Summary: Ms X complains Avery the Care Provider failed to look after her late uncle, Mr Y, properly, resulting in him having a fall and causing her avoidable distress. Mr Y’s fall was an unfortunate accident, rather than due to fault by the Care Provider.

The complaint

1. The complainant, whom I shall refer to as Ms X, complains Avery at Loxley Park (Homecare) Limited (the Care Provider) failed to look after her late uncle, Mr Y, properly, resulting in him having a fall and causing her avoidable distress.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(4), as amended)
3. 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 Care Provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to Covid-19”.

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How I considered this complaint

4. I have:
• considered the complaint and the documents provided by Ms X;
• considered the documents the Care Provider has sent to us; and
• shared a draft of this statement with Ms X and the Care Provider, and taken account of the comments received.

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What I found

Key facts

5. Mr Y lived in an apartment in a retirement complex where the Care Provider provides care and support to those who needed it. Mr Y had Alzheimer’s disease, impaired mobility and other age-related medical conditions. He received four visits a day to help with continence (catheter care), washing, dressing and medication. He had a history of falls (six since November 2019, all without injury) and was a “very high falls risk”. He used a wheeled walker when mobilising. He used to have his lunch and evening meal with other residents. But because of COVID-19 residents were no longer socialising with each other and remained in their apartments.
6. On 24 April 2020 the Care Provider first visited Mr Y at 05.39 and helped him with washing, dressing, breakfast and medication. At 07.43 the Care Provider asked for a GP visit due to “increased confusion, challenging behaviour, undressing etc”. At 11.10 the Care Provider spoke to a GP who prescribed antibiotics to treat an infection. According to the Care Provider’s records, the GP noted Mr Y had had an infection before which made his behaviour “quite bizarre”. The Care Provider was to monitor Mr Y and if he did not improve the GP would visit. The Care Provider visited Mr Y again at 12.11. He had undressed and removed his catheter bag, which had emptied on the floor of his lounge. Mr Y left his apartment in the afternoon. At 15.24 he was found on the floor in the car park, having had a fall. An ambulance took him to hospital.
7. An ambulance brought Mr Y home at 00.20. He was immobile, so the paramedics helped get him into bed. The Care Provider checked on him hourly. By 04.30 he was awake and was asked to stay in bed. He remained awake and “content” but at 12.10 he was found on the floor. It was not clear whether he had fallen out of bed or fell trying to get up. As he was in pain the Care Provider called an ambulance, which took Mr Y back to hospital where he was operated on for a broken hip. Mr Y caught COVID-19 in hospital and died there on 24 May.
8. When the Care Provider responded to a complaint made by other members of Mr Y’s family in June, it said:
• it was unfortunate no one saw Mr Y leave the building on 24 April;
• because residents were self-isolating in their apartments, few people were in the main reception area;
• it had to redeploy staff to other duties, which meant that when Mr Y left the building the receptionist was delivering drinks to other residents; and
• residents had to have the right to leave the complex whenever they wanted.
9. Ms X complained to the Care Provider in August. When the Care Provider responded to her complaint in September, it said:
• the retirement village was not the same as a care home, as residents could leave when they wanted and re-enter using a key fob;
• assisted living did not come under the Deprivation of Liberty Safeguards, so it could not lock people in;
• they had agreed to continue supporting Mr Y for as long as possible after he received the diagnosis of Alzheimer’s disease;
• despite his memory problems, Mr Y had the mental capacity to make decisions for himself; and
• COVID-19 had an impact on staffing levels due to absences, so it had to redeploy staff to keep residents safe and reassured.
10. Ms X has questioned whether the Care Provider should have carried extra checks on 24 April, given Mr Y was behaving oddly and was unwell. She has also questioned why the reception was left unstaffed.

Did the care provider’s actions cause injustice?

11. The Care Provider was not at fault for failing to carry out extra checks on 24 April. Mr Y was behaving oddly, removing his catheter and clothes, but had not left his apartment. The GP had said to monitor his health, but that did not require additional visits above the four the Care Provider was already doing.
12. The Care Provider’s staffing levels were reduced because of COVID-19. Because of this the receptionist had been asked to deliver drinks to other residents at the time Mr Y left the retirement complex. The Care Provider was not at fault over this. Had residents not been staying in their apartments and been able to receive visits from other people, the reception would have been a busy area. Because of the pandemic it was quiet. The Care Provider was not at fault for prioritising other work over staffing the reception.

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Final decision

13. I have completed my investigation on the basis that the Care Provider has not been at fault, so is not responsible for Mr Y’s accident.

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Investigator's decision on behalf of the Ombudsman