• The complaint
• The Ombudsman’s role and powers
• How I considered this complaint
• What I found
• Final decision

The Ombudsman's final decision:

Summary: The Ombudsman upholds the complaint from Mr X about communication from the Council and about the care delivered to his late mother, Mrs Y. There were some gaps in social workers’ contact with Mr X and the care home failed to adhere to its own falls policy. The Council agreed to apologise to Mr X and pay him £500 to recognise the distress caused to him by these faults. The Council will also remind its staff about the importance of regular communication; carry out an audit to ensure the care home is applying its falls policy correctly; and consider how care providers can report concerns more effectively.

The complaint

1. Mr X complains:
   • 1. the Council discharged his late mother, Mrs Y, too quickly from Bishopsgate Lodge care home. Mr X says his mother had not made significant progress during her stay and because of the early discharge she was quickly readmitted to the home;
     2. there was high turnover of staff and a lack of communication from social services. He says the social workers misunderstood his mother’s primary need was her anxiety rather than her mobility; and
     3. about the care received by his mother when she fell and injured herself on two occasions.

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The Ombudsman’s role and powers

2. 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, section 30(1B) and 34H(i), as amended)
3. 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. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, sections 26(1), 26A(1) and 34(3), as amended)
4. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

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How I considered this complaint

5. I considered the complaint made by Mr X.
6. I considered the Council’s comments about the complaint and the documents it provided in response to my enquiries.
7. I gave Mr X and the Council an opportunity to comment on my draft decision.

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What I found

8. The Council provides an ‘Intermediate Care Plus’ service with local NHS providers. The government’s guidance which accompanies the Care Act 2014 defines intermediate care as: “services provided to people, usually older people, after they have left hospital or when they are at risk of being sent to hospital…to assist a person to maintain or regain the ability to live independently.”
9. Intermediate care is time limited, usually delivered for no more than six weeks and often lasting as little as one or two weeks. The Council said to be eligible to receive an Intermediate Care Plus service a person has to be “clinically stable and experience a sudden change in their physical functioning.”
10. The Council also operates ‘Time to Think’ beds. These are temporary placements which allow a person to remain in residential care whilst their long-term care and support needs are assessed.
11. In its guidance ‘Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care,’ the Department of Health says services should start planning for discharge before or on admission, and should set an expected date of discharge or transfer within 24 to 48 hours.
12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:
    • Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences.
    • Safety (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
    • Good governance (Regulation 17): The provider must maintain securely an accurate, complete and contemporaneous record in respect of each service user.
13. The CQC also requires registered providers to report any serious injuries which occur in the setting.
14. Bishopsgate Lodge care home’s falls prevention and management policy says staff should complete an incident report and investigation, review and update any risk assessments and take steps to reduce the risk of further falls.
15. Regarding communication with service users and their families, the Council says contact is usually made to complete initial assessments, carry out a review after six weeks and then carry out annual reviews. Outside of this schedule, any other contact is decided on a case by case basis.

What happened?

16. Mrs Y lived in her own home and received support from a care provider four times a day. She also had access to the Council’s telecare service in an emergency. Mr X provided additional support to his mother.
17. In April 2018, the care provider began to raise concerns with the Council that Mrs Y was struggling with her mobility and had lost her confidence. She had recently been diagnosed with a vitamin deficiency which her GP felt was causing her to be more confused than usual. She was receiving treatment.
18. A nurse from the Intermediate Care Plus team carried out a care and support review of Mrs Y which decided she needed “intensive rehabilitation for mobility progression."

