Summary: Miss X complained about the care her mother, Mrs Y, received from Newgrange of Cheshunt Limited. The Care Provider was at fault. Staff did not properly follow policies on using a transfer aid and on wound care management whilst providing care to Mrs Y. Staff also did not notify Mrs Y’s family about her injury. The Care Provider has recognised its faults and has put measures in place to prevent a recurrence of fault. The Care Provider has also agreed to apologise to Mrs Y and her family for the distress the faults caused them. It will make a symbolic payment of £150 to Mrs Y. In addition, the Care Provider has agreed it will review staff knowledge and understanding in relation to the poor care it delivered to Mrs Y.

The complaint

1. Miss X complained about the care her mother, Mrs Y, received during a respite stay at Newgrange Residential Home which is run by Care Provider, Newgrange of Cheshunt Limited. She said:
1. her mother received a skin tear to her arm whilst staff assisted to transfer her during personal care;
2. staff did not properly dress her mother’s wound;
3. staff did not inform Miss X or her family of her mother’s injury; and
4. staff damaged her mother’s wheelchair.
2. Miss X said the matter caused her mother distress and resulted in her mother leaving the Care Home before her discharge date. Miss X wants care staff to receive the appropriate training for moving and handling people who use the service and for wound care management.

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What I have investigated

3. I have investigated section a, b and c of Miss X’s complaint. I have not investigated section d and have explained why at the end of this decision statement.

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The Ombudsman’s role and powers

4. 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)
5. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. 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)

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How I considered this complaint

7. I spoke with Miss X and considered the information she provided.
8. I considered the information provided by the Care Provider.
9. I considered our ‘Guidance on Remedies’.
10. Miss X and the Care Provider had the opportunity to comment on the draft version of this decision. I considered their comments before making the final decision.
11. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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What I found

12. 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) is the statutory regulator of care services. It has issued guidance on how to meet the fundamental standards below which care must never fall:
• Regulation 12 sets out what care providers must do to prevent people from receiving unsafe care and treatment. This includes care providers ensuring the equipment they use for providing care and treatment to people is safe for use and used in a safe way.
• Regulation 18 sets out care providers must ensure staff receive appropriate support and training for them to carry out their role and responsibilities.

The Care Provider’s policy on using a Rota Stand

13. The policy states the Rota Stand should only be used to pivot a resident from a sitting to a standing position and then to a sitting position again. It should not be used to move a resident any distance.
14. All staff need to complete the Care Provider’s moving and handling training each year which supports them to use the Rota Stand.

The Care Provider’s policy on wound care management

15. The policy states staff should adhere to the following procedure when managing wound care:
• apply a non-stick dressing to the wound.
• mark on the dressing with an arrow, the direction of the tear and where the flap is to ensure the skin flap remains intact when the dressing is removed.
• contact the District Nurse Team for an immediate visit.

What happened

16. Mrs Y was admitted to the Care Home towards the end of June 2021 for three weeks of respite care. Mrs Y’s mobility is poor. She requires the support of two staff and a transfer aid to support her to move and transfer positions. Mrs Y also uses a wheelchair to support her with her mobility. In addition, Mrs Y is at high risk of tissue damage as she has poor skin integrity.
17. In July 2021, two care workers supported Mrs Y in the morning with her personal care. Mrs Y requested to be ready by 07:45 as her family was planning on collecting her at that time to take her to an outpatient hospital appointment. The Care Workers assisted Mrs Y to get onto a Rota Stand from her bed. They then moved Mrs Y into the bathroom, whilst she was on the Rota Stand. The Care Workers assisted Mrs Y with oral care at the sink basin, as Mrs Y was standing on the Rota Stand. During this time, Mrs Y’s arm got caught between the Rota Stand and the sink basin which resulted in a significant skin tear on her arm. The Care Workers cleaned and dressed the wound.
18. Shortly after the incident, Mrs Y’s family arrived at the Care Home to collect Mrs Y for her hospital appointment. Staff did not inform Mrs Y’s family of her injury. At the hospital, a Matron noticed Mrs Y’s injury to her arm and applied a new dressing.
19. Mrs Y did not return to the Care Home after her hospital appointment because she and her family did not feel she was safe there following her injury.

Miss X’s complaint

20. Following the incident, Miss X complained to the Care Provider. She wanted to know how her mother had been injured and why staff had not informed her or her family of the incident, especially as they had collected Mrs Y from the Care Home shortly after the incident. She also said staff had not properly dressed the wound. In addition, Miss X said a footplate on her mother’s wheelchair had been damaged at the Care Home and she wanted to know how this had happened.
21. The Care Provider carried out an investigation into Miss X’s concerns and responded to her. It explained to Miss X how her mother had been injured. It said all staff at its Care Home had completed appropriate moving and handling training however, it recognised staff required further training on using the Rota Stand. It said it would arrange this further training. The Care Provider continued and said staff had applied the dressing to Mrs Y’s wound correctly and with great care.
22. The Care Provider explained to Miss X why it did not inform her or her family her mother had been injured. It said staff had not been able to document the incident before they came to collect Mrs Y for her hospital appointment.
23. In addition, the Care Provider said Mrs Y’s wheelchair was damaged but it did not have any information on how it happened and it was unable to take responsibility for the damage. The Care Provider offered to fix the wheelchair but Mrs Y and her family declined the offer.
24. The Care Provider completed its investigation.
25. Miss X remained unhappy and complained to us. As part of her complaint, Miss X provided us with pictures of her mother’s wound and the dressing staff at the Care Home had applied on it. The dressing did not have any markings on it, indicating the direction of the tear and the skin flap.

The Care Provider’s response to our enquiries

26. In response to our enquiries, the Care Provider:
• provided us with training certificates in relation to mandatory moving and handling training which had been completed by the Care Workers who were with Mrs Y, when she was injured.
• said it recognised the Care Workers had not used the Rota Stand correctly. Following the incident, the Care Workers completed additional moving and handling training and attended a team meeting to discuss the lessons learned. The Care Provider provided us with evidence of this.
• said since the incident, the Care Home no longer uses the Rota Stand with residents as a transfer aid.
• said staff did not refer Mrs Y to the District Nurse Team following the incident as Mrs Y did not return to the Care Home.
• explained staff did not notify Mrs Y’s family of the incident immediately because the Care Workers had not written up Mrs Y’s incident before her family had arrived to collect her. It said Mrs Y was collected around the time of the regular staff changeover so staff starting on the shift were not aware of the incident when Mrs Y’s family arrived to collect her. It said this was an isolated incident. It said in future it would discourage residents from leaving the Care Home between 7am and 8am as this was a busy time and it was challenging for staff to communicate with families at this time during shift changeovers.

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Findings

27. The Care Workers at the Care Home did not use the Rota Stand correctly. They used it as a mobility aid to move Mrs Y from her bedroom and into the bathroom. The Care Workers then supported Mrs Y with personal care whilst she remained standing on the Rota Stand. This was not in line with the Care Provider’s policy on how to use a Rota Stand correctly. It was not safe practice and contributed to the injury on her arm. In addition, it was not in line with the CQC’s fundamental standards. The Care Provider was at fault. Since the incident, the Care Provider investigated Miss X’s complaint appropriately through its complaints procedure and following this, it has taken action to prevent a recurrence of the fault. It addressed the matter with the Care Workers and the wider team appropriately.
28. Furthermore, it has provided evidence the Care Workers had completed the appropriate training before the incident had occurred and had completed further training after the incident, as part of lessons learned.
29. Following the incident, the Care Provider said staff had correctly applied a dressing to the wound however, from reviewing the pictures of the dressing from Miss X, staff did not mark the dressing to identify the direction of the tear and the skin flap. This was fault as it was not in line with the Care Provider’s policy on wound care management. It would have been appropriate for staff to follow the policy correctly to prevent the possibility of further injury to the wound when re-applying a dressing, particularly when Mrs Y is at high risk of tissue damage.
30. Further to the Care Provider’s policy on wound care management, staff did not refer Mrs Y to the District Nurse Team. However, as Mrs Y did not return to the Care Home, I cannot say this caused an injustice to her.
31. Staff at the Care Home did not inform Mrs Y’s family of her injury. This was fault. It would have been appropriate for the Care Home to notify Mrs Y’s family of the incident immediately. Instead, they discovered Mrs Y’s injury during a hospital appointment. The Care Provider explained this was an isolated incident due to the timing of her family collecting her from the Care Home. However, this caused Mrs Y’s family uncertainty about the care she was receiving at the Care Home.

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Agreed actions

32. Within one month of the final decision, the Care Provider will:
• apologise to Mrs Y and her family for the distress the faults identified above caused them.
• make a symbolic payment to Mrs Y of £150 to acknowledge the distress the faults identified above caused her.
33. Within one month of the final decision, the Care Provider will also remind staff to appropriately follow its procedure on wound care management. The Care Provider will then provide evidence to the Ombudsman it has completed this action.

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Final decision

34. I have now completed my investigation. The Care Provider was at fault which caused an injustice. It has agreed to remedy the injustice caused by the fault identified.

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Parts of the complaint that I did not investigate

35. I did not investigate point d of Miss X’s complaint in relation to her mother’s wheelchair being damaged. This is because there is insufficient evidence to make a finding of fault and the Care Provider offered to fix the wheelchair. So, there is nothing more I could achieve by investigating this further.

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Investigator's decision on behalf of the Ombudsman