Summary: Mrs X complained the Council placed her husband in an unsuitable care home for his care needs, which led to a fall. The Council was at fault as it placed Mr X in an unsuitable care home, did not involve Mrs X in this decision and failed to ensure an appropriate handover took place between care homes. There was no fault in the way the care home sought to meet Mr X’s care needs or sought to mitigate his high fall risk. However, the choice of placement leaves Mrs X with a sense of uncertainty over whether the fall could have been avoided. The Council has agreed to apologise and make a symbolic payment to Mrs X. It has also agreed to remind officers of the need to involve representatives in the choice of care home and to provide appropriate information to prospective care homes

The complaint

1. Mrs X complained the Council placed her late husband, Mr X, in a Council-commissioned care home, care home B, which was unsuitable for his care needs and which led to a fall. Mrs X believes this contributed to his death. Mrs X also complained there were inconsistencies about what happened when Mr X fell concerning whether a sensor mat was in place, which has caused her distress and confusion.

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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. We investigate complaints about councils and certain other bodies. 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)

4. If we are satisfied with an organisation’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)

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How I considered this complaint

5. I have considered the information provided by Mrs X and discussed the complaint with her on the phone. I have considered the information provided by the Council in response to my enquiries.
6. I gave Mrs X and the Council the opportunity to comment on a draft of this decision. I considered any comments I received in reaching a final decision.

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What I found

Discharge to assess

7. From 19 March 2020, there was a requirement to free up hospital beds for the anticipated wave of COVID-19 admissions. Government guidance at that time directed rapid discharge of all patients who were clinically ready to leave hospital, either home or to another place of care.
8. Where patients were discharged under this government guidance, the NHS fully funded the cost of care for up to six weeks while a care assessment was carried out to decide the person’s long-term needs.

EMI care homes

9. Specialist care homes for those with dementia are sometimes referred to as EMI (elderly mentally infirm) care homes. As opposed to EMI residential care homes, EMI nursing homes provide nursing care and have a qualified nurse available 24 hours a day.

Continuing Health Care (CHC) checklist

10. The CHC checklist is used as a first step to assess whether someone may be eligible for NHS support with their care funding. Where an individual is assessed as having a primary health need their care will be arranged and funded by the NHS.

Mental capacity

11. A person aged 16 or over must be presumed to have capacity to make a decision unless it is established they lack capacity. A person should not be treated as unable to make a decision:

• because they make an unwise decision;
• based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
• before all practicable steps to help the person to do so have been taken without success.

12. The council must assess someone’s ability to make a decision when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision. An assessment of someone’s capacity is specific to the decision to be made at a particular time.
13. Any decision made on behalf of a person who lacks capacity must be in that person’s best interests.

What happened

14. Mr X had dementia and was admitted to hospital after having a stroke. Mrs X had lasting power of attorney for Mr X’s health and welfare. This enabled Mrs X to make decisions about Mr X’s health and welfare when he became unable to make such decisions himself.
15. The hospital completed a fact-finding assessment for a discharge to assess bed to give Mr X further time to improve before discharging him home. The assessment stated Mr X required assistance from one or two people for his personal care needs, was able to move around with handheld support from two staff and did not require an airflow mattress (a mattress designed to support those with low mobility at high risk of pressure sores). The hospital assessed Mr X did not have capacity and consulted Mrs X who agreed to a period of assessment in a nursing home.
16. Mr X was discharged to care home A, an EMI nursing home, in mid-August 2021. The case notes record he was initially aggressive but became more settled. During his time at care home A, Mr X remained in bed and did not engage with therapy.
17. Mr X’s social worker completed a care needs assessment in September 2021. This recorded Mr X required support with personal care and dressing, prompting with nutrition and support with medication. Mr X was doubly incontinent and cared for in bed. It noted Mr X chose to remain in bed, Mr X was at high risk of pressure sores and was repositioned every four hours. They recommended Mr X go into a nursing home as he had deteriorated and would not be able to look after himself at home, even with a care package. Mrs X was consulted as part of the assessment and agreed to a nursing home placement for Mr X.
18. The social worker completed a mental capacity assessment and at that time considered Mr X did not have capacity to make decisions about his care and support needs. The social worker completed a CHC checklist which recommended a nursing EMI facility. The scores indicated Mr X should be referred for further assessment. In the rationale for decision section of the CHC checklist the social worker wrote stated Mr X’s ‘LPA and other professionals have concluded that he would be safer in an EMI nursing facility where he will be well looked after with fewer risks’
19. Mr X’s social worker contacted several care homes; however they did not have any availability. Care home B, an EMI residential care home, advised the social worker it had vacancies and requested to see Mr X’s fact-finding assessment. The social worker shared the fact-finding assessment completed by the hospital with care home B. They did not share Mr X’s needs assessment. Care home B agreed to liaise with care home A about Mr X’s needs. Care home B says it called care home A to discuss Mr X, but staff were too busy to talk to them at that time and said they would call back but failed to do so. Care home A has no record of this call. In late September 2021 the Council agreed to fund Mr X’s placement at care home B.
20. Mr X had a hospital appointment in late September 2021. The social worker noted Mr X would return to care home A after his hospital appointment and would then be taken to care home B the following day. Mrs X says the social worker telephoned her and advised Mr X would be moving to care home B the next day. Mrs X telephoned care home B to ask if she could sit with Mr X when he arrived at the care home. Care home B says this was the first it knew about Mr Y moving there. Care home B said it was not expecting Mr X and had not received confirmation of his funding or that he was arriving. Mr X attended the hospital appointment, after which he was transported straight to care home B. The manager was not in care home B that day and care home B says it agreed to accept Mr X as it felt it could not send him back.
21. Later that day, staff found Mr X on the floor in his room. He had no injuries but they noted he was unsteady on his feet and was unable to weight bear. Two days later the nurse visited and made a referral for an air flow mattress for Mr X. The notes record an alarm mat was in place.
22. Care home B noted Mr X had a high Waterlow score (an assessment of the risk of pressure sores) and completed a falls risk assessment which noted Mr X was at very high risk of falls. Its movement risk assessment noted Mr X could not effectively weight bear and he required full hoisting. It completed a bed rails assessment for Mr X. It concluded bed rails were not a safe option due to Mr X’s risks of tissue damage and agitation/confusion. Care home B spoke to the Occupational Therapist who confirmed Mr X was not mobile and had declined therapy at care home A.
23. The daily care records show Mr X often rang the call bell repeatedly but did not want anything when staff attended and had periods of agitation.
24. Two weeks later care home B contacted the social worker to give notice as it was not able to meet Mr X’s long-term needs. It said the assessment it received stated Mr X could mobilise but he was not able to mobilise at all and had a stiff torso making moving and handling difficult. He had shown signs of aggression when moving and handling tasks were carried out.
25. At that time care home B completed an advanced falls risk assessment for Mr X. It noted:
• Mr X was trying to stand from his bed. He was not at risk of falling out of bed but was at risk of tripping while trying to mobilise. It considered a low rise bed was not an option as Mr X may topple forward trying to get from sitting to standing if the bed was lower.
• the crash mat was not a safe option as it created a tripping hazard.
• Mr X also tried to mobilise from a chair and would actively try and avoid the alarm mat which was in place.
• Mr X had previously pulled the alarm mat out of the wall.
• Mr X had at times been verbally aggressive towards staff. On these occasions staff should reassure him as he believed he could still mobilise.
• Staff should prompt Mr X to use his call bell and should respond to it as quickly as possible.
26. The risk assessment stated Mr X should not be left in a chair in his room unsupervised. Staff should ensure the alarm mat was in place and active. Bed rails should not be used as Mr X may try and move without support and could damage his skin on the rails as his risk of skin damage was high.
27. During the day Mr X usually sat in the lounge where staff could supervise him. Over the next few days there were several incidents: Mr X was found sat on the side of the bed one night and had also tried standing from his chair, not understanding that he could not walk. He had repeatedly rung the call bell for no reason and had pulled the alarm mat out of the wall. He shredded his incontinence pad on three separate nights and pushed his bedside tray over.
28. The social worker arranged a review for mid-October to discuss Mr X’s future care needs with Mrs X. To inform this they contacted care home A who advised Mr X was initially aggressive but had then settled at the care home. Care home A confirmed Mr X was nursed in bed but could weight bear and transfer with the assistance of two staff members. They advised on his last day hospital staff reported Mr X had been able to walk with the assistance of two staff members for his hospital appointment.
29. The night before the planned review meeting Mr X had a fall at care home B. The records show staff checked Mr X at 23:50 and he was fine. They heard shouting and found him on the floor at 01:10. There was an alarm mat in place but it did not cover the full length of the bed. It appeared Mr X had moved to the end of the bed to try and avoid the alarm mat. Mr X was made comfortable and staff stayed with Mr X while waiting for the ambulance, which took several hours to arrive.
30. Staff at care home B completed an incident report and completed a ‘provider record for alternative actions to raising a safeguarding concern’, to record the actions it had taken. This noted there was no abuse suspected or identified and it had notified the Care Quality Commission (the regulator of care services) of the accident.
31. Mr X was admitted to hospital with a broken hip. Following his hospital admission Mr X was discharged to a nursing home later that month, where Mr X lived until his death in Spring 2022.
32. Mrs X complained to the Council. She said she had received mixed messages over whether an alarm mat was in place, she was not consulted on the placement and care home B was not informed of Mr X’s arrival.
33. The Council accepted there was no proper handover between care home A and care home B and that Mrs X was not consulted about the placement. It confirmed there was an alarm mat in place but this was not triggered and it found no fault in the way the care home responded to Mr X’s fall.
34. It advised it had established a discharge planning process to prevent a recurrence of the faults which involved ensuring needs assessments were shared with future placements and representatives were involved in the discharge planning process.
35. In response to my enquiries the Council has advised it no longer commissioned discharge to assess beds with care home A. It confirmed that staff now make welfare calls to receiving care homes to ensure the placement is proceeding safely and any emerging issues are communicated back to the social work team. This is appropriate. I have made recommendations for further service improvements to prevent recurrence of the faults.

Findings

36. The social worker considered Mr X required an EMI nursing facility. However, the Council agreed to fund a placement at a residential EMI facility. The Council says this was following discussion with care home A which said Mr X had settled and had a reduced need for nursing care. However, I have seen no documented evidence of this. This was not in line with his needs assessment and the CHC checklist which both supported the move to a nursing EMI facility. This was fault.
37. The option of care home B was not discussed with Mrs X before Mr X was placed there and she was not afforded the opportunity to visit care home B before Mr X’s move. This was fault. Mrs X could have given her view on whether she considered the care home suitable for Mr X given his needs. This has caused Mrs X distress and uncertainty over whether the inappropriate move to care home B could have been averted had she been consulted during the decision making
38. The Council failed to ensure there was an appropriate handover when Mr X moved from care home A to care home B. Care home B agreed to contact care home A. It says it rang but there is no evidence in support of this. It did not update the social worker it had not heard from care home A or try and call it again. This was fault.
39. The social worker failed to provide care home B with a copy of Mr X’s needs assessment so it was not aware of how Mr X’s needs had changed since his admission to care home A. This was fault. When Mr X arrived at care home B it believed from the fact finding assessment Mr X could mobilise with the assistance of two staff. However, it found Mr X could not weight bear and required hoist transfers. Had a proper handover been completed it is likely care home B would not have accepted Mr X.
40. The records show Mr X received appropriate care to meet his needs at care home B. It correctly assessed Mr X’s needs and his falls risk and sought to manage the risks. The records show it supported Mr X to eat, to manage his personal care and continence. When it concluded it could not support Mr X long term it informed the social worker who arranged to meet with Mrs X to look at alternative options. There was no immediate urgent need to move, and the social worker arranged a review with Mrs X within a week of the care provider giving notice.
41. Care home B did not assess Mr X as requiring one to one care but care home staff checked him every two hours. It had an alarm mat in place and ensured Mr X was not sat in a chair unsupervised. Mr X fell but there is no evidence Mr X’s fall was as a direct result of fault in the actions of care home B. However, the failure to place Mr X in an EMI nursing home leaves Mrs X with a sense of uncertainty over whether alternative measures could have been introduced to mitigate the falls risk further.
42. Care home B acted appropriately in response to Mr X’s fall. It sought medical assistance, made Mr X comfortable and a staff member stayed with him until the ambulance arrived. It completed the appropriate paperwork to record the incident and was not at fault.
43. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. As Mr X has died I cannot provide a remedy for any injustice the faults caused him. However, the Council’s failure to ensure Mr X was in a suitable care home to meet his long-term needs caused Mrs X distress and uncertainty over whether the outcome may have been different had Mr X been placed in an EMI nursing home. Where this is the case, we can recommend a symbolic amount to acknowledge the impact of the fault.

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Agreed action

44. Within one month of the final decision the Council has agreed to:
1. Apologise to Mrs X and make her a symbolic payment of £200 to acknowledge the distress and uncertainty caused to her by its faults.
2. Remind staff to ensure a receiving care home confirms it has received sufficient information about a potential resident, and has agreed it can meet their needs, before confirming a placement;
3. Remind staff to ensure that representatives are involved in decisions about future care home placements and that this is noted in the case records, particularly in cases where there is an LPA in place for a person who lacks capacity.
45. The Council should provide us with evidence it has complied with the above actions.

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Final decision

46. I have completed my investigation. The Council was at fault for which it has agreed a remedy and service improvements.

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Investigator's decision on behalf of the Ombudsman