Care South (18 004 455)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 02 Jan 2019

The Ombudsman's final decision:

Summary: Ms B complained about the care of her father Mr C by Care South in one of its homes prior to his death. She also complained about the loss of some of his records and the failure to provide information about the care given. There was fault by Care South in its record keeping and in the failure to properly answer Ms B’s request.

The complaint

  1. Ms B complains that Care South (the Care Provider):
    • failed to properly care for her father, Mr C;
    • failed to keep adequate records of the care; and
    • failed to provide information reasonably requested by Ms B in respect of the care given.

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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. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
  2. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
  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

  1. I have considered the complaint and the documents provided by the complainant, made enquiries of the Care Provider and considered the comments and documents sent by the Care Provider. I have written to Ms B and the Care Provider with my draft decision and considered their comments.

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What I found

  1. Ms B’s father, Mr C, went into a care home run by the Care Provider in early October 2017. He had dementia, reduced mobility and was at a high risk of falling.
  2. The assessment carried out prior to his admission to the home, identified that he was at risk of falling and due to cognitive impairment he was unable to recognise the risk. It noted his mobility was slow and that he used a walking frame and wheelchair. In order to mitigate the risk, the Care Provider put in place a special bed, an alarmed pressure mat on the floor beside his bed and a chair alarm, to alert staff if he got up at night.
  3. On 4 October 2017 the Care Provider carried out risk assessments regarding mobility, pressure sores, moving around, staying safe and falls and fractures. It recommended appropriate footwear, encouraging Mr C to mobilise and change position, the use of a pressure mat in his room, and supervision when he moved around.

Bed rails

  1. Mr C fell on 9 October 2017 in the lounge. Staff attended him straight away and he was uninjured. The Care Provider says after this fall, staff spoke with Ms B’s sister, Ms D who mentioned that when in hospital Mr C had bed rails in place. The Care Provider cannot find the assessment relating to bed rails but says staff recall that bedrails were used around this date. There is no record of the conversation with Ms D.
  2. There are references to carers finding Mr C with his legs hanging over the rails on six occasions between 29 and 31 October 2017. There is a further reference to the rails being up on 12 November 2017 and Mr C with his legs over the rails on 23 November 2017. The Care Provider says that it stopped using the bed rails on or around 23 November 2017 due to concerns about Mr C injuring himself.


  1. There is a record that Mr C fell on 14 October 2017 in the lounge area. He was uninjured. The Care Provider carried out a further assessment on this day noting Mr C was increasingly frail and often attempted to mobilise without his frame. The plan of support again noted the need to ensure Mr C was wearing the correct footwear and to prompt him to use his frame. It also said carers should ensure the pressure mat plan is followed and the environment clear from trip hazards. It said if falls recur staff will inform the duty manager and consult Mr C’s doctor.
  2. Mr C fell again on 16 October (in the toilet), 23 October (in the lounge) and 6 November (in the bedroom). He was uninjured but the home reviewed his care plan each time and contacted the district nurse service for advice. Mr C fell again on 14 November 2017 in the lounge. The Care Provider referred Mr C to the Community Rehabilitation Team (CRT) on 15 November 2017 for advice on further action they could take. An occupational therapist from the CRT visited on 21 November 2017. The case notes do not record the outcome of the assessment and the Care Provider does not have a copy. But the notes of contact with the district nurse say that the occupational therapist, visited and assessed Mr C on 21 November 2017. She was going to return the following week to try a four-wheeled sit and stand walker. She also adjusted the height of his zimmer frame.
  3. There are references in the case records to the pressure mat being on or activated during October and November. He fell in the lounge on 15 December and was found on the bedroom floor on 21 December.

Deprivation of Liberty Safeguard

  1. The Deprivation of Liberty Safeguards (DoLS) provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. The DoLS protect people from being deprived of their liberty, unless it is in their best interests and there is no less restrictive alternative. The legislation sets out the procedure to follow to obtain authorisation to deprive an individual of their liberty. Without the authorisation, the deprivation of liberty is unlawful. It is the responsibility of the care home, hospital to apply for authorisation.
  2. The ‘managing authority’ of the care home (the person registered or required to be registered by statute) must request authorisation from the ‘supervisory body’ (the local authority). There must be a request and an authorisation before a person is lawfully deprived of his or her liberty.
  3. The application for authorisation should be made within 28 days. The manager of the Home applied for a DoLs for Mr C on 30 October 2017.

Fall on 23 December 2017

  1. On 23 December 2017 staff checked Mr C at 20:00 and said he was settled in bed. The case records say they found him on the bedroom floor at 23:15, lying on his right side and complaining of pain in his hip. The manager was called. They called 111 and then paramedics arrived to take him to A&E. He was admitted to hospital with a fractured hip. This information was completed on the fall summary record.
  2. An accident record form was completed by the duty manager that night. It said staff heard a loud thump from Mr C’s room and found him lying on his right side on the floor. The manager was called, who checked for injuries, called 111, then paramedics took him to hospital. The deputy manager reviewed the form. They added that the pressure mat was in place and bed rails were not suitable; he was known to be at risk from falling due to dementia, was very frail and unaware of his capabilities. Staff regularly checked him when he was in his bedroom. They did not consider it was a serious untoward incident.
  3. The manager completed a second form on 29 December 2017 as they considered the first one had not been completed properly. It is largely the same as the first except the date of the fall is recorded incorrectly as 28 December 2017. It said that staff had been planning to request hip protectors and head gear to reduce injury due to the frequency of his falls.
  4. Mr C had surgery on his hip but unfortunately developed pneumonia and his health deteriorated. The hospital considered he was nearing the end of his life and discharged him back to the home in accordance with his end of life wishes, endorsed by Ms D.
  5. The records note that end of life care was undertaken with a high frequency of checks for mouth care, comfort and repositioning, supported and reviewed by district nurse visits. Mr C died on 3 January 2018.
  6. At the end of January 2018 Ms B requested copies of Mr C’s care records from the Care Provider. She completed the appropriate consent from on 8 February 2018. The Care Provider acknowledged the request on 14 February 2018 and said it would provide the information by 23 March 2018. On 1 March 2018 the Care Provider contacted Ms B to say it could not locate all of Mr C’s records. On 23 March 2018 it sent Ms B the documents it had found. It had not found the care planning documents including the falls risk assessments.
  7. On 28 March 2018, the Care Provider found the missing documents and sent them to Ms B on 3 April 2018. Ms B wrote to the Care Provider asking a number of questions about the care provided to Mr C particularly regarding the use of the pressure mat and bed rails. The Care Provider apologised for the delay in providing the information and said it could not answer her further questions as these related to health records. Ms B then complained to us.


  1. From the information provided there is evidence that the Care Provider carried out appropriate assessments of Mr C’s needs before he entered the home and risk assessments on arrival. It noted his propensity for falling and took measures to minimise the risk. It applied for the DoLS within the required timeframe. It used a pressure mat, tried bed rails and encouraged Mr C to wear appropriate footwear. After Mr C had fallen several times it involved the occupational therapy service to see if any more could be done. It liaised with the district nurse service frequently and contacted Ms D on each occasion when Mr C fell. I cannot identify any fault in the Care Provider’s actions to indicate poor care.
  2. The Care Provider could not provide copies of the bed rails or pressure mat assessments. This is fault. The Care Provider should have had copies of these assessments and be able to account for decisions made in respect of these aids. But there is evidence from the case records that bed rails were tried then stopped due to safety concerns. Similarly, there is evidence in the case records that the pressure mat was used. Even though the alarm did not go off when Mr C fell on 23 December 2017, staff heard the fall and attended immediately. I do not consider the lack of documentation has affected the care given to Mr C. But it has caused uncertainty to Ms B.
  3. From the information provided there is no record of what the occupational therapist concluded after the visit on 21 November 2017. Given that the Care Provider referred Mr C to the service to see what else could be done to minimise the risk of falling, it should have a copy of the response and any note of changes that were made. The failure to do so is fault. I cannot say it affected Mr C’s care but it does leave uncertainty for Ms B as to what was concluded.
  4. In respect of providing information to Ms B, despite mislaying the documents, the Care Provider sent the remaining case records to Ms B less than two weeks after the required deadline. It caused Ms B some frustration and additional time and trouble but the Care Provider has apologised and I do not consider any further action is necessary.
  5. I consider the Care Provider could have responded to some of Ms B’s additional questions in her letter sent in April 2018. It was inaccurate to say all the information amounted to health records. For example:
    • it could have informed Ms B that the DoLs was applied for on 30 October 2017 within the required time frame;
    • it could have given some information about the bed rails and pressure mats from the case records and admitted that it did not have the assessments; and
    • it could have explained the discrepancy between the two accident forms and sent copies.
  6. The failure to answer any aspect of this letter increased Ms B’s frustration and prompted her to pursue her complaint to the Ombudsman, causing her time and trouble.

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Agreed action

  1. To recognise the frustration, uncertainty and time and trouble caused to Ms B, I asked the Care Provider to pay her £150.
  2. I also asked the Care Provider to:
    • ensure all case records, documents and assessments are accurately filed so that questions from relatives can be more promptly and easily answered; and
    • ensure it is not unnecessarily restrictive in its complaint responses.
  3. The Care Provider has agreed to my recommendations

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Final decision

  1. I consider this is a fair and reasonable way of resolving the complaint and I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman

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