Summary: The Care Provider acknowledged the care provided to Mrs Y was below an acceptable standard before the involvement of this office, but it did not offer an appropriate remedy for the injustice caused.

The complaint

1. Mrs X complained about the quality of care provided to her grandmother Mrs Y in Belmont Castle Care Home, (Care Provider). She is dissatisfied with the Care Provider’s response.

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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 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)
3. We can decide whether to start or discontinue an investigation into a complaint within our jurisdiction. (Local Government Act 1974, sections 24A(6) and 34B(8), as amended)

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How I considered this complaint

4. I have:
• considered the complaint and discussed it with Mrs X;
• considered the correspondence between Mrs X and the Care Provider, including the Care Provider’s response to the complaint;
• considered relevant legislation;
• offered Mrs X and the Care Provider an opportunity to comment on a draft of this statement, and considered the comments made.

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What I found

Relevant legislation

5. 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.
6. Regulation 12 Safe Care & Treatment says people must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Care Providers must assess the risks to a person’s health and safety during any care or treatment and make sure care staff have the qualifications, competence, skills, and experience to keep people safe.

Pressure sores

7. 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.
8. Under the European Pressure Ulcer Advisory Panel classification system, pressure sores are graded in severity from 1 to 4. Grade 1 indicates the first signs of pressure damage; including redness, discolouration, swelling or heat but with intact skin. Grade 2 is usually an abrasion or blister and involves a partial thinning of the skin. Grade 3 involves full loss of skin thickness with damage to, or death of, the underlying tissue. Grade 4 indicates severe pressure damage, usually a deep wound that may go down to the bone and involve the death of underlying tissue.

Key facts

9. Mrs Y is in her nineties. She went into the care home for short stay on 6 August 2021 and left on 6 September 2021. During her stay she developed a grade 4 pressure area sore to her heels. The care home failed to inform the district nurse and consequently Mrs Y did not receive appropriate wound and pressure area care. This has had a significant impact on her health and limited her mobility.
10. Mrs X complained to the Care Provider. It investigated the complaint and wrote to Mrs X setting out its findings.
11. I have had sight of the Care Provider’s complaint response letters, dated 2 September 2021 and 22 August 2021.The August date appears to be an error as the letter refers to matters in September 2021. The first letter confirms care staff identified a sore to Mrs Y’s left heel on two separate occasions and recorded it on the ‘body map’ in Mrs Y’s care record. A photograph was also taken. It acknowledges that on both occasions care staff failed to contact the district nurse, and that the information was not “…handed over from shift to shift appropriately...". It says care staff appear to have missed the skin breakdown to Mrs Y’s right heel and says several missed opportunities to inform the district nurse were identified. It apologised that “…[Mrs Y] has suffered this discomfort”.
12. It goes onto say it addressed the issues with the care staff involved and said they would be subject to ongoing performance management and regular supervision. Direction on identifying and reporting ‘skin integrity’ had been given to all care staff. It says lines of communication needed to be addressed and meetings with senior staff had been held to “…explore how it happened and prevent it happening again”.
13. Mrs X believes the response to be inadequate. She would like reassurance that appropriate policies and procedures are in place and implemented for every resident within the care home.

Analysis

14. The Care Provider acknowledged it failed to provide Mrs Y with adequate pressure area care before the complaint came to this office. It accepted that Mrs Y has suffered ‘discomfort’ and apologised.
15. I do not consider this to be sufficient. Mrs Y suffered a tangible injustice which requires more than an apology. Mrs Y was not provided with the standard of care set out in the CQC’s fundamental standards, and which she had a right to expect. This had a direct impact on her health and mobility.

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Agreed action

16. The Care Provider will, within four weeks of the final decision:
• reimburse Mrs Y half the cost of the care fees paid for her stay;
• provide evidence of service improvements and staff training to this office.

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Final decision

17. The Care Provider acknowledged the care provided to Mrs Y was below an acceptable standard, however, it failed to offer an appropriate remedy for the injustice caused.
18. The above recommendations are a suitable way to settle the complaint.
19. It is on this basis; the complaint will be closed.
20. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

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Investigator's decision on behalf of the Ombudsman