First stay

19. Mrs Y began a period of intermediate care at Bishopsgate Lodge care home in late April. Ten days later, the Intermediate Care Plus team’s occupational therapist contacted the Council to suggest planning started for discharge as Mrs Y was moving around well. The occupational therapist said Mrs Y was reluctant to agree to this but the team needed to stop her from “bedding in.”
20. A social work assistant visited Mrs Y to carry out a review in readiness for her discharge home. She noted Mrs Y was mobilising well with her frame. She also noted that while Mrs Y was nervous about returning home, she still wished to do so. The social work assistant suggested Mrs Y be discharged the following week, just over two weeks after she arrived.
21. Mr X felt his mother was going home too soon. He told the social work assistant that she appeared more confused. Therapy staff at the home confirmed this. However, a senior carer in the home said while Mrs Y wasn’t herself, she didn’t need medical attention.
22. In the records provided by health services, there are two references to Mrs Y appearing confused around this time. The physiotherapist recorded that she was “a little forgetful” during a therapy visit, and the following the day the occupational therapist noted Mrs Y was having difficulty following the conversation. A couple of days later, the care home’s daily records note one incident of Mrs Y seeming more confused than normal.
23. There are no other references in the notes from this stay which suggest Mrs Y was experiencing difficulties overnight, was excessively calling for assistance, or was showing signs of anxiety or distress.
24. The social work assistant decided to delay Mrs Y’s discharge home while she continued her review and asked for a mental health practitioner to visit. The practitioner said Mrs Y’s confusion was caused by her vitamin deficiency and should stabilise with continued treatment.
25. The review highlighted Mrs Y’s primary needs were her reduced mobility and confusion. While Mrs Y and Mr X reported her mobility was much improved, the review notes Mrs Y was at risk of further falls due to her limited mobility. She had a falls detector as well as a telecare pendant to use at home. The review mentions Mrs Y experienced some short-term memory loss and often fixated on different physical conditions. The social work assistant noted that Mrs Y had no overnight care needs and her confusion, which she attributed to vitamin deficiency, was settling after treatment. The outcome of the review was for Mrs Y to return home with her previous package of care.
26. The following week, Mrs Y appeared less confused and was communicating more clearly. Mr X was still worried about her going home but the social work assistant felt Mrs Y was showing she was ready for home. There was a risk the longer she stayed, the more unsettled she would be at the prospect of returning home. The social work assistant updated Mrs Y’s care plan. At Mr X’s request, the Council delayed Mrs Y’s discharge until the end of the week so he could be available over the weekend to support her.
27. Records show Mrs Y received 15 visits from either a physiotherapist, occupational therapist or health care support worker to work on her mobility during her stay. A nurse also visited on three occasions. The records show she engaged well with her therapy plan. In one of the first visits, the physiotherapist noted Mrs Y “didn’t seem happy at the thought of going home.” However, the day before she was discharged, the physiotherapist noted Mrs Y was “excited to be going home.”
28. Mrs Y returned home after four weeks in intermediate care.

Between stays

29. One week later, Mr X contacted the Council to say his mother was frightened at home and carers had been contacting him to say she was not coping. Mrs Y was frequently using her pendant to call telecare. Mr X asked if his mother could go back to Bishopsgate Lodge.
30. The social work assistant visited Mrs Y on the same day. Mrs Y said she was nervous being on her own but wanted to stay at home. She said she wasn’t frightened. The social work assistant noted the change in environment may have contributed to Mrs Y’s confusion and this would be worse if she moved again. She spoke to telecare and the care provider and asked them to monitor Mrs Y closely and report any concerns to the Council. She handed the case over to the locality team.
31. The Council assigned a new social worker at the start of June. Shortly after, the care provider called the Council to say the care package was not going well. Mrs Y was increasingly confused and carers were spending longer than their allocated time at the home. The care provider felt she needed 24-hour care. However, when Mrs Y’s social worker spoke to the care provider the following day, it said there were no safety concerns. The care provider raised some concerns about toileting.
32. The social worker discussed the concerns with Mr X. She agreed to speak to telecare and the sensory support team to see if there was a way to manage Mrs Y’s frequent use of her pendant. Mr X said he didn’t feel the social worker needed to visit and she said she would monitor and review in two weeks.
33. The following week Mr X called the Council to say his mother had activated her pendant 70 times over the weekend. She had finished antibiotics for an infection but was not sleeping well and was exhausted. When the duty social worker spoke to the care coordinator at the care provider, she said the concerns were not immediate. However, when the social worker visited Mrs Y she spoke to the carers team leader who said she felt Mrs Y came home too soon and this had knocked her confidence. The social worker noted Mrs Y was confused and anxious, was pressing her pendant excessively and struggling with her mobility at night. Mrs Y agreed to go back into intermediate care to help her regain some confidence.

Second stay

34. Mrs Y returned to Bishopsgate Lodge at the end of June. A multidisciplinary team meeting in early July noted she was moving around well but was anxious about returning home and had been constantly using her call button for assistance. The occupational therapist noted Mrs Y appeared steadier with her mobility than on her previous admission. The team felt it needed to start planning for discharge as Mrs Y was starting to like being in 24-hour care.
35. Almost four weeks passed where there was no contact between the social worker and Mr X once Mrs Y went back in to the care home.
36. Mrs Y’s behaviour was much more unsettled during her second stay. The care home’s daily records say she was particularly worried at night, frequently calling staff for reassurance.
37. About a month after Mrs Y started her second stay, the social worker began preparing for her discharge. The home told her Mrs Y was back to where she had been during her last stay, moving around independently. It said she was still calling for staff at night looking for reassurance. The home said it was waiting for her to begin taking medication for her anxiety.
38. As Mrs Y was not receiving any more therapy, her placement at the home changed from intermediate care to a ‘Time to Think’ bed while the social worker reviewed her care needs.
39. In early August, the social worker spoke to Mr X about his mother. He said she had not yet started the medication and he did not feel Mrs Y had reached her full potential. He felt there had not been enough time for the medication to begin helping her to manage her anxiety. Mrs Y remained at Bishopsgate Lodge.
40. The social worker left the department and the Council assigned a new social worker towards the end of August. Mr X told the Council he would like to try to get his mother back home. The Council told him the new worker would contact him to assess whether it could meet Mrs Y’s needs at home. There was another gap of two weeks before the worker contacted Mr X.
41. By the time the new worker contacted Mr X, Mrs Y had suffered a fall at the home and broken her hip. She underwent surgery but died a short time later.

Falls

42. Bishopsgate Lodge care home has only provided a falls risk assessment for Mrs Y’s second stay. The assessment states there is no history of falling, despite this being clearly documented in her social care and health records. It says Mrs Y had no difficulties with transfers, however Mrs Y told the social worker she was struggling to use the commode at night when she was at home. The assessment says Mrs Y was not presenting with any ‘cognitive impairment’, despite her confusion being one reason for her readmission. The assessment notes that Mrs Y usually wore skirts.
43. The care home did not put a falls care plan in place and did not provide Mrs Y with any equipment to mitigate the risk of falling.
44. The care home’s daily records show Mrs Y suffered at least three falls during her second stay, on 25 July, 14 August and 24 August:
    • On 25 July, staff found Mrs Y on the floor next to her bed in the early hours of the morning. A nurse attended and checked her over. There were no signs of injuries or pain and staff helped her back into bed.
    • There is no further information available about the fall on 14 August.
    • On the night of 24 August, another resident saw Mrs Y fall as she left the toilet as she had not pulled up her trousers. She fell to her knees and staff found her sitting on the floor. Staff noted both her knees were red. The records show staff did not contact Mr X at the time as it was late in the evening. Carers checked on Mrs Y through the night. The following morning Mrs Y complained of pain in her right leg and nursing staff called an ambulance due to concerns about a possible fracture.
45. The care home has only provided documentation about Mrs Y’s third fall, in which she suffered a hip fracture. A member of staff reviewed Mrs Y’s falls risk assessment on 27 July but it is unclear whether this was a routine review or in response to the fall two days earlier.
46. It is clear from the records that staff noticed an injury to Mrs Y’s finger on 15 August following her fall the previous day. Mr X said he made repeated requests for his mother to see a medical professional. However, there is no evidence the care home sought medical advice until 24 August when she was taken to urgent care with a suspected broken finger.
47. The Council sent me a copy of the incident report, investigation report and notification to the CQC following the fall on 24 August. All three documents say Mrs Y had been admitted to Bishopsgate Lodge care home as she could not manage independently at home due to early onset Dementia. This was identified as a possible reason for her fall. However, neither Mrs Y’s care and support assessments or health records support this. Dementia services had reviewed Mrs Y in mid-June and had not noted any concerns.
48. The investigation report recommended staff discuss Mrs Y at the next falls meeting and that Mrs Y wear skirts instead of trousers to prevent potential trip hazards.
49. In its response to Mr X’s complaint, the care home provider accepted it had failed to follow its procedures in responding to Mrs Y’s falls. It also identified the following lessons learned from its handling of the incident:
    • Staff had not completed Mrs Y’s care file and case records correctly and in full.
    • Communication between staff, external professionals and Mr X had been poor.
50. The Council has provided evidence of how the care home provider responded to the lessons learned from the incidents and complaint investigation, including reminding staff:
    • the most senior member of staff on duty must be the one who checks residents for injuries after a fall;
    • about the importance of contacting next of kin;
    • of the need to complete documentation fully and to complete an incident report after a fall;
    • what a falls risk assessment is and how to complete one correctly; and
    • what a falls care plan should like and what information it should contain.
51. The care home provider also delivered further training and supervision to staff about completing paperwork for residents admitted under the Intermediate Care Plus programme, and care plan training.

Findings

52. The Council was not at fault when it started making plans for Mrs Y’s discharge shortly after her first stay at Bishopsgate Lodge care home began. This was in line with good practice guidance.
53. The records of the social work assistant, therapy staff and the care home do not suggest Mrs Y was suffering from persistent confusion or anxiety during her first stay at the home. When Mr X raised concerns, the social work assistant delayed her return home and brought in other professionals to assess Mrs Y. Mrs Y’s care and support needs were reviewed and she agreed with the plan to go home. Mrs Y’s anxiety and confusion increased once she returned home and this continued throughout her second stay. The Council could not have pre-empted this therefore I cannot find fault in the way the Council decided to discharge Mrs Y from her first stay.
54. There was not a high turnover of staff in the period April to August. The case transferred from the first worker to the second worker because responsibility for reviewing Mrs Y’s care and support needs moved from the Intermediate Care Plus team to the locality team. The second change was due to the social worker leaving, which was not the responsibility of the Council. Therefore, I cannot find fault on this part of the complaint.
55. There was regular communication between Mr X and the social work assistant during his mother’s first stay including phone calls, text messages and visits. There were some gaps in communication when the locality social worker was allocated and again when the case was reallocated. These gaps came at important times for Mrs Y when she had recently undergone another move and discussions were taking place about what care she may need long term. They also happened when Mr X was particularly concerned about the care his mother was receiving. The Council has already recognised and apologised that there was a delay in the social worker carrying out a review of Mrs Y’s care and support needs. Together with the lack of timely review, this caused uncertainty and was fault.
56. The records suggest Mrs Y was not presenting as particularly anxious before or during her first stay. Carers and therapeutic staff make some references in their records to Mrs Y feeling worried about going home but Mrs Y was clear she did want to go home. Alongside her mobility, the primary concern was Mrs Y’s confusion which, other professionals assured the social work assistant, would resolve as the treatment for her vitamin deficiency continued. There was also a concern that delaying discharge may have a greater impact on Mrs Y’s well-being as she risked becoming too used to being in residential care. In my view, the social work assistant did consider Mrs Y’s confusion and anxiety but weighed this against her other needs when making decisions about her care and support.
57. Once Mrs Y returned home, there appears to have been a difference of opinion between the care coordinator at the care provider and the carers and carers team leader about Mrs Y’s level of need. This must have caused confusion for Mr X, as carers were raising concerns with him but the care provider was not reflecting these same concerns to the social worker. However, when the social worker visited Mrs Y herself, she noted the confusion was causing Mrs X anxiety in addition to her mobility difficulties and immediately agreed to another stay in intermediate care. I am satisfied the Council considered Mrs Y’s anxiety alongside her mobility issued and I do not find fault.
58. Bishopsgate Lodge care home has accepted that staff failed to follow its procedures after Mrs Y’s falls. It failed to complete the required paperwork, failed to seek prompt medical attention, and failed to communicate effectively with Mr X. I also find fault in the way the home assessed Mrs Y’s risk of falls on admission and failed to put in place measures to reduce this risk despite knowing about it. These faults amount to a breach of the fundamental standards identified in paragraph 13 of this decision. I cannot say these actions would have prevented Mrs Y from falling, had they been carried out without fault. However, the care home’s faults have left Mr X with an enduring sense of doubt that Mrs Y received proper care.

Conclusion

59. I cannot remedy the injustice to Mrs Y of the faults identified. However, it should be noted the failure to seek medical attention for her broken finger amounts to significant harm. This caused Mr X considerable distress, as did the care home’s handling of his mother’s other falls and the periods of poor communication.

Agreed action

60. To remedy the injustice I have identified, within four weeks of the final decision, the Council will:
    • Apologise to Mr X for the faults identified as part of this investigation.
    • Pay £500 to Mr X in recognition of the distress caused by the identified faults.
    • Remind its staff about the importance of regular communication with service users and family members, including making arrangements for continuity of communication when an allocated worker is part time or away from the office for any other reason.
61. Within three months of the final decision, the Council will:
    • Audit the handling of any falls which occurred at Bishopsgate Lodge care home since September 2018 to ensure the care provider is compliant with its own policy and the learning identified from its complaint investigation. The Council will report its findings back to the Ombudsman.
    • Consult with its domiciliary care providers on the most appropriate way to report concerns about service users, to ensure concerns are reported in a consistent way to both the Council and to family members. The Council will report the outcome of the consultation back to the Ombudsman.

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Final decision

For the reasons explained in the Analysis section, I have completed my investigation and uphold Mr X’s complaints about communication and the care delivered to his mother.

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Investigator's decision on behalf of the Ombudsman

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