Summary: Mr X complains the Avenue Nursing Home failed to look after his father properly, resulting in him injuring his head. He also complains the Council failed to deal properly with the safeguarding concerns about his father’s injury. While the Nursing Home was not responsible for his father’s injury, it did not handle the incident properly and its records are not entirely accurate. This resulted in a loss of trust and has made it difficult to find out what happened. The care provider needs to apologise and improve its record keeping. There was no fault by the Council over its handling of the safeguarding concerns.

The complaints

1. The complainant, whom I shall refer to as Mr X, complains:
• The Avenue Nursing Home failed to look after his father properly resulting in him injuring his head which the Nursing Home, apart from cleaning the wound, failed to do anything about until Mr X pointed it out.
• The Council failed to deal properly with the safeguarding concerns about the injury his father sustained while staying at the Avenue Nursing Home, as it failed to address the fact that someone at the care home must have cleaned up the wound before he visited his father and discovered the injury.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)
4. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mr X;
• discussed the complaint with Mr X;
• considered the comments and documents the Council and the care provider have provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Mr X, the Council and the care provider, and taken account of the comments received.

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What I found

Key facts

6. Mr X’s father, Mr Y, has dementia. He went to stay at the Avenue Nursing Home (the Nursing Home), which is run by The Avenue Care Home (Bradford) Limited (the care provider) in January 2023. He had been living at home with his wife and son but they had struggled to meet his needs. His wife and son visited him each day he was at the Nursing Home.
7. The Nursing Home kept records of the care and support provided to Mr Y. It also did risk assessments and produced care plans for Mr Y. I refer to the key contents in this statement. The picture the Nursing Home took of Mr Y shows he had a fulsome moustache.
8. The Nursing Home assessed Mr Y as a high risk of falls. This was linked to a deficit in his spatial and visual awareness, which could result in him walking into doorways or furniture. It identified the need to:
• Provide support when walking to reduce the risk of falls.
• Use a wheelchair if going longer distances or if Mr Y appeared “very tired and unsteady on his feet”.
• Have a sensor mat by his bed, in case he got up during the night, so staff could support him.
9. The Nursing Home checked on Mr Y every two to four hours at night. During the day he spent his time with other residents.
10. During his first night at the Nursing Home Mr Y was “very vocal from the beginning of the shift”. He was mostly awake and trying to get out of bed.
11. The next night Mr Y was asleep when checked. In the morning staff helped him wash and shave. He ate little for breakfast but his fluid intake was good. He had a snack in the morning and ate most of his lunch. He had another snack in the afternoon and his fluid intake remained good. At teatime he ate most of his meal but his fluid intake was poor. He took part in an activity and appeared happy. However, the notes say he was unsettled at times and trying to stand up unaided. He was “very irritated” when helped to bed. He was awake when checked during the night and had a period when he activated his sensor mat.
12. According to the notes, by 06.55 in the morning Mr Y had had a shower but “refused washing tasks” and refused a shave. He needed full assistance with changing and dressing. However, these notes were made by the care worker who attended to Mr Y overnight, not the care worker who later admitted to having shaved off Mr Y’s moustache in error. According to the statement made by that care worker later in the day, they used Mr Y’s electric shaver. When they took off Mr Y’s hat they noticed the wound and a lump on his head. Mr Y said he did not know how it happened. The care worker assumed staff were already aware of the wound as it appeared dry and old. They also helped Mr Y with personal care. They said he was happy and agitated to go back to the lounge.
13. By 10.22 Mr Y had eaten his breakfast and had good fluid intake.
14. Mr X visited with his mother late morning. When they took his hat off, they found Mr Y had a cut and lump on the back of his head. The cut had clearly bled, as there was dried blood in the wound. They also noted other lumps and bruising to his head.
15. Mr X raised concerns about the injury with the Nursing Home, which had not been aware of it. Mr X said his father’s compression stockings had been put on inside out and had not been pulled up properly (this is supported by a photograph). He also noted his father’s moustache had been shaved off. He suggested someone had done this to hide the fact they could not get blood out of it. He said there was dried blood on his father’s shoes (a photograph shows a stain on a shoe).
16. The Nursing Home apologised and said it would fully investigate the incident. It took medical advice remotely. This was to take observations and monitor Mr Y, which it did. Mr X wanted a GP to visit, but the GP said there was no point as they could not provide any more advice than had already been given.
17. Mr X and his mother stayed with Mr Y during the afternoon, while he settled, and then took him home as they were unhappy with the Nursing Home’s response to their concerns.
18. Three days later Mr X took his father to see a GP. The GP referred Mr Y for a CT scan. However, the wound needed no treatment. Mr X says the GP agreed the wound had been cleaned up. Mr X also contacted the Police about the injury but they did not take any action.
19. The Nursing Home’s investigation into the incident says:
• The care worker who helped Mr Y change into his nightwear before he went to bed said there was no evidence of an injury but he appeared very unsettled. His sensor mat was activated several times and responded to promptly. Mr Y was walking around his bedroom and opened his wardrobe and drawers. In the morning the care worker noticed a dry cut to Mr Y’s head, but did not report it as there was no evidence of blood. The care worker apologised for this failure.
• The care worker who shaved off Mr Y’s moustache apologised to the family (Mr X disputes this) and said they did not realise they should not have shaved it off. They noticed the wound to Mr Y’s head but assumed it was old as it was small and dry.
• It assumed Mr Y had had an unwitnessed incident during the night.
• Mr X believed a member of staff hurt his father and cleaned up the evidence of blood in his room.
20. Mr X complained to the Council about what had happened on 23 February. His complaint was passed to its safeguarding team on 28 February. The Council made enquiries into the safeguarding concerns under Section 42 of the Care act 2014. Its records show it spoke to Mr X about his concerns. It also consulted the Nursing Home’s records and spoke to it, passing on Mr X’s allegations. The Nursing Home told the Council:
• The care worker who helped Mr Y to bed did not notice an injury. Mr Y had been wearing his hat but took it off before going to bed.
• The care worker who supported Mr Y in the morning noticed the injury but did not report it as it was dry and did not appear to be fresh. They accepted they should have reported the injury.
• Mr Y was agitated during the night and activated his senor mat a number of times. Each time staff went to his room, gave assurance and spent time with him to help him settle. They made a cup of tea on one occasion. They encouraged Mr Y to get back into bed, but once or twice he chose to stay in his chair. Although there was a side lamp on, the room was dark. Staff saw no blood in Mr Y’s room, including his pillow, or anywhere in the bathroom.
• The care worker who shaved Mr Y did not realise he kept a moustache. They said he agreed to being shaved and showed no sign of agitation or distress while being shaved.
• They accepted errors had been made (shaving Mr Y, failing to notice the injury sooner and failing to report it when it was noticed).
21. When the Council closed its safeguarding enquiries, it noted lessons had been discussed with the Nursing Home about the need to report safeguarding concerns. It told Mr X it could not say how Mr Y sustained the injury but it was satisfied the Nursing Home had learnt from the incident, through supervision with individual staff members and the wider team about the importance of recording.
22. The Council accepts it was unable to provide Mr X with the answers he was looking for (e.g. how Mr Y injured himself). It says it passed on Mr X’s claim, that someone must have cleaned the wound to Mr Y’s head and the blood which must have been in the room, to the Nursing Home. But the Nursing Home was adamant that no traces of blood were found. The Council says that without evidence or a confession, it could not establish exactly what happened. It says its safeguarding enquiries were appropriate and proportionate.
23. Mr X complained to the care provider in June about the Nursing Home’s handling of the incident. When the care provider replied the same day, it said:
• It apologised for the upset caused by the incident.
• It was satisfied appropriate action had been taken over the incident.
• It had told the Council and the Care Quality Commission (CQC) about the incident.
• The Council had closed its investigation.
• CQC’s investigation was pending contact with the Nursing Home.
• Mr X had not taken up the Nursing Home’s offer to speak to him about his concerns.
24. The care provider charged Mr Y £1,250 for a one week stay at the Nursing Home. Mr X disputed this in June and understands the care provider is no longer seeking payment, as he has not received a further request for payment.

