Summary: The care provider called for medical attention promptly when the late Mrs X fell, and acted on the advice given. The care provider should have called Mrs F to inform her of the first fall in line with its policy but has apologised for that omission.

The complaint

1. Mrs F (as I shall call the complainant) complains about the care provider’s actions after her mother fell in her room. She also complains that the care provider failed to mend a broken door strip in Mrs X’s room, and that it did not tell her about the decline in her mother’s mental health and weight loss, even though she had power of attorney for her mother’s affairs.

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What I have investigated

2. I have investigated the complaint as set out above. Mrs F has made a number of complaints about other organisations involved in her mother’s care but those bodies have not yet had the opportunity to investigate her complaints so the Ombudsman cannot consider them at the moment.

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The Ombudsman’s role and powers

3. 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. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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 council has done. (Local Government Act 1974, sections 26B and 34D, as amended). In this case we agreed to investigate as Mrs F had not received timely responses from the some of the bodies about which she complained.

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How I considered this complaint

6. I considered the written information provided by Mrs F and by the care provider. I spoke to Mrs F. Both Mrs F and the care provider had an opportunity to comment on an earlier draft of this statement and I considered their comments before I reached a final decision.

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What I found

7. 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 Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
8. The Regulations say providers must have processes in place to take appropriate action if there is a clinical or medical emergency.
9. The Regulations also say providers should include people’s nutrition and hydration needs in their assessment and care plans, and review these on a regular basis.
10. The Regulations say complaints must be investigated and responded to, and any appropriate action taken.
11. The Regulations say where a person lacks metal capacity to make a decision or give informed consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and its associated code of practice.
12. The Mental Capacity Act 2005 introduced the “Lasting Power of Attorney (LPA),” which replaced the Enduring Power of Attorney (EPA). An LPA is a legal document, which allows people to choose one person (or several) to make decisions about their health and welfare and/or their finances and property, for when they become unable to do so for themselves. The 'attorney' is the person chosen to make a decision, which has to be in the person’s best interests, on their behalf.

There are two types of LPA:

Property and Finance LPA – this gives the attorney(s) the power to make decisions about the person's financial and property matters, such as selling a house or managing a bank account.

Health and Welfare LPA – this gives the attorney(s) the power to make decisions about the person's health and personal welfare, such as day-to-day care, medical treatment, or where they should live.

What happened

13. Mrs X first went into the care home in December 2015 for a period of respite while Mrs F, who looked after her, went on holiday. Mrs X liked the home and wanted to stay, so she became a permanent resident. Prior to her admission she had seen the local Community Mental Health Team and a diagnosis of possible Alzheimer’s and vascular dementia was made, but Mrs X had not attended the follow up appointments for a brain scan or out-patient appointment.
14. The care plan which the care provider drew up for Mrs X noted she had short term memory loss which could lead to confusion. In June 2016 the care plan was amended to say Mrs X had now been diagnosed with advanced dementia.
15. The care plan also noted Mrs X was at possible risk of self-neglect, malnutrition and dehydration because of the dementia. It stipulated that carers should monitor Mrs X’s food and weigh her regularly. By June 2017 she was noted to be losing weight and staff were told to keep a closer watch on her food intake. The care provider’s records show Mrs X was hiding some of her food to feed a stray cat in the gardens of the home. The care provider took steps to prevent this by buying separate cat food, but Mrs X said the cat only wanted human food. The care provider started to give bigger portions to Mrs X to account for the amount of food she fed to the cat. By November 2017 Mrs X had put on a small amount of weight again.
16. Mrs F disputes the care provider’s records that her mother fed the cat. She says the care provider should have alerted her to her mother’s loss of weight and she would have provided supplement drinks. She says her mother rarely went into the garden because the paths were uneven and slippery.

The falls

17. The care provider’s records show Mrs X had an unwitnessed fall in her room on 19 November 2017. The accident report says she was found “mobilising slowly and in a lot of pain, no obvious sign of injury”. Staff called 111 for advice. The clinician who returned the call advised staff to give painkillers and see how Mrs X was in the morning: when told that Mrs X said her hip hurt, the same advice was repeated. On 20 November the care provider called Mrs X’s GP to visit. He said he would arrange for a non-urgent x-ray.
18. On 21 November staff recorded Mrs X appeared confused and was “screaming and lashing out”. Staff called an ambulance and notified Mrs F. The home’s records note Mrs X was diagnosed with a urinary tract infection for which she was prescribed antibiotics (as the hospital discharge summery records) and discharged back to the care home on 22 November.
19. The care home records show Mrs F had complained about Mrs X’s call bell being out of her reach. Staff explained they had tried to show Mrs X how to use it but she became too confused. The diary notes show staff made another attempt to explain the call bell to Mrs X on her return from hospital but “she did not seem to understand”. Mrs F says the home manager told her Mrs X had never had a call bell because she could not understand its use.
20. On 24 November a carer found Mrs X had fallen in her room between the end of the bed and the commode, according to the home’s records. The carer called 999 and Mrs F, and Mrs X was taken to hospital. Mrs F says her mother told her she had fallen over the raised door strip between the en-suite bathroom and the bedroom. Paramedics who attended submitted a report saying they considered the door strip in Mrs X’s room to be a trip hazard. Mrs F says X-rays showed Mrs X had fractured her hip and pelvis. The care home manager notified the CQC of the fall in accordance with the regulations.

The complaint and safeguarding action

21. Mrs F made a complaint to the home and raised a safeguarding alert with the local council. The manager and the care home owner both wrote to Mrs F asking her to meet them to discuss the complaint but she did not respond.
22. Mrs F complained that the care provider had not told her of her mother’s first fall and that her mother had gone to hospital unaccompanied. She said Mrs X had no call-bell in her room. She said there was an inch-high door strip which was a trip hazard in Mrs X’s room. She complained the home had arranged for a mental health assessment of her mother without Mrs F’s permission, and she had been diagnosed with dementia.
23. The care provider responded to the council’s safeguarding lead about the complaint and the issues raised by Mrs F. She said carers were not allowed to go to hospital with residents and so family were called for 999 calls. She said Mrs X had been accompanied by paramedics to hospital. She explained Mrs X’s confusion over the call bell. She said the door strip had now been removed at Mrs F’s behest but Mrs X had not fallen over it. She said Mrs F knew of the diagnosis of dementia prior to Mrs X’s admission and the home had called a Community Psychiatric Nurse (CPN) subsequently so that Mrs X could receive the help she needed.
24. After further enquiries the council safeguarding lead wrote to the care provider to say it would not take any further action.
25. Mrs X did not return to the care home.
26. The care provider says she has apologised to Mrs F for failing to call her after Mrs X’s first fall on 19 November but she says medical help was called promptly. Mrs F says she has never had a proper apology.

Analysis

27. The care provider called for medical help promptly when Mrs X fell. There is no evidence of fault there. It says it has already apologised for not notifying Mrs F immediately after the first fall (although Mrs F disputes that) but there is no evidence that failure caused any significant injustice.
28. The care provider’s records show that it monitored Mrs X’s weight and took appropriate action. Mrs F expresses concern that she was not also told of the problems with her mother’s weight but the care provider addressed the matter properly.
29. The care provider responded quickly to Mrs F’s complaint, but she did not accept the offer to meet, and instead took Mrs X away from the home after she left hospital.
30. It was a matter for the safeguarding investigation to consider Mrs F’s concerns about any trip hazard posed by the raised door-strip, and it is not for the Ombudsman to investigate that issue again. It was open to Mrs F to complain about the safeguarding investigation if she wished, but she has not done so.

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Final decision

31. The actions of the care provider did not cause injustice to Mrs X.

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Investigator's decision on behalf of the Ombudsman