Summary: Ms Y complains about the lack of action taken by Chetwynd House Care Home Limited after her late father, Mr W, suffered significant bruising while in their care. We find the home’s record keeping fell below the required standard which in turn created uncertainty about Mr W’s injuries and the pain he experienced. The home also failed to notify the family in a timely way of Mr W’s injuries. The home will apologise and pay £300 in recognition of the avoidable distress caused and implement updated staff guidance or training.

The complaint

1. The complainant, Ms Y, complains about the lack of action taken by the home after her father, Mr W, sustained significant bruising while resident there. In particular, Ms Y complains about the home’s poor record keeping, its failure to notify the family of Mr W’s injuries and its failure to seek appropriate and timely medical intervention.
2. Ms Y says the care provider’s actions caused injustice. Mr W endured pain and discomfort for longer than necessary, and the family experienced distress as a result of the care provider’s poor handling of the incident.

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The Ombudsman’s role and powers

3. 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)
4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

6. During my investigation I discussed the complaint with Ms Y and considered the documentation she submitted.
7. I made enquiries of the home and considered its response.
8. I consulted the law and guidance relevant to this complaint, referenced where necessary in this statement.
9. I issued a draft decision statement and invited comments from Ms Y and the care provider. I considered any comments received before making a final decision.
10. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

What should happen

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. Regulation 12 places a requirement on social care providers to give safe care and treatment and to prevent avoidable harm or risk of harm. In doing so, providers must:
• assess the risks to the health and safety of service users of receiving the care or treatment.
• do all that is reasonably practicable to mitigate any such risks.
• ensure the proper and safe management of medicines.

What happened

13. At the time of the matters complained about, Mr W was resident at Chetwynd House, which I will refer to as ‘the home’. Mr W has since passed away and his daughter, Ms Y, pursues the complaint on his behalf.
14. Ms Y had cause to complain after an incident at the home involving Mr W on 30 June 2020. She says Mr W suffered significant bruising, but the exact cause of the bruising and the circumstances around the bruising are not known.
15. Mr W was taken to hospital on 3 July after a GP raised concerns about the bruising. The home informed Ms Y of her father’s admission to hospital on this day. This is the first time she was aware of the incident and Mr W’s injuries.
16. While at hospital Mr W received X-Rays on both arms, but no fractures were identified. The hospital noted the bruising but did not document any indication of the possible cause. Mr W returned to the home.
17. Ms Y complained to the home because she was not happy with the lack of communication with the family about Mr W’s injuries. She also complained the home had delayed in seeking medical intervention for Mr W which meant he experienced pain and distress for longer than necessary.
18. The home completed an investigation into the matters complained about. A manager met with relevant staff, discussed the incident with Ms Y and Mr W and reviewed Mr W’s care records. The investigation made the following findings:
• There is no clear evidence about Mr W’s bruising. The first entry in the daily care notes about the injury is on 1 July at 11:44. This notes that Mr W expressed pain in his shoulder, which appeared swollen. Mr W had some pain relief. On the same day, the home also noted bruising on Mr W’s inner elbow and upper arm. Mr W was ‘content’.
• The home made further recordings over the following three days about Mr W expressing pain. The manager found that staff had created wound entries in Mr W’s notes, but these entries were not completed or followed up. The medication records show that Mr W received regular pain relief.
• Monitoring of audio recordings from Mr W’s room on 30 June did not reveal any sign of a fall by Mr W. The audio only revealed that Mr W was assisted to the toilet. The home speculates that Mr W would not have been able to get himself up independently, had he fallen.
• When asked about the incident, Mr W said that he heard noise outside of his room and went to see what was happening. He saw his neighbour shouting and the manager was present. He does not remember everything, but that he did fall and bang his arm. Mr W said he felt better. He is happy at the home and is not worried. He said the staff are good.
19. The investigation found fault in the actions of the home, because:
• The documentation about Mr W’s injury, and the way it was managed, was inadequate. In future, the home said it would take regular photographs of any wounds or bruises. The wounds should be measured, and the notes updated regularly, to monitor progress. The home should also report any wounds using the incident/accident process so managers can review accordingly.
• The communication between the home and the family could have been better. The family should have been told about the bruising as a matter of course. The lack of family contact was exacerbated by the COVID-19 visiting restrictions and so staff members should have been even more vigilant with contact.
• There were gaps in Mr W’s care plan, which meant it was not clear that he needed the assistance of one staff member whenever he mobilised. Mr W’s care plan needs a full review.
20. The home also made a referral to the Council’s safeguarding team on 14 August. The Council responded on 21 August and confirmed “… it is inconclusive as to how [Mr W] ascertained the bruising to his arm, but on the balance of probability, it is unlikely it was as a result of abuse or neglect by [the home] …. [Mr W] was on blood thinning medication at the time and this increased the likelihood of bruising and this spreading. Health professionals have not shared any concerns regarding the bruising when they have observed this at the time”.

Was there fault in the actions of the care provider causing injustice?

21. Ms Y complained to the Ombudsman because she felt the home’s investigation did not accurately reflect the serious nature of what happened, and that management continue to lack accountability. Ms Y also suspected that Mr W’s bruising occurred when a senior member of staff, who was not trained in manual handling, lifted Mr W from the floor after a fall on the evening of 30 June 2020.
22. I have reviewed documentation provided by the home and Ms Y to decide whether there is evidence of further fault causing injustice. I agree with the recommendations already made by the home. From reviewing the evidence, it is clear there are gaps in Mr W’s care records. For example, about the developing nature of Mr W’s bruising because the home has not provided any body mapping images to show the extent and development of the bruising.
23. I also find gaps in the recording about Mr W’s medication and the home has not provided copies of a Medication Administration Record (MAR) chart. This creates uncertainty about whether Mr W was left without pain relief for long periods of time, and therefore experienced avoidable levels of pain and distress.
24. Although the administration of Mr W’s medication is sometimes recorded by carers in the daily care notes, these notes do not provide the same detail as a MAR chart would. For example, entries sometimes refer only to ‘pain relief’ so it is unclear whether Mr W received paracetamol or codeine, as later prescribed by the GP. This would have been clear if recorded on a MAR chart because they must provide the following additional details:
• which medicines are prescribed for the person
• when they must be given
• what the dose is
• any special information, such as whether to be given with or without food.
25. There is also a lack of rationale in Mr W’s notes to explain why the home did not feel it was necessary to seek the advice of a GP until 3 July and three days after the bruising appeared, despite Mr W regularly complaining that his pain was increasing. These omissions create uncertainty.
26. The risk assessment completed for Mr W in August 2020 placed him at a high risk of falls. Mr W’s care plan, also updated in August, said that Mr W always needed the support of one staff member to access the toilet. The plan said that Mr W’s mobility should be assessed daily to decide the equipment he needed.
27. As part of my enquiries, I asked the home to provide copies of the care plan and risk assessment in place at the time of the incident in June 2020. The home has only provided the versions updated in August. Therefore, it is not possible to determine what level of risk Mr W was assessed as being in June when the incident occurred. However, the home’s investigation and ‘Root Cause Analysis’ confirmed that Mr W’s care plan required updating as it was not clear that he needed help when toileting. From this I can therefore ascertain, on the balance of probabilities, that Mr W has always needed the help of at least one carer when mobilising.
28. Mr W’s care notes show that staff were aware that Mr W sometimes used the toilet independently during the night. While I cannot reach any conclusions about what happened on the evening that Mr W sustained the bruising, it is concerning that Mr W’s care plan was seemingly unclear. Therefore, it is possible that some staff may not have known they needed to help Mr W when they heard or saw him mobilising independently during the night. This creates further uncertainty about whether Mr W had a fall which could have been avoided.
29. As Mr W has now passed away, the Ombudsman cannot remedy the injustice he suffered. However, we can look at the impact on his family and specifically Ms Y who brought this complaint. The distress experienced by the family when Mr W sustained injuries was further exacerbated by the home’s failure to notify them in a timely way of Mr W’s extensive bruising and pain.
30. In addition to the measures already proposed and implemented by the home, we recommend the further actions listed in the following section of this statement.

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Agreed action

31. Within four weeks of my final decision, the home has agreed to take the following action to remedy the avoidable distress caused by the service failure identified in this statement:
• Apologise for the faults identified and pay £300 to Ms Y in recognition of the avoidable distress she experienced. This arises from the failure to notify her in a timely way of Mr W’s injuries and the uncertainty created by gaps in the home’s care recording.
32. Within six weeks of my final decision, the home has agreed to provide evidence of the following:
• Evidence that it has reminded staff members, either via updated written guidance or through training, of the requirement to complete body mapping to regularly monitor wounds, bruising and general injuries.
• Evidence that it has reminded staff members, either via updated written guidance or through training, of the requirement to record the administration of medication through MAR charts.

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Final decision

33. We have completed our investigation with a finding of fault causing injustice for the reasons explained in this statement.

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Investigator's decision on behalf of the Ombudsman