Summary: There were multiple failures in the late Mrs Y’s care at a council-funded care home, including an avoidable serious deep tissue injury. The council needs to apologise and make her daughter Mrs X a symbolic payment to reflect her avoidable distress. The council will take action described in this statement to minimise the chance of recurrence.

The complaint

1. Mrs X complained about her late mother Mrs Y’s care at Croxteth Park Care Home (the Care Home) owned by Four Seasons Healthcare Group (the Care Provider). Liverpool City Council (the Council) arranged and funded Mrs Y’s placement.
2. Mrs X complained about:
1. Over-use of a sedative
2. Weight loss
3. Poor care of pressure sores and moisture lesions
4. Poor communication
5. Three falls out of bed.
3. Mrs X told us the Care Home’s failings caused her avoidable distress.

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The Ombudsman’s role and powers

4. 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)
5. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company, like a care provider, 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)
6. The Care Home provided services on behalf of the Council so we can investigate its actions.

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How I considered this complaint

7. I considered the complaint to us, the Council’s response to the complaint and I discussed the complaint with Mrs X.
8. I have taken they key events from the Council’s and the Care Home’s records. The council officer who completed a safeguarding report also had copies of some of the district nurse’s records. I have not seen the district nurse’s records, but I have relied on the summary of the district nurses’ notes, as set out in the Council’s safeguarding report described later in this statement.
9. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

10. 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. When looking at complaints about standards of care in council-funded care placements, we consider the 2014 Regulations and associated guidance from the Care Quality Commission (the Fundamental Standards).
11. 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.
12. Regulation 12 of the 2014 Regulations says care must be provided in a safe way including assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks. Guidance explains medicines should be given accurately and in line with the prescriber’s instructions and at suitable times to ensure the person is not placed at risk.
13. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
14. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.
15. Regulation 20 of the 2014 Regulations (the duty of candour) requires care providers to be open and transparent when things have gone wrong. As soon as the care provider becomes aware of a safety incident, it must tell the person or their relative; provide reasonable support, advise them of any further enquiries, keep a written record and apologise.
16. Regulation 13(1) requires care providers to have effective systems to prevent abuse of service users. The Fundamental Standards explain staff must prevent, identify and report abuse when providing care and treatment. This includes referral to other agencies.
17. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.
18. Regulation 15(1) requires care providers to ensure equipment is properly used and maintained.
19. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)
20. 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.  If a resident has pressure sores, they would need to be treated by a qualified nurse and this would usually be the role of the district nurses.
21. Moisture lesions (also called moisture ulcers or incontinence associated dermatitis) are skin damage caused by excessive moisture. They are often confused with pressure sores, but the treatment for them is not the same as for pressure sores and may involve using a special cleaning solution and a prescription barrier spray to prevent moisture soaking into the skin.

What happened

Background

22. Mrs Y had dementia and lived in the Care Home, which is a residential care home (without nursing) specialising in dementia care, from the start of March 2020 until June 2020 when she moved to a nursing home. Mrs Y died within three weeks of moving to the nursing home. The nursing home is not part of this investigation.
23. Before moving to the Care Home, Mrs Y had been in hospital. Before hospital, she lived in her own home and had a care package which included six visits a day from care workers and visits from the district nurse. The Council’s records indicate there was concern about Mrs Y coping at home and it was thought she was anxious when alone. Mrs Y’s psychiatrist said her dementia was progressing and her family agreed 24-hour care was in Mrs Y’s best interests. The Council arranged short-term care in the Care Home for Mrs Y. The intention was to see how she settled in a care home environment to support long-term planning. The Council’s assessment did not conclude Mrs Y required care in a nursing home and the records indicate that staff from a nursing unit visited Mrs Y in hospital in February and felt she did not need nursing care.
24. Mrs Y had an existing pressure sore on her left foot when she moved into the Care Home. The district nurses visited regularly to examine and dress this.
25. The Council told me the intention was to carry out a review of Mrs Y’s care needs within 28 days of her moving into the Care Home, but this did not take place because of COVID-19.

The Care Home’s assessments

26. The Care Home’s records for Mrs Y included two respite care booklets both partly completed on 5 and 11 March 2020. The Care Home did not explain why there were two booklets. The booklets contained the assessments and care plans for staff to complete when a resident moved in. The sections for care plans and reviews are blank. Mrs Y’s medical conditions are listed and included dementia and chronic leg ulcers.
27. The moving and handling assessment said Mrs Y was at high risk regarding skin integrity. She needed a hoist and two staff to transfer her and she was immobile and used a wheelchair. She needed a slide sheet for repositioning in bed. She was at high risk of falls.
28. The booklet completed on 11 March said Mrs Y:
• Could take her medication without supervision. (This was incorrect as the Care Home also kept medicine charts which recorded staff giving Mrs Y medication)
• Had high needs in relation to mobility and could not weight bear
• Had low needs in relation to nutrition. The standard malnutrition screening tool was left blank. Her weight on admission was 66.4kg
• Had a low risk of choking.

The Care Home’s care plans

29. The Care Home drew up care plans for Mrs Y. These should have been available at the start of March when she first moved in. For reasons which the Care Home has not given, care plans were not done until the middle of April.
30. The falls risk assessment said Mrs Y was at high risk of falls. She used a hoist and needed two staff to support her with transfers (moving from bed to chair, chair to toilet and so forth). There was a falls pressure mat by her bed. Staff were to check all equipment when moving Mrs Y.
31. Mrs Y was at low risk of malnutrition. The monthly weight charts said she weighed 63.5 kg in the middle of April and 66.4 kg at the end of May. Staff noted it was hard to get an accurate reading on the scale because Mrs Y was anxious when being weighed.
32. The continence care plan said Mrs Y needed two carers to help her to locate and use the toilet. She was incontinent and used pads, but she was sometimes aware she needed the toilet and would shout until assisted. Staff were to encourage her to use toilet.
33. Mrs Y’s care plan for behaviour said she had a high level of need. There is no detail about her assessed needs or expected outcomes. The care plan is blank, other than to state she had a high level of need.
34. The Care Home’s daily records indicate Mrs Y was often distressed and shouted out inappropriate comments at staff and other residents. Mrs Y’s care plan for communication noted she continued to shout out and she could show signs of anxiety and needed care staff to reassure her.
35. Mrs Y was prescribed a sedative to treat anxiety, agitation and restlessness. This was to be taken when required. The Care Home had a care plan in place which said Mrs Y could have 0.5mg every 4 hours up to a maximum of 2 mg every 24 hours. The care plan set out guidelines for when the sedative should be given and advised regular observation. The medication records show Mrs Y never received more than the prescribed amount and when it was given, she mainly received one or two doses within a 24-hour period. On some days, she did not receive any.
36. Care staff spoke with the mental health team about Mrs Y’s behaviour at the start of May and the plan was to refer her to see a consultant psychiatrist. A social worker spoke to care staff in the middle of May. Mrs Y’s behaviour was the same and the so the social worker said she would arrange for a nursing assessment to see if Mrs Y needed to be in a nursing home.

Health needs assessment

37. A nurse assessor completed a health needs assessment in the third week of May. This noted the Care Home was struggling to meet Mrs Y’s needs. The nurse assessor said the records indicated a known history of mental health problems and Mrs Y may have been inappropriately placed in the Care Home. The outcome was Mrs Y would be moved to a nursing home. The health needs assessment noted:
• Mrs Y had fallen out of bed on 11 April reaching for chocolate. She would try to get out of bed unaided.
• There was a falls alarm and crash mattress in place (Mrs X disputes this and told me there was no crash mattress) and she had two falls in four weeks. There were no bed rails in place because of Mrs Y’s cognitive problems.
• Her weight in hospital on 9 February was 63.9kg. Her weight on the day of the health needs assessment was 54.15 kg. She needed feeding now apart from finger foods.
• She was taking a sedative, but this had no impact on her. She was due a mental health review.

District nursing visits

38. The district nurses visited Mrs Y on 21 May to provide routine care for her leg ulcer. In addition to the leg ulcer, the district nurse examined Mrs Y’s left buttock and found two wounds – both category two pressure damage. The district nurse planned to change the seat cushion Mrs Y was using. There was no evidence repositioning was discussed, though the district nurse told care staff about the new wounds on her buttock.
39. The Care Home contacted the district nurses on 22 May asking for a visit and stating there were two new moisture lesions to Mrs Y’s right buttock. The district nurse visited the following day, although their record said the reason for the visit was that dressings had come off and details how the category two pressure damage was cleaned and redressed. There was no direct reference to the areas described by the Care Home as moisture lesions on the referral the day before.
40. On 25 May, the district nurse visited again following further contact from the Care Home regarding pressure damage to Mrs Y’s hip and foot. The district nurse recorded the following:
• Wound G: right buttock, category 2 pressure damage 3 cm by 2.5 cm
• Wound I: right elbow, deep tissue injury 3 cm by 3cm
• Wound J: right hip, 14 cm by 11 cm (this was the wound noted by care staff)
• Wound K: right shin – multiple deep tissue injuries noted
• Wound L: right heel, deep tissue injury 1.5 cm by 1.5 cm
• Wound M: right toe, deep tissue injury, 1cm by 2 cm
• Wound N: left foot, also noticed by carers. 5 cm by 5cm blood filled blister/deep tissue injury.
41. At this visit, the district nurse identified Mrs Y’s pressure relieving mattress was not plugged in and there were no repositioning charts. It was not known how long the mattress was unplugged. The district nurse’s advice was two hourly repositioning. The district nurse reported the issue to the Council as a safeguarding concern and the Council started a safeguarding investigation.
42. The Care Home manager’s note on 25 May said she had implemented two hourly repositioning. But the Care Provider has not given me positioning charts other than for 25 May and partly completed charts for 26 and 27 May and a completed chart for 8 June.
43. The Care Home kept records of the monthly checks it did on all pressure mattresses in the home to make sure they were not worn or damaged. The Care Home did not do any checks to ensure pressure mattresses were plugged in or working.
44. Mrs Y’s care plan for skin integrity was initially completed on 25 May. She was at very high risk of pressure sores. The care plan noted she had a deep tissue injury to the right hip, which was ungradable but when it broke down would likely be grade 4 and another deep tissue injury to the left heel and she needed two hourly pressure relief. Staff were to check her skin at each intervention and report changes to the district nurse. She had pressure relieving equipment in place and the district nurse had ordered boots and gel pads.
45. The daily notes record Mrs Y had a fall from her bed in the middle of the night on 2 June. There is no detailed record about what happened and I understand the fall was unwitnessed. A body map noted bruising to her left eye. Staff called the paramedics to check Mrs Y and contacted one of her daughters (not Mrs X). Mrs Y was taken to hospital by ambulance for checks. Care staff referred Mrs Y to the district nurses again on 7 June as her eye was swollen. A body map completed on 9 June noted Mrs Y had bruising above the left eye and swelling under the eye and a bruise on top of her head, as well as the injuries noted by the district nurse.
46. The Care Home started keeping records of Mrs Y’s food and fluid intake from 25 May. There was no stated reason for this as there was no update to the care plan.
47. The Care Provider completed a serious incident analysis into Mrs Y’s care. The report found:
• The verbal handover was Mrs Y had bad bruising (to the hip) but had not fallen. The unit manager then identified the bruise as a deep tissue injury.
• Up until the 22 May, Mrs Y did not require any re-positioning in bed as she could turn herself. On 22 May, she had acquired two moisture lesions on her buttocks. But staff failed to act, report or escalate these. Her general health was deteriorating and staff failed to escalate the need for pressure relief. On the day of the incident, it was noted the pressure relieving mattress was unplugged. Staff failed in delivering effective continence care
• There were failures by staff in: not recognising a decline in general health, not reporting moisture lesions, not upgrading the Waterlow (skin integrity) risk assessment and not introducing re-positioning charts.
• Staff lacked knowledge and skills in pressure relief management. Staff did not understand policies and procedures in relation to mattress and well-being checks.
• There was a failure by senior personnel leading the care team in monitoring the level of care being delivered within the service. The 24-hour handover was insufficient and often incomplete.
• Mrs Y lost 10 kg since admission to the Care Home. She was malnourished and staff could not monitor her weight weekly due to her distress reaction.
• An appropriate care plan not developed as Mrs Y was ‘admitted as a respite client.’
• There was no evidence of an appropriate skin assessment on admission.
• The wounds were avoidable as they were a deep tissue injury which occurred due to poor pressure relief management.
48. The report set out an action plan with recommendations which included Mrs Y moving to a nursing home, full staff training in pressure care and supervision about record keeping. Four members of staff were disciplined.

Safeguarding

49. The Council’s safeguarding enquiry concluded Mrs Y suffered neglect because:
• She had a high risk of pressure sores and needed support with repositioning but there was no record of this taking place so the frequency of repositioning before the end of May was unknown
• She had ulcers on the buttock noted in May, but there was no change to the care plan
• The district nurse found a deep tissue injury and one pressure sore and noted the pressure mattress was not on.
50. The safeguarding enquiry made recommendations for risk management plans and for staff to check and record equipment was working and keep repositioning records, as well as for training in skin management and pressure sore care.

The Care Provider’s complaint responses

51. The Care Provider’s responses to the complaints said:
• There was a referral to the district nurses to treat Mrs Y’s long-term leg ulcers. She was at high risk of pressure sores and so had an air-flow (pressure relieving) mattress
• It was hard to monitor Mrs Y’s weight because she got anxious during weight monitoring
• Staff identified within two weeks of moving in that Mrs Y required nursing care and referred her for a nursing assessment
• The mental health team agreed Mrs Y needed nursing care in May, but a move was delayed until June because of the pandemic.
• Staff noticed moisture lesions on each buttock in the middle of May and told the district nurses. The Care Home’s record keeping in relation to the decline of Mrs Y’s skin was not up to standard. The district nurses visited at the end of May and had no concerns about the management plan for the lesions.
• Mobility and skin integrity risk assessments were not completed as well as they should have been. There were no records of two hourly pressure relief until the end of May.
• Records were contradictory: one assessment said Mrs Y had high needs for continence care, but a care plan said she had low needs. However, the care plan said she needed two staff for support and there were records confirming regular continence care.
• Communication with Mrs X was acceptable (there were four contacts to tell her about changes to Mrs Y’s care). Communication was more difficult during lock down.
• The district nurses noticed the mattress was turned off on 25 May. They had visited urgently because staff noticed Mrs Y had developed discolouration to her right hip and right foot. The managers at the Care Home referred the case to the Council’s safeguarding team.
• Mrs Y received as and when required medicine in line with the GP’s prescription and advice from the mental health team.
52. The Care Home’s complaint response included a summary of actions it had taken as a result of Mrs X’s complaint. They included:
• Internal disciplinary procedures
• Training in incident reporting and record keeping for senior managers
• Supervision in record keeping and pressure area care, all staff completed training in pressure damage. Further training from the tissue viability team had been requested
• In-house training in distressed reaction.
53. At the end of June, the manager of the Care Home notified the Care Quality Commission of the safeguarding concern.

Findings: Was there fault?

54. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So any fault by the Care Home was fault by the Council.
55. Generally, the Care Home was at fault because it did not complete a proper pre-admission assessment and did not complete care plans until several weeks after Mrs Y was admitted to the Care Home. Some of the care plans, such as the one for behaviour, were not adequate in terms of the detail. This meant staff did not have any instructions about Mrs Y’s needs and how to deliver care to meet those needs. This was poor record keeping and a failure to act in line with Regulations 9 and 17 of the 2014 Regulations.

Complaint a: over-use of a sedative

56. There was no fault. The Care Home had an individual care plan for the use of as and when required medication and the medication records showed Mrs Y received the sedative in line with the care plan. Care was in line with Regulation 9 of the 2014 Regulations as it was tailored to Mrs Y’s specific needs and in line with Regulation 12 because it was given accurately, at suitable times and in line with prescribed instructions.

Complaint b: Weight loss

57. The Care Home had difficulty weighing Mrs Y because of her distress and there were some weights in her care records that do not make sense. One entry in the weight chart suggested she weighed 66 kg in May (see paragraph 31) which if accurate, was a gain since the previous weight. However, the Care Provider accepted Mrs Y had lost 10kg in its own incident report into her care (see paragraph 47). This was a significant loss in less than three months. The Care Provider started to note Mrs Y’s food and fluid intake in response to this. It should also have referred Mrs Y to her GP to enable urgent access to more specialist healthcare like a dietician. As these referrals were not made, I find there was a failure to work effectively with professionals to ensure Mrs Y received appropriate healthcare and this was not in line with Regulation 12(1). There was also a failure in providing care to meet Mrs Y’s nutritional needs in line with Regulation 15.

Complaint c: Poor care of pressure sores and moisture lesions

58. The Care Home should have kept a skin integrity care plan for Mrs Y from the outset as she had an existing leg sore when she moved in. I note the district nurses were responsible for treating this, but my view is there should still have been a care plan identifying Mrs Y’s needs around skin care and setting out the agreed plan of care and communication between the district nurses and the care home staff.
59. The district nurse found the mattress was unplugged. This was a gross failure in basic standards of care by the Care Home. Mrs Y’s mattress should have been checked on each care intervention to ensure it was plugged in, switched on and on the correct settings. This was in Mrs Y’s care plan and it was also an obvious action for each member of care staff who looked after her to take. This failure in care caused Mrs Y to develop a deep tissue injury, which the Care Provider accepted was avoidable in its serious incident analysis.
60. Moreover, as the Care Home did not keep any records of checks it did to make sure pressure mattresses were plugged in, switched on and at the correct pressure, I cannot say how long Mrs Y was without pressure relief. This was not in line with:
• Regulation 17 because it was a failure to keep required records
• Regulation 12 because it was a failure to provide safe care or provide care in a way that mitigated reasonable risk
• Regulation 15 because it was a failure to ensure equipment was properly used or maintained
• Regulation 13 because it was a failure to ensure care was delivered in a way that minimised the risk of abuse. (The definition of abuse includes unintentional neglect, such as poor delivery of care)
61. The Care Home updated Mrs Y’s care plan after 25 May to say Mrs Y required two hourly turns. It did not record those turns other than for four days. This was a further failure in delivering appropriate person-centred and safe care under Regulation 9 and a failure in record keeping under Regulation 17.
62. There is some ambiguity in the evidence about whether the injury noted to the buttocks around 21/22 May was a moisture lesion or pressure sore. The two conditions are often misidentified but may require different treatment. I note the district nurses were responsible for wounds requiring dressing. However, the Care Home was responsible for Mrs Y’s personal care and that included cleaning intimate areas. My view is liaison by the Care Home’s staff with the district nurses was inadequate. The Care Home should have liaised with the district nurses to establish whether the wounds on the buttocks were moisture lesions or something else and whether a specific cleansing regime was required. The skin integrity care plan should have then been updated in line with the district nurse’s advice. This was a further failure to deliver care in line with Regulation 12(i) (failure to work effectively with health care professionals) and a failure to deliver person-centred care as set out in Regulation 9.

Complaint d: Poor communication

63. The Care Home’s report indicated staff contacted Mrs X (or one of the other daughters, the records are not clear) to tell the family what had happened about the mattress. The Care Provider apologised in the complaint response. This was in line with the duty of candour.
64. I have seen no other records of communication between staff and Mrs X. I note communication with relatives was exceptionally difficult during the first lockdown, for reasons outside the Care Home’s control, however I would expect to see some records of phone contact during this period. Poor communication with Mrs X was a further fault.

Complaint e: Three falls out of bed.

65. The Care Home’s records only described one fall from bed in June, however, the nursing needs assessment referred to two additional falls from bed in April. As such, I do not consider the Care Home’s record-keeping to be in line with accepted standards or in line with Regulation 17. Each fall should have been clearly documented in the records including action taken once the fall was discovered.
66. Mrs Y’s care plan indicates she had a pressure mat in place to alert staff when she had moved from bed. The care plan should have been reviewed and updated to reflect the falls she’d had and to see whether other steps needed to be taken to reduce the risk of recurrence (such as a referral to the falls team). This was a failure to deliver tailored individual care in line with Regulation 9 or to work effectively with healthcare professionals in line with Regulation 12(1).

Agreed action

67. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the Care Home, I have made recommendations to the Council.
68. I consider the failings in Mrs Y’s care caused her avoidable distress and suffering. The Council and Care Provider both accepted the deep tissue injuries were avoidable. However, Mrs Y is no longer with us and we don’t generally recommend payments to the estate for that person’s avoidable distress and suffering.
69. I consider Mrs X has also suffered avoidable distress in learning of the multiple failures in her mother’s care. The Council needs to apologise and make her a symbolic payment of £500 to recognise this distress.
70. The Council should also, within one month, carry out a quality monitoring visit. The Council should ensure:
• all residents it places in the Care Home have up to date assessments and comprehensive care plans
• the Care Home is doing frequent checks to make sure pressure mattresses are plugged in, switched on and is documenting those checks.
• all staff at the Care Home are properly documenting repositioning for those residents who require it.
• all staff have had appropriate training in identifying the signs of increased risk of developing pressure sores.
71. After the initial quality monitoring visit, the Council should include spot checks on care plans and equipment maintenance as part of its routine quality monitoring.
72. We will require evidence of compliance.

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Final decision

73. There were multiple failures in the late Mrs Y’s care at a council-funded care home, including an avoidable serious deep tissue injury. The Council will apologise and make her daughter Mrs X a symbolic payment to reflect her avoidable distress. The Council will also take action described in this draft statement to minimise the chance of recurrence.
74. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman