor care in late 2018 meant Mr X was left to lie in diarrhoea for hours and the carer said this was acceptable

  1. Mr X developed a bowel infection towards the end of 2018 and lasted for several months. This meant he was experiencing episodes of diarrhoea and so was frequently soiled. Mrs Y mentions an incident when Mr X had soiled himself and he pressed his buzzer for assistance but no-one attended. Mrs Y has not provided a date for this incident.
  2. Mrs Y says that she spoke to a member of staff about this and asked what Mr X was supposed to do if no-one came when he used the call button. Mrs Y says the carer confirmed that he would just have to lie in it until his next scheduled care call.
  3. The case notes provided by the Council from November 2018 onwards show Mr X was having considerable problems with diarrhoea. The notes show that carers responded on several occasions when Mr X used the call bell. The notes also show that there were many occasions when Mr X was not aware he had had a bowel movement and so did not call carers who then changed him at the scheduled call time.
  4. In response to my enquiries, the Council says that there is no evidence that Mr X was left for extended periods of time in a soiled bed. It acknowledges the conversation between Mrs Y and a member of staff but believes it has been misinterpreted. It says the comments were made in the course of a general conversation and not in response to a particular incident. The Council confirms that it would never be acceptable to leave someone for hours if they need personal care.
  5. There is evidence that Mr X was experiencing diarrhoea and this meant he was often soiled. When the scheduled calls took place the carers would find Mr X would need to be changed but it is reported he often didn’t even realise it had happened. There is also evidence that carers would attend when Mr X used the call button during this period of time. As no specific date or time has been identified for when Mr X was left for hours in a soiled bed I cannot conclude there is fault on this issue.

A call from Mr X at night for an ear spray was ignored

  1. Mrs Y reports that one night Mr X pressed the call button when he had very bad ear pain. He wanted a carer to get him a new ear spray. Mr X is unable to get out of bed unaided. Mrs Y says the carer answered the call and said “go to sleep its 1am in the morning”. Mrs Y says Mr X had to lie in pain until the carer visited in the morning.
  2. In response to my enquiries, the Council says it cannot evidence any call about an ear spray in its records. It says that without a specific date it cannot respond any further. However it notes that cameras were installed in Mr X’s room in November 2018 and so wonders if there is footage which would help evidence the incident.
  3. I cannot say there is fault on this point on the basis of the information provided. I note the Council’s offer to look into it again if further evidence can be provided. I also note that there is evidence that the carers did respond to Mr X on many occasions when he used the call button and so even if this call was not responded to, there is nothing to suggest this is an systemic problem.

On repeated occasions the catheter valve was not opened and put Mr X at risk of urinary tract infections

  1. Mr X has a catheter as he is unable to get out of bed to use the toilet. Mrs Y says that on several occasions she noticed that the small bag was full with virtually nothing in the large bag. Mrs Y says she realised that a valve had not been opened which was preventing the urine moving into the larger bag. Mrs Y says this is potentially very dangerous and could result in a serious infection.
  2. The Council acknowledges that Mrs Y reported one incident of the catheter value not being opened. It says the matter was dealt with immediately and carers were reminded to double check the valve in the future.
  3. There is no evidence to suggest that Mr X had an infection as a result of problems with the catheter valve. I can understand why Mrs Y was concerned about this but it appears the matter was resolved without any significant injustice caused to Mr X and so the Ombudsman will not pursue this matter further.

An incident on 4 October 2019 resulted in Mr X injuring himself after being trapped in a door and the carer was aggressive and shouted at him

  1. Mrs Y says that on this date Mr X decided to go to the bistro on the site to attend a coffee morning. Mr X was in his wheelchair and when he felt tired, Mrs Y agreed to take him back to his flat.
  2. Mrs Y pressed the button to open the double electric doors but only one door opened. Mrs Y says that as the wheelchair was going through the door he became trapped in the door when it banged into his hand and leg. Mrs Y says that no-one came to assist them even though Mr X was crying out in pain. Mrs Y believes the problem occurred because the carers did not put Mr X into the wheelchair correctly.
  3. The Council says that concerns had been raised with Mrs Y and Mr X about the suitability of the wheelchair before they purchased it. It acknowledges there was an ongoing fault with the doors so that only one opened. A carer who witnessed the incident says that Mr X’s wheelchair was at an angle going through the door and then he became trapped. The worker says she checked if Mr X was hurt and he said he wasn’t. The carer says Mr X was not crying out in pain.
  4. After Mr X returned to his flat, carers attended to help him into bed. There is nothing to suggest Mr X reported being in pain. The Council says Mrs Y was in the kitchen when the carer spoke to her. The carers’ version of what happened is different to that reported by Mrs Y. The Council notes that the incident would be on camera footage and so could be provided and it would review it.
  5. I cannot take a view on whether the carer spoke inappropriately to Mrs Y as I was not present. I am aware that the issues about how the carer interacts with Mrs Y have been addressed and it is my understanding Mrs Y said she was satisfied with the outcome. I am not persuaded any further investigation of this matter would change the outcome.
  6. Regarding the incident when Mr X was injured, it seems this was an accident. The carers were not pushing Mr X in his wheelchair at the time. There is also a suggestion that the wheelchair may not be totally appropriate for Mr X’s needs. There is no evidence to suggest Mr X suffered a significant injury or required any medical assistance after the incident.
  7. While I appreciate the incident was upsetting for all involved, I am not persuaded there is evidence to suggest this was the result of any fault by the Council.

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Final decision

  1. I will now complete my investigation as there is no evidence of fault causing a significant injustice in this case.

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Investigator's decision on behalf of the Ombudsman

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