Kingsview Homes Limited (18 000 538)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 09 Apr 2019

The Ombudsman's final decision:

Summary: Mrs X complains about the care her sister, Ms Y received at a care home. She says the home did not properly respond to complaints and delayed in refunding care fees. The Ombudsman finds Ms Y suffered injustice because of two of the issues raised. We recommend the Home apologise to Ms Y and update its procedures.

The complaint

  1. Mrs X complains about the care her sister, Ms Y, received at Newton Hall Care Home (“the Home “) and the Home’s response to her complaint. Mrs X says:
      1. The Home did not properly handle a fall by Ms Y in March 2017 as:
  • The fall was caused by a vacuum cleaner left unattended in a corridor; and
  • It took four days for an X-Ray to be conducted.
      1. The Home did not suitably handle a fall by Ms Y in January 2018 as:
  • It did not properly deal with reports of Ms Y’s back pain, which Mrs X said led to the fall;
  • Staff moved Ms Y when they should not have done;
  • It delayed in calling an ambulance.
      1. It could not find a copy of Mrs X’s Power of Attorney document.
      2. It took over four months to get a refund for overcharged care.
      3. There was no contract between Mrs X and the Home.
      4. The Home did not reply to correspondence unless it was sent recorded delivery to the managing director.

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The Ombudsman’s role and powers

  1. 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 or others. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
  2. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a body has done. (Local Government Act 1974, sections 26B and 34D, as amended)
  3. If we are satisfied with a 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)
  4. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

  1. My colleague was initially the investigator for this complaint. She spoke to Mrs X then made enquiries of the Home. I then took over the investigation and reviewed all the information provided, including the record of her call with Mrs X. I made further enquiries of the Home.
  2. I sent a copy of my draft decision to the Home and Mrs X for their comments.

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What I found

  1. Health and care workers should consider any national guidance and the policies of their own organisation when delivering care.
  2. The National Institute for Health and Care Excellence (“NICE”) produces clinical guidance and quality standards on many areas of care, including managing the risk of falls. The NICE CG161 – Falls in older people: assessing risk and prevention guidance says:
    • Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment.
  3. It also says:
    • Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function.
  4. The Home’s ‘Moving and Handling’ policy says every individual should have a moving and handling assessment on admission. Staff should write the assessment down and produce an individual handling plan. Staff should review the plan at least monthly.
  5. The Home’s ‘Prevention of Falls’ policy says all falls should be thoroughly investigated. A falls risk assessment should take place for anyone suffering frequent falls and the identified action should be clearly documented on the resulting care plan.

Background

  1. Ms Y was a resident of the Home from early 2013 until January 2018. Her falls diary shows Ms Y had a fall in March 2013. Staff found her on the bedroom floor after a pressure mat sounded. Ms Y did not suffer any injury. Ms Y did not have any more falls until 2017. This investigation is only considering events from March 2017. Information about historical events are provided by way of context.
  2. Staff completed an up to date manual handling assessment in January 2017. This showed Ms Y was independently mobile while inside. It said two carers needed to use a hoist to transfer Ms Y from the floor if fallen.
  3. Ms Y did not have any falls between 2014 and 2017, so staff decided Ms Y’s risk of falls reduced and she no longer needed a pressure mat in her room. Ms Y did not have a falls or mobility care plan as she was not assessed as at risk of falling. Instead, staff included mobility on Ms Y’s safe environment care plan.
  4. The safe environment plan was reviewed monthly and updated annually. Staff updated the plan in February 2016, at which point it said:
    • ‘Ms Y is independently mobile with a zimmer frame, which she doesn’t use very much in the small space which is her bedroom. Staff must ensure it is free from clutter and potential hazards.’

Fall in 2017

  1. In March 2017 Ms Y had a fall. It is not clear what led to the fall, as the Home has given three different accounts.
  2. In its response to our enquiries the Home said this was an unwitnessed fall. It said staff found Ms Y sitting on the floor in the corridor near her bedroom. The accident report book and other care records are consistent with this account. The communication records show the Home contacted Mrs X on the day of the fall, to tell her what happened.
  3. The Home Manager went to see Ms Y following the fall. She noted Ms Y was sat in her room in the chair, with no obvious injury, no bruising, no skin damage and no complaints of pain. Ms Y was added to the GP’s list for that day.
  4. The GP felt there was no obvious injury but could not tell without an X-Ray, which he ordered. The Home says, at that point, Ms Y refused to attend hospital. Records are consistent that staff and family continued to try and persuade Ms Y to go to hospital.
  5. Ms Y’s nephew visited the Home two days after the fall to encourage Ms Y to attend hospital. The family managed to get Ms Y to Accident and Emergency but while there she refused to be seen and walked out so the family brought her back to the care home.
  6. The Home says Ms Y’s arm started to bruise later that day. Mrs X says her arm showed bruising before this date.
  7. The Home says staff were concerned and asked an out of hours GP to attend. The GP requested a non-emergency ambulance to take Ms Y to hospital for an X-Ray. The ambulance report shows that Ms Y refused to be taken to the hospital. The care home also records that Ms Y had capacity to make that decision. The Ambulance staff advised the Home should contact a relative the following day to take Ms Y to hospital.
  8. The following day, the Home Manager received a phone call from the Senior in charge to say Ms Y had said if the Manager would go with her she would go to the hospital. The Manager went in and took Ms Y to the hospital with another member of staff. The hospital diagnosed that Ms Y had a closed fracture that required no further treatment.
  9. Staff made a note of the fall on the evaluation section of Ms Y’s moving and handling plan. No changes were made to the plan and the evaluation says Ms Y remains independent and mobile. Staff did not conduct any further falls risk assessment at first and did not complete a falls care plan. The Home says this is because it was her first fall and staff felt it was an accident and not part of her condition deteriorating. It says, on reflection, staff would now have completed a care plan and risk assessment.
  10. The Home sent a statutory notification to the Care Quality Commission (“CQC”) four days after the fall. It said staff witnessed Ms Y turn into the corridor and lose her footing, banging her left arm on the handrail in the corridor.
  11. Mrs X says staff told her Ms Y had tripped over a vacuum cleaner. In the Home’s first response to Mrs X’s complaint in April 2018, it says a senior carer witnessed the fall outside Ms Y’s room. It says it is unclear from the records whether the vacuum cleaner was left in an unsafe position.
  12. In June 2017, a senior carer reviewed Ms Y’s safe environment care plan and decided it was necessary to start a falls risk assessment following the fall. This is not recorded on the care plan but records show Ms Y was then regularly risk assessed using a multifactorial assessment tool from June to December 2017. Ms Y’s risk of falls remained at medium throughout.

Fall in 2018

  1. In January 2018 Ms Y had another fall. Four days before the fall, the Home recorded that Ms Y was complaining of back pain. Mrs X says she and other family members told staff that Ms Y was suffering from back pain several days before this.
  2. The Home arranged for the GP to visit Ms Y. Ms Y did not let the GP complete his examination. He prescribed paracetamol for the back pain and the record shows an x-ray was arranged.
  3. Mrs X says Ms Y preferred female doctors and the Home knew this. The manager at the Home says she was not aware of this and Ms Y had often been seen by male doctors. The professional visit records show the same doctor had visited Mrs Y three times in the past two months.
  4. Ms Y fell in her bedroom and staff did not witness this. A carer found Ms Y on the floor in her bedroom next to her bed. The Home says the carer found Ms Y at 08:20. The daily progress notes show staff checked on Ms Y at 07:30 and she appeared to have slept well. However, Mrs X says that, at the time, staff told her Ms Y had been found at 07:00.
  5. The carer called for help from a senior carer and the deputy manager. The deputy manager says she tried to check Ms Y over but she refused, said she was not in pain and tried to stand despite encouragement to stay where she was. Staff therefore assisted her onto the bed. The deputy manager tried to check her again but Ms Y started to shout and hit out. Staff decided to leave Ms Y to calm down until they could check her over.
  6. The timeline from that point on is not completely clear. The senior carer says she checked on Ms Y 20 minutes later and she had settled. She fetched the deputy manager who checked Ms Y over and saw some rotation in her leg, swelling and that one leg was slightly shorter than the other. Staff then called an ambulance and called Mrs X to let her know what had happened. The carer says she cannot remember the exact time she called an ambulance but thinks it was at around 09:20. The deputy manager cannot remember the timeframe.
  7. Mrs X says her daughter arrived at the Home at 10:00. At this point staff had not telephoned for an ambulance and seemed uncertain about how to proceed. Mrs X says her daughter insisted staff call an ambulance.
  8. When the ambulance arrived, Ms Y refused to allow the paramedics to check her over or go to hospital. Mrs X said she was power of attorney and insisted the paramedics took Ms Y to hospital. The paramedics would not do so without first seeing the power of attorney document.
  9. Staff could not find the document in Ms Y’s care file or the main office. Mrs X went home to get another copy and brought it back for the paramedics, who then took Ms Y to hospital.
  10. Mrs X says she gave the power of attorney to the Home in 2013. The Home says it cannot find any reference to receiving the power of attorney. It also says there is a section about power of attorney on her deprivation of liberty (“DoL”) form, which is blank. The Home says this indicates the manager did not have access to the power of attorney information. However, the Home says it has reviewed its admission procedure in relation to power of attorney.
  11. Ms Y was diagnosed with a broken hip. She could not be discharged back to the Home as she could not mobilise with the use of an aid, which mean the Home could not meet her needs. She instead moved to a different care home in March 2018 and was placed on end of life care. Ms Y passed away in April 2018.

Complaint handling and overcharge

  1. In February 2018 Mrs X received an invoice for care at the Home between February and March 2018. The amount was paid from Ms Y’s account by standing order.
  2. Ms Y had been in hospital throughout this time and was discharged to a different care home, so Mrs X asked the company that owned the Home to refund the fees. Mrs X did not receive a response so wrote to the company again. The company responded in April 2018 and refunded the fees.
  3. The Home says the company raised a credit note at the end of February 2018 for the refund but did not send this until April 2018 and apologised to Mrs X for this oversight.
  4. Mrs X complained to the Home in April 2018 as she felt the Home had been ineffective in responding to Ms Y’s back pain before the fall and in staff’s actions on the day. The Home responded to her complaint and said it felt staff had done all they could in the circumstance. However, there was an error in the address on the Home’s letter to Mrs X. The Home apologises for this error and says all letters will be proof read by a second person going forward to prevent any further errors.
  5. Mrs X says the Home did not have a proper contract for Ms Y. The Home says it cannot find Ms Y’s contract but has a standard terms and conditions that should be signed for all residents. It says it has updated its procedure so all contracts are now held in the company’s head office once completed.

Findings

Fall in March 2017

  1. I have exercised my discretion to investigate the fall in March 2017, although it is longer than 12 months before we received the complaint. I have done so as it is reasonable in the circumstances to establish whether there were any links between that and the later fall in 2018.
  2. I have looked at the following issues relating to the fall in 2017:
    • Ms Y’s risk assessments and care plans before the fall;
    • Any risk assessments completed and care plans put in place after the fall; and
    • The Home’s notification to the CQC.
  3. The Home’s policy suggests every resident should have a moving and handling plan. Ms Y did not have a moving and handling plan but did have a manual handling assessment and safe environment plan, which set out that she could mobilise independently.
  4. I do not feel able to criticise the Home for not having a specific moving and handling plan for Ms Y. This is because she was moving independently since admission, and had not fallen for four years between 2013 and 2017. It was therefore reasonable for staff to decide she was at low risk of falls.
  5. A separate care plan would likely not have contained more information than recorded in the safe environment plan, manual handling assessment and falls diary. While the Home’s policy does indicate there should be a separate plan, I cannot say the Home did not adequately risk assess Ms Y or meet her needs leading up to the fall.
  6. I also cannot say the Home did not respond properly to fall at the time. Staff arranged for a GP to see Ms Y and the GP did not find obvious signs of injury. The records show staff encouraged her to have an x-ray and arranged for an out of hours GP to visit when they became concerned about a possible injury. Staff were eventually able to convince Ms Y to attend hospital.
  7. Mrs X raises concerns about whether Ms Y had capacity to refuse treatment. However, there do not appear to be any concerns from any of the professionals involved, including the two GP’s about Ms Y’s capacity. I also do not have evidence Ms Y’s family raised concerns about her capacity at the time. From the evidence available, it appears all involved at that time accepted the approach of encouraging Ms Y to attend hospital. I therefore cannot find fault in how the Home assessed Ms Y’s capacity to decline treatment.
  8. It is not clear what steps staff should have taken following the fall. The Home’s policy on falls prevention only says a risk assessment and falls care plan should be put in place if someone has frequent falls. It is not clear if that is different if someone is injured or hospitalised from a single event.
  9. The NICE guidance suggests professionals should at least risk assess older people who have fallen and injured themselves.
  10. The Home did put in place a regular falls risk assessment for Ms Y but not until three months after the fall. It is not clear why there was a delay or why in June 2017, staff felt the risk was different to immediately after the fall in March 2018.
  11. Despite the delay, I cannot say this caused an injustice to Ms Y as she did not suffer any more falls until January 2018, at which point staff were properly assessing her risk of falls.
  12. Staff consistently recorded her risk of falls as ‘medium’. The risk assessment chart does not require staff to put in place a falls care plan unless the risk is ‘high’. The NICE guidance is not entirely clear about what intervention should take place in a situation like this. I therefore cannot say the Home should have had a specific falls care plan for Ms Y. However, the NICE guidance may indicate more is expected after someone has suffered an injury from a fall.
  13. I cannot find that, if a falls care plan did exist, Ms Y would not have then fallen in January 2018. The Home says staff felt the fall in March 2017 was a one-off accident, rather than due to a decline in her condition. However, it accepts that on reflection, it would now put in place a care plan to identify any individual factors that may have increased Ms Y’s risk of falls. Even so, Home’s policy could have been clearer about its expectations when someone suffers an injury or is hospitalised following a single fall.
  14. It is a concern that staff appear to have given three different versions of what happened. I note the Home says this was an unwitnessed fall and any comments otherwise to the CQC were a mistake. However, the referral to the CQC is quite descriptive about what happened – Ms Y falling over as she turned a corner and hitting her arm on a railing. The other version given to Ms Y is also descriptive in that staff saw her trip over a hoover. Therefore, it is not clear which is accurate.
  15. Whether a fall is witnessed or not, may be relevant for several reasons. This could be because further investigation is needed to identify the cause of the fall. It may not also be clear if someone hit their head. For the CQC’s purposes, it may be relevant as, if falls are commonly not witnessed, it may raise questions about staffing levels.
  16. I cannot find the discrepancies caused Ms Y or Mrs X a significant injustice. This is because the Home’s clinical records are generally consistent that staff did not witness the fall. What staff told the CQC or Mrs X is unlikely to have altered the care Ms Y received going forward. However, it is a factor in my decision to share this statement with the CQC.

Fall in January 2018

  1. I have looked at the following issues relating to the fall in 2018:
    • Action taken for Ms Y’s complaints of back pain before the fall;
    • How staff responded to the fall; and
    • Any delays in calling for an ambulance and getting Ms Y to hospital.
  2. The care records show staff contacted a GP to see Ms Y on the day it is recorded she first complained about back pain. I understand there is some conflict between what the Home says and what Mrs X says about when staff first became aware of Ms Y’s back pain and if they recorded this. I cannot reach an evidence based conclusion on when staff first became aware of back pain. I also note that, while it would be fault not to record complaints of back pain for several days, it was recorded four days before the fall and Mrs Y was seen by a GP. It is therefore not possible for me to say that, had the back pain been recorded earlier, it would have prevented a fall.
  3. The GP prescribed paracetamol and arranged for an x-ray. I cannot say the Home should have taken any more action than asking the GP to see Ms Y. I also cannot say for certain whether, whatever caused the back pain, also caused Ms Y to fall.
  4. I note that when responding to the fall, staff did not follow the procedure set out in her manual handling assessment. However, I accept that if Ms Y was trying to stand up herself, it may not have been possible to follow this procedure and so cannot criticise the fact staff helped her to stand without a hoist.
  5. I am not certain why staff would have told Mrs X they found Ms Y at 07:00. However, the care records show staff checked on her at 07:30. All records and statements are consistent that staff found Ms Y at 08:20, so I am not able to question this timeframe.
  6. The timeframe from that point on is less clear. The deputy manager cannot remember when she called an ambulance but the carer thought it was around 09:20. This is an hour after staff found Ms Y and does not appear to fit in with the comments that she checked her 20 minutes after staff had left her to calm down. I also note the discrepancy between this version of events and that of Mrs X.
  7. However, I understand the carer cannot remember the time for certain. I also cannot say how long actions such as getting Ms Y onto the bed, trying to examine her, then later examining her and calling the ambulance, took. Therefore, on this information alone, I could not say there were unnecessary delays in Ms Y receiving medical attention. I also cannot resolve the conflict between the versions of events from staff and Mrs X. However, an hour does seem like a long time considering the injuries Ms Y sustained. As explained below, it does appear that on balance, with all things considered, there were avoidable delays.
  8. It is clear the power of attorney form not being available caused delays as Mrs X had to go home to get this before she could be taken by ambulance.
  9. I understand the Home does not have record of receiving the power of attorney. The blank section on the DoL form may suggest it did not have this information. However, it may also suggest this should have been filled in as it is clear Mrs X did have power of attorney. It would be normal for a Home to ask for and hold information about power of attorney for its residents, as it is relevant to decisions about their care.
  10. I cannot evidence that the Home received Ms Y’s power of attorney document in 2013. However, it is reasonable to conclude the Home should have had this information available. On balance, this combined with the uncertainty of the timeframe in calling for an ambulance, means it is also reasonable to conclude there were avoidable delays in Ms Y being taken to hospital.

Complaint handling and overcharge

  1. It is clear the company that owns the Home did not respond to Mrs X’s initial letter in March 2018. There were some delays before the Home refunded the fees for the time Ms Y had been in hospital. However, it did refund these fees and the length of the delay is not such that I could find it caused a significant injustice.
  2. I also acknowledge the Home should have clear records of Ms Y’s contract. However, again I cannot find it causes a significant injustice that it cannot locate this, as the fees have now been refunded.
  3. The response to Mrs X’s complaint was sent promptly after her complaint but did contain an incorrect address. The Home apologises to Mrs X for this and has updated its procedure to prevent it happening again. I accept this suitably remedies the matter and would not recommend anything substantially different.

Injustice and consideration of remedy

  1. I have found that two main issues could have caused injustice to Ms Y:
    • The Home’s ‘Prevention of Falls’ policy is not clear on what to do in terms of risk assessments and/or care planning if a resident has a single fall that causes injury.
    • There were avoidable delays in Ms Y being transferred to hospital for medical treatment after her fall in January 2018.
  2. It is difficult to assess the level of injustice these issues may have caused.
  3. I cannot say exactly what the policy should have contained. Only that NICE guidance suggests a single fall that causes injury should be treated differently to a one-off incident that does not, and proper assessments carried out. It is for the Home to determine what level of risk assessments or care planning this would include. I therefore cannot say, had the policy addressed single incidents that cause injuries, the Home’s actions would have been different (at least not after it put the risk assessment in place in June 2017).
  4. For this reason, I do not feel able to recommend a personal remedy, for injustice caused specifically to Ms Y. However, I recommend the Home review and update its policy.
  5. In relation to the fall in January 2018, it is clear Ms Y had already suffered a serious injury. While there should not have been any avoidable delays, it is impossible to say what, if any, difference it would have made to Ms Y’s prognosis, had the delays not occurred. I recommend the Home apologise to Mrs X for these delays. However, because it is impossible for me to assess any level of injustice, I cannot recommend any further personal remedy.
  6. I can see the Home says it has reviewed its admission procedure in relation to powers of attorney. I am not certain what changes it has made. I therefore also recommend the Home review its admission procedures to ensure information about any power of attorney is obtained for all new residents and copies of the documentation is kept in their care file, so it is easily available.

Agreed action

  1. The Home has agreed to, within a month of this decision:
    • Apologise to Mrs X for the avoidable delays caused in Ms Y being taken to hospital after her fall in January 2018.
  2. The Home has also agreed to, within three months of this decision:
    • Review and update its Prevention of Falls policy to consider what risk assessments and/or care planning should take place if a resident has a single fall that causes injury or hospitalisation; and
    • Review its admissions procedure to ensure information about power of attorney is obtained from new residents and copies of power of attorney ‘health and welfare’ documents are kept easily available in residents’ care files.

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Final decision

  1. Ms Y suffered injustice due to the Home not having a clear policy on what risk assessments to conduct following a single fall that causes injury and for avoidable delays in Ms Y being transferred to hospital. I recommend the Home apologise to Mrs X and update its procedures.

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Investigator's decision on behalf of the Ombudsman

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