13. As we noted above, we have reached a resolution on this complaint. Below, we give the reasons for reaching this decision.
Mr N’s continence support at the Home
14. In her complaint to us and the Home, Mrs R complained staff at the Home left Mr N sitting in urine and excrement, despite her family paying for the incontinence pads he needed. She added Mr N’s skin was intact when he arrived at the Home on 8 April 2021, and the moisture lesion he developed is proof of the poor care that staff provided.
15. In its complaint process, the Home said Mr N’s records showed he developed a moisture lesion on his lower buttocks on 23 April. Staff also identified redness and excoriation. It added there was no evidence of any skin breakdown or redness when staff admitted Mr N.
16. The Home said staff then called the GP it uses. Staff obtained a prescription of Proshield foam spray (a foam and spray cleanser which staff use for incontinence management and to prevent and manage moisture lesions) and Cavilon barrier cream (a moisturiser to prevent or treat dry, flaking and itchy skin).
17. Following our review of the evidence, we believe staff at the Home did not act in line with relevant clinical standards.
18. The Pressure Ulcer Guidance says organisations admitting patients into care homes for NHS care must perform an assessment of pressure ulcer risk. It recommends using a validated scale such as the Waterlow scale to assess this risk. The Waterlow scale considers a variety of factors influencing someone’s pressure ulcer risk, including their level of continence.
19. The Home assessed Mr N when staff admitted him. His Waterlow score was 14. A score of 10 to 14 indicates someone is ‘at risk’ of developing pressure ulcers. Our nurse adviser identified an error in the Waterlow assessment so that Mr N’s score should have been 15, which meant he was ‘at high risk’ (a score of 15 to 19) of developing pressure ulcers.
20. The Home’s care plan for Mr N identified that, when he was admitted, he had poor nutritional status (not eating enough or not eating enough of the right food to give the body the nutrients it needs). The Waterlow scale says where someone is eating poorly or they lack appetite, staff should add 1 to the patient’s overall score. The Home did not do this for Mr N’s Waterlow assessment.
21. Section 10.2 of the NMC Code says staff must identify any risks or problems arising, and note the steps taken to deal with them.
22. In its care plan, the Home identified that Mr N was doubly incontinent (unable to control the excretion of urine or the contents of the bowels). He used incontinence pads, and he needed staff to change them for him. To maintain his dignity and comfort, staff noted they needed to check his pads at least every four hours and change them if they were soiled or wet.
23. So, based on Mr N’s needs, to manage his high risk of pressure ulcers, staff should have repositioned him every four hours. They should also have checked his incontinence pads and provided personal continence care, including changing his pads if needed.
24. The Home’s staff kept paperwork of Mr N’s changes in position, including when they checked his incontinence pads and changed them. These records show that throughout his admission, staff did not reposition him and check his pads every four hours.
25. Over the period Mr N was at the Home, we saw gaps of five hours or more in staff performing these checks on 20 dates during his admission. Ten of these dates were in the 16-day period before staff found Mr N’s moisture lesion on 23 April.
The impact of the Home’s continence support
26. Mrs R said the care Home staff provided left Mr N sore, smelly and uncomfortable, and he developed a moisture lesion and skin excoriation. She said this affected his dignity and the breakdown of his skin caused him pain and distress until he died. She said her family found it distressing that staff left him in this condition.
27. We carefully considered these impacts and found we could link them to the poor continence support staff provided.
28. Our nurse adviser said moisture lesions can form in areas like the buttocks when staff leave a patient in wet or soiled incontinence pads and this moisture is in direct contact with the skin. Not changing the patient’s position regularly also contributes to this.
29. Throughout his stay at the Home, we saw periods of five hours or more between staff checking Mr N’s incontinence pads and the next entry in the record noting staff changed his pads because they were wet or soiled.
30. For instance, on 10 April, staff checked and repositioned Mr N at 11.45am. Seven hours later, at 6.45pm, they checked him again and needed to change his pads. On 16 April, staff changed his pads at 12pm. When staff checked him again at 10.15pm, over ten hours later, they needed to change his pads again.
31. Given Mr N went long periods between checks several times, and he soiled his incontinence pads during those periods, there were times when this moisture was in direct contact with his skin. Together with not changing position regularly, this created conditions in which a moisture lesion could develop. Our nurse adviser, from their review of the evidence, said Mr N experienced avoidable skin breakdown as a result.
32. Mr N’s care records show staff first found the moisture lesion between his buttocks on 23 April. This was not noted in their skincare assessment when he arrived at the Home. In their plan to minimise further skin damage in the area after finding the lesion, staff noted the importance of replacing his pads when he soiled them.
33. The Moisture Lesion Study says moisture lesions can be extremely uncomfortable, painful and distressing for patients.
34. As Mrs R said in her complaint, we recognise this was the case for Mr N. We saw, after his moisture lesion developed, staff noted occasions when they saw Mr N was uncomfortable or in pain when they performed continence care.
35. The GP the Home consulted also prescribed the treatments we described above for Mr N’s moisture lesion from 23 April. His records show staff needed to continue this treatment until he died. In our view, this is compelling evidence that shows the moisture lesion continued to affect Mr N until he died.
36. We also consider that the time gaps in staff checking and changing his soiled incontinence pads, both before and after developing his moisture lesion, would have left Mr N feeling uncomfortable. We consider the smell would have been unpleasant for him too, and this would have affected his dignity during his time at the Home.
37. Mrs R said her family found all this distressing and it was difficult to see Mr N experiencing this. We do not underestimate the impact this had on her and her family.
Our view on whether the Home put things right in its complaint process
38. Our Service Guidance says we use our Principles for Remedy to determine our approach to put right the hardship caused by things an organisation has done wrong. But we should also consider the outcomes the complainant wants.
39. To resolve her complaint, Mrs R said she wanted the Home to accept what it did wrong in Mr N’s care and the impact this had. She also wanted the Home to make service improvements to ensure its staff provide appropriate care with respect and dignity in the future.
40. Our Principles for Remedy say that, where poor service has led to hardship and an organisation cannot return the person affected to the position they would have otherwise been in, these are appropriate actions to take.
41. During its complaint process, and before we opened this case in November 2022, the Home had not taken these actions. It accepted that Mr N developed a moisture lesion on 23 April 2021, which was not present when staff admitted him. It apologised if Mrs R felt its staff did not effectively meet her father’s care needs.
42. The Home did not accept that its staff should have been repositioning Mr N and checking his incontinence pads every four hours during his stay. It apologised only for Mrs R feeling that staff did not provide appropriate care. On this basis, the Home failed to clearly accept that it did not provide appropriate support in line with the relevant standards.
43. The Home did not accept that Mr N developed a moisture lesion because of the poor continence support staff provided. It did not accept that the breakdown of Mr N’s skin caused him pain and distress. It did not accept that its care caused Mr N discomfort, or that leaving him in soiled incontinence pads compromised his dignity. It also did not accept how distressing his family found this.
44. Our Principles for Remedy say organisations should learn from poor care or service. They should consider ways to prevent the same thing from happening again, for example by revising procedures, training or supervising staff, or a combination of these things. This was not something the Home did in response to Mrs R’s complaint.
45. As the Home did not take these actions during its complaint process, we saw it had not put right the impact we identified above. On this basis, we proposed a resolution, which we explain in more detail below.
The resolution we agreed
46. Our Service Guidance says we can resolve a complaint without conducting a detailed investigation if we can deliver the outcomes a complainant asks us to achieve at an earlier point in our case-handling process.
47. During our primary investigations, we obtained all the records of Mr N’s care at the Home. We gathered the accounts of what happened from the parties involved, the Home’s responses to Mrs R’s complaints, and clinical advice on both the failings in care Mrs R complained of and their impact.
48. We could not see that we would obtain significant new evidence by proceeding to a detailed investigation. Based on the evidence and advice we obtained, we believe we reached a well-informed opinion about the events.
49. On this basis, we approached the Home to share our thinking. We asked the Home if it would consider performing the actions we identified it should have as we describe above. We also asked Mrs R for her views on our proposed resolution.
50. When we contacted the Home, we found it was in the process of writing another response to Mrs R’s complaint.
51. In its second response, the Home agreed to include the thinking we shared with it about staff not taking preventative measures in line with relevant standards to minimise the risk of Mr N experiencing skin breakdown and developing a moisture lesion. The Home also agreed to apologise for the distress this caused Mr N’s family.
52. The Home sent us a draft version of this response. It included its acceptance of the things that we saw went wrong in Mr N’s care. It also included an acceptance of and apology for the impact we identified.
53. The Home’s draft response also described recent action it has taken to avoid repeating what happened during Mr N’s care. The Home:
• has reviewed, in partnership with a local hospice, how it provides care for residents approaching the end of their life • has developed an end-of-life care audit process • has introduced a procedure where the nurse in charge on each shift countersigns charts (for example, charts on a resident’s positional changes) • has introduced a system where its management performs spot checks on residents • now has daily staff safety huddles to discuss in detail any resident who experiences changes to the condition of their skin.
54. The Home explained it recently used its new audit process for three of its residents.
55. The Home’s new procedures, checks, audits and increased supervision of staff are in line with our Principles for Remedy. In our view, this action reduces the chance of staff repeating the mistakes they made in Mr N’s care. We also consider the new checks mean the Home is better able to identify such mistakes and correct them quickly.
56. In her views on our proposed resolution, Mrs R repeated she wanted the Home to accept what it did wrong and the impact it had. She also wants it to make improvements to make sure its staff provide appropriate care with respect and dignity.
57. Given the content of the Home’s second response, which it agreed to send to Mrs R, we decided this was a satisfactory resolution and achieves the outcomes she wants. On this basis, we decided not to conduct a detailed investigation.
58. We recognise, as Mrs R said in her comments on our proposed resolution, it does not change what happened to Mr N. We hope the personal redress the Home is providing helps bring Mrs R and her family closure. We also hope the Home’s service changes assure Mrs R it has learned from Mr N’s experience and has improved its service.