Summary: There is no evidence the care provider failed to provide a good standard of care to Mrs X.

The complaint

1. Mrs A (as I shall call her) complains the care provider failed to care for her late mother’s skin properly so she developed pressure sores; failed to provide adequate nutrition and hydration; and did not treat her mother with dignity at all times. She says the failure to provide proper care worsened her mother’s pressure sore and increased her discomfort.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)

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How I considered this complaint

3. I considered the information provided by Mrs A and by the care provider. Both the care provider and Mrs A had an opportunity to comment on an earlier draft of this statement and I considered their comments before I reached a final decision.

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What I found

Relevant law and guidance

4. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
5. Regulation 9 says care and treatment must be appropriate and meet service users’ needs;
6. Regulation 10 says service users must be treated with dignity and respect at all times;
7. Regulation 14 says the nutritional and hydration needs of service users must be met.
8. NICE provides guidance on the prevention and management of pressure sores. It says, “Adults considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors (for example, significantly limited mobility, nutritional deficiency, inability to reposition themselves, significant cognitive impairment) identified during risk assessment with or without a validated risk assessment tool. Adults with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.”

In respect of risk assessments, it says:

“Carry out and document an assessment of pressure ulcer risk for adults:

being admitted to secondary care or care homes in which NHS care is provided or

receiving NHS care in other settings (such as primary and community care and emergency departments) if they have a risk factor, for example:

significantly limited mobility (for example, people with a spinal cord injury)

significant loss of sensation

a previous or current pressure ulcer

nutritional deficiency

the inability to reposition themselves

significant cognitive impairment.

Consider using a validated scale to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale) when assessing pressure ulcer risk.

Reassess pressure ulcer risk if there is a change in clinical status (for example, after surgery, on worsening of an underlying condition or with a change in mobility).”

What happened

9. The late Mrs X became resident at the care home in July 2020. Initially she was admitted for a respite stay after a hospital admission. Her husband was her main carer and had also been admitted to hospital at the time.
10. The care provider carried out risk assessments for Mrs X. Her pressure sore assessment showed she was at high risk of developing pressure sores. The care provider also carried out a recommended Waterlow assessment and she was found to be at very high risk of pressure sores developing. At the time of the assessment on 30 July her skin was intact, according to the care home notes. She was described as being able to move herself independently to relieve pressure. Her care plan noted her skin was checked every day and any abnormalities would be reported to the nurse.
11. The care plan was reviewed on a monthly basis. By 13 September 2020 Mrs X had developed a pressure sore on her sacrum. The care home notes say, “(Mrs X) needs to be repositioned every three hours but she is non-compliant with repositioning and will reposition herself”.
12. The care provider made an urgent referral to the Tissue Viability Nurse on 28 September.
13. Mrs X was described as ‘confused’ at the time she entered the home but did not have a formal diagnosis of cognitive impairment. In line with her family’s wishes, in August the care provider arranged for the doctor to examine her as she was showing signs of dementia.
14. Mrs X’s nutrition and hydration care plan noted that on entry to the home she was independent with eating and could eat a normal diet. She lost some weight over the next two months as her dementia worsened and the care home instituted a fluid intake chart to ensure she was offered sufficient fluids and her intake was monitored.
15. Mrs X fell twice during her stay in the care home. She fell on 12 August and staff notified her family. On 13 September she was found lying on her bedroom floor with her head bleeding. She was fully conscious and the nurse followed the home’s protocol in checking her. The care home records show that checks were carried out at specified intervals after the fall. The doctor was informed and advised further contact if there were any changes in her condition.
16. The care provider noted that Mrs X was low in mood after the death of her husband in August, her appetite suffered, and she developed a rash. The care home arranged for the GP to visit. The GP considered Mrs X was suffering from reactive depression after the death of her husband and prescribed anti-depressants which were later discontinued by the hospital in case they were exacerbating her skin rash.
17. By September Mrs X was assessed as no longer having capacity to make her own decisions about her future care and treatment. The care provider’s files show that her GP agreed a DNAR (‘do not attempt resuscitation’) plan with Mrs X’s family on 23 September. Sadly, Mrs X died shortly afterwards.

The complaint

18. Mrs A complained to the care provider in October 2020. She complained about her mother’s skin integrity and treatment of pressure sores. She also complained that when her mother had been taken into hospital, the straps placed around her on the stretcher were too tight.
19. The care provider replied in December (having previously acknowledged the complaint and explained that a full response would take 60 days). It gave a full explanation of the way in which it had approached the problem of Mrs X’s skin integrity. It said it developed a care plan as soon as it noticed the pressure sore: it provided an air mattress and air cushion for when Mrs X was sitting out of bed. It said although it had a repositioning plan in place, because Mrs X was able to move independently she would move herself back. She also took to removing newly-applied dressings. The GP was aware of the pressure sore and advised care staff to continue with the care as planned.
20. The care provider also responded to Mrs A’s complaint about the straps on the stretcher. It said as Mrs X was then under the care of paramedics, that was a matter for them.
21. In January 2021 Mrs A complained again. She said the care plan was put in place too late. She complained about her mother’s food and fluid intake and said the home had not done enough to combat her mother’s poor appetite. She complained that the DNAR notice had not been discussed with family. She complained about a lack of dignity and staff not encouraging Mrs X to use the commode.
22. The care provider replied that Mrs X’s skin had been checked on a daily basis but no signs of a sore had been seen before 13 September, when the care plan was implemented straight away. It repeated that unfortunately Mrs X repositioned herself and removed the dressing. It said in accordance with regulations, a notice of the pressure sore was submitted to the CQC.
23. Mrs A says the pressure sore had closed over with new tissue by the time it was noticed and that was why she could not keep the dressings on.
24. The care provider’s records showed the GP had discussed the DNAR notice with the family. He had agreed with the family that as Mrs X was nearing the end of life, she would continue to be treated in the home and no fluids or nasogastric feeding would take place as it would not be in her best interests to do so.
25. In respect of the use of the commode, the care provider said there was one occasion when a commode was not instantly available and so the carer had sought to reassure Mrs X that she was wearing an incontinence pad. The care provider said it had reminded staff to be clear in their communications with residents to avoid any future misunderstandings. Mrs A says she was present when the carer told Mrs X it would be ‘easier’ if she relieved herself and not be moved to the commode.
26. Mrs A complained again, about the care of the pressure sores, the food and fluid intake and the language staff had used about the use of the commode. The care provider responded again in detail to her concerns. It also said it had now concluded its internal investigations of her complaints.
27. Mrs A complained to us that the care provider had not responded properly to her complaints. She says it was the carers in the home which placed the straps too tightly round her mother in the wheelchair before the paramedics moved her to a stretcher.

Analysis

28. The care provider’s records show it took action to implement an appropriate care plan as soon as a pressure sore was noted on Mrs X’s skin. Its care plan complied with the guidelines. The difficulty of treating the area was exacerbated by Mrs X’s habits of turning herself back after repositioning, and removing the dressings. The GP advised the care provider to continue with its care plan. The care provider appropriately referred Mrs X to the Tissue Viability Nurse and reported the pressure sore to the CQC. I note Mrs A’s point about the fragility of the regrown tissue but I am satisfied that it was known to clinical professionals.
29. The care provider’s records show that Mrs X’s food and fluid intake deteriorated during the time she was in the home. Although the care provider encouraged Mrs X to eat and drink, and offered supplements, Mrs X refused to take them. The GP was aware of Mrs X’s loss of appetite and agreed that it was not in her best interests to admit her to hospital or start artificial feeding.
30. There is no evidence the care staff treated Mrs X with a lack of respect.

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Final decision

31. I have now completed this investigation. I find the actions of the care provider did not cause injustice to Mrs X.

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Investigator's decision on behalf of the Ombudsman