Summary: Mrs X complains the Council’s care provider, Churchfields Nursing Home, failed to provide her mother with the support she needed, resulting in her having a fall, and failed to respond properly to the incident, causing further distress. Churchfields was wrong to leave Mrs Y unsupervised when her family visited her. The Council needs to apologise to Mrs Y and her family for the distress they have been caused.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council’s care provider, Churchfields Nursing Home (“Churchfields”), failed to provide her mother with the support she needed, resulting in her having a fall, and failed to respond properly to the incident, causing further distress.

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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. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the Council and care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
5. 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)

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How I considered this complaint

6. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries; and
• shared a draft of this statement with Mrs X and the Council, and invited comments for me to consider before making my final decision.

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What I found

What happened

7. Mrs X’s mother, Mrs Y, went to live in Churchfields in March 2020 because her dementia meant it was no longer safe for her to live independently.
8. The Council reviewed Mrs Y’s needs in December 2020. The review said:
• Mrs Y no longer had nursing needs so needed to move to a residential care setting;
• Mrs Y had been diagnosed with “drop falls”, which could put her at risk of injury as she remained independently mobile;
• her worsening dementia meant she was more forgetful and her ability to understand and retain instructions was low; and
• her safety awareness was low, so she needed constant monitoring.
9. On 16 December another care home agreed to take Mrs Y. Her family decided to leave her at Churchfields until the New Year, as they would not have been able to visit her in the new care home over Christmas because of the need for her to isolate following a move.
10. Mrs X and Mr Y went for a pre-arranged visit with Mrs Y on 1 January 2021. Because of COVID-19, visits took place in a room away from other residents. Mrs X and Mr Y were separated from Mrs Y by free-standing screens (this is reflected in a photograph Mrs X had provided). A Care Worker brought Mrs Y to the room and sat behind the screen with her. Not long after their arrival, the Care Worker assisted Mrs Y to the toilet and another Care Worker brought her back.
11. Mrs X says another member of staff “bellowed” at the Care Worker, telling him to come to the lounge. The Care Worker therefore left Mrs Y on her own behind the screens. Mrs X says her mother started to come towards them, using the screens for support. But she fell over bringing two of the screens down on top of her, with the third falling by her side, and banging her head on the wall by the door.
12. Mrs X says they called out for help. They could not help themselves because of the need to keep two metres apart from Mrs Y. A Nurse arrived who aided Mrs Y back into her chair. Mrs X says the Nurse:
• said they did not have enough staff to support Mrs Y as they were on their breaks or supporting other residents;
• refused to check Mrs Y for injuries but said she would do this “later”;
• lacked empathy for Mrs Y and her family;
• after helping Mrs Y to sit down again, stood by the door and shouted at her when she started to get up again.
13. Mrs X complained to Churchfields on 2 January.
14. When Churchfields replied to Mrs X’s complaint it said:
• the Care Worker had made no complaint about the way a colleague had spoken to him;
• Mrs Y did not require one-to-one support;
• Churchfields had “gone above and beyond” to ensure Mrs Y had one-to-one support at all times to avoid falls as she wandered on a regular basis;
• but the Council was not funding it to provide one-to-one support so if Care Workers had to help another resident they had to do that while ensuring Mrs Y was “left in a safe environment”;
• it disputed the claim the screens had fallen over as “all screens were still fixed in their original position” when checked on 4 January and there had been no one working who could have fixed them back into position;
• two Nurses had checked Mrs Y over for cuts or bruises and found none, then recorded an unwitnessed fall in the accident book;
• the two Nurses denied being rude or abrupt;
• Mrs Y was monitored for 48 hours and showed no signs of injury;
• the relationship between Mrs X and staff at Churchfields had gone “beyond resolve”;
• it had told the Council to find an alternative placement for Mrs Y by 1 February;
• no visits would be allowed due to the outbreak of COVID-19 and to ensure Mrs Y was not agitated during visits.
15. When the Council e-mailed Churchfields on 7 January, it:
• said Mrs Y was soon moving to another care home;
• she was not hurt when she fell back and the glass screens fell on her;
• asked for the first aid and incident recording protocols to safeguard Mrs Y and other residents from such accidents;
• said a protection plan needed to be in place to for recording the incident, providing first aid, monitoring Mrs Y until a GP had seen her.
16. When Churchfields replied it said:
• the glass screens did not fall on Mrs Y, as they were fixed in position with anti-fall legs and would require some force to push over, which Mrs Y could not do;
• the unwitnessed fall had been recorded in the accident book, in line with procedures;
• Mrs Y suffered no injury.
17. Mrs Y moved to another care home on 12 January.

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

18. Mrs Y should not have been left unsupervised during the visit. The Council had assessed Mrs Y as needing constant monitoring. That is not the same as one-to-one care. Mrs Y’s visitors could not monitor her properly when they were behind a screen and needed to stay two meters away from her. According to Churchfields, it recorded the incident as an “unwitnessed” fall. But Mrs X and Mr Y witnessed the fall. Churchfields said the screens were fixed and could not have been put back in place after the incident if they had fallen over. However, the photograph Mrs X has provided shows the screens were not fixed down. These are faults for which the Council is accountable (see paragraph 5 above).
19. Churchfields response to the complaint was inappropriate. There was no need to give Mrs Y notice when it had already been agreed she should move to another care home. While there was no fault in saying the family could not visit while there were cases of COVID-19 in the home, there was no basis to say the family should not visit to prevent Mrs Y from getting agitated. The Council is also accountable for these faults.
20. There is no evidence Mrs Y suffered physical harm from her fall. However, the faults I have identified caused avoidable distress to her and her family.

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Agreed action

21. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Care Provider as well as the Council, I have only made recommendations to the Council.
22. I recommended the Council:
• within four weeks write to Mrs Y and her family apologising for any distress they have been caused;
• within eight weeks, work with Churchfields to ensure it has suitable arrangements in place for receiving visitors.

The Council has agreed to do this.

23. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of my final decision statement.

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Final decision

24. I have completed my investigation as the Council has agreed to take the action I recommended.

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Investigator's decision on behalf of the Ombudsman