Summary: Mrs Y complains about the failure of a care provider to ensure a sore on her mother’s leg was appropriately cleaned, dressed and treated. We find fault because there is no evidence to show the care provider properly assessed the sore or sought medical help. This fault creates distress and uncertainty for Mrs Y which the Council will remedy with an apology, a payment of £300 and some procedural improvements.

The complaint

1. Mrs Y complains about the lack of care and treatment her mother received while resident at ‘Holmes House Care Home’ provided by ‘Prime Life Limited’.
2. Mrs Y says the home failed to ensure that a dressing on her mother’s leg was regularly cleaned and re-dressed, which led to the wound becoming infected.
3. Mrs Y also says the home failed to seek appropriate medical help for the infection and did not keep accurate records which meant it was not possible to ascertain the level of care her mother had received.

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The Ombudsman’s role and powers

4. 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)
5. 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)
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council or a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)

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

7. During my investigation I discussed the complaint with Mrs Y and considered any information she provided.
8. I made enquiries of the Council and considered its response, which included information from the care provider.
9. I consulted the relevant law and guidance around the standards of social care, which I have referenced where necessary in this statement.
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.
11. I issued my provisional findings in a draft decision to the Council and Mrs Y. I considered any comments they made before I issued my final decision.

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What I found

What should happen

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards which registered providers of care must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
13. 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 receiving care or treatment;
• do all that is reasonably practicable to mitigate any risks;
• ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely;
• assess the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated;
• work with service users and other appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of the service users.
14. Regulation 17 places a requirement on social care providers to securely maintain an accurate, complete and contemporaneous record for each service user. This includes a record of the care and treatment of the person, as well as any decisions made about their treatment. in doing so, providers must:
• ensure records are complete, legible and accurate and updated without delay.
• record all decisions taken about care and treatment, including discussions with service users and other relevant people.
15. The home’s policy ‘Prevention of Pressure Ulcers’ contains the following information:
• Should a pressure ulcer exist on admission to the home, the GP/District Nurse/Tissue Viability Nurse must be informed and consulted regarding the treatment to be given
• The Nurse/District Nurse/Tissue Viability Nurse will decide how to wash and maintain existing sores
• Wounds will require assessment to grade the severity to provide the most effective management and treatment
• The home will use a recognised assessment tool within 24 hours of admission to assess risk

What happened

Background information

16. Mrs Y’s mother, whom I will call Mrs X, was resident at ‘Holmes House Care Home’ in February 2020 for short-term respite care commissioned by the Council. I will refer to the care provider throughout the rest of this statement as ‘the home’.
17. Before going into the home, Mrs X had received emergency surgery to remove a tumour from her colon. Following the surgery, Mrs Y says her mother’s body retained excess fluid and consequently she developed an ulcerated sore on her leg which needed regular cleaning and dressing.
18. Mrs Y says her mother left the home after ten days. During that time Mrs Y says Mrs X’s wound was not cleaned or checked by the appropriate professionals and as a result Mrs X sustained an avoidable infection.
19. Mrs X passed away before Mrs Y complained to the LGSCO.

Actions of the care provider

20. A body map completed by the home on Mrs X’s admission recorded “dressing on pressure sore on right shine [sic]”. Two days later the home updated the body map with additional information: “[Mrs X] has red sore areas under both breasts, this was seen upon personal care”. The home recorded that it had washed and dried Mrs X’s chest and used specialist wipes to soak up any excess sweat.
21. Mrs X’s care plan also said, “[Mrs X] is coming into the home with all her pressure areas intact but does have her legs in dressing due to swollen weepy legs and the district nurses deal with this”. An undated handwritten document states, “will need DN [District Nurse] to visit for legs and operation wound”.
22. The home has provided daily care records for Mrs X. Three of the ten days are missing. The records which have been provided make no reference to Mrs X’s sore or provide details of any medical intervention.
23. The day before her departure the home completed an evaluation of Mrs X’ care plan, which stated, “no changes since arrival. DN for legs. GP input. Staff to monitor and report changes” and “[Mrs X] has no pressure sores or skin [illegible word] but has bandages on legs DN comes changes. Staff to monitor report to senior”.

Complaint handling

24. Mrs Y made a formal written complaint to the home in October 2020. The home provided a response four days later. The response was brief and did not demonstrate any investigation or analysis undertaken by the care provider. Instead, the home reiterated that its staff were not able to carry out clinical tasks such as the dressing of wounds. The care provider was not able to say when District Nurses visited Mrs X or on how many occasions.
25. The care provider also failed to inform Mrs Y of her right to escalate her complaint to the LGSCO, which caused some delay in Mrs Y approaching us. For this reason we exercised discretion to investigate matters which Mrs Y has been aware of for more than 12 months.

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

26. The LGSCO recognises and accepts that social care staff are not trained or qualified to dress and clean wounds. This would fall within the remit of a registered nurse. However, the LGSCO expects care providers to have oversight of the service users it cares for to ensure that proportionate and timely medical intervention is sought when necessary.
27. The home says that Mrs X was receiving input from the DN before her admission, and this continued during her stay at the home. However, there is no record of any such input during the ten days Mrs X resided there. Therefore, in my view and based on the information seen I find fault because:
• The home’s body map says that Mrs X had an existing pressure sore on her right shin, yet there is no evidence the home consulted any healthcare professionals to establish what existing treatment, if any, Mrs X was receiving at the time. This is not in accordance with its policy on the management and prevention of pressure sores. This also represents a breach of the fundamental standards of care because the home did not act to mitigate the risk to Mrs X.
• The home failed to arrange a ‘waterlow’ assessment on Mrs X’s admission. This assessment will have determined the grade of Mrs X’s sore and would have informed the type and frequency of treatment to be administered by healthcare professionals.
• The home asserts that a District Nurse visited to attend to Mrs X during her stay there, however there is no record of these key visits nor is there any record of any medical intervention. Furthermore, there are three missing days of care records for Mrs X. This is a further breach of the fundamental standards of care.
28. We cannot conclude with certainty whether Mrs X received any input from healthcare professionals during her stay at the home. Mrs Y says that her mother’s leg was in a very poor state upon her departure from the home and she sustained an infection as a direct consequence of the home’s failures. The LGSCO cannot make a causal link between the home’s actions and Mrs X’s medical ailments, however we find the home’s actions created avoidable uncertainty and distress for the family which the Council will remedy.

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Agreed action

29. 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 we found fault with the actions of the care provider, we have made recommendations to the Council.
30. Within four weeks of my final decision, the Council has agreed to:
• Pay £300 to Mrs X’s family for the avoidable uncertainty and distress caused by the maladministration identified in this statement; and
• Provide an apology from the care provider for the failures identified.
31. Within twelve weeks of my final decision, the Council will ensure that:
• The care provider updates its ‘Comments Complaints & Compliments Policy and Procedure’ to ensure that all final complaint responses include signposting to the LGSCO;
• The care provider reminds its staff (either through written guidance, training or supervision) of the requirement to adhere to the ‘Prevention of Pressure Ulcers’ policy, in particular with the assessment of wounds and seeking intervention from medical professionals when appropriate; and
• The care provider reminds its staff (either through written guidance, training or supervision) of the requirement to keep complete and accurate notes relating to the care and treatment of all service users.

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Final decision

32. We have completed our investigation with a finding of fault causing injustice for the reasons explained in this statement. The actions listed above will provide an appropriate remedy for the injustice caused by fault.

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Investigator's decision on behalf of the Ombudsman