Did the care provider’s actions cause injustice?

25. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. CQC has issued guidance on how to meet the fundamental standards below which care must never fall. Regulation 10 requires care providers to treat people with dignity and respect. Regulation 17 requires care providers to maintain an accurate, complete and contemporaneous record of the care provided for each service user.
26. There is no way of knowing how Mr Y injured his head. There is no evidence to suggest he was the victim of an assault. If there had been it would have been a matter for the Police.
27. There is no dispute over the fact that the care worker was wrong to shave off Mr Y’s moustache. It reflected a lack of person-centred care. That is a potential breach of Regulation 10 (see paragraph 25 above). It is difficult to understand how anyone could have thought it appropriate to shave off Mr Y’s moustache. It is clear from the Nursing Home’s photograph that it was fulsome and was therefore something he had had for some time. Its records say Mr Y refused a shave that morning, but clearly that was not the case. This is a possible breach of Regulation 17. The lack of accuracy creates some doubt over the accuracy of the other records.
28. There is no dispute over the fact that the two care workers who saw the wound should have reported it. The failure to do so caused a loss of trust in the Nursing Home. It is understandable that his family did not want Mr Y to stay there. The care provider needs to accept responsibility for that.
29. It is possible Mr Y injured himself when he was in his room at night. During the day he was with other residents, so it is unlikely he could have injured himself without people noticing. During the night Mr Y was restless and wandered around his room. This will have put him at risk. He did not always agree to go back to bed, but stayed in his chair. That will have put him at further risk, as if he got up from his chair he may not have activated the sensor mat by his bed. This could have allowed time for him to have an accident without anyone realising it. With regard to the lack of blood in Mr Y’s room, this may be explained by the fact he liked to wear his hat all the time. One care worker removed the hat before he went to bed and another care worker removed it before providing personal care in the morning. When Mr X and his mother visited later in the morning Mr Y was wearing his hat again. The cleanliness of the wound could be explained by the shower he is recorded as having had in the morning.
30. I would have recommended a financial remedy for the injustice caused to Mr Y. However, on the understanding that the care provider is not seeking payment for Mr Y’s stay at the Nursing Home, I have not done so.

Is there evidence of fault by the Council which caused injustice?

31. There is no evidence of fault by the Council over its handling of the safeguarding concerns. It took account of Mr X’s concerns and addressed them with the Nursing Home. It could not establish exactly what happened. While it identified some failings over reporting the incident, it found no evidence to support the claim that the Nursing Home was responsible for Mr Y’s injury.

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Recommended action

32. I recommend the care provider:
• Within four weeks sends Mr X an apology in line with our published Guidance on Remedies, addressing the inaccuracy in the Nursing Home’s records and the failure to report the wound when it was identified and the family’s consequential loss of trust in the Nursing Home.
• Within eight weeks confirms the action the Nursing Home has taken to improve record keeping.
33. The care provider should provide us with evidence it has complied with the above actions.
34. Under the terms of our Memorandum of Understanding and information sharing agreement with CQC, I will send it a copy of my final decision statement.

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Final decision

35. I have completed my investigations on the basis:
• the care provider’s actions have caused injustice which requires a remedy;
• there was no fault by the Council over its handling of the safeguarding allegations.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman