Summary: Mrs X complained, on behalf of her and her mother Ms Y, about the way the care provider responded when their late relative Mr Z had two falls in his flat. We cannot make a finding on the extent to which staff assisted Mr Z get off the floor. The care provider was not at fault in the way it sought medical assistance after the fall, in line with Mr Z’s wishes. The care provider’s record keeping was poor and this is fault. It has already taken action to address this through staff training. The care provider has agreed to apologise to Mrs X and Ms Y and make a payment to acknowledge the uncertainty and distress caused to them by the poor records.

The complaint

1. Mrs X complains, on behalf of her and her mother Ms Y, about the way the care provider responded when their late relative Mr Z had two falls in his flat. She says staff wrongly assisted him off the floor and failed to call an ambulance. The care provider also failed to fill in the daily log/care notes correctly and failed to notify the family of Mr Z’s falls. Mrs X says this led to a deterioration in Mr Z’s condition and caused distress to her and Ms Y.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. If we are satisfied with a care provider’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

4. I have considered the information provided by Mrs X and discussed the complaint with her on the telephone. I have considered the care provider’s response to my enquiries.
5. I have considered the relevant law and guidance and our guidance on remedies.
6. I gave Mrs X and the care provider the opportunity to comment on a draft of this decision and considered any comments I received in reaching the final decision.
7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this final decision with CQC.

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What I found

Relevant Law and Guidance

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
9. 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 CQC has issued guidance on how to meet the fundamental standards below which care must never fall.
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• The nutritional and hydration needs of the service user must be met. (regulation 14).
• The care provider must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)
10. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. A person must be presumed to have capacity to make a decision unless it is established that he or she lacks capacity. A person should not be treated as unable to make a decision just because they make an unwise decision.

What happened

11. Mr Z lived in an extra care housing scheme. He received care calls in the morning and evening to assist with personal care and with preparing breakfast and evening meals. He was also taken to and from the communal restaurant at lunchtimes. Mr Z had one sided weakness following a stroke. His care plan showed he used a stick or frame to assist him with moving round his flat and a wheelchair for longer trips. He could independently transfer from chair to bed or to the commode but needed some assistance getting out of bed. Mr Z liked to be as independent as possible and had capacity to make his own decisions. He had a lifeline pendant buzzer to call for assistance if required.
12. The care notes show Mr Z was often already out of bed and dressed when carers arrived in the mornings.
13. In late October 2019, a carer noted in Mr Z’s daily care records that Mr Z’s foot was very painful, red and swollen. The care provider contacted 111. The notes record the paramedics attended but did not consider Mr Z should be admitted to hospital and called the out of hours GP to organise antibiotics for Mr Z. Mr Z was prescribed antibiotics and a carer noted in Mr Z’s records that he chose to self-administer these.
14. The notes record the GP visited Mr Z in early November to look at his foot. They prescribed antibiotics. The next day carers noted Mr Z was in a lot of pain with his foot.
15. The next morning, carer A attended Mr Z’s morning call and found him on the bedroom floor. They requested help from another staff member, carer B, and Mr Z got on to the bed. Carer B then left. Carer A then assisted Mr Z, who used his frame, to get to the toilet. They asked Mr Z to alert them when he was finished. Carer A checked Mr Z and found him on the bathroom floor. They pressed the alarm. Carer C and then carer B arrived at which time Mr Z was in his wheelchair. In the daily care records, carer A noted carer C ‘assisted me with [Mr Z], to get up off the bathroom floor, assisted to armchair’. Carer C telephoned the GP.
16. Carer A completed an incident log reporting they found Mr Z on the floor of the bedroom and bathroom. He ‘wanted to get up off the floor….he got onto his knee, got onto bed. He got dressed, wanted the toilet, assisted to toilet. Told him to call me when he had finished but he did not. Ended up on the floor. Phoned [carer C] to assist me but got up so put wheelchair for him to sit on. Took through to lounge…..he told me he had just fallen that morning’ .Carer B completed an incident form noting ‘I assisted [carer A] to get [Mr Z] up on to the bed.’
17. Carer A stayed with Mr Z for around an hour and a District Nurse visited to take a blood sample. Another District Nurse attended who also called the GP to support the request for a visit.
18. Carer C took Mr Z’s lunch to his flat. They did not record this in the care notes but completed an incident report later noting they had failed to record this. They also recorded Mr Z had wanted them to leave.
19. The paramedic attached to the GP surgery visited in the afternoon and reported Mr Z’s observations were fine. They said Mr Z also reported feeling well in himself. They agreed he could stay at home at that time and arranged for Mr Z to go to hospital the next morning for intravenous antibiotics. They booked an ambulance to take him. Carer C updated Ms Y.
20. Carer D visited Mr Z to offer him a shower that afternoon. Mr Z declined as he was in pain. At the time Mr Z was sat in his recliner chair. He said the GP paramedic told him not to put weight on his foot. Carer D checked with the office if Mr Z would be sleeping in his recliner chair that night. Carer C spoke on the telephone to the GP paramedic who agreed Mr Z would be better staying in his chair. When carer D visited Mr Z for his evening call they found him lying on the bed. They asked how he got to the bed and Mr Z said he had crawled there. Mr Z was in a lot of pain and carer D was concerned about Mr Z’s condition so called 999. They noted this in the care records and completed an incident form.
21. The paramedics arrived in the early hours. A carer completed an incident form as the paramedics were concerned the care notes did not record when Mr Z last changed his continence pad, there was no record of food and drink offered to Mr Z and Mr Z reported falling twice that morning and being lifted up by carers. Also, there was no record of why the District Nurse had visited to take bloods. The paramedics questioned why they were not called in the morning.
22. The form completed by paramedics at the time noted Mr Z had leg pain due to cellulitis. They noted he was due to visit the hospital the next day and carers had visited in the evening and called 999 due to decreasing mobility.
23. Ms Y complained to the care providers about the inaccurate care notes and asked why the emergency services were not called when Mr Z fell earlier that day.
24. The care provider responded to Ms Y’s complaint in mid-November 2019. It found staff had delivered food and fluids to Mr Z and Mr Z declined personal care due to his pain levels. He had passed urine as a carer reported they had witnessed a wet pad in the bin. The care provider accepted all of this should have been documented in the care records. It advised all the staff who supported Mr Z that day would be retrained in report writing and this would also be addressed during staff supervision. It said Mr Z was found on the floor by his bed and fell again in the bathroom and was found by the bathroom window. Staff had reported Mr Z got himself off the floor. He reported he was fine and did not want any medical assistance.
25. The response said carer C persuaded Mr Z to allow them to call the GP and noted Mr Z was seen by the District Nurse and paramedic.
26. In early December 2019 Mrs X made a safeguarding report to the Council as Ms Y had noticed there were three days with no entries for Mr Z’s epilepsy medication on the medication administration records (MAR) chart. She also reported her concerns that staff had picked Mr Z up off the floor which they were denying and not sought medical assistance after he fell.
27. The care provider investigated. It found the medication was administered on one of the three days concerned but the carer had signed the wrong column on the MAR chart. On the two other days the carers (who were agency staff) recorded in the notes that medication was administered and had signed all the other columns in the MAR chart but the one relating to Mr Z’s epilepsy medication. The care provider said Mr Z had taken this medication for a long time so it was unlikely he would let a carer leave without him taking it. It said it had asked the agency to remind staff to ensure, in future, they signed MAR sheets.
28. The care provider interviewed the carers about Mr Z’s falls. In the interviews the carers reported they had not picked Mr Z off the floor as they knew it was against policy and their training. Carer B noted they had stated in the incident report they assisted Mr Z up but said due to their own medical issues they could not have lifted Mr Z. They noted Mr Z was angry and had refused medical assistance. Carer C said they had to be firm with Mr Z about getting checked and allowing them to call the GP. The care provider concluded it did not support the family claims that Mr Z was lifted off the floor. It accepted the client notes were scant and said staff were retrained in report writing.
29. The care provider also accepted it made a factual error in the complaint response to Ms Y as Mr Z was first found close to the bedroom window and later in the bathroom – not near the bathroom window.

Findings

30. The records show, from late October 2019, the care provider sought appropriate medical attention, in line with Mr Z’s wishes, in relation to his sore leg.
31. When Mr Z fell in November 2019, there is no evidence to show he suffered an injury. Mr Z reported he was not injured, and he was conscious throughout. The care provider acted appropriately by seeking medical assistance in line with Mr Z’s wishes. Mr Z had capacity to make his own decisions about the care and support he received. The care provider was not at fault.
32. I cannot establish the extent to which, if at all, the carers helped Mr Z off the floor after his falls. Mrs X and Ms Y do not consider Mr Z could get himself up off the floor. The care provider properly investigated the incident and interviewed staff who denied lifting Mr Z up and said it was not in line with their training. Mr Z was very independent and later that day he independently transferred himself from his recliner chair to the bed. He did not use his lifeline buzzer to seek assistance despite being advised to.
33. Even if I were to establish staff assisted Mr Z, I cannot conclude that caused him an injustice. Two district nurses saw Mr Z shortly after the falls and a paramedic visited that afternoon. It was for the medical professionals, not the care provider, to decide whether Mr Z required hospital admission and they did not consider it necessary at that time.
34. The care provider did not contact family members after Mr Z fell. However, that is not fault. Mr Z had capacity to decide whether to request contact with family and he did not suffer any injury from the falls. The care provider updated Ms Y when it was decided Mr Z needed to attend hospital. The care provider was not at fault.
35. The care provider has already accepted the care notes completed that day were of poor quality. The notes do not show whether Mr Z ate that day or whether he urinated. This meant the ambulance crew who attended had insufficient information to properly assess Mr Z’s condition. This was not in line with regulation 17 of the 2014 regulations and is fault. The care provider has already taken appropriate action to address this and to prevent recurrence of the fault.
36. The care provider also failed to ensure Mr Z’s MAR charts were completed correctly. This is fault. The care provider considered it likely Mr Z received this medication. However, this still leaves Mrs X and Ms Y with a sense of uncertainty. The care provider says it contacted the agency and asked them to remind staff to sign all MAR sheets. This is appropriate.
37. The poor records caused uncertainty and distress to Mrs X and Ms Y as they could not be certain Mr Z had received appropriate treatment.

Agreed action

38. Within one month of the final decision on this complaint the care provider has agreed to apologise to Mrs X and Ms Y and to make a symbolic payment of £150 to each of them to acknowledge the uncertainty and distress caused by the poor record keeping.

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Final decision

39. I have completed my investigation. There was evidence of fault causing injustice which the care provider has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman