Summary: Mr and Mrs X complained about the care Mrs X’s mother, Mrs Y, received at Hadrian House. They said the Care Provider did not do enough to stop Mrs Y’s injuries and left her in bed for six weeks unnecessarily. They felt this caused Mrs Y’s health and wellbeing to worsen and ultimately led to her death. We found the Care Provider was not at fault.

The complaint

1. The complainants, whom I shall refer to as Mr and Mrs X, complain about the care provided by Care UK Community Partnerships Limited (the Care Provider). They say that, while resident at Hadrian House, the Care Provider:
• did not properly care for Mrs Y, Mrs X’s late mother. Mrs Y suffered numerous injuries and it did not act to prevent this;
• kept Mrs Y in bed for six weeks waiting for a sling when it could have moved her using a sling it already had;
• did not serve proper notice; and
• packed Mrs Y’s belongings in black plastic bags when they moved her to a nursing home.
2. Mr and Mrs X say the time in bed triggered Mrs Y “shutting down mentally” and began the acute constipation which eventually led to her death.

Back to top

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. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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) We consider Mr and Mrs X suitable people to complain on Mrs Y’s behalf.
6. If we are satisfied with a 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)

Back to top

How I considered this complaint

7. I considered information from the complainant and from the Council.
8. I will send both parties a copy of my draft decision for comment and will take account of the comments I receive in response.

Back to top

What I found

Background

The Care Quality Commission (CQC)

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve.
10. The CQC is the statutory regulator of care services. It has issued guidance on how to meet the fundamental standards below which care must never fall. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.

Continuing healthcare

11. NHS Continuing Healthcare (CHC) is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. CHC funding can be provided in any setting and can be used to pay for a person’s residential nursing home fees in some circumstances.
12. A person’s local Clinical Commissioning Group (CCG) is responsible for assessing their eligibility for CHC and providing the funding. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC Checklist. If the completed CHC Checklist indicates the person may be eligible for CHC, the next step is a full multidisciplinary assessment. A nurse will usually co-ordinate a full multidisciplinary assessment and complete a Decision Support Tool (DST) form.
13. The NHS is also responsible for meeting the cost of care provided by registered nurses to residents in all types of care homes. People who need to move into care homes with nursing should have a comprehensive assessment to identify any nursing needs, including the possible need for NHS-funded continuing healthcare (CHC) or for NHS-funded nursing care (FNC).

Constipation

14. The NHS website says “If you’re caring for someone with dementia, constipation may be easily missed. It’s important to be aware of any changes in their behaviour that might mean they are in pain or discomfort, although it’s not always easy”.

What happened

15. Mrs Y had been diagnosed with dementia over ten years previously and was resident at Hadrian House where she had lived for over three years. Hadrian House is a residential care home run by Care UK Community Partnerships Limited (the Care Provider).
16. In early 2018, Mrs Y was admitted to hospital. Following discharge Mrs Y’s mobility care plan recorded that she could no longer mobilise around the home. Staff would help Mrs Y to mobilise into a wheelchair with the use of a stand aid.
17. At the end of August 2019, the Care Provider submitted a CHC checklist assessment as her needs had increased and it believed she needed nursing care. Towards the end of September 2019, following a period when Mrs Y had not left her bed, Mrs Y had a full CHC assessment which found she needed nursing care. Mr and Mrs X felt Mrs Y had deteriorated significantly since being confined to bed. They noticed she was holding food and drink in her mouth. The Care Provider told Mr and Mrs X she had been sick once or twice but that she was eating and drinking and having bowel movements. Mr and Mrs X believed Mrs Y had been in bed so long she was “shutting down mentally” and this was the start of acute constipation which led to a perforated bowel. The Care Provider asked Mr and Mrs X to move Mrs Y to a nursing home as soon as possible. Sadly, around one week after moving, early in October 2019, Mrs Y died due to sepsis caused by the perforated bowel. Mr and Mrs X complained because they were concerned the Care Provider had not cared adequately for Mrs Y. They said Mrs Y had also had an increasing number of injuries since arriving at the home.

Injuries

18. The Care Provider recorded that Mrs Y had one fall before coming to the home and assessed her as at medium risk of falls early on. It also recorded that she was at high risk of pressure damage. It put in place an overlay mattress and pressure relieving cushion.
19. Throughout her stay at Hadrian House, Mrs Y suffered various injuries, including bruising and skin tears. I saw records of 16 occasions when the Care Provider reported small bruises or skin tears over more than three years, including five in 2019.
20. On each of these occasions staff attended to Mrs Y, reported the incident to the person in charge and completed an incident report. On some occasions the incident was reported to the local authority safeguarding team, and/or the CQC. Following one incident the matter was reported to the police, who took no further action.
21. I saw the Care Provider’s detailed wound care plans. On one occasion, the GP thought she was probably scratching herself due to itchiness caused by a medication. He did not want to change the medication because that would have increased other risks. Mrs Y, at Mrs X’s request, also kept her nails long and was prone to scratching herself. One wound is noted to have been probably caused by Mrs Y’s bra and another by her knickers. This demonstrates the delicate nature of her skin and the ease with which it was damaged which was also noted. A sharp area on the bed frame was found and resolved after another incident. Care plans show appropriate action including consultation and regular visits by the district nursing (DN) team. In late September 2019, the Care Provider called the DN team due to a large blister on Mrs Y’s sacrum. The DN team advised the Care Provider to care for Mrs Y in bed and to reposition her to the left and right only; the DN team would review in a couple of days. This was updated the next day so Mrs Y was to be repositioned every two hours. An ‘in situ’ sling was noted to be the likely cause of the blister. An ‘in situ’ sling is a sling which is not removed after hoisting; the person remains seated on the sling which is designed to minimise the risk of damage to the skin. Usually, slings are intended to be used during hoisting only. Slings must be a suitable size for the person and support them adequately while in use.

Confined to bed

22. In September 2018 the Care Provider found Mrs Y needed a full body hoist as she could no longer bear any weight. Two members of staff would support her to transfer to her wheelchair using the hoist and a suitable sling.
23. In mid July 2019 staff reported difficulty transferring Mrs Y into a sling as she became very rigid and was at risk of falling out. It took three people to support her for each move but staff felt this was still not safe enough. The manager completed a risk assessment and decided she should remain in bed to ensure her safety and that of staff. She then contacted an equipment provider who recommended two in-situ slings that Mrs Y could remain in while sat in her chair or wheelchair. The Care Provider ordered the slings but, on arrival in early August 2019, found they were open and too small so posed an unacceptable risk to Mrs X. The Care Provider referred Mrs Y for an occupational therapy (OT) assessment and ordered another sling but the wait was up to three weeks.
24. Mr and Mrs X said the Care Provider should not leave Mrs Y confined to bed as it was harmful to her health and quality of life. She said staff could transfer Mrs Y using the toileting sling. The Care Provider said it needed to follow procedures and would only use a toileting sling to transfer Mrs Y to the toilet. A toileting sling is designed to remain in place during toileting and is not intended to be sat on for long periods of time. The Care Provider told Mrs X that Mrs Y needed an in-situ sling, which is designed so people can safely sit on them for longer periods of time. The Care Provider updated Mrs Y’s care plans to include increased actions to avoid pressure damage to her skin while in bed.
25. On one occasion in late August 2019, Mrs Y’s bed malfunctioned. Staff had to leave it on the lowest setting which meant they were caring for Mrs Y on their knees. On this one occasion, staff used the toileting sling to transfer Mrs Y to the commode while the bed was repaired. The Care Provider decided this was less of a risk than leaving the bed unrepaired.
26. The Care Provider received a new sling in mid-September 2019 and was able to transfer Mrs Y using this.

Notice

27. When Mrs Y’s needs increased, the Care Provider arranged for a CHC assessment which found that Mrs Y needed nursing care. Mrs Y’s social worker was present, also Mrs X and the manager, deputy manager, and senior care worker from Hadrian House. The Care Provider and social worker told Mrs X that Mrs Y should be moved to more suitable accommodation as soon as possible. Mr and Mrs X complain that the Care Provider did not provide this notice in writing and told Mrs X that Mrs Y must be out “by next week”. The social worker says they discussed Mrs Y’s move “in a professional manner” and answered Mrs X’s questions “in detail”. She says they did this until they were sure she understood the “system and process associated with a move and change in category of care”. Also, that “the sooner it happens the better” for Mrs Y given the “struggle” she and the staff faced recently due to her “rapid decline in physical health”. She says this was intended to minimise any further distress to Mrs Y and her family.
28. When Mr and Mrs X arrived to take Mrs Y to her new home, staff had already packed all her clothes in black plastic bags which was upsetting for them. The Care Provider wrote to Mr and Mrs X in response to their complaint. It apologised that staff had used black plastic bags and said staff had felt they had been helping as Mrs Y had no luggage at the home. It said it would ensure staff were aware not to pack any belongings unless asked by a resident or their family, and not to use black bags if they are. It has already addressed this directly with the staff concerned.

Did the Care Provider cause injustice?

Injuries

29. It is not unusual for older people to experience frequent bruises and skin tears. Although these can indicate cause for concern, this is often not the case. Staff investigated each of the incidents and where a cause was identified, took action to resolve this. The Care Provider took appropriate actions at the time for all incidents. Its records clearly set out the action it took, and it consulted appropriately with the GP and the DN team. Neither the GP nor the DN team raised concerns about the injuries or the care provided at the home. The safeguarding team also considered some of these but also found no cause for concern. I am satisfied that, on the balance of probability, the injuries to Mrs Y were not due to any problem with the quality of care delivered by the Care Provider. It did not cause any injustice here.

Confined to bed

30. The Care Provider properly considered the difficulties in transferring Mrs Y which were largely caused by her rigidity and difficulty understanding. A toileting sling is designed to remain in place while using a toilet or commode, but not while sitting in a chair, which would have created other risks. Although being confined to bed was not helpful to Mrs Y’s health and wellbeing, I found the Care Provider took this decision with good reason, balancing the risks appropriately. It did not cause injustice here.

Notice

31. Once the Care Provider had decided it could no longer meet Mrs Y’s needs, it needed to ensure she moved to a suitable placement as soon as possible. It did not need to give 28 days’ notice because it was important that she move to a more suitable placement quickly. There is no evidence that the Care Provider would have expected Mrs Y to leave without a suitable place to go. It could have put the notice in writing, which may have been helpful, but Mr and Mrs X were clear that Mrs Y had to move quickly. It did not cause injustice here.
32. The Care Provider did inappropriately use black plastic bags to pack Mrs Y’s belongings, but it has already satisfactorily remedied the injustice it caused by doing this.

Back to top

Final decision

33. I have completed my investigation and have not upheld Mr and Mrs X’s complaints that the Care Provider:
• did not properly care for Mrs X’s late mother, Mrs Y. Mrs Y suffered numerous injuries and it did not act to prevent this;
• kept Mrs Y in bed for six weeks waiting for a sling when it could have moved her using a sling it already had; and
• did not serve proper notice.
34. I have upheld Mr and Mrs X’s complaint that the Care Provider packed Mrs Y’s belongings in black plastic bags when they moved her to a nursing home. The Care Provider had already remedied the injustice it caused here, so I made no recommendations.

Back to top

Investigator's decision on behalf of the Ombudsman