Mrs F, who was in a care home, developed a red area on her hip. The red area developed into a severe pressure sore that needed hospital treatment.
What happened
Mrs F was at high risk of developing a pressure sore. She had a red area on her hip following a fall and staff called a GP to the care home. The GP thought it was an abscess. However, the wound deteriorated and hospital staff saw Mrs F at an outpatient appointment. A doctor decided she had a pressure sore.
Care home staff subsequently did not take appropriate action and the pressure sore deteriorated to grade 4, which is very severe. This was distressing for Mrs F and she had to go into hospital. She was eventually discharged to a different care home.
What we found
We partly upheld this complaint. Mrs F's wound should have prompted care home staff to take further action. The care home had not addressed fundamental issues about the assessment, prevention and management of pressure sores. Nursing staff needed more education and training in this fundamental aspect of care.
We found no fault in other aspects of Mrs F's care.
Putting it right
BUPA put systems in place to monitor the result of any education and training that it gave nursing staff about pressure sore management.
BUPA apologised to Mrs F's daughter and acknowledged its mistakes.
Bupa Care Homes (CFCCare) Ltd
Merseyside
Did not apologise properly or do enough to put things right
Did not take sufficient steps to improve service
Apology
Recommendation to change policy or procedure