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Gloucestershire Health and Care NHS Foundation Trust (20 007 614b)

Category : Health > Community hospital services

Decision : Upheld

Decision date : 16 Sep 2021

The Ombudsman's final decision:

Summary: Miss B and Mrs C complain about the care their late grandmother Mrs P received in a council-funded care home and from district nurses. Failings in Mrs P’s care by the Home and district nurses led to her developing severe pressures ulcers in the last weeks of her life. The Council did not investigate key issues in the complaint. The organisations should apologise and make a payment to Miss B and Mrs C to acknowledge the distress they suffered. The Council should also ensure the Home makes service improvements.

The complaint

  1. The complainants, Miss B and Mrs C, complain about the care their late grandmother Mrs P received in November 2019 at The Elms (the Home), a dementia respite placement the Council arranged. They say Gloucestershire County Council’s (the Council) assessment of Mrs P’s needs was not adequate and the placement at the Home was not suitable. They say the Home failed to manage Mrs P’s pain, medication and continence needs adequately. They also say she developed severe pressures ulcers and unexplained bruising due to poor care by the Home and visiting district nurses who were employed by Gloucestershire Health and Care NHS Foundation Trust (the Trust).
  2. Miss B and Mrs C complain the Home did not communicate adequately with them and did not take appropriate action once Mrs P’s pressure ulcers developed. They say the Home failed to follow up a referral to Palliative Nursing, and the Council caused delays in the assessment process for Mrs P’s potential eligibility for NHS Continuing Healthcare funding (CHC).
  3. Miss B and Mrs C say Mrs P suffered significant avoidable pain and distress, including tissue loss due to the pressure ulcers. She died a few weeks later at a different care home and Miss B and Mrs C think she suffered unnecessary pain in the last weeks of her life. They say the family suffered unnecessary upset and stress, including having to find a more suitable care home placement at short notice and without support from the Council.
  4. Miss B and Mrs C want the Council, Home and Trust to acknowledge all the failings in Mrs P’s care, and to apologise for the impact this had both on her and her family. They want an explanation of why the Council did not feel Mrs P’s needs warranted nursing care, and why Mrs P did not have a full eligibility assessment for CHC sooner. They want to see evidence of learning from their complaint, and action to reduce the risk of this happening to other elderly people and their families.

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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, a single team has considered these complaints 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) If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
  3. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
  4. The Council commissioned and arranged Mrs P’s care at the Home under its duties set out in the Care Act 2014. Any fault in the Home’s service is fault by the Council.
  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 information Miss B and Mrs C provided in writing and by phone. I have also considered written information from the Council, Trust, and the Home, as well as relevant law and guidance.
  2. I shared a draft of this decision with Miss B, Mrs C and the organisations and I took their comments into account before making my final decision.
  3. Under the information sharing agreement between us and the Care Quality Commission (CQC), we will send it a copy of our final decision.

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What I found

Background

  1. Mrs P had several health conditions including ovarian cancer and dementia. She lived at home with a package of care of four visits daily, and support from her daughter and family. In early November 2019 the Council arranged a respite placement for Mrs P at the Home for two weeks as her mental and physical health had declined.
  2. Mrs P’s family wanted her to go to a different home (which I will call Home B) but it had no vacancies. The family felt Mrs P needed a nursing home placement rather than residential, and that she should be eligible for NHS CHC funding.
  3. Mrs P had a history of developing pressure ulcers. Whilst she was in the Home she developed a pressure ulcer on her sacrum (base of the spine).
  4. Mrs P stayed at the Home for two weeks. During that time, she had a hospital appointment which her family tried to take her to, but they could not get her into the car so Mrs P could not attend the appointment.
  5. A placement was then arranged at Home B. Mrs P’s family drove her to the new placement on 15 November. They said they were left to arrange transport themselves without help or advice from the Home, Council or district nurses on what arrangements Mrs P needed. When Mrs P arrived at Home B it found she had several pressure ulcers including a Grade 3 ulcer on her sacrum and an unstageable ulcer on her heel. They made a safeguarding referral to the Council and completed a Datix incident report. They also started a care plan for Mrs P’s pressure sores.
  6. Mrs P remained at Home B until she sadly passed away in early December 2019. The causes of her death were cancer, a heart condition and dementia. Her family felt her pressure ulcers contributed to her rapid decline and caused her avoidable pain and distress in the last few weeks of her life.
  7. Mrs P’s family complained to the Council about her care at the Home. The Council responded in February 2020, having met with staff at the Home and representatives of the Trust. The Council said for the most part Mrs P’s care at the Home was appropriate and in line with expected standards.
  8. In January 2020 the Trust decided to carry out a Serious Incident Investigation looking at the actions of the district nurses. The Trust finally shared the investigation findings with Mrs P’s family in January 2021.

Pressure area care – the Home

Relevant law and guidance

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (‘the CQC 2014 Regulations’) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC)’s Fundamental Standards give guidance to care providers on how to meet the requirements of the Regulations. has issued guidance on meeting the regulations (the Fundamental Standards). The following standards are relevant to how the Home managed Mrs P’s pressure areas:
    • Regulation 12 - providers must prevent people from receiving unsafe care and treatment, and prevent avoidable harm or risk of harm
    • Regulation 17 - providers must keep accurate, complete and detailed records of care and treatment
    • Regulation 18 - providers must tell the CQC of all incidents that affect the health, safety and welfare of people who use services, including the development of a pressure ulcer or grade 3 or above
    • Regulation 20 - providers must be open and transparent with people using their services and their families and must notify them and apologise if something has gone wrong with the person’s care or treatment. Providers must tell the person or their representative if there has been a ‘notifiable safety incident’, which includes pressure ulcers of grade 3 or above.
  2. Pressure ulcers (also called pressure sores) are injuries to the skin and underlying tissue, usually caused by prolonged pressure on the skin. They are most common on the heels, sacrum, elbows and hips. They often develop gradually but can sometimes form in a few hours. Many pressure ulcers are preventable and are a key indicator of the quality and experience of patient care.
  3. Pressure ulcers are graded in severity from 1 to 4. Grade 1 indicates the first sign of pressure damage and grade 2 is usually an abrasion or blister. Grade 3 is a deep wound that reaches the deeper layers of the skin, and grade 4 is a very deep wound that may reach the muscle and bone. An unstageable ulcer involves tissue loss like a grade 3 or 4 ulcer, but the depth of the wound is not known.
  4. Factors that increase the likelihood of pressure ulcers include lack of mobility, incontinence, cognitive impairment and a previous history of pressure ulcers. Treatment options include regularly changing position, using special mattresses to reduce pressure, and dressings to help heal the ulcer. Care planning and regular inspection of the skin are key steps in pressure ulcer prevention and management.
  5. A person’s Waterlow score gives an estimate of their risk of developing of a pressure ulcer. A score over 20 indicates the person is at very high risk of developing pressure ulcers. Mrs P had a Waterlow score of 21 when she arrived at the Home.
  6. The relevant guidance for care homes and NHS organisations when carrying out prevention and management of pressure ulcers includes:
    • National Institute for Health and Care Excellence (NICE) clinical guideline CG 179 Pressure ulcers: prevention and management (2015)
    • NICE quality standard QS89 Pressure ulcers (2015)
    • National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide (2019)
    • NICE and Social Care Institute for Excellence (SCIE) Helping to prevent pressure ulcers: a quick guide for registered managers of care homes (2019)
    • NHS England and NHS Improvement’s campaign Stop the Pressure
  7. The Trust’s guidance CLP119 Prevention and Management of Pressure Ulcers (2019) is the local guideline for staff about prevention, identification, management and reporting of pressure ulcers.

The Council’s investigation

  1. The Council’s complaint investigation did not comment in detail on the Home’s management of Mrs P’s pressure area care and whether it was in line with relevant standards and regulations. It said the Trust was investigating the input of district nurses into the management of Mrs P’s pressure areas. The Council told us the Trust made it very clear at the meeting with Mrs P’s family in January 2020 it would investigate all matters concerning how the Home managed Mrs P’s pressure areas, including the district nursing support provided. The Council said on that basis it did not investigate how the Home had managed Mrs P’s pressure areas.
  2. The Council’s investigation made the following findings that are relevant to pressure area care:
    • the ratio of staff to residents was appropriate in terms of being able to respond to residents’ needs such as continence
    • there was evidence in Mrs P’s records to suggest staff attended to her personal care regularly, but on occasion there was leakage from her incontinence pads
    • the Home’s Registered Manager thought the family was arranging appropriate transport for Mrs P to Home B, and she should have stopped the family from transporting Mrs P to Home B by car
  3. The Council did not investigate whether the Home’s management of Mrs P’s pressure areas was in line with relevant standards, regulations and guidance. It said this was because the Trust said it would cover these issues in its Serious Incident investigation. Nevertheless, I consider it was fault that the Home’s management of Mrs P’s pressure areas was not investigated by the Council, or the Trust, apparently due to a misunderstanding or breakdown in communication between them. The Council also decided not to carry out a s42 safeguarding investigation.
  4. The safeguarding referral and the complaint raised concerns about poor care and significant harm. It is surprising the Council did not investigate these matters through the safeguarding process. Although Mrs P had moved to another home and since died, the Council needed to know whether the alleged poor care could affect other service users at the Home. Local authorities should ensure the services they commission are safe, effective and of high quality. The Council told us it decided not to carry out a safeguarding investigation because it felt the complaints investigation would be a proportionate way to address the concerns. However, as I have outlined above, the Council’s complaints investigation did not look in any detail at the Home’s management of Mrs P’s pressure areas. I conclude it was fault that the Council did not investigate the Home’s management of Mrs P’s pressure areas in any detail, either through its complaints process or safeguarding.

Analysis

  1. The records show the Home assessed Mrs P’s risk of developing pressure ulcers when she was admitted as very high (21). It did not draw up a care plan for pressure area monitoring and care, despite the Waterlow tool stating staff should create a SKIN care plan when the score is over 15. There were no entries in Mrs P’s records at all about pressure area care or monitoring for five days, until the Home completed a Short Stay Care Plan on 6 November.
  2. The Short Stay Care Plan noted Mrs P’s history of pressure ulcers and risk factors, and said staff should “make sure to monitor her skin”. Again, the Home did not draw up a specific care plan for pressure area monitoring and care. There were no regular entries in Mrs P’s care records about staff checking her pressure areas for signs of damage. Staff were carrying out personal and continence care each day, and should have regularly checked and documented Mrs P’s skin integrity and pressure areas in view of her very high risk.
  3. A carer first noted a sore spot on Mrs P’s sacrum on 8 November, and on 9 November a carer noted the skin was broken. On 10 November the Home said it had referred Mrs P to the district nurses (the Trust says the Home sent the referral on 11 November). On 11 November a student district nurse reviewed Mrs P. This district nursing review was not until three days after a carer first noted redness on Mrs P’s sacrum, despite Mrs P being at very high risk of pressure ulcers. NICE guidance emphasises the importance of prompt intervention to prevent further deterioration.
  4. After the district nursing visits started the Home still did not have a care plan for Mrs P’s pressure areas. There are very few entries in the Home’s records about staff checking her pressure areas before she moved to Home B. The records do not provide assurance that the Home gave Mrs P appropriate pressure area care or monitored her to look for other areas of potential pressure damage. There is also no evidence the Home checked Mrs P’s heels for pressure damage, despite the heels and sacrum being the most common site for pressure ulcers in high-risk patients like Mrs P. When Mrs P arrived at Home B staff found she had an unstageable black ulcer on her heel.
  5. There is no evidence the Home used a repositioning schedule for Mrs P. Her care plan said she had dementia and needed very simple instructions. She is unlikely to have understood the need to reposition herself regularly to avoid pressure damage. There is no evidence the Home spoke with her about repositioning or put in place a repositioning schedule for staff to use. There is also no evidence the Home fitted a pump to Mrs P’s mattress, after the district nurses ordered it and it was delivered on 14 November.
  6. Mrs P’s family complained about an occasion after the Home knew she had a sacral pressure ulcer when she was in bed for 16 ½ hours as the Home’s lift was being serviced. There is no evidence of care staff either repositioning Mrs P at regular intervals or encouraging her to reposition herself during that prolonged period in bed. Guidance recommends repositioning every four hours for people at high risk.
  7. The Home said the district nurses were “taking over” once the Home had referred Mrs P to them. Although the district nurses were providing additional nursing input and care, the Home was still providing day to day care for Mrs P. This should have included monitoring her skin integrity to look for signs of other ulcers developing, evaluating whether her care was appropriate, and considering whether she needed additional pain relief. Mrs P’s family said the Home did not tell them about the extent of Mrs P’s pressure sores so they did not know they needed to ask for help to arrange her transfer from the Home to Home B.
  8. I conclude Mrs P’s pressure area care at the Home did not meet with the CQC’s fundamental standards to provide safe care and to keep accurate and detailed records.
  9. Mrs P might have developed pressure ulcers even if she had received care in line with relevant standards and guidance, due to her very high risk. But appropriate pressure area care might have prevented the ulcers, or enabled earlier intervention and reduction of the degree of harm to Mrs P.
  10. We cannot now seek a remedy for the impact on Mrs P as she has died. But the knowledge Mrs P received poor care and may have suffered preventable harm and distress in the last weeks of her life has caused distress to her family which the Council should remedy.
  11. The Home told us it has made some changes in pressure area care since this complaint. It has introduced:
    • a Prevention of Pressure Sores care plan
    • daily checking of all pressure areas, with a pressure point map in the resident’s care plan
    • a system for care staff to be present when district nurses visit so the care records reflect the action the district nurses have taken
  12. I have recommended further action by the Council later in this decision statement, to remedy the distress to Miss B and Mrs C, and to minimise the risk of future harm to other residents at the Home.

Pressure area care – the Trust

Relevant law and guidance

  1. In addition to the relevant law, guidance and standards set out in the previous section, NHS England has a Serious Incident Framework: supporting learning to prevent recurrence (2015). This explains the responsibilities and processes for dealing with Serious Incidents in the NHS and the tools available. Serious Incident investigations are carried out for the purposes of learning to prevent a recurrence.

The Trust’s Serious Incident investigation

  1. The Trust’s Serious Incident investigation found significant failings in Mrs P’s care from district nurses:
    • the delay in identifying and appropriately managing Mrs P’s sacral pressure ulcer contributed to its rapid deterioration to a Grade 3 ulcer and an unstageable right heel ulcer
    • it was not possible to say when or how the heel ulcer developed as the skin assessments were incomplete. The heel ulcer was not mentioned in the Home or district nursing records throughout Mrs P’s time at the Home
    • staff failed to carry out a full initial assessment of Mrs P’s pressure areas to identify the risk of deterioration, did not take photographs or complete a Datix incident report
    • staff missed opportunities to escalate Mrs P’s case, and there was a loss of team and senior awareness of her pressure damage
    • student district nurses were being relied on to carry out assessments without adequate safeguarding in terms of countersigning
    • training on pressure ulcer identification and management was lacking at all levels in the community team
    • the family’s attempt to transfer Mrs P by car on 12 November, and her transfer by car to Home B on 15 November, will have impacted on her pressure areas due to lack of pressure relieving equipment
  2. The Serious Incident investigation made recommendations in 15 different areas of care delivery, to address the failings summarised above. It also set out 30 specific actions within an Action Plan. The actions include the following themes:
    • training to improve pressure ulcer prevention awareness and pressure ulcer assessment (senior nurses in triage did not initially recognise the severity of Mrs P’s wound and it was mis-graded as a grade 2)
    • taking photographs of wounds and using wound templates
    • students not carrying out initial assessments of patients without a qualified supervising member of staff there
    • providing district nurses including students with better equipment including digital cameras, for wound pictures
    • improvements in the content and detail of record keeping
  3. The Trust sent us an updated Action Plan in April 2021, showing it had completed 29 of the 30 actions. The outstanding item related to ensuring all student district nurses work ‘supernumerary’ (for protected learning time) with their assigned mentor before working alone.
  4. The Trust sent us an update on 16 August 2021, confirming that the outstanding work was due to be completed by the end of September 2021.
  5. The Trust’s Serious Incident investigation found significant failings in Mrs P’s district nursing care, which are likely to have caused deterioration in her pressure areas.
  6. We do not normally reinvestigate the issues a Serious Incident investigation has considered unless we find the Serious Incident investigation was flawed. We look at whether the investigation followed appropriate procedures, was based on relevant evidence, addressed the relevant issues and reached robust conclusions. We also look at whether it recommended appropriate actions to address any failings it identified.
  7. I have not found the Serious Incident investigation process or the report’s findings were flawed or unsound. It complies with the NHS England Serious Incident Framework, including that it:
    • has clearly defined terms of reference
    • is an objective and thorough investigation into the incident, with lessons learned to help prevent the incident from recurring
    • is based on relevant evidence
    • involved relevant witnesses
    • is based on Root Cause Analysis, carried out by people with appropriate skills and training, to identify the ‘what, how and why’ the incident happened
    • involved meaningful engagement with Mrs P’s family during the investigation process
    • acknowledges what went wrong, apologised, and provided explanations to Mrs P’s family both in the report and at a meeting to discuss its findings
    • outlines any limitations to the investigation
  8. I consider the actions the Trust has taken to improve its district nursing service in pressure area management and care are appropriate and robust, and will significantly reduce the risk of this situation happening again.
  9. The Serious Incident report did not comply with the timeframes set out in the Serious Incident Framework, but there are circumstances in which an extended timeframe can be agreed. Much of the investigation took place from March 2021 onwards, during the COVID-19 pandemic when there were unprecedented pressures on the NHS, including on the Trust’s Patient Safety Team. The Trust contacted Mrs P’s family in April 2021 to advise of the delay in completion of the report and to apologise for this.
  10. There was a three-month delay between the completion of the report in September 2020 and the Trust meeting with the family to discuss its findings in January 2021. The Trust said it apologised for the delay when it met with the family, and explained the delays were largely due to the challenges the Trust had faced because of the COVID-19 pandemic. I consider a delay of three months was potentially avoidable and amounts to fault. This caused an injustice to Miss B and Mrs C due to their prolonged wait for answers to their concerns about Mrs P’s NHS care. I have recommended further action by the Trust, to apologise in writing for the impact of the delay in meeting with the family to share the findings of the Serious Incident investigation.

NHS Continuing Healthcare funding - delays

Relevant law and guidance

  1. NHS Continuing Healthcare (CHC) is a complete package of ongoing NHS and social care support care arranged and funded by the NHS. It means the NHS pays for all a person’s care package as they have a ‘primary health need’. The 2018 National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care sets out the principles and processes staff must follow when deciding on a person’s eligibility for CHC.
  2. For most people the first step in assessing whether they should receive CHC is for a health or social care professional to complete a CHC Checklist. The CHC Checklist helps identify which patients need a full assessment of their eligibility for CHC and the threshold is set low.
  3. If the completed CHC Checklist indicates the person may be eligible for CHC (a ‘positive Checklist’), the next step is a full multidisciplinary assessment using a Decision Support Tool (DST). The Clinical Commissioning Group (CCG) should give a decision on whether the person is eligible for CHC within 28 days of receiving the completed DST. If the CHC Checklist is ‘negative’ it indicates the person does not need a full assessment and is not eligible for CHC.
  4. If a person’s health is deteriorating quickly and they are nearing the end of their life, they should be considered for the CHC fast-track pathway. This enables an NHS-funded care and support package to be put in place as soon as possible, usually within 48 hours.

Analysis

  1. During 2019, health and social care professionals assessed Mrs P numerous times for potential eligibility for CHC funding. When Mrs P went into the Home her family was unhappy she was not deemed eligible for CHC as they felt she needed a placement in a nursing home.
  2. The family went into the Home for a meeting on 5 November to discuss Mrs P’s CHC eligibility. They also asked the Trust to assess Mrs P again and the district nurses completed further CHC checklists, a full CHC assessment and a request for Fast-Track CHC during November. Due to the high frequency of checklists, the CCG sent a specialist CHC assessor out to see Mrs P on 21 November. A full assessment took place and in January 2020 the CCG decided Mrs P was eligible for CHC for a short period before she died, and it arranged for a rebate of some care fees. This period did not include Mrs P’s time at the Home.
  3. We do not question the merits of a decision that has been properly taken. On the evidence I have seen, the Council, Home and Trust considered Mrs P’s CHC eligibility many times during 2019. They reviewed the evidence about her needs and met with the family to include their views. The CCG then sent a specialist CHC assessor to see Mrs P in late November 2019. In January 2020 the CCG decided Mrs P had been eligible for CHC for a short period before she died and it arranged for a rebate of some care fees. This period of backdating did not include Mrs P’s time at the Home.
  4. Mrs P does not appear to have suffered any injustice in terms of the short delay in deciding she was eligible for CHC. Miss B and Mrs C believe Mrs P should have had CHC funding either before or during the time she was in the Home. They also think she should have gone to a placement with nursing care. They believe this may have prevented her developing pressure ulcers if she had been in a nursing home. Having considered the evidence, including the decision of the specialist CHC assessor and the CCG’s comments to the Trust, it seems very unlikely Mrs P would have been deemed eligible for CHC before her admission to the Home or during her time there. The short delay in determining her eligibility for CHC did not impact on the fact the Council placed her at the Home and she developed pressure ulcers there.

The Council’s assessment of Mrs P’s needs and the suitability of the placement at the Home

  1. The Council said a social worker assessed Mrs P on 1 November and looked for an urgent respite placement for two weeks. Her main needs at the time were pain control and restless nights. The Home was the only placement able to accept Mrs P that day. The Council said it seems the family wanted Mrs P to go to Home B from the outset, and were reluctant for her to go to the Home as they felt her needs warranted a nursing placement rather than a residential one.
  2. As explained above, we cannot question the merits of a decision that has been properly taken. The Council’s records show the social worker was involved with Mrs P at various points during 2019, assessing her needs and arranging support. On 1 November the social worker visited Mrs P at home, spoke with her daughter, and liaised with her GP about her needs. The social worker also noted a GP and district nurse had considered Mrs P’s potential eligibility for CHC a week earlier and decided she was not eligible. On the evidence I have seen, the social worker took relevant information into account when deciding that Mrs P’s needs could be met in a residential home rather than a nursing home. I have not seen evidence of fault here.
  3. During Mrs P’s time at the home the social worker spoke with the family and the Home about Mrs P’s needs and whether the Home was meeting them. She met with the family and the Home on 5 November with the aim of completing a CHC Checklist, but the meeting stopped due to disagreements.
  4. The social worker spoke with district nurses on 14 November who said there were no concerns about Mrs P’s care. With hindsight and the benefit of the Trust’s Serious Incident investigation, it is clear there should have been concerns about Mrs P’s care at the Home. However, it was reasonable for the social worker to rely on information from the district nurse that there were no concerns about Mrs P’s care. Mrs P then moved to Home B the next day. I have not seen any evidence of fault in how the social worker considered the suitability of the placement at the Home during Mrs P’s time there.

Medication – the Home

  1. The Council said it had reviewed the Home’s Medication Administration Records (MAR). It said staff gave Mrs P her medication appropriately, other than on two occasions relating to her eye drops. While Mrs P’s family were concerned there may have been occasions when Mrs P’s medication was left on the side and not given, the Council said it was impossible to determine if this had happened. The MAR charts do not show any gaps in oral medication.
  2. The Council said the Home and Mrs P’s daughter had disagreed about arrangements for her pain relief prescription when she moved from the Home to Home B. Mrs P therefore moved to Home B without her prescribed pain relief medication. However, the Council has explained that Home B got a prescription from an Out of Hours GP on the day Mrs P moved there, so she did not go without her pain relief.
  3. The lack of further evidence means I have not been able to determine whether there was fault here. However, I have not seen that Mrs P suffered any injustice as Home B made sure she received her pain relief medication by obtaining a prescription from an Out of Hours GP.

Continence care – the Home

Relevant law and guidance

  1. The CQC’s fundamental standard on person-centred care says providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences. This includes conditions such as continence support needs and dementia in older people. The CQC fundamental standards also say providers must make sure they treat people with dignity and respect at all times, including providing support to wash, bathe and use the toilet.
  2. NICE guideline CG49 Faecal incontinence in adults: management (2007) and NICE Quality Standard QS54 Faecal incontinence in adults provide guidance on managing faecal incontinence that applies in care homes.
  3. When a care home resident is dependent on others for access to the toilet, help should be readily available. The resident should have a management plan that covers any specific issues relating to toilet access and use of incontinence aids.

Analysis

  1. The Council said it could not investigate the detail of complaints that Mrs P and other residents had been asking and then waiting for help to go to the toilet, due to lack of evidence. It acknowledged there would be times when a resident asks for help but cannot be seen immediately due to other priorities. It said the ratio of staff to residents at the home was appropriate, and a CQC inspector who visited at the time Mrs P was a resident had confirmed this. It also said Mrs P’s records for her personal care show the Home attended to this on a regular basis, but sometimes when staff checked her there had been leakage from her pads.
  2. The Home told us staff took Mrs P to the toilet regularly but she was getting increasingly incontinent and was also using pads.
  3. I reviewed the Home’s daily carer records to see how much support staff gave Mrs P with toileting. It shows staff provided regular support in this area. On balance of probabilities, there may have been occasions where Mrs P would have to wait for staff to take her to the toilet when staff were dealing with other residents. It is not possible to determine how often this happened.
  4. The CQC inspection that took place in November 2019 when Mrs P was a resident rated the Home as Good, said staff were attentive to residents’ needs, and residents were treated with dignity and respect. It said there were enough staff to ensure people received the support they needed.
  5. I do not doubt Miss B and Mrs C’s account that there were occasions where Mrs P had to wait for staff to help her to the toilet. However, on the evidence available, I have not seen fault in the care the Home provided for Mrs P’s continence needs.

Referral to palliative nursing – the Home

  1. Miss B and Mrs C complained the Home failed to follow up a referral to palliative nursing. The Council said the Home spoke with a GP about whether Mrs P needed a referral to community palliative care services when the GP came to assess Mrs P’s pain on 8 November. The GP did not feel Mrs P needed a palliative referral at that time.
  2. The Trust’s Serious Incident report noted that Mrs P’s own GP (not the GP that assessed Mrs P in the Home) had referred her to a palliative nursing service on 24 October 2019. This was before she went into the Home.
  3. I have not seen evidence of fault in how the Home responded to the family’s queries about a referral to palliative nursing. It asked for a GP’s advice on this, and the GP who was visiting Mrs P in the Home said Mrs P did not need a referral at that time. I have also taken into account that this was intended to be a two‑week respite placement, and Mrs P would then have returned to the care of her usual GP who could have followed this issue up.

Communication with Mrs P’s family – the Home

  1. Miss B and Mrs C complained the Home manager was unapproachable, rude and unhelpful.
  2. The Council said it was not possible to comment on this further as it was a subjective matter. However, it reviewed the email exchanges between the family and the Home, and the actions the Home took to respond to the family’s concerns. The Council said the relationship between the family and the Home appeared to have deteriorated which made the situation challenging for all involved. The Council said it did not think this impacted on Mrs P’s care.
  3. The Council told us some difficulties in communication were due to the number of Mrs P’s family members who were communicating with the home and professionals. The Council also said the family had a negative reaction to the emergency respite placement at the Home as they wanted Mrs P to go elsewhere. The Home said it communicated with the family daily, often by phone rather than email, to try and deal with the family’s concerns and worries about Mrs P’s care. The Home accepts its record keeping about communication with the family could have been more detailed. It does not agree that communication with the family was rude, unhelpful or that staff were unapproachable.
  4. I have reviewed the accounts of Miss B and Mrs C, the Home, the Council, and the email exchanges about Mrs P’s care. It does appear there were difficulties and tensions in the relationship between the family and the Home. I am not able to say whether the Home manager was unapproachable or unhelpful, as there is no further evidence to be able to determine this and the family and the Home disagree. I appreciate and acknowledge that Miss B and Mrs C say they suffered distress, and that the situation appears to have been difficult for everyone involved. However, I cannot make a finding of fault here due to lack of independent evidence.

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Agreed action

  1. To remedy the distress to Miss B and Mrs C due to the failings we have identified, the Council and the Trust have agreed to:
    • write to Miss B and Mrs C to apologise for the faults we have identified above and for the impact this had on Mrs P including the worsening of her pressure ulcers, which has caused Miss B and Mrs C avoidable distress, within one month of our final decision
    • pay Miss B and Mrs C £250 each (splitting the total cost between the two organisations) to recognise their avoidable distress, within one month of our final decision
  2. The Council (which commissioned Mrs P’s care at the Home) has agreed to:
    • apologise to Miss B and Mrs C for the uncertainty caused by its poor record keeping of Mrs P’s care, within one month of our final decision
    • write to Miss B and Mrs C to explain what action it has taken to ensure the Home provides pressure area care that is in line with CQC fundamental standards, including ensuring there is:
      1. appropriate care planning for patients at significant risk of developing pressure ulcers
      2. a plan, schedule and documentation for repositioning these residents where appropriate
      3. clear documentation of checks of residents’ pressure areas when they are at significant risk of developing pressure ulcers
      4. a system for care staff to be present when district nurses visit so that care records reflect the action district nurses have taken

The Council should complete this within three months of our final decision. We recognise the Home has already made some improvements in this area, so it should make further improvements where needed, based on the above.

  1. The Council has agreed to explain what action it will take, having reflected on what happened in this case. The Council should ensure significant concerns about care it has commissioned or provided are addressed, either through safeguarding or complaints processes. This will ensure other service users are protected and the Council ensures itself the services it commissions are safe, effective and of high quality. This should be completed within three months of our final decision.
  2. The Trust has agreed to explain what action it will take to ensure it shares completed Serious Incident investigation reports with patients / families / carers promptly, to avoid a prolonged wait for answers to their concerns about care. This should be completed within one month of our final decision.

Final decision

  1. Failings in Mrs P’s care by the Home and district nurses led to her developing severe pressures ulcers in the last weeks of her life. The Council did not investigate key issues in the complaint.
  2. These failings caused avoidable distress to Miss B and Mrs C. The Council and Trust have agreed to take action to remedy the injustice to them.

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Investigator's decision on behalf of the Ombudsman

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