Summary: Mr H complained about the care provided at a council commissioned care home for his wife Mrs X. There was no fault in the care provided. The Council was at fault when it failed to ensure an effective handover between care homes. The Council has agreed to apologise to Mr H and to pay him £150 to acknowledge the frustration and worry this caused. It has also agreed to remind council commissioned care providers of the need to ensure an effective handover of care, when residents move between care homes.

The complaint

1. Mr H complains the Council commissioned care provider, care home A, failed to provide adequate care to his wife Mrs X during the last six months of her stay there. In particular:
• it failed to manage her continence properly, leaving her wet and soiled on occasions;
• she developed pressure sores causing her distress and discomfort;
• family were not allowed to support her at mealtimes but staff did not offer support; and
• the staffing levels were inadequate with staff never visible upstairs in the care home.
2. Mr H says this meant Mrs X was without adequate care and caused him significant worry and distress.

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The Ombudsman’s role and powers

3. 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)
4. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
5. 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). In this case the care provider was commissioned by the Council so was providing services on its behalf.
6. 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)
7. 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

8. I have considered the information provided by Mr H’s son, Mr Y, on his behalf and have spoken to Mr Y on the telephone. I have considered the Council’s response to my enquiries. This includes the Council’s social care records, records from the care provider which I have referred to as care home A in the statement and from the new care home (referred to as care home B).
9. I have considered the relevant law and guidance. I have considered our guidance on remedies.
10. I gave Mr H and the Council the opportunity to comment on a draft of this decision. I considered the comments I received in reaching a final decision.

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What I found

11. 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.
12. One of the fundamental standards under regulation 9 is about person-centred care. This says each person should receive person-centred care and treatment, based on their individual needs.
13. Regulation 10 sets out that service users must be treated with dignity and respect. Staff must respect people’s personal preferences, lifestyle and care choices.
14. Regulation 17 is about good governance. This includes keeping accurate, complete and detailed records about people receiving care, including records of care provided and decisions made relating to care.
15. Regulation 18 concerns staffing and sets out that providers must provide sufficient numbers of suitably qualified staff, competent, skilled and experienced staff to meet the needs of the people using the service at all times.

Mental capacity

16. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so themselves
17. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity, must be in that person’s best interests.

Pressure sores

18. Pressure sores (also called pressure ulcers or bed sores) are wounds caused by pressure on part of the body interrupting the blood supply to the skin. People with mobility difficulties and who are over 70 are more at risk. Under the European Pressure Ulcer Advisory Panel classification system, pressure sores are graded in severity from 1 to 4.
19. Grade 1 indicates the first signs of pressure damage; including redness, discolouration, swelling or heat but with intact skin. Grade 2 is usually an abrasion or blister and involves a partial thinning of the skin. Grade 3 involves full loss of skin thickness with damage to, or death of, the underlying tissue. Grade 4 indicates severe pressure damage, usually a deep wound that may go down to the bone and involve the death of underlying tissue. 

What happened

20. Mrs X has dementia. In November 2017 she moved into care home A. At that time, care home A assessed Mrs X as fully continent and fully mobile. She had a normal diet but required prompting at mealtimes. It noted Mrs X had fluctuating capacity, was at high risk of falls and at risk of developing pressure sores. The care plan noted Mrs X’s skin should be checked daily and staff should wash and dry her after an episode of incontinence to prevent her skin becoming sore. Mrs X also had a skin cream regularly applied and a lotion for her bath. Mrs X’s husband, Mr H, visited regularly along with two of her adult sons, Mr Y and Mr Z.
21. The care home carried out monthly reviews of Mrs X’s care plans, including monthly monitoring of her weight. This showed minor fluctuations with some weight gain and no significant weight loss. Through 2018 the reviews noted Mrs X had an occasional episode of incontinence and in February 2018 Mrs X was initially referred to the continence service. In August 2018, after increased episodes of incontinence Mrs X was assessed for continence pads. By late 2018 the care home noted increased episodes of incontinence as Mrs X’s mental health was declining. The review noted Mrs X wore incontinence aids and by early 2019 it noted Mrs X was doubly incontinent.
22. Mrs X had regular visits home, however, in Autumn 2018 care home A raised concerns with Mrs X’s social worker that Mrs X’s behaviour was deteriorating after the home visits. The care plan review noted Mrs X was shouting and trying to hit out at others. The care home held a review meeting in October 2018 which Mr H, Mr Y, the Community Psychiatric Nurse (CPN) and social worker attended. All agreed to stop Mrs X’s visits home for two months to assess the impact.
23. Care home A held a review meeting in December 2018 which Mr H attended. All agreed Mrs X’s behaviour was more settled. The notes record Mr H accepted home visits were not beneficial to Mrs X at present. At the meeting the care home raised concerns Mr H was visiting at breakfast time and feeding Mrs X when she was able to do this herself. It was concerned this was affecting her independence. The care home generally tried to operate ‘protected mealtimes’ that is to avoid interruptions at mealtimes so staff could monitor residents’ nutrition and assist with feeding. The notes record Mr H agreed not to visit before 10am to enable staff to monitor Mrs X’s well-being and to promote her independence.
24. Mrs X had a fall in February 2019. Staff found Mrs X face down in her room with a bump on her head. They called 999 and Mrs X went to hospital where she was discharged later that day. Following this, the GP and CPN reviewed her medication as they believed this may have increased her risk of falling.
25. Mr H was unhappy he could not support Mrs X at mealtimes. He also raised concerns that Mrs X was not always warm and was not included in activities enough. The social worker arranged a further meeting at the care home in February 2019. Mr H, Mr Y, Mr Z, the CPN, care home staff and the social worker attended. Mr H remained unhappy about the protected mealtimes but understood why this was in place. The care home did not agree Mrs X was not warm enough but agreed to check this. They also advised they included Mrs X in activities wherever possible and that Mr H or his sons could support Mrs X to access activities. Mr H wanted to continue the visits home. He agreed Mrs X did not recognise her surroundings or evidence pleasure at being there. The meeting reached a best interests’ decision that there was no emotional benefit to Mrs X from the visits and that they should not continue. Mr H was not in 100% agreement but did not wish to challenge the decision. The notes also record Mr H should liaise with staff if he had concerns but should not shout in front of other residents as the care home stated he did. At the meeting the family confirmed it did not want to consider an alternative placement for Mrs X. The social worker and CPN noted they were happy with the care Mrs X was receiving.
26. In early April 2019 care home A noted Mrs X was not well. The GP visited but found no sign of a chest infection. They considered Mrs X had a cold. Care home A raised their concern Mrs X was leaning forward when walking. The GP’s view was this could be related to her being unwell or due to a progression of the dementia. When Mrs X was leaning when walking, care home A put her to bed for bed rest. Later that week Mrs X fell out of a chair in the care home lounge. A visitor to another resident alerted staff who examined Mrs X and called 111. The nurse advised the care home to monitor Mrs X. The care home updated Mrs X’s family.
27. The care home remained concerned about Mrs X’s general decline. It noted she was sleepy and leaning forward and asked the GP to visit. A health professional visited Mrs X later that day. They noted she continued to have viral cold symptoms but no obvious signs of infection. Her mobility was poor. They advised the care home to continue to monitor Mrs X, to encourage food and fluids and encourage mobility.
28. A week later care home A noticed a blister on Mrs X’s heel and a purple mark on her right foot. They informed the District Nurse who visited and dressed Mrs X’s feet. The District Nurse believed the blister was trauma caused by Mrs X rubbing her feet on the mattress. Care home A reported the sore to its head office. They ordered some specialist equipment and two days later the care home received a specialist mattress and cushion for Mrs X plus special foot protectors for Mrs X to wear. Care home A also introduced positional change records, ensuring Mrs X changed position every two hours. The District Nurse continued to monitor Mrs X’s feet. A week later the care home noted Mrs X now had a blister on her right foot. The District Nurse dressed both feet. The care home also reviewed Mrs X’s moving and handling and decided to use a hoist to reposition Mrs X to prevent pressure on the sore areas. The District Nurse also tried to take a blood sample but was unable to do so as Mrs X would not cooperate.
29. In April 2019 a new care provider contacted the social worker as the family had asked them to assess Mrs X for a possible transfer to a new care home. Mrs X’s son, Mr Z, also phoned care home A to advise they were looking to move Mrs X to a home closer to Mr H. The social worker spoke to Mr Z. The notes record Mr Z had no new concerns about care home A however the relationship between Mr H and the staff at care home A had broken down and Mr H and Mr Y felt uncomfortable visiting the home.
30. The potential new care provider assessed Mrs X. It noted Mrs X had dementia. She was fine on most occasions but could be tearful and did have some challenging behaviours. It noted Mrs X could speak but not coherently due to dementia. It noted Mrs X’s mobility was very poor needing a wheelchair for distances and assistance from one or two staff members. It noted her recent falls. Under ‘does the individual suffer from any known skin conditions’ it noted Mrs X had blisters on both feet and dressings. Mrs X’s heels were discoloured and she had foot protectors in place. It noted ‘stated by deputy manager and senior care that Mrs X has [foot protectors] but no other equipment.’ It noted Mrs X was doubly incontinent.
31. The District Nurse visited Mrs X but was again unable to take a blood sample. They noted the blister on Mrs X’s heel had burst and applied a bandage. They reminded staff to use the foot protectors at all times. Care home A contacted the social worker who advised that Mr H and Mr Y wanted to move Mrs X as they felt uncomfortable visiting.
32. The District Nurse visited again three days later and managed to take a blood sample. They noted Mrs X now had two small blisters on her right heel and applied a dressing.
33. Care home A spoke to Mrs X’s son, Mr Z in mid-April for a review regarding the sores. It explained the blisters were due to trauma and staff were doing all they could to manage them. Mr Z asked about Mrs X’s fall. Care home A advised that when Mrs X fell from the chair in the lounge no staff were present in the lounge but were nearby and attended her straight away. They had put measures in place, including a bigger chair, and bed rest if needed, to reduce the risk of falls. The care home noted the blood results were that no further action was required. The notes also record Mr H said he had no concerns about the care provided but wanted Mrs X moved closer to him.
34. The following day the GP phoned and reported the blood results were abnormal but this could be due to Mrs X’s cold. The care home reported Mrs X leaned forward when walking. The GP considered this was dementia related. The care home updated Mr Z who asked if Mrs X could be assessed for a walking frame. The District Nurse visited later in the month and assessed Mrs X for a frame.
35. At the end of April, the potential new care provider informed the Council it had assessed Mrs X and would take her but it did not have any availability. It offered her a place one of its other homes, care home B, on a temporary basis. The Council would not agree to this as it considered two moves would not be in Mrs X’s best interests. The family visited care home B and agreed to Mrs X moving there on a permanent basis.
36. Care home B carried out an initial assessment of Mrs X. It noted Mrs X ‘communicates well’. It answered no to ‘is the individual likely to display challenging behaviour’. It noted Mrs X ‘walks around herself with blisters she is in pain’. It recorded ‘no’ to ‘does the individual have any current pressure sores'. Under this it noted in writing 'blisters on heels’. It did not answer the question ‘does the individual have any pressure relieving equipment’. It noted Mrs X had a high risk of falls and needed assistance when mobilising. It noted she required falls equipment for use at night. It noted Mrs X had no problems with her weight but needed assistance with food and drink.
37. The social worker completed a capacity assessment and made a best interests’ decision that Mrs X should move due to the breakdown in relationship between the care home staff and family. In early May 2019 Mrs X moved to care home B. Care home A completed a body map noting the presence of dry blisters on Mrs X’s right and left heels. The notes record when Mr H and Mr Y collected Mrs X, Mr H refused to take the foot protectors. In the notes care home A recorded they ‘contacted the new home to make them aware of the [foot protectors] due to him refusing to take them so they are aware she needs to wear these. I also went to check what mattress she used and gave them the name of the mattress and made them aware they needed to order one’.
38. The notes record the social worker spoke to care home B who confirmed Mrs X was there and appeared to be settling well. Care home B completed a body map five days later. This noted blanched skin to Mrs X’s left heel and a category 2-3 pressure sore on her right heel. The District Nurse dressed the wounds and advised this was an old wound.
39. A week after Mrs X moved to care home B it telephoned the Council. The District Nurse had raised a safeguarding concern Mrs X was neglected at care home A. Staff at care home B had noticed skin damage to Mrs X’s heels and ankles. The District Nurse had confirmed these were old pressure sores graded 1-2. Mrs X was struggling to weight bear and had been admitted to hospital. The notes record she had an infection in her damaged feet. Care home B stated it had contacted care home A to ask about pressure relieving equipment but was advised they did not know what she had.
40. The Council spoke to the District Nurse who had been dealing with the pressure sores at care home A. The District Nurse advised they had no concerns that there were any issues with Mrs X’s care and there was extensive documentation of the action taken. The pressure sores were appropriately assessed and pressure relieving equipment was in place. The Council closed the safeguarding concern as it was satisfied care home A had taken appropriate action.

Findings

41. When the family raised concerns, care home A acted appropriately and arranged review meetings, involving the Council as the commissioning body. Care home A carried out regular reviews of Mrs X’s care plans and appropriately involved health professionals when it had concerns. The Council’s records show no concerns were raised by the social worker or CPN regarding Mrs X’s care at care home A and the Council acted appropriately, carrying out capacity assessments and reaching best interest decisions when necessary. The notes record a breakdown in the relationship between the care home and Mr H and Mr Y as the reason for Mrs X’s change in care home. There is no evidence of fault in the care provided to Mrs X by care home A. In relation to Mr H’s particular concerns:

Continence management

42. The records show Mrs X’s continence decreased during 2018. The care provider acted appropriately by involving the continence service when this happened. The care provider regularly reviewed Mrs X’s continence assessment.
43. There is no evidence in the daily records or notes of the review meetings to show the family raised any concerns about Mrs X’s continence management with care home A. On the evidence considered, there is no evidence of fault in the way the care provider managed Mrs X’s continence care.

Family support with eating

44. Care home A tried to operate ‘protected’ mealtimes. Mr H liked to support Mrs X with breakfast. However, care home A’s view was that Mrs X could feed herself breakfast. It wanted to promote her independence and monitor her mood and behaviour in the mornings. There is no fault in the care provider taking that view. Care home A explained its position to Mr H at the review meeting in December 2018 and Mr H agreed to visit after 10am. It reiterated its view at a later meeting in February 2019.
45. Mr H says staff did not support Mrs X at mealtimes. However, there is no evidence to show staff failed to support Mrs X. The monthly care review noted Mrs X’s appetite fluctuated so she was weighed on a weekly basis. The weight records show whilst her weight fluctuated there was no evidence of significant weight loss and Mrs X’s body mass index remained in the healthy range throughout her stay at care home A.

Staffing levels

46. Mrs X fell out of her chair in April 2019. Mr H had concerns that no staff were present at the time. However, Mrs X did not require 1:1 support. When staff were alerted, they attended to Mrs X straightaway and acted appropriately. The care provider says no agency staff were employed at the care home during Mrs X’s stay as staffing levels were always adequate and in line with their staffing ratios. The most recent CQC inspection of care home A noted no concerns about staffing levels and the family raised no concerns about staffing levels at the regular review meetings. It may be that staff were not obvious when family members visited and staff may not have been able to respond immediately. However, this is not unusual in a busy care home where staff are required to support individuals, sometimes two at a time. There is no evidence of fault with the staffing levels at care home A.

Pressure sores

47. The records show staff regularly checked Mrs X’s skin integrity. When care home A noticed blisters on her feet it completed an incident report, reported the wounds to head office and completed a body map. It sought support from the District Nurse who believed the sores were caused by Mrs X rubbing her feet together or on the bed sheets. The dressing and medical treatment of the pressure sores was a matter for the District Nurse. Care home A also obtained appropriate pressure relieving equipment for Mrs X including specialist foot supports, a cushion and specialist mattress. It also introduced a repositioning schedule and used a hoist to relieve the pressure on Mrs X’s feet. The notes also show Care Home A discussed the sores with Mr Z. Care home A was not at fault in how it responded when it identified Mrs X’s sores.
48. Care home A completed a body map on the day Mrs X left the care home. There was no record of any other wounds or sores. The notes record Mr H refused to take the foot supports when Mrs X moved to care home B. The note also records care home A spoke to care home B about this and the mattress Mrs X required.
49. The initial assessments completed by the new care provider and care home B noted the presence of the sores. However, neither of these assessments accurately recorded the pressure relieving equipment used to support Mrs X. The body map completed by care home B five days after her admission noted the presence of the sores on Mrs X’s feet and the District Nurse reported these were ‘old’. The District Nurse later raised a safeguarding concern.
50. The Council responded appropriately to the safeguarding concern. It was satisfied, following consultation with the previous District Nurse, that care home A had followed its procedures and did all it could to respond to Mrs X’s sores. However, I am concerned the safeguarding concern was raised in the first place.
51. The Council commissioned Mrs X’s care at both care homes so remains responsible for her care. There is no evidence of a clear handover between care home A and care home B regarding Mrs X’s care and in particular the sores on her heels. This is fault. Care home A’s notes record it told care home B about the pressure relieving equipment Mrs X used. Yet when Care home B spoke to the Council it said it had spoken to care home A but staff did not know what pressure relieving equipment she had.
52. Care home B’s initial assessment of Mrs X does not record any pressure relieving equipment and the body map noting the sores was not completed until five days after Mrs X’s admission. The fact a safeguarding was raised suggests a lack of coordination between the two homes. This caused Mr H uncertainty and distress over whether Mrs X was properly cared for. Mrs X was admitted to hospital for an infection, but I have seen no evidence this was as a result of fault by care home A.

Agreed action

53. Within one month of the final decision the Council has agreed to apologise to Mr X and to pay him £150 to acknowledge the uncertainty caused by the failure to ensure an effective handover of Mrs X’s care.
54. Within two months of the final decision the Council has agreed to remind Council commissioned care providers to ensure when a change of provider occurs there is effective communication of the individual’s needs and the support required.

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Final decision

55. I have completed my investigation. There was fault causing injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman