Summary: Ms J complained the Care Provider caused her late grandmother an injustice by failing to follow her care plan and its procedures. She also says it failed to communicate with her properly. As a result, she says she and her grandmother experienced distress, and she had a loss of opportunity to visit her during COVID-19. The Care Provider agreed it was at fault for failing to follow its procedures when moving Mrs X. However, we cannot say if this caused the fracture to her leg. We also found it caused a short delay in calling an ambulance and did not call Ms J as agreed when it arrived. The Provider has agreed to apologise and make payment to Ms J to remedy the distress it caused.

The complaint

1. Ms J complained on behalf of her grandmother, Mrs X, who has passed away. She said Altruistic Care Limited, the Care Provider, failed to:
• follow its procedures when transferring Mrs X from and to her bed;
• call an ambulance without delay when its Registered Nurse attended to Mrs X;
• explain how Mrs X sustained the fracture to her leg; and
• communicate as agreed with Ms J and tell her about its COVID-19 visitation procedures.
2. As a result, Ms J said Ms X experienced pain and distress. Ms J also said she experienced distress due to witnessing Mrs X’s distress and her lost opportunity to visit her during COVID-19.

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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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
4. If we are satisfied with a care 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)
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. As part of my investigation, I have:
• considered Ms J’s complaint and the Care Provider’s responses;
• discussed the complaint with Ms J;
• considered the information provided by the Care Provider;
• considered relevant law, guidance and policy; and
• given Ms J and the Care Provider the opportunity to comment on a draft version of this decision and considered the comments I received.

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What I found

Law and guidance

7. 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. We consider the 2014 Regulations and the Fundamental Standards, as well as a provider’s policies and procedures, when determining complaints about poor standards of care. The following regulations are relevant to this complaint:
8. Regulation 9 (Person-centred care) says each service user should receive care that is personalised specifically for them, that meets their needs and reflects their preferences.
9. Regulation 12 (Safe care and treatment) says care providers should prevent service users from receiving unsafe care and treatment, in order to prevent any avoidable harm or risk of harm. It includes the requirement to exchange information where responsibility for the care and treatment of service users is shared with, or transferred to, other persons (in this case the ambulance service).

What happened

10. Mrs X was bedbound and required support with all her care needs.
11. Mrs X’s care was provided by Altruistic Care Limited (the Care Provider), in its Plane Tree Court care home in Stockport.
12. Mrs X’s care plan said she could bruise easily due to her medication and set out the procedure for how she should be transferred to and from her bed. This required the use of a hoist at all times to prevent injury.
13. In early 2021 Mrs X received her COVID-19 vaccination at her GP. Due to her medical conditions this was administered to her right thigh.
14. The following day Mrs X was assisted out of bed on two occasions. The first included the use of the hoist to as set out in her care plan. At night, the staff noticed Mrs X had a swelling on her right thigh. They told the Registered Nurse who found this it was likely to be due to the COVID-19 vaccine. Later that night the staff noticed her bed had deflated. They decided to use a sheet to move her from the bed to a bucket chair and from this to a bed in another room.
15. The next day Mrs X was moved back to her own room as her bed had been inflated. The hoist was used as set out in her care plan.
16. Two days after Mrs X’s bed transfer, Mrs X was examined by her GP. Although, her thigh had a swelling, the GP did not find any injury to her leg, and she was not in pain.
17. The following day Mrs X told staff she was in pain. The Registered Nurse decided to call her GP as this was set out in her care plan to be her preferred medical support. The Nurse also called Ms J. However, before the GP could visit, the Care Provider’s Deputy Manager examined Mrs X. He found her leg to be displaced and decided she needed to be taken to hospital. It was agreed with Ms J the Care Provider would call her when the ambulance arrived.
18. Mrs X was taken to hospital and stayed there. An Orthopaedic Consultant examined her and found she was extremely osteopenic, which means she was severely fragile, and injury could occur with minimal contact. He found Mrs X’s leg may have become displaced sometime after the contact or rotation of her leg.
19. The Care Provider notified the Care Quality Commission about the incident.
20. Mrs X’s son asked the Council to open a safeguarding investigation due to his concerns about the care Mrs X had received from the Care Provider in the days leading up to her hospitalisation.
21. After a short period in hospital, Mrs X was moved to another care home. She did not return to the Care Provider’s home due to the ongoing safeguarding investigation. Sadly, a few weeks after leaving hospital Mrs X passed away.

Ms J’s complaint

22. Ms J complained to the Care Provider about its handling of Mrs X’s care in the days leading up to her hospitalisation. She said:
• it should explain how Mrs X’s leg became displaced and why its staff delayed calling an ambulance when it was clear her leg was displaced;
• its Duty Manager had failed to call her as agreed when the ambulance arrived;
• she had not been told about the GP’s visit due to concerns about the swelling on Mrs X’s thigh following her COVID-19 vaccination;
• it had failed to tell her she could have visited Mrs X once a month during COVID-19.

The Care Provider’s response

23. The Care Provider told Ms J it had investigated her concerns. It said:
• its staff had moved Mrs X to and from her bed on two occasions with a sheet. This was not as set out in her care plan, and it breached its Moving and Handling Policy and procedures. It had taken appropriate disciplinary action against the staff involved;
• it could not say when Mrs X’s leg displacement occurred. This was because her GP had examined her two days after the staff had incorrectly moved Mrs X but found no sign of displacement. It also said she was not in pain or discomfort until the day after the GP’s visit;
• it explained it was not aware Mrs X had osteoporotic bones. This was first diagnosed by the Orthopaedic Consultant when she was in hospital. It said it had since worked with her GP to assess her bone density and it intended for medication to be prescribed;
• it apologised its Deputy Manager had not called Mrs J when the ambulance arrived. It explained he was on calls with the hospital regarding Mrs X’s care. He would have called Mrs J but she managed to call him first;
• it explained it believed its Deputy Manager had told Ms J about visitations during COVID-19 and it wrote to her three times to advise how families could visit; and
• it offered to discuss any further concerns Ms J had with it or Mrs X’s GP.
24. Ms J was not satisfied with the Care Provider’s response and brought her concerns to the attention of the Ombudsman.

The Safeguarding and Coroner’s findings

25. The Council considered Mrs X’s son’s safeguarding concerns and held a strategy meeting. It discussed the Orthopaedic Consultant’s report and found the Care Provider’s actions amounted to neglect. However, it did not find this was wilful neglect by the staff as they did not intend to harm Mrs X.
26. The Coroner’s report found he could not ascertain when Mrs X’s injury to her leg occurred. He explained it would only take minimal contact for this to happen, so this could have occurred during her regular care in the days before her hospitalisation.

Analysis

27. The Care Provider agreed its staff failed to follow the correct procedure when transferring Mrs X from her bed and to another bed. Their use of a sheet was against its Policy and the procedure set out in Mrs X’s Care Plan.
28. However, based on Mrs X’s care records, the correct moving and handling procedures appears to have been followed before and after this incident. These also show it provided support as set out in her Care Plan and reported concerns to the Registered Nurse and her GP when the swelling to her thigh appeared. In addition, the Care Home has confirmed all its staff has received appropriate training and this is up to date. I am therefore satisfied the breach of procedures only related to the staff who moved Ms X and it has taken disciplinary action against the staff involved.
29. I understand Ms J feels the Care Provider caused Mrs X’s leg displacement and it failed tell her how Mrs X’s leg became displaced. However, I cannot say the Care Provider’s actions caused her injury. This is because no one, including the Orthopaedic Consultant and the Coroner, were able to establish when the injury occurred. I am therefore satisfied its response to Ms J explained the events and its actions as much as this was possible.
30. When the Registered Nurse attended to Mrs X, she found her leg was swollen and she called her GP as set out in her care plan. The Care Provider’s Deputy Manager attended shortly after and decided she needed to be taken to hospital instead as her leg was fractured. I acknowledge the Deputy Manager had clinical experience. However, on balance, I am satisfied the Registered Nurse should have arranged for an ambulance when she attended to Mrs X. This is because Mrs X Care Plan says her GP should be called if her general health worsens, but an ambulance should be called if she has serious injuries such as the leg fracture. I therefore found this caused a short delay and Mrs X may have experience some distress during this short period.
31. The Care Provider agreed it did not call Ms J when the ambulance arrived. It said it intended to do so. I acknowledge the Deputy Manager may have been busy with liaising with the hospital, however, I am satisfied there was a short delay in telling Ms J the ambulance had arrived. This caused Ms J some distress. The Care Provider apologised to Ms J, and I am satisfied this is enough to remedy the injustice this caused her.
32. Ms J also said the Care Home did not properly communicate visitation opportunities during the COVID-19 pandemic. She was therefore not aware she could have visited Mrs X. The Care Provider said it did tell Ms J about visitation, but it apologised if this was not clear. It sent several letters and newsletters to relatives of its residents. I cannot say if all of these were sent to Ms J, however, the evidence shows it did send three communications to her. These explained visitation was possible and who she could contact to arrange a visit during COVID-19. I am therefore not satisfied the Care Provider caused Ms J an injustice on this matter.

Injustice

33. As I cannot say what caused Mrs X’s leg displacement, I cannot say the Care Provider’s actions caused the pain and distress she experienced. Therefore, the main injustice is the uncertainty (distress) of not knowing whether things would have been different if the Care Provider had followed its own procedures.
34. Sadly, Mrs X, who suffered the main injustice from the Care Provider’s fault, has passed away and therefore any injustice to her cannot be remedied.
35. The injustice of distress cannot generally be remedied by a payment, so we seek a symbolic amount to acknowledge the impact of the fault. The Ombudsman usually recommends a payment of between £100 and £300 for distress. I am of the view that £150 would be appropriate in this case.

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Agreed action

36. To remedy the injustice the Care Provider caused to Ms J, the Care Provider should, within one month of the final decision:
1. Apologise in writing to Ms J for its faults; and
2. Pay Ms J £150 to acknowledge the distress she experienced due to the uncertainty its faults caused.

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Final decision

37. I have completed my investigation with a finding of fault by the Care Provider. The actions the Care Provider has agreed to take are sufficient to remedy the uncertainty it caused.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman