Summary: Mr X complained on behalf of his mother, Ms Y about the care provided to her and about the care provider’s response to a fall. There was no fault in the care provider’s actions to consