Summary: Mrs B complains about the care home’s delay in calling an ambulance for her mother and says her mother suffered dehydration and pressure sores because of the care home’s failures in care. We have not found fault in the way the care home decided to call an ambulance or its provision of liquids when Mrs B’s mother was taken to the hospital. However, there was fault in the way the care home assessed the risk of pressure sores and its care planning in this respect. The Home has agreed to apologise and carry out a service improvement.

The complaint

1. Mrs B complains on behalf of her mother, Mrs C, who resided at Tudor Lodge care home, Fareham. Mrs B said the Home failed to give appropriate skin care to Mrs C, failed to manage her liquid intake and delayed calling an ambulance.

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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 a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) 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 discussed the complaint with Mrs B. I have considered the documents that she and the Home have provided, the relevant law, guidance and policies and both sides’ comments on the draft decision.

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What I found

Care Quality Commission and fundamental standards

5. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards which says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• The care and treatment must be provided in a safe way for service users (regulation 12).
• The nutritional and hydration needs of the service user must be met. (regulation 14).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17).

Safeguarding

7. The Care Act 2014 and the Care and Support Statutory Guidance 2014 set out a local authority’s safeguarding duties. Section 42 of the Care Act 2014 says the local authority should start a safeguarding enquiry if an adult in its area:
• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
8. Early sharing of information is the key to providing an effective response where there are emerging concerns. All organisations (for example care homes, hospitals, GP surgeries) must have safeguarding arrangements in place which set out clearly the processes and the principles for sharing information.

Pressure sores

9. 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. Under the European Pressure Ulcer Advisory Panel classification system, pressure sores are graded in severity from 1 to 4.
10. 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. 
11. The government wrote updated guidance called ‘Safeguarding adults protocol: pressure ulcers and raising a safeguarding concern’ in July 2024.
12. A Braden Scale assessment assesses the risk of developing pressure ulcers. The lower the number, the higher the risk. A score of 13-14 is moderate risk and a score of 10-12 is high risk.

What happened

Background

13. Mrs C is an older woman who has physical disabilities and showed signs of cognitive decline. She moved to the Home in April 2022.
14. Mrs C was taken to hospital on 15 November 2023. There had been a decline in Mrs C’s health in the weeks before her admission.

Complaint – 22 November 2023

15. Mrs B complained to the Home on 22 November 2023. Mrs B said her complaint should be investigated as a serious incident review (NHS’s process of investigating serious incidents). Mrs B said:

Care plan – skin care

• Mrs C had a large bed sore on her lower back / buttock when she was admitted to hospital. The hospital told Mrs B that people who had limited mobility like Mrs C should be repositioned frequently. In the hospital Mrs C was repositioned every two hours.
• Mrs B said the Home did not take enough preventative action, such as repositioning and that this led to the pressure sore.

Liquids

• Mrs C was dehydrated when she was admitted to hospital. Mrs C’s urostomy bag was empty when she arrived at the hospital and was still empty at teatime. She showed signs of dehydration that the Home missed. Mrs B said the Home did not sufficiently ensure that Mrs C was drinking enough and was not monitoring her fluid intake properly.

Delay in calling an ambulance

• The Home delayed calling an ambulance for Mrs C. Mrs C had been declining in the weeks before her hospital admission. Mrs B visited Mrs C around 11 am and said Mrs C looked very ill. The nurse delayed calling an ambulance and relied too much on the automated system to make their decisions.

Home’s response to the complaint -

16. The Home responded to the complaint and said:
• It had reviewed the care records, the care plans, the CCTV and the documentation relevant to the complaints.
• Mrs C did not have a pressure sore when she left the Home. She previously had a graze/scab on her left buttock on 20 October 2023 but this had been treated and no dressing was required after 7 November 2023. The Home had documentation of the daily skin treatments and checks in the weeks before the admission to hospital and no pressure sore had been recorded. The Home’s director was notified of any pressure sores above grade 2. Staff applied barrier cream every day to Mrs C’s buttocks and this would not have been possible if there had been a large pressure sore.
• The Home had assessed Mrs C’s risk of pressure sores using the Braden scale and her risk was 14 which was moderate risk. Mrs C had a special mattress which helped in preventing pressure sores.
• The Home added that the hospital sent a treatment plan for Mrs C on 20 November and this did not record any pressure sore or red patch. The Home questioned whether Mrs C had a pressure sore when she was admitted to hospital as pressures sores did not heal that quickly. The Home pointed out that the hospital did not raise a safeguarding referral to the local authority about the Home.
• Mrs C was not dehydrated prior to hospitalisation. Mrs C had a urostomy bag and the recordings showed that she had a normal output until she went to hospital. Mrs C had vomited on 15 November and this may have caused her heart rate to increase and a dry mouth. Mrs C was given assistance to drink and the Home also left drinks with her as it was its policy to leave drinks in the room so that drinks were readily available for staff to give to residents.
• The Home had taken advice from the relevant health professionals in the days before Mrs C’s admission to hospital. The Home’s nurses and care staff were fully trained. The Home used an NHS computer system which assisted staff in the decision making. The nurse made decisions on the day, with the help of this system and appropriately contacted the out of hours GP.
17. Mrs C responded as she was not satisfied with the complaint response. She said the Home had not carried out a serious incident review and had limited its response to her complaints.
18. Mrs C took her complaint to the CQC, the ICB and the Ombudsman. She provided some additional information. She said:
• Mrs B arrived at the Home at 11.30 am. Mrs C went to hospital by ambulance around 1.30 pm and arrived at the hospital around 2:00 pm. Mrs C had to wait in the ambulance for a couple of hours and, during this time, her urostomy bag was empty. Mrs C arrived on the ward at around 4.30 pm. A blood sample was processed at 5.17 pm. Mrs C had severe dehydration, pneumonia and a UTI.

Records provided

19. I have focussed on the care provided by the Home in the two weeks before Mrs C went to hospital but have referred to earlier dates if it was necessary to investigate the complaint.
20. Concerns were raised in the last weeks of October that Mrs C was becoming more sleepy and had more episodes of unresponsiveness so the Home had involved the GP surgery and the advanced nurse practitioner (ANP).
21. The ANP visited Mrs C on 19 October 2023 and discussed the plan with Mrs B. It was suspected that the increased sleepiness was either linked to an increase in a particular medication or an underlying infection so blood and urine samples had been taken to determine this. The GP had prescribed antibiotics.
22. The Home started a ‘wound monitoring record’ on 20 October 2023. Mrs C had ‘two small broken areas, various sizes’ on the left upper buttock – grade 2.’ The daily record said: ‘regular turns as much as [Mrs C] can tolerate’. The Home left a message for Mrs B to update her.
23. The Home put a treatment plan in place which included putting a dressing on the sore. The Home monitored the progress every four days.
24. The Home carried out a Braden scale assessment of Mrs C on 21 October 2023 which noted: ‘Hoist transfer, able to sit in her chair. Braden scale is 12 now as [Mrs C] has a broken skin on her buttocks.’ The Home then added up the risk factors and said the risk score was 13 which represented moderate risk. However, when I added up the numbers the score came to 12 which would have put Mrs C at high risk.
25. The GP prescribed antibiotics on 21 October as Mrs C had a UTI. The ANP did a further blood test on 2 November 2023.
26. The wounds were checked on 25 and 29 October and 3 November and the sores were improving but continued to be grade 2. On 7 November 2023 a dressing was no longer required. The observations on 12 and 13 November noticed ‘granulation’ (this is wound healing – appearance of red newly formed tissue on the surface of a wound). No dressing was required but a barrier cream was to be applied.
27. On 6 November 2023, Mrs C was unresponsive for an hour and the Home carried out observations using its automated system. She later vomited. Around 3 pm, the Home decide to escalate the concern to senior staff, and, if there was no improvement within 2 hours, the GP should be contacted.
28. The Home contacted the GP around 5:00 pm and the GP organised an ambulance. Mrs C improved during the evening and the Home decided the risk was reduced. The ambulance arrived after midnight. Mrs B had also arrived at the Home. The paramedic spoke to the out of hours GP and it was decided that Mrs C should stay at the Home.
29. On 7 November 2023 the Home contacted the GP for a review as it was concerned about Mrs C’s presentation (confusion). The Home updated Mrs B. The Home updated the GP with everything that had happened since yesterday and the latest observations in its automated system. Mrs B had spoken to the GP. The plan was to collect a blood and urine sample to rule out infection and the ANP would review Mrs C at the next round.
30. Mrs C had an unresponsive episode on 9 November. The ANP visited Mrs C later that day. It was agreed to change some of Mrs C’s medication in the hope that this would improve her sleepiness. The ANP and Mrs B discussed the plan for Mrs C. Mrs B said she did not want Mrs C to go to hospital unless for a fracture or reversible causes and the ANP said she would update the record to reflect this.
31. Mrs C had an unresponsive episode on 10 November. The Home informed Mrs B and the nurse started observations which were within the normal range. Mrs C vomited on 12 November and the Home gave her medication for sickness/nausea. A small sore was noted on Mrs C’s buttock. The nurse was informed. A dressing was not needed and barrier cream was applied.
32. Mrs C’s care plan was reviewed on 12 November 2023. The plan said:
• In terms of skin care, the plan said Mrs C’s Braden score was 14. Mrs C’s skin had to be checked at least daily as she was at moderate risk of pressure sores.
• In terms of mobility, the plan said Mrs C needed a hoist for transfers between the chair or the bed. She was unable to walk. Mrs C should get up (out of bed) before lunch and then go back to bed after activities were finished. Mrs C was able to reposition herself in her chair, but may need help. She was unable to turn in bed so needed assistance from staff.
• There were no changes made to the care plan on 12 November in the management of Mrs C’s skin care or in her mobility requirements.
• Mrs C had a urostomy bag and her urine output had to be monitored.
33. On 13 November 2023 Mrs C had a tiny skin tear bleeding on her upper left back. The nurse was made aware, a picture was taken for monitoring and recorded. Mrs C ate all her breakfast, but had an episode of unresponsiveness before lunch. The Home alerted the nurse who carried out observations. Mrs C did not eat lunch but drank water. The Home contacted Mrs B to update her. Mrs C had a drink at 3.16 pm and Mrs B gave her a two cups of drink at 4:00 pm.
34. Mrs C had a full body wash on 14 November and barrier cream was applied. The pressure area was recorded to be intact.
35. Mrs C ate all of her breakfast on 14 November, but did not eat much lunch. She vomited in the morning but then had a settled night with no vomiting. The nurse monitored Mrs C.
36. On 15 November the Home gave Mrs C anti-nausea medication with her regular medication before breakfast as she had vomited after taking her regular medication the day before. Mrs C ate her breakfast and had tea at 9:04, but vomited at 10:18.
37. Mrs C had a full body wash on 15 November at 10:18 and barrier cream was applied. The pressure area was recorded to be intact. Mrs C’s urostomy bag was emptied at 10:19 and the urine was clear. Mrs C was offered a drink at 10:31, but declined the drinks as she was not feeling well.
38. Mrs B arrived at 10:37. Mrs B asked the nurse to carry out observations as she was concerned about Mrs C’s presentation. The nurse carried out observations and said these were in the normal range apart from Mrs C’s pulse. The nurse said he would not call 999 as they would not accept this as an emergency, so he suggested ringing the out of hours GP and Mrs B agreed.
39. Mrs B asked the nurse whether the Home’s GP had provided the results of Mrs C’s recent blood tests. The nurse said that the GP had not sent them yet so Mrs B rang Mrs C’s GP while the nurse rang the out of hours GP. Mrs C’s GP surgery said the blood and urine tests were satisfactory. The out of hours GP spoke to the nurse and the GP noticed that one of the markers for infection was slightly raised.
40. The family asked if this was an indication of sepsis and the GP said it was not but it could develop into sepsis and, if this was the case, then Mrs C ‘to go to hospital for further investigation’. Mrs B said Mrs C should still go to hospital if it was for a reversible cause so it was agreed to take Mrs C to hospital and the GP said they would call for an ambulance.

Further information

41. The daily records showed that Mrs C had a full body wash every day in November and that the staff carried out a skin check every day.
42. The Home recorded Mrs C’s urine output and provided daily totals. These showed that in the two weeks before 15 November, Mrs C’s output was on average 1000 ml a day. The Home also recorded the colour of the urine as dark urine may indicate that Mrs C was becoming dehydrated.
43. On the day before Mrs C went to hospital (14 November) her output was 950ml and her urine was clear all day so there was no indication that she was dehydrated. On 15 November, Mrs C’s output was 500 ml and the urine was dark at the first recording but clear again at the second recording.
44. Mrs C was sometimes hoisted from her bed to her chair until 2 November. After that date, Mrs C was cared for in bed.
45. I asked the Home whether it had changed Mrs C’s care plan to address the fact that Mrs C was cared for in bed after 2 November and why it did not include repositioning in the plan.
46. The Home said Mrs C had many unresponsive episodes and because of this she was not on a regular turning regime. The Home had discussed this with the family in August 2023 and agreed that pillows would be used to position Mrs C’s head and neck position. Mrs C was able to make small movement changes herself and it was felt not appropriate to be turned frequently and risk further episodes. The Home said the care plans were reviewed but not updated as they should have been. This had since been addressed.
47. Mrs B said, in her response to the draft decision that the Home never informed the family that it would not reposition Mrs C nor that this would increase the risk of an unresponsive episode.
48. So I asked the Home to send me evidence that it had discussed this with the family. The Home sent me evidence that it had discussed the use of pillows to support and position Mrs C’s head and neck with the family. But I could not find evidence that the Home had discussed with the family that it would not reposition Mrs C because this would increase the risk of an unresponsive episode.

Hospital documents

49. Mrs B said the hospital’s ‘activities of daily living’ document said Mrs C had ‘2 areas of moisture damage and a grade 1 pressure damage to the right buttock’. I have not seen that document.
50. Mrs B has sent me the hospital’s photos dated 16 November 2023 which clearly show the pressure sores. I have also seen the hospital’s admission document which said:
• The hospital carried out a ‘Modified Anderson Pressure Ulcer Risk Assessment Tool’ on 15 November 2023 at 17:00 and said Mrs C was at level ‘red’ as she had a pressure sore and should therefore be repositioned every 2 hours.
• The hospital said that, at 17:25, Mrs C had a ‘pressure sore at sacral area and red and blanching skin over buttocks.’ The document said there had been a recent decline in Mrs C’s presentation and she was now ‘bedbound’.
• The hospital staff had an ‘honest discussion with family’ and explained that Mrs C was increasingly frail and very unwell and that this may not be reversible.
• At a handover on 15 November at 21:42 it was noted that Mrs C had been admitted on a hospital bed with no air mattress and said ‘with 3rd degree bedsore – datix done’. (Note: datix is the NHS’s online system to report incidents and risks.) An air mattress was requested.

Analysis

Skincare

51. I cannot say that the Home’s actions caused the pressure sores which were identified by the hospital for the following reasons:
• The Home has provided evidence that on 12 and 13 November the pressure sores (identified on 20 October) had healed to the granulation stage which meant that cream could be applied.
• The Home also noted Mrs C may have a possible new pressure sore on 12 November but the nurse said cream should be applied and the area should be monitored.
• The Home has provided evidence that Mrs C’s skin was checked on 14 and 15 November (at 10:18) and was still intact.
• The hospital evidence shows that Mrs C had a grade 1 pressure sore (ie intact skin, but possible signs of redness, discolouration and swelling) when she arrived at the hospital, but there had been a delay where Mrs C had to wait several hours in the ambulance before being admitted to hospital.
• Later in the day (21:42) the hospital said Mrs C had a grade 3 pressure sore, but the notes showed that Mrs C had been lying on a hospital bed without a pressure mattress for hours.
• I also note that neither the ambulance crew nor the hospital made a safeguarding referral to the Council about Mrs C’s presentation when she arrived at the hospital. So neither the ambulance crew nor the hospital were of the view that Mrs C’s presentation met the threshold for a safeguarding referral.
52. So therefore overall, I cannot say that the Home caused the pressure sores identified by the hospital. My investigation has therefore focussed on whether the Home provided appropriate skin care to Mrs C and took the necessary actions to prevent pressure sores.
53. I note that the Home identified pressure sores on 20 October 2023 and took appropriate action. The Home recorded the sores and put an appropriate treatment plan in place. The Home informed Mrs B. The treatment was correctly provided over the following days and the pressure sures were properly monitored and the treatment recorded. The sores healed to the point that, by 7 November, the Home could put barrier cream on the sores. I find no fault in that respect.
54. I also find no fault in the Home’s daily monitoring of the pressure sores. Mrs C had a full body wash every day and her skin was checked for sores every day. Any change was noted, recorded and acted upon. A small sore was detected on Mrs C’s buttock on 12 November. The nurse was informed and the sore did not require dressing, but needed further monitoring. I find no fault in this respect.
55. However, there was fault in the Home’s care planning for pressure sore prevention. Firstly, the Home’s Braden scale assessment was incorrect as the scale was 12 from 20 October onwards, and this put Mrs C in the high risk category, but the Home said Mrs C was in the moderate category. Therefore it was possible that the Home’s incorrect risk assessment for pressure sores meant that the Home was not properly addressing the risk of pressure sores in the care plan.
56. In addition, the care plan was reviewed on 12 November and the Home said there was ‘no change’ under the headings ‘mobility’ and ‘skin care’. Mrs C had been cared for in bed for almost two weeks. This would have increased her risk of pressure sores significantly and I would have expected the care plan to review the risk of pressure sores to address this. The failure to do so was fault.
57. The Home said that it did not decide to reposition Mrs C in November as a decision was made earlier (in August 2023) that repositioning may increase the risk of triggering an episode of unresponsiveness. The Home said the family agreed this plan. However, I do not accept this argument as the Home has been unable to provide evidence of its discussions with the family that it would not reposition Mrs C. Also the Home should have recorded this in its care plan and I found no reference to this in the care plan documents.
58. I note that, once Mrs C was admitted to hospital on 15 November 2023 the hospital carried out a Pressure Ulcer Risk Assessment Tool. This put Mrs C at the highest risk (red) of pressure sores and said Mrs C had to be repositioned every two hours. So I presume the hospital did not share the Home’s concerns that repositioning Mrs C would trigger an unresponsive episode.
59. In any event, the fact remains that the Home should have reviewed Mrs C’s risk of pressure sores on 20 October when the Braden scale was changed and on 12 November as Mrs C was now at a higher risk of pressure sores than she would have been in the past as she was cared for in bed. The Home’s failure to do so was fault.

Liquids

60. The Home did not monitor Mrs C’s fluid intake but, as Mrs C had a urostomy bag, the Home recorded and monitored Mrs C’s output instead. The Home also recorded the colouring of the urine which was another indicator of hydration status. So I find no fault in the monitoring and recording.
61. There were no concerns from the recordings of Mrs C’s urine that Mrs C was dehydrated on the day she went to hospital (15 November) or the day before.
62. Mrs C drank liquids in the morning of 15 November but then vomited. She was offered additional liquids but refused so I cannot say there was fault in that respect. It is true that her urostomy bag was empty when Mrs B arrived but that was because it had been emptied minutes before Mrs C’s arrival. So overall I cannot say that there was any fault in the Home’s actions until this point.
63. It is difficult to say what happened after that as the records focussed on the involvement of the medical professionals who were making the decision whether to take Mrs C to hospital. Mrs B said she offered Mrs C a drink but Mrs C was unable to drink as she was too weak.

Ambulance

64. Mrs B said Mrs C became increasingly ill in the weeks before she went to hospital but the Home failed to pick up the signs and then delayed calling an ambulance on 15 November.
65. The records showed that Mrs C had episodes of sleepiness, unresponsiveness and vomiting in the weeks before 15 November. This was not unusual for Mrs C but the episodes were happening more frequently. However, the Home noted this and had acted appropriately in response. The Home involved the relevant medical professionals, including nurses, the advanced nurse practitioner or the GP every time Mrs C showed signs of unresponsiveness or vomiting.
66. An ambulance was called on 6 November. The paramedics consulted with the out of hours GP and it was decided that Mrs C should stay at the Home.
67. The GP surgery continued to be involved and the medical professionals were trying to establish what the underlying cause was of Mrs C’s symptoms. The GP thought the symptoms may be linked to medication or an underlying infection. Blood and urine samples were submitted several times in the weeks before the hospital admission to find out what the underlying cause was. Different medication was tried to address Mrs C’s nausea.
68. The Home monitored Mrs C closely using observations which it entered into its automated system. The ANP from the GP surgery visited Mrs C and it was decided to change Mrs C’s medications. The ANP discussed the plan with Mrs B and Mrs B agreed Mrs C should not go to hospital unless it was for a reversible cause or a fracture.
69. So overall I cannot say that there was fault in the Home’s actions in the weeks before Mrs C went to hospital. The Home had noted that Mrs C was not well and had involved the relevant medical professionals and was following their advice.
70. I also find no fault with the Home’s actions on the day when Mrs C was taken to hospital. It is true that the nurse did not immediately ring the ambulance but decided to call the out of hours GP first, but that, in itself, was not fault. The nurse used their professional judgement and the observations to decide how urgent the situation was. I note that Mrs C’s GP had no concerns about Mrs C from the blood and test results that had recently been provided. I also note that there was a long discussion with the out of hours GP where Mrs C’s presentation was discussed before it was decided to take Mrs C to hospital for further investigation and that this was done to carry out further investigations.

Complaint response

71. I find no fault in the Home’s response to Mrs B’s complaint. The Home responded to Mrs C’s complaints in detail and addressed each concern that she had raised. It considered the relevant information including the daily records, care plan and CCTV.

Injustice

72. I have considered the injustice Mrs C has suffered from the fault I have identified. The Home failed to provide evidence that it had properly risk assessed and reviewed Mrs C’s mobility and risk of pressure sores when the care plan was reviewed.
73. Therefore there was uncertainty whether the plan would have changed if the review had taken place. I accept that this uncertainty may have caused Mrs B distress so I recommend the Home apologises to Mrs B.
74. I note that the Home has accepted that it failed to update the care plan on 12 November 2023 and says this has been addressed, although it does not say how it has been addressed. I recommend the Home reminds relevant staff of the need to review a resident’s needs and update the care plan if there has been a change in the person’s needs (for example, if they become ‘bedbound’.)
75. Under our information sharing agreement, we will also share this decision with the Care Quality Commission (CQC).

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Agreed action

76. The Home has agreed to take the following actions within one month of the final decision. It will:
• Apologise in writing to Mrs B for the fault I have identified.
• Remind relevant staff of the need to review a resident’s needs and update the care plan if there has been a change in the person’s needs.

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Final decision

77. I have completed my investigation and uphold part of Mrs B’s complaint. I have made recommendations the organisation has agreed to carry out.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman