Summary: There was fault in the late Mr X’s wound care. The Council will apologise, make a symbolic payment to his relative Ms Y and take action set out in this statement to minimise the risk of recurrence.

The complaint

1. Ms Y complained about her late relative Mr Y’s care in Riverside Care Home, a Care UK care home (the Care Home) which Tameside Metropolitan Borough Council (the Council) commissioned. She said staff failed to take appropriate and timely action when Mr Y developed a pressure sore which turned into a large, infected wound.
2. Ms Y said this caused her and her late relative avoidable distress.

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What I have and have not investigated

3. I have investigated the Care Home and Council’s actions. I have not investigated the district nursing service because NHS services are not within our remit. I have referred to information from the district nursing service where this is relevant to Ms Y’s complaint about the Care Home. Ms Y needs to complain to the Parliamentary and Health Service Ombudsman about the district nurses.

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The Ombudsman’s role and powers

4. 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)
5. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
6. The Council funded Mr X’s care under its legal responsibilities in the Care Act 2014. We can investigate the Care Home’s actions, but the Council is responsible for any fault.
7. 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

8. I considered Ms Y’s complaint to us, the Care Home’s responses and documents described in this statement. I discussed the complaint with Ms Y.
9. Ms Y, the Care Home 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

Relevant law and guidance

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
11. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
12. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
13. Regulation 20 of the 2014 Regulations explains the general duty to be open and transparent with people receiving care. It is referred to as ‘the duty of candour’
14. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)

What happened

15. The Care Home has units which are registered for nursing care as well as residential units for people who do need care from a registered nurse. Mr X had dementia. He went into the residential unit in February 2022. The NHS response to a complaint about Mr X’s health care from the district nursing service indicates that just before he moved into the Care Home, he had a moisture lesion on his sacrum (soreness and blistering where the skin was exposed to moisture.) The district nurses treated this until he moved into the Care Home on 10 February at which time it had healed.
16. The Care Home had care plans which described the care and support Mr X required to meet his care needs. The care plan noted a very high risk of developing pressure sores. He needed repositioning every two hours using a slide sheet as he would not roll on his own. He was to be positioned on either side to maintain skin integrity, but this was hard because he preferred being on his back and would roll onto his back after being positioned on his side.
17. On 11 February an NHS healthcare support worker from the district nursing team visited and advised Mr X did not need a dressing on his sacrum anymore. The Council’s safeguarding records indicate the advice from the healthcare support worker was for care home staff to apply barrier cream every day. There are no records of this having been done other than once. The Council’s safeguarding records go on to say that a district nurse visited Mr X on 15 February and was told by a member of staff that they continued to wash and apply cream daily. However, as I have stated, the Care Home has no records of cream being applied other than once on 16 February (see next paragraph). The district nurse advised staff to contact them if any further concerns. There is no record of this advice in the Care Home’s records.
18. On 16 February, staff noted Mr X was sliding in his chair causing redness and a small break in the skin on his sacrum. The Care Home’s incident reports say a member of staff applied cream and a dressing, turning charts were put in place, the district nurses and his family were informed. Mr X’s fluid and food intake was noted to be poor and he had a cough.
19. I asked the Care Home to provide me with copies of turning charts. It provided me with completed charts between 22 February and 2 March. These showed staff repositioned Mr X about every two hours.
20. On 17 February, the Care Home’s records say someone called the district nurses booking service which confirmed they would be visiting Mr X the following day. On 18 February there is a note saying the district nurses were supposed to come but did not. The NHS complaint response said this visit was cancelled but it was unclear why (it wasn’t the Care Home which cancelled it.)
21. 19 and 20 February were a weekend and the district nurses would not usually visit.
22. On 22 February, the Care Home chased up the referral to the district nurses. Staff were advised to cover the sacral area with a dry dressing until they came. This was done. The district nurse visited later and changed Mr X’s dressing. They ordered a pressure relieving mattress for him.
23. On 23 February, a pressure relieving mattress arrived for Mr X and the district nurse visited. The district nurse visited a second time in the evening and changed Mr X’s catheter. The notes say another district nurse was to come the next day to assess Mr X’s sacrum because he kept shuffling off his chair which was dislodging the dressing.
24. On 24 February, Mr X’s GP visited and prescribed antibiotics for an infection (either a chest infection or an infection in the wound) and pain relief for Mr X to take when turning him. The district nurse visited to change Mr X’s sacrum dressing.
25. On 27 February, staff noted Mr X was aggressive when staff tried to turn him and he had taken little food or fluids. The district nurse visited to change his dressing.
26. On 28 February, Mr X was not taking much fluid or food. The district nurse visited to change his dressing.
27. On 1 March, staff contacted Mr X’s family to discuss transferring Mr X to the nursing unit. He continued to take very little food or drink.
28. On 2 March, the district nurse visited again and applied a new dressing. Later in the day, the Care Home decided Mr X needed to be in hospital. He was not eating or drinking, was spitting out his medicine and needed better pain control. His family were informed.
29. Mr X died after several months in hospital.
30. The Council opened a safeguarding enquiry. A safeguarding officer considered relevant case records. There was a meeting in June 2022 with Mr X's relative, the safeguarding officer and the Care Home’s deputy manager. The minutes noted there was a history of pressure issues when Mr X was admitted and the Care Home had only given records of turning from 22 February. The Care Home noted skin breakdown on 16 February and referred Mr X to the district nurses, but they did not visit for 6 days.
31. The conclusion of the safeguarding enquiry was there were no serious issues with Mr X’s care at the Care Home and the problems lay with ‘external referral processes outside the home and its staff’s control.’
32. The Care Home’s first response to Ms Y’s complaint said a turning chart was put in place on 9 February (this was not the case). The second complaint response said there was no record of cream being in the building or applied to Mr X. It went on to say the manager now books in new residents’ medication.
33. The NHS complaint response about Mr X’s district nursing input said a review indicated information was sent to the wrong district nursing team and this could have contributed to the development of the wound.

Findings

34. Mr X had a history of problems with the sacral area and was considered at very high risk of developing further problems with his skin. The Care Home’s care plans recognised this and said he needed to have two hourly turns. Yet the Care Home did not put in place a turning chart until 22 February. This was not in line with his care plan. Mr X did not receive person-centred care and this was not in line with Regulations 9 or 12 and so was fault. The lack of two-hourly turns from 9 to 15 February increased the risk of Mr X developing a pressure sore. And from 16 February to 22 February, the lack of two hourly turns increased the risk of further deterioration of the sacral area.
35. The Care Home’s complaint response was inaccurate as it said that there were turning charts in place from the date Mr X moved in. Giving misleading information in a complaint response was fault. It calls into question the Care Home’s openness and transparency and is a potential breach of the duty of candour.
36. The Care Home has no control over the NHS district nursing service and cannot mandate when nurses visit. I am satisfied there was appropriate liaison to chase up the referral to the district nurses made on 16 February. The Care Home communicated appropriately to try and secure timely healthcare from the district nursing service for Mr X.
37. I note Mr X was not in a nursing unit. However, the Care Home does have a nursing unit and so there are nurses on site. I would expect care staff to have sought brief verbal advice about Mr X from nurses on the nursing unit after the NHS district nurse did not turn up on 18 February. The Care Home has a responsibility to ensure it is providing safe effective care. My view is that it was fault not to obtain the advice of in-house nurses until the NHS district nurses visited. Alternatively, the Care Home should have sought telephone advice from 111 or from Mr X’s GP about what action they could take to minimise further deterioration of the sacral area until the district nurses could attend.
38. I note the safeguarding enquiry picked up on the lack of turning charts for the first three weeks of Mr X’s residence. This was not identified as a concern about the quality of care and it is unclear why the safeguarding officer did not question the lack of turning charts for the earlier part of Mr X’s stay. This was a missed opportunity to identify a possible service improvement and was a failure to consider relevant information which was fault.
39. I note also that the district nursing service advised Mr X needed to have barrier cream applied daily. Yet the Care Home accepted it did not have barrier cream available for Mr X. This was fault. Care was not in line with Regulations 9 or 12. The Care Home should have ensured Mr X had barrier cream in line with the advice from the healthcare support worker and district nurse and his care plan said this needed to be applied daily. The Council’s safeguarding enquiry also did not pick up on this issue as a potential concern about neglect which was a further failure to consider relevant evidence and fault. This was a second missed opportunity to identify service improvements.

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Agreed action

40. 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 I found fault with the actions of the Care Home, I have made recommendations to the Council.
41. Within one month of my final decision, the Council needs to:
• Apologise to Ms Y for the avoidable distress caused by the poor care Mr X received
• Make her a symbolic payment of £250.
• Complete a quality monitoring visit to the Care Home, ensure that those residents whose care plans say they are at high risk of pressure sores, have appropriate repositioning charts in place and barrier creams are being applied where these have been recommended and/or prescribed.
42. The Council should provide us with evidence it has complied with the above actions.

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Final decision

43. There was fault in the late Mr X’s wound care. The Council will apologise, make a symbolic payment to his relative Ms Y and take action set out in this statement to minimise the risk of recurrence.
44. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman