Summary: Mrs B complained about the care provided to her mother Mrs C during a two week stay at a care home commissioned by the Council. We have not found fault with the Council.

The complaint

1. Mrs B complained that the care home (where the Council commissioned two weeks’ respite care for her mother, Mrs C), failed to properly look after Mrs C, causing an injury to her toe which led to a dramatic deterioration in her health and end of life care. The Home also failed to return some items of clothing and jewellery belonging to Mrs C. This caused Mrs C significant discomfort and distress as well as distress and worry to her family.

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The Ombudsman’s role and powers

2. 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)
3. If we are satisfied with an organisation’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

4. I have considered the complaint and the documents provided by the complainant, made enquiries of the Council and considered the comments and documents the Council provided. Mrs B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found’

5. Mrs C went to a care home (the Home) run by the Council for two weeks’ respite care in September 2021. She had dementia and diabetes and was being cared for by her daughter (Mrs E). Her other daughter (Mrs B) said that when she went to the Home her cognition was only slightly impaired, and she could walk slowly with a walking stick. Mrs B said when they arrived at the Home, they were left standing at the front door for 5 to 10 minutes while staff found a wheelchair for her. She said Mrs C had her wedding and engagement rings, a small case of appropriate clothing, skin products and medication. She said Mrs C’s shoes were ‘soft fitting velcro orthopaedic open-toed slippers’.
6. Mrs C’s care needs assessment completed on 9 September 2021 noted that Mrs C was often reluctant to co-operate with her family providing personal care, could be unwilling to eat, unpredictable in what she would eat and required a lot of encouragement. As a result, her diabetes was unstable. The assessment noted that Mrs C had been very unpredictable with accepting care from people outside her family presenting as verbally abusive and resistant to accepting support.
7. The Home’s inventory of Mrs C’s belongings does not mention any rings or socks and includes ‘Black outside shoes’.
8. The daily care records show that Mrs B refused food on approximately nine occasions, personal care four times, and the Home monitored her fluid intake on six occasions. The notes of a call with Mrs B on 21 September 2021 say the Home told her that Mrs B was non-compliant at times, her diet and fluid intake were poor, and she had deteriorated since her last stay. The notes also show that the Home carried out skin checks every day and did not notice any bruises or redness on her toes. Mrs C refused the checks completely on one day and partially on three others.
9. Mrs B says the family made several calls during the two-week stay and said the information provided was sporadic, with staff reporting she had refused her food and medication and indicated she was difficult because of the time it took to get her to take her medication.
10. Mrs E went to collect Mrs C at midday on 27 September 2021. The Home says staff had washed and dressed her that morning and put on her outdoor shoes. She sat in a wheelchair in the lounge. During this time, she took off her shoes. As staff were putting her shoes back on, they noticed a small red mark or bruise on her big toe, smaller than a fivepence piece. The Home says they informed Mrs B’s sister of this mark and that they were unsure what had caused it, as it had only just been noticed.
11. The records also note that Mrs C had removed her coat twice when the staff were trying to take her out to meet her daughter. Staff also apologised because there were a few items of clothing missing as they were still in the laundry and would contact them once they were all found.
12. Mrs B says when Mrs E went to collect Mrs C she was inappropriately dressed for the temperature which was extremely cold. Staff said her coat was in her bag because she did not want to wear it. Mrs B said they made no attempt to put it over her shoulders or offer her a blanket.
13. Mrs B rang the Home later that day to say that a lot of clothes were missing. Mrs E sent an email the following day complaining that the clothes were missing and that staff who had spoken to Mrs B had been rude. The Home agreed to look for the clothes and speak to the staff member.
14. On 4 October 2021 Mrs B called asking how the bruise on Mrs C’s toe had occurred, as the doctor wanted to know. The Home said it was not sure. It speculated that it could have been due to her long toenails catching on the shoe. Mrs B denied this could have happened. The Home said they had only noticed the bruise just before she left the Home and no other incident or accident had occurred. Mrs B said it was the Home’s fault that the situation had arisen and now Mrs C may have her toe amputated. Mrs B said she had not been able to get a doctor to come out and had not taken her to hospital due to the waiting times. The Home said it would drop off the missing clothes at Mrs C’s house.
15. On 31 October 2021 Mrs B rang the Home to complain that Mrs C was now in hospital on end of life care due to poor care while she was at the Home leading to the mark on her toe which had now got worse.
16. In November 2021 Mrs E reported a safeguarding concern to the Council and the Care Quality Commission (CQC), alleging that poor care at the Home had caused Mrs C’s deterioration. Mrs E said she had contacted the GP on 28 September 2021, but no appointments were available. She called back the following day and was told the district nurse would attend but they did not. She called the GP again who advised to take her to the chiropodist, but she could not do this due to Mrs C’s lack of mobility and general frailty. By Sunday 3 October 2021, Mrs C’s toe had worsened significantly. An on-call doctor visited later that evening and advised Mrs E to contact Mrs C’s GP the following day as a matter of urgency. Following the GP visit the next day Mrs C was admitted to hospital as an emergency. Mrs E said the hospital had diagnosed prolonged pressure and trauma to both feet causing the injury and that this must have occurred while Mrs C was at the Home. Mrs E also alleged that the Home had lost Mrs C’s engagement ring.
17. The Council did not carry out a safeguarding investigation, because Mrs C was no longer at the Home. It asked the Home to do its own investigation.
18. The Home carried out an internal investigation into the allegations. It noted Mrs C’s medical conditions including diabetes and that she was a high risk of skin integrity problems. It noted a deterioration in her mobility, communication and weight loss, since she last stayed there and that the bottom halves of her legs were swollen. It said staff frequently elevated her legs, but that Mrs C would move them herself. It said Mrs C was frequently non-compliant and needed two carers to complete all care tasks. She required a lot of encouragement and sometimes hit out at staff. She had a poor food and fluid intake and required regular prompting and assistance with eating, including sequencing of meals. The Home said it could take 20 minutes to administer medication and she often refused initially.
19. The report said that Mrs C only came to the Home with black outdoor shoes and not orthopaedic ones.
20. It said throughout Mrs C’s stay they carried out full body skin checks and did not note any concerns including on the morning of 27 September 2021. It was only when putting Mrs C’s shoes back on just before she left that staff noticed the mark. Staff noted that the shoes were a snug fit due to the swelling and that the black outdoor shoes were the only ones provided, without any socks. The staff informed Mrs E about the mark. The Home said that if Mrs C had remained with them, they would have investigated further and sought medical advice .
21. In respect of the rings the Home said Mrs C did not come to the Home wearing any rings. The Home said her daughters had confirmed the wedding ring was found at home on 31 October 2021.
22. In respect of the clothing worn on the day of discharge. Mrs C was wearing undergarments, a top, trousers, black outdoor shoes and her coat was provided. Mrs C had removed her coat twice and staff had encouraged three times to put it back on. As she refused, they put the coat in a bag and took her out in a wheelchair to meet Mrs E.
23. The Home said it had reviewed its admissions and discharge process: it required two staff signatures to support discharges, to take pictures of personal items such as jewellery and to obtain family signatures to verify the content of the inventory and review the content with family members to query potential inappropriate or missing items.
24. The Home sent the investigation outcome to Mrs B, Mrs E, the Council and CQC on 31 December 2021.

Analysis

25. It must have been distressing for the family to witness Mrs C’s deterioration following her stay at the Home. However, I have not found evidence of fault in the Home’s actions to substantiate the allegation that this was due to poor care.
26. The Home’s records are thorough and detailed showing that it was aware of Mrs C’s medical conditions and the risk to her skin. It carried out daily skin checks and always recorded her fluid and food intake, monitoring the fluid intake more closely on several occasions when it was low. The records noted that Mrs C was generally content but non-compliant at times with eating, drinking, personal care and medication. This was consistent with her care needs assessment carried out shortly before she arrived at the Home.
27. There is no record or note of any incident or accident or any bruise or red mark on Mrs C’s toe prior to just before she was discharged. At that point it was a very small red mark. The Home informed Mrs E straightaway as Mrs C was going home with her. I do not consider it could have done any more given the timing of the discovery.
28. There is some contradictory information over the nature of Mrs C’s shoes which has added to the uncertainty about what happened. Mrs B says they were orthopaedic shoes, open-toed with Velcro fastenings. The inventory records ‘black outside shoes’, and the internal investigation said they were ‘black outdoor shoes’. Given that Mrs C kept taking off her shoes and the fact that her feet were swollen, it is likely they were the open-toed soft types as described by Mrs B. I note the Home has improved its inventory procedures to provide more clarity over residents’ belongings when they arrive.
29. I realise this must be upsetting for the family, but I am unable to conclude that the Home was responsible for the loss of the engagement ring because there is no documentary evidence that Mrs C was wearing the engagement ring when she entered the Home. I note the family found her wedding ring after Mrs C had returned home. Again, the Home has improved its inventory procedures which will hopefully prevent this uncertainty recurring.

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Final decision

30. I have completed my investigation into this complaint as I am unable to find fault causing injustice in the actions of the Council towards Mrs B or Mrs C

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman