Summary: Mrs X and Mrs Y complain that the Council failed to undertake an appropriate safeguarding investigation after their sister Ms A developed a serious pressure sore in the care home where she lived. The evidence available shows that the Council considered properly how the care provider acted in accordance with the relevant guidance.

The complaint

1. Mrs X and Mrs Y (the complainants) say the Council did not properly investigate their concerns about the management of Ms Y’s pressure sore in the home, allowed the care home manager to investigate the matter and excluded them from the process.

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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 significant injustice, or that could cause injustice to others in the future 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 considered evidence provided by the Council and by Mrs X and Mrs Y, as well as the relevant law, policy and guidance which I detail below.
5. Both parties had an opportunity to comment on my draft decision before I reached a final decision.

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What I found

Relevant law and guidance

6. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)
7. The Care and Statutory Support Guidance (CSSG) sets out the aims of adult safeguarding (14.11):

prevent harm and reduce the risk of abuse or neglect to adults with care and support needs

stop abuse or neglect wherever possible

safeguard adults in a way that supports them in making choices and having control about how they want to live

promote an approach that concentrates on improving life for the adults concerned

raise public awareness so that communities as a whole, alongside professionals, play their part in preventing, identifying and responding to abuse and neglect

provide information and support in accessible ways to help people understand the different types of abuse, how to stay safe and what to do to raise a concern about the safety or well-being of an adult

address what has caused the abuse or neglect.

8. One type of abuse is organisational abuse: “including neglect and poor care practice within an institution or specific care setting such as a hospital or care home, for example, or in relation to care provided in one’s own home. This may range from one off incidents to on-going ill-treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation.” (CSSG 14.17)
9. Neglect and acts of omission include ignoring medical or physical care needs and failing to provide access to appropriate healthcare services.
10. The CSSG also says (14.70) that in cases of suspected abuse in regulated care settings – a care home, for example – “The employer should investigate any concern (and provide any additional support that the adult may need) unless there is compelling reason why it is inappropriate or unsafe to do this”. The CSSG adds “If the local authority decides that another organisation should make the enquiry, for example a care provider, then the local authority should be clear about timescales, the need to know the outcomes of the enquiry and what action will follow if this is not done”.

Guidance on Wound Care

11. The National Wound Care Strategy Programme gives guidance to health and care practitioners, service managers and commissioners about the fundamentals of care for people who have or are at risk of developing pressure ulcers. The clinical pathway recommends “regular review and monitoring of healing at least 4-weekly” followed by onward referral to specialist services as needed.
12. Additionally there is an online pressure sore management resource produced by the local health authority for care staff, “React to Red”.

What happened

13. Ms A is a disabled and vulnerable adult who has lived in the care home for some years. She has limited mobility and cannot express herself verbally. In 2023 she was admitted to hospital: staff from the care home accompanied her to provide personal care. The care home staff reported to the hospital staff that Ms A had a small split in her natal cleft (between her buttocks). Mrs X says this was treated with barrier cream while in hospital. Ms A was discharged back to the care home on 16 August. Neither the hospital discharge letter nor the body map completed at the care home on her return mentioned the split.
14. The care home notes over the next few weeks refer to the treatment of the split and re-positioning of Ms A for pressure relief. Ms A’s GP was aware and gave advice on barrier cream application and the appropriate dressings. Between 16 August and 19 October there are multiple references to Ms A being in pain, crying with pain, being tearful and being given medication for the pain. At times the split was said to be healing well, then it reopened.
15. On 19 October the care home staff contacted the GP with their concerns about the split. The GP recommended continuing with the barrier creams and said he would speak to the practice nurse about the matter. The District Nursing service contacted the care home as a result: the notes record “They said because we are a Nursing Care Home that they cannot help. I rang the Drs back and spoke to … the receptionist and he said he will put it through as a Task for (the GP) to refer to the Tissue Viability Nurse.”
16. Care home staff spoke to the TV nurse on 30 October. The nurse looked at the photos the care home staff had sent. The notes of the conversation say, “it looked like it was a Pressure Damage Category 3 at least. To review our Waterlow Score. That (Ms A) should have bed rest and sitting out for meals at most…… She wanted to know what mattress she used and wheelchair cushion and a most recent photo of the pressure sore, all of which I have completed and sent. We are to alert Safeguarding.” The TV nurse saw Ms A the following week when she recommended an airflow mattress. She said she would return to test the wheelchair pressure.
17. In December Mrs X visited her sister and found her in considerable pain and distress. She says care staff were showering Ms A while she was sitting on a hard plastic chair directly on the area of the pressure sore and they appeared to be ‘task focused’ – more concerned about completing the set task than about Ms A’s obvious distress. She says she also asked the care staff if Ms A had been given her pain medication before the personal care, but they told her no medication had been given since 9pm the previous evening. Mrs X telephoned the placing council and the TV nurse to alert them to her concerns. The TV nurse contacted the GP to prescribe morphine patches for Ms A, and said the plastic shower chair should not be used again: bed baths should be used for the foreseeable future.

The safeguarding enquiry

18. The Council opened a safeguarding enquiry. The manager of the care home was tasked with the initial investigation and reported back to the Council by the end of November. The care home manager detailed the timeline of the pressure wound management. She acknowledged there might have been some breakdown in communications between staff and members of Ms A’s family. She said she recognised the family had Ms A’s interests at heart and had a valuable role to play, but it was the nursing team which had responsibility for Ms A’s care and had to adhere to clinical guidelines.
19. The safeguarding social worker visited the care home in December and reviewed all the documentation in relation to Ms A’s nursing care. Her notes state there were no issues or evidence raised around Ms A’s care, support or documented records. She emailed Mrs X and said she had completed an unannounced visit to the home to see the records, and had also shared relevant information with Ms A's social worker from the placing council so she could review the appropriateness of the placement. The allocated social worker from the placing authority also visited the care home.
20. The safeguarding social worker spoke to Mrs X to let her know that there was no evidence to suggest the staff at the care home were not following the guidance from healthcare professionals. She said she had asked the allocated social worker to arrange a multidisciplinary meeting (MDT) “for all professionals involved and family to attend so that any issues can be discussed and addressed.”

The MDT and the complaint

21. An MDT was held in January 2024. Ms A’s sisters raised their concerns that PRN medication was not given appropriately, that they were consistently told by staff that ‘everything was fine’ despite ongoing concerns about the pressure sore, and that the care home had not properly managed the pressure sore.
22. The care home manager said that as a nursing home they were able to manage the sore until/ unless it advanced to grade 3. She said they were in contact with the GP and (through the GP) the TVN. Mrs X asked how the sore had progressed from its appearance at the discharge from hospital to being a grade 3 sore if it was being properly managed.
23. One agreement from the MDT was that a communication plan was to be put in place between the care home and the family. The safeguarding investigator would examine how the sore progressed to become grade 3. The meeting notes add “All who attended this MDT agreed that (Ms A) has improved and her pain management is under control.” Overall, the outcomes were that the safeguarding concerns were partially substantiated due to poor communication from the care home to the family. In respect of the pressure sore management, there was no evidence to suggest that the correct protocol had not been followed. The safeguarding enquiry was closed.
24. In February the Council wrote to Mrs X and Mrs Y with the outcome of the safeguarding enquiry. The Council said, “The purpose of the safeguarding investigation was to ascertain if there were any acts of negligence or omissions of care that led to this occurrence’. Evidence provided by all parties has shown that appropriate medical advice was sought, and plans implemented by the tissue viability nurse were followed correctly by the placement.” It said “(the safeguarding investigator) identified that the provider sought appropriate medical intervention in a timely manner, and followed all medical advice given.”
25. Mrs Y complained in February and again in April. She said they were both now happy with the care Ms A was receiving and agreed that Ms A was well on the way to a recovery and was largely pain free. She said however that this had not been the case and that they believed Ms A had been let down. She asked how it was that the care home manager had been allowed to conduct the safeguarding investigation, given the conflict of interest (ie that she was managing the service about which the safeguarding alert had been raised)? She said she had asked about the pressure sore management procedures in place but not been given any information and she asked for these again. She said the fact that the sore had developed suggested either the procedures had not been followed, or they had been followed and were ineffective therefore should be reviewed
26. Mrs Y also said they were concerned the care home did not really manage their sister’s pain adequately. She said they had both seen Ms A seated in distress on a hard plastic chair about which concerns had already been raised. She was allowed to sit in her wheelchair for up to 6 hours on visits. She said when she asked about pain relief, staff told her it was difficult to get Ms A to take it as she was also refusing to eat and drink. Mrs Y said it was she who asked if the medication could be given by another route to ensure it was taken, and the TV nurse who contacted the GP about morphine patches.
27. In conclusion Mrs Y said Ms A had left hospital with a red pressure area in August which by December had deteriorated to a grade 3 sore and they did not believe that it was managed effectively. She said they did not accept the outcome of the safeguarding enquiry.
28. The Disability Team Manager responded to the complaint. She said it was not unusual for the Council to ask the registered manager to undertake an investigation. She said, “It is also of note that this internal investigation was overseen by the Quality Manager of (the care provider) to ensure a level of additional scrutiny and quality assurance.”
29. The Team Manager gave details of the local NHS Trust’s React to Red policy which the care home followed. She said the care home manager also offered to go through all the procedures and plans with Mrs X and Mrs Y if they wished. Finally, she said that as she had previously advised, if they retained concerns about the pain management they should speak to Ms A’s GP. She said the care home “sought GP involvement in a timely manner and were guided by the GP as to what the appropriate pain relief should be.”
30. Mrs X and Mrs Y complained to us about the safeguarding investigation. They said it had not been a thorough and robust investigation but had relied on the findings of the care home manager, and the review of papers by the safeguarding investigator. They disputed the conclusion that proper documentation meant proper care and management. They said their sister had not been heard.
31. In response to our enquiries the Council says all the care home’s notes were reviewed by the Best Interests assessor and Ms A’s allocated social worker. The care home manager says, “The nurses managed the wound daily – they are qualified and aware of pressure care management. React to Red is a universal tool that is used to develop our own tools to manage pressure care. We support people with very limited mobility who are very vulnerable and susceptible to pressure ulcers. We reduce the risk of pressure areas routinely. This is done with care planning, risk assessment, and an understanding of repositioning/continence/illness/disease/sensory impairment/diet. as well as the safeguarding investigator.”
32. In respect of the management of Ms A’s pain, the Council says “The care notes and RCA demonstrated that (Ms A’s) pain levels were discussed regularly with the GP. The GP then attended a multi-disciplinary team meeting – with family present – to discuss further the complexities of managing pain medications.

The GP confirmed that pain medication could not be increased due to its interaction with (Ms A’s) pre-existing health needs; because of this, it was not deemed to be in (Ms A’s) best interests by the GP to increase pain medication.”

33. The Team Manager responded to our enquiries about a perceived delay in escalating the management of the pressure sore. She says, “The nurses are trained to manage pressure sore care up until a stage where the wound has not responded to treatment for 4 weeks or the sore has reached stage 3. From initial deterioration there was clear evidence of GP oversight of the care being provided by the nurses with images being uploaded to the GP’s system to track the progress of the sore. The GP then advised different dressings to be tried and then latterly suggested a period of the wound being uncovered to attempt to encourage healing. When the wound did not heal the matter was then referred to Tissue Viability nurses. The criteria for such referral includes the consideration of a wound that has failed to respond to 4 weeks of treatment which was applicable in this case and the wound was deteriorating further.

It was not considered that there was evidence of omission or neglect by the provider regarding the pressure care as the correct treatment protocol had been followed and provided by Registered nurses under the close instruction of the GP. Tissue Viability nurses had been correctly referred to when the wound was not responding to treatment as per the guidance”.

34. Mrs Y and Mrs Z say if it had not been for family members repeatedly raising concerns their sister’s health would have deteriorated even further. They say form their point of view, Ms A “did experience significant harm as a result of poor practice and ineffective treatment and management of her pressure area.”

Analysis

35. This was a very distressing time for Ms A and her family. Mrs X and Mrs Y say, and the MDT agreed, that the communications from the care home about Ms A’s health were sometimes poor. A communications plan was put in place as part of the overall care strategy for Ms A. In my view that action is sufficient to remedy that aspect of the complaint.
36. The main aspect of the complaint was the conduct of the safeguarding investigation – that the care home manager was requested to undertake it, that the safeguarding investigator was satisfied with a review of the papers and that the Council had concluded there was no evidence to substantiate the allegation that Ms A had suffered abuse by way of neglect or omission by the care home.
37. I have not seen any evidence in the way the safeguarding investigation was conducted. There was appropriate overview of the manager’s investigation by the care provider and by the safeguarding social worker, and Ms A's own allocated social worker. On the basis of the evidence and information available to it, and in consideration of the steps required by the national wound care strategy as well as local policies, it was not fault for the Council to reach the conclusion that the care home had followed the relevant procedures.

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Final Decision

38. I have completed this investigation on the basis that I do not find evidence of fault by the Council.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman