Brooklands Nursing & Residential Home (17 012 513a)

Category : Health > Community hospital services

Decision : Upheld

Decision date : 11 Apr 2019

The Ombudsman's final decision:

Summary: Mrs Y complains about the social care provided to her father, Mr X. She also complains about elements of the community nursing care provided by the NHS Trust. The Ombudsmen found some of the home’s actions caused injustice, which it will remedy with the actions listed at the end of this statement. The Ombudsmen finds some minor fault in the actions of the NHS Trust. However this did not, in our view, impact on Mr X.

The complaint

  1. The complainant, whom I will call Mrs Y, complains that Brooklands Care Home ‘the home’ failed to provide safe and appropriate care for her father, whom I will call Mr X.
  2. Mrs Y also complains about the wound care provided by District Nurses employed by Norfolk Community Health and Care NHS Trust ‘the Trust’.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
  2. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
  3. 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. (Local Government Act 1974, sections 34B and 34C)
  4. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
  5. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

  1. I have considered a written complaint from Mrs Y and discussed the matter with her. I have sent the summary of complaint to all the organisations involved and invited comments, which I have considered with supporting records.
  2. I have sought advice from a senior nurse (our nurse advisor). I have considered this advice with relevant law and guidance before coming to a view.
  3. I issued a draft decision and invited comments from Mrs Y and the organisations involved. I considered any comments received before making a final decision.
  4. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards which registered providers of care must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
  2. Regulation 12 places a requirement on social care providers to give safe care and treatment and to prevent avoidable harm or risk of harm. In doing so, providers must:
    • assess the risks to the health and safety of service users of receiving the care or treatment;
    • do all that is reasonably practicable to mitigate any such risks;
    • ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely;
    • ensure that the premises used by the service provider are safe to use for their intended purpose and are used in a safe way;
    • ensure that the equipment used by the service provider for providing care or treatment to a service user is safe for such use and is used in a safe way;
    • where equipment or medicines are supplied by the service provider, ensure that there are sufficient quantities of these to ensure the safety of service users and to meet their needs;
    • ensure the proper and safe management of medicines;
    • assess the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated;
    • work with service users and other appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of the service users.

Health care

  1. The Trust’s policy for the ‘Prevention and Management of Pressure Ulcers in Adult Patients’ is written in accordance with the National Institute for Health and Care Excellence (NICE) guidelines, and sets out what actions its staff should take to prevent and manage pressure sores. The policy says:

“The cause of the pressure ulcer must be identified, and where possible removed or reduced”

“All pressure ulcers will be graded using the NHS Midlands and East pressure ulcer grading tool (adapted from European Pressure Ulcer Advisory Panel (EPUAP, 2009) (Appendix J) at the time of the assessment and documented to include site of damage, grade of pressure ulcer, visual characteristics of the wound, dimension, pain, odour, exudate, any infection with the date and time in the patient’s notes or System One”

“The pressure ulcer management plan will be documented and includes all aspects of the prevention plan as well as a wound management care plan”

“An evaluation of the pressure ulcer is conducted at each dressing change; however the treatment plan is adjusted as required by a registered nurse. Findings from wound evaluation are to be documented on the individualised care plan or System One, to include location and grade of each pressure ulcer and any indication of wound infection. Clinical observations must be taken if any indication of wound infection and recorded within the patient notes. The registered nurse will document the frequency of the review on the plan as required for individualised care”

What happened

  1. Mr X, who sadly passed away during this investigation, moved into Brooklands Care Home in November 2016. I will refer to this as ‘the home’. Mr X’s placement there was privately arranged and funded by his family. At first Mr X resided within the home’s residential unit. But two weeks after moving there, the home decided to move Mr X to its specialist dementia unit. Mr X resided at the home for approximately three months.
  2. Mr X’s daughter, Mrs Y, regularly visited Mr X at the home. Mrs Y began to note concerns about the standard of care provided to Mr X and in February 2017 she raised a formal complaint. I will consider each of those complaints below.

Personal care and clothing

  1. Mrs Y said the home failed to ensure Mr X was dressed appropriately and in clean clothing. Mr X’s care plan noted: “[Mr X] needs some help with choosing appropriate clothes for the conditions and with selecting clothes he likes to wear”
  2. I have reviewed the daily care records. It is clear from these that, as per the care plan, Mr X did require assistance with dressing. It is also clear that Mr X sometimes refused personal care. On occasion, the notes also show that Mr X would sometimes undress himself after staff had assisted him in getting ready.
  3. As a result of his dementia, the notes show Mr X sometimes acted in a confused and agitated manner. Sometimes he would accept personal care, and on other occasions he would not: “he is refusing personal care and is currently walking up and down the unit floor” and, “[Mr X] refused any help with personal care or changing of clothes, he walk around the unit” and, “I asked [Mr X] if he would like to shower as he was really messy, he declined becoming quite agitated, so I asked if I could assist him in a full body wash which he agreed to”.
  4. The notes show that Mrs Y raised concerns on 24 January that Mr X, in her opinion, sometimes appeared unkempt and would often be wearing pyjamas when she visited. When reading the notes in context, it is evident that around this time Mr X had often refused personal care.
  5. I appreciate it would be upsetting for Mrs Y to see her father on occasions when he appeared unkempt and not fully dressed. However, based on the information I have seen, it is apparent that the home washed and dressed Mr X when they were able to. It was not possible nor appropriate for staff to provide personal care to Mr X against his wishes, and the times Mr X refused personal care are clearly recorded. For this reason, I do not uphold this part of Mrs Y’s complaint.


  1. Mr X’s care plan states that: “trained staff should always administer [Mr X’s] medications as indicated on [Mr X’s] MAR (Medical Administration Record) sheet” and says the home should: “safely administer medication and adhere to the medication administration policy at all times. Should a medication error occur, protocols should be followed”
  2. On 18 January 2017 the home recorded, “Asked Dr [name removed] that if [Mr X’ had missed a dose of warfarin would there be any health implications, he said no there wouldn’t be”. The notes from this day also show the GP visited the home and reviewed Mr X’s MAR, “from checking medication – [Mr X’s] warfarin count is incorrect and doesn’t correspond to MAR. Discussed with Dr [name removed] he is not concerned”.
  3. The home raised a safeguarding alert with the Council regarding the missed medication. It also contacted Mrs Y to explain the error with Mr X’s medication, and confirmed it had reported the concerns to the local authority. The notes show that Mrs Y thanked the home for the information.
  4. After reviewing the incident, the home confirmed to the Council, “we discussed the medication error, I have told [officer name] that we have introduced a new form that the staff member who is administrating the medication had to complete after each drug round they have to date and sign and say everything is complete”
  5. The home accepts that there was an error in the administration of Mr X’s warfarin medication. Consequently, it breached the CQC fundamental standards of care. Although the provider maintained a MAR sheet for Mr X, it accepts that staff should do more to ensure the safe and effective administration of medication. The home agreed to introduce new measures following correspondence with the Council about the safeguarding concerns.
  6. Mrs Y also complains that the home arranged for additional medication to be prescribed to Mr X, without informing her. I understand the purpose of this was to reduce Mr X’s agitation and anxiety. The home accepts that it failed to advise Mrs Y of the changes to Mr X’s medication.
  7. I uphold this part of Mrs Y’s complaint because the home did not administer two of Mr X’s warfarin tablets. It also failed to notify Mrs Y of an important change in Mr X’s medication. Based on the information I have seen, the home took appropriate action once it became aware of the error; raising a safeguarding alert with the Council and liaising with a GP who reviewed the MAR and confirmed that they had no health concerns about Mr X. Although the actions of the home had no impact on Mr X on this occasion, I find its failure to properly administer Mr X’s medication could have caused an injustice.

Accidents and injury

  1. Mrs Y complains that she was not informed of an incident between Mr X and another resident. Mrs Y believes the incident occurred on 14 February. I have considered the case notes, as well as the safeguarding papers provided by the Council. These show the incident happened on 5 January. It is recorded that Mr X was punched in the arm by another resident, but that he was not injured.
  2. The home raised a safeguarding alert with the Council. The notes also show it called Mrs Y at 17:24, “Informed [Mrs Y] of the incident this evening. She also fed back that she is concerned with him [Mr X] sleeping in the day”.
  3. I am satisfied the home took appropriate steps in response to this incident, and I do not therefore uphold this element of Mrs Y’s complaint.
  4. However, Mr X then suffered a fall the following month. Mr X’s care plan places him at ‘moderate’ risk of falls. At the time of completion, the plan noted that Mr X had not fallen within the past twelve months but that the effects of his prescribed medication placed him at risk of falls during the day.
  5. The daily care notes recorded by the home are comprehensive. The recording on 24 February describes the fall and the home’s response. The notes show the nurse employed by the home checked Mr X before staff moved him, and found “there was no visible cuts, slight redness to his left lower back [nurse] said she couldn’t feel anything wrong and we can get [Mr X] up”.
  6. Shortly after the fall, the notes show a member of staff washed Mr X. During the wash, Mr X complained of pain in his left side. The carer noted slight redness. Later that day Mr X expressed pain again. A carer asked him whether his back was still hurting following the fall, and Mr X confirmed it was.
  7. Mr X complained of pain on a further two occasions during the afternoon of 24 February. The notes show Mr X then awoke at 2am complaining of pain in his side and back. He became agitated and angry, and a carer helped him back to bed.
  8. Mrs Y visited Mr X on the afternoon of 25 February. She said that Mr X had cried out in pain when hugged. Mrs Y noted bruising, cuts and grazing to his left arm. Mrs Y enquired with care staff, who then informed her that Mr X had suffered a fall the previous day.
  9. The home’s ‘Accidents, Incidents and Emergencies’ Policy Statement says, “ in the event of a minor injury or health related incident the first Aid Policy should be followed…an incident or accident form should be completed and the resident’s GP informed…the responsible line manager should then ensure that arrangements are made for relatives or friends of the casualty to be advised fully of the situation, if necessary, and to ensure that an incident report form and any other relevant paperwork is completed as soon as possible”.
  10. The home completed an incident form, but did not initially inform Mrs Y or Mr X’s GP of the fall. This is not in accordance with its accident reporting policy. In its response to Mrs Y’s complaint, the care provider acknowledged this was not acceptable, and confirmed that it had discussed the incident with the carer in question. The care provider apologised to Mrs Y and confirmed it had recently undergone a “significant period of change” involving training of existing staff, and the appointment of additional staff.
  11. After Mrs Y’s visit on 25 February, Mr X expressed pain again when a carer helped him to bed. Mr X said he could not locate the exact area of the pain. The carer noted that Mr X had taken all his medication, including painkillers.
  12. The following day it is recorded that Mr X “seemed to be in a lot of pain”. On further observation, care staff noted slight swelling on Mr X’s side which was painful to the touch. The carer asked the nurse to check Mr X again.
  13. The nurse assessed Mr X. She felt a lump on his left side, but recorded that Mr X did not appear to express pain on assessment. The nurse advised carers to continue administering pain medication and to inform her if they required further advice. The nurse also asked staff to contact the GP surgery the following day.
  14. Mrs Y visited later that day. She told staff she was unhappy that Mr X had not been seen by a doctor. The staff advised Mrs Y they had contacted an on-call doctor, but were awaiting a call-back. Mrs Y was unhappy with the timescales and told care staff she intended to call 999.
  15. In the meantime, the home received a call from the on-call doctor. The notes of that conversation show the doctor advised the home to continue with the administration of pain medication, and that further intervention may not be required unless Mr X had shortness of breath. The doctor also noted that Mr X’s symptoms could be the result of a fractured rib, but that there was no treatment for this. The doctor gave his opinion that it would be unfair to transfer Mr X to hospital due to his age and mental capacity unless he was “acutely unwell”.
  16. Paramedics then arrived at 7pm and transferred Mr X to hospital. The ambulance staff raised a safeguarding alert following concerns it had about Mr X’s care.
  17. It is not possible for the Ombudsman to conclude whether the fall Mr X suffered was a result of poor care and thus avoidable. Falls can happen for many unavoidable reasons. However, the home did not follow its policy after the fall, which states that family members and the resident’s GP are to be informed. The home contacted the on-call GP three days after the incident, despite Mr X expressing pain during that period. The home’s nurse decided that Mr X’s injuries did not warrant GP intervention at the time of the fall. The home policy says that even minor incidents should be reported to the service-user’s GP.
  18. The Council decided to take no further action in response to the safeguarding alert made. It concluded, “… It appears that appropriate steps were taken following fall, [Mr X] not initially complaining of pain, Out of Hours GP unavailable to visit and 999 called. Grade 4 pressure ulcer on heel is under the care of the District Nurse. Safeguarding concerns cannot be substantiated and no evidence that abuse has taken place. [Mr X] appears to require more support than can be provided by a Residential Care placement. Previous safeguarding concerns were managed with a Safeguarding Alert. No Safeguarding Actions required”.
  19. It is not clear what records the Council considered when reaching this view. But it is not the body in jurisdiction for this case as Mrs Y’s complaint is against the care home, so I will not consider the actions of the Council. However, it is clear from the records I have seen that Mr X complained of pain five times over the course of three days before the home arranged to call the doctor.
  20. Mr X transferred to hospital two days after his fall. Mrs Y tells me that Mr X had a fractured rib, as suspected. The on-call doctor had advised the home that there was no treatment for a fractured rib and Mr X should remain in the home.
  21. I uphold this part of Mrs Y’s complaint because the home’s actions following Mr X’s fall were not in accordance with its policy. I have to consider whether this did, or could have, caused Mr X injustice. I am mindful that Mr X was admitted to hospital two days after his fall where he received appropriate care and treatment. We do not know what advice the GP would have provided had the home made contact on the day of Mr X’s fall. However, with hindsight, we know that Mr X had suffered a fractured rib. The GP had speculated that this may have been the case when the home eventually made contact on 27 February.
  22. The NHS website confirms, “Ribs can't be easily splinted or supported like other bones, so they're usually left to heal naturally. There's often no need for an X-ray…and usually get better by themselves within 3 to 6 weeks.”.
  23. On balance, I consider the delay in contacting the GP did not cause any significant injustice to Mr X because, other than providing pain relief which the home had already done, there was little which could be done to treat the fractured rib. However, the delay in informing Mrs Y of the fall caused her avoidable distress. To remedy the effects of the distress, the home has agreed to undertake the actions listed at the end of this statement to strengthen its processes around accident reporting.

Pressure sore

  1. Mr X’s care plan placed him at ‘medium risk’ of pressure sores.
  2. Pressure sores are graded on a scale of one to four, depending on their severity. The lowest grade pressure sore is grade one, which are often characterised by redness. The most severe type of sore is grade four where there is extensive tissue damage.
  3. After moving into the home, Mr X developed a grade two pressure-sore on the heel of his left foot. The home first discovered a large half-peeled blister on 11 February 2017. A nurse employed by the home checked and dressed the sore before making a referral to the NHS District Nurse (DN). The home says that responsibility for general management of the wound lay with the DN, but that its care staff checked and replaced the dressing when required.
  4. A daily note entered on 11 February 2017 at 15:10 records, “Phoned [Mrs Y] to let her about [sic] [Mr X’s] heel which she was fine about and about testing his urine as he has been a little sleepy”.
  5. The home then made a referral to the DN on 13 February. Mr X’s NHS patient records shows the DN visited the following day. The DN carried out an assessment of the sore, and decided it was a ‘grade two’ pressure sore. The DN notes that Mr X had worn ill-fitting shoes, causing pressure. The DN found no evidence of infection, no odour and no pain. The DN decided that it was necessary to visit Mr X every Tuesday and Friday to attend to the wound, and that carers in the home should wash, dry and dress the wound in between DN visits.
  6. The home called Mrs Y later than day to relay details of the DN’s visit. The home also records a request for Mrs Y to purchase some suitable footwear for Mr X.
  7. The following day the home records: “wet soiled dressing removed, heal cleaned and fresh tagaderm foam adhesive dressing applied”. Then again on 16 February, “the unit lead re-dressed his foot and then I settled him in his room with his feet elevated”.
  8. The DN’s scheduled visit to the home on 17 February to review Mr X did not go ahead. This was due to an outbreak of a contagious sickness bug in the home. This is supported by the DN’s notes.
  9. On 18 February the home recorded a deterioration in Mr X’s sore, “dressing was soiled, removed and area cleaned. The skin over the heal has become very loose and detached in areas. The flesh underneath is dark red and brown”. Later that day Mrs Y called the home and it relayed an update regarding Mr X’s heel.
  10. The home cleaned Mr X’s heel on 19 February and replaced the dressing.
  11. Mrs Y then called the home on 20 February. She asked when the home planned to re-dress the wound. The staff member said she would find out and return Mrs Y’s call.
  12. A healthcare assistant (HCA) visited Mr X on 21 February, redressed the wound and noted “necrotic” tissue, but no signs of infection. The notes show the HCA discussed the case with care staff and ordered a pressure relieving air mattress for Mr X.
  13. During the next visit on 24 February, the DN noted a deterioration in the wound. She said that Mr X had expressed pain during dressing change, and the wound is now a “grade three” pressure ulcer with a “slight odour” and “seeping fluid”. The DN decided there were no clinical signs of infection, but the wound should be monitored and kept as dry as possible. The DN advised care staff to help Mr X try to avoid pressure.
  14. On 26 February, a member of care staff at the home recorded, “I left the socks on [Mr X] that he had on as he didn’t have any more in his room”.
  15. When the DN visited on 27 February, care staff advised that Mr X was in hospital. The DN’s involvement in Mr X’s wound care ended.
  16. I have consulted the records made by the DNs who cared for Mr X. I have also considered the two ‘Waterlow’ assessments completed in relation to Mr X’s sore. The assessments were completed six days apart. The first assessment was completed three days before the home identified Mr X’s sore, and the second assessment completed three days after. The results of the assessments are key in identifying risk and planning the appropriate level of care. Errors in the assessments could impact on the level of care provided.
  17. The assessments I have considered are inconsistent. The first assessment refers to Mr X as being ‘average BMI’ with ‘multiple organ failure’ and no signs of diabetes. The second assessment records an ‘obese BMI’ and diabetes. This concluded that Mr X was ‘high risk’.
  18. With that said, the level of intervention and the frequency of the DNs visits in Mr X’s case was appropriate, based on both the classification of the wound and the management plan. There are no standards or guidelines relating to the frequency of visits; this is determined based on the findings of the initial assessment. The second assessment appears to be an accurate reflection of Mr X’s needs.
  19. The Trust’s own policy stipulates that, “the cause of the pressure ulcer must be identified, and where possible removed or reduced”. This is because most pressure sores are avoidable. Consequently, when a service-user develops a pressure sore it often means the provider of care did not:
    • evaluate the person’s clinical condition and pressure ulcer risk factors;
    • plan and implement interventions that are consistent with the person’s needs and goals and recognised standard of practice;
    • monitor and evaluate the impact of the interventions or revise the interventions as appropriate.
  20. The records suggest the Mr X’s pressure sore might have developed because of ill-fitting shoes. Our clinical advisor has confirmed that specialist boots could not have been issued to Mr X due to his risk of falling. However, as per the above guidelines, I consider there was a missed opportunity by the home to identify, and possibly eliminate, the cause of the sore sooner. Although the poor fitting shoes were a factor, the records show the home only mentioned this to Mrs Y on one occasion on 14 February. I also find the home failed to ensure appropriate infection control because it did not change Mr X’s dirty socks, despite his sore having deteriorated to grade three. I therefore uphold this part of Mrs Y’s complaint.
  21. There is also some fault in the actions of NHS staff. As per the Trust’s policy, Mr X should have received a referral to the Community Podiatrist once his sore developed to grade three. However, this had no impact on Mr X because he was admitted to hospital just three days after the sore deteriorated and so there would have been little opportunity to receive input from the Podiatrist.
  22. Mr X sadly developed sepsis from his sore. Mrs Y feels there was a lost opportunity to identify the onset of the infection sooner. The Trust’s policy states that “clinical observations must be taken if any indication of wound infection and recorded within the patient notes”. The Trust did record its clinical observations. Based on the records I have seen, there is nothing within the notes to show there were any concerns or indications about wound infection. I do not, therefore, find there was a lost opportunity to identify or prevent sepsis as a result of procedural fault by the home or the Trust.

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Agreed actions

  1. Within four weeks of the Ombudsman’s final decision, the care provider will:
    • Apologise to Mrs Y for the failure to identify the cause of Mr X’s sore sooner and to take the appropriate preventative steps;
    • Apologise to Mrs Y for the failures in administering Mr X’s medication; and
    • Pay £500 to Mrs Y for the distress caused by the missed opportunity to identify the cause of Mr X’s sore and take steps to try and prevent the sore;
  2. Within twelve weeks of the Ombudsmen’s final decision, the care provider will provide evidence to the Ombudsmen:
    • that it has reminded its staff of the requirements of its ‘Accident and Incident’ policy, especially around the reporting of accidents to the service-user’s family and registered GP;
    • of its new method of MAR reporting; and
    • that it has arranged staff training around the prevention and management of pressure sores.

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Final decision

  1. I have completed my investigation. The actions of the care provider caused injustice which it will remedy with the actions listed above.
  2. The procedural fault found with the actions of the Trust had no impact on Mr X, and so I have not recommended any remedial action for this part of the complaint.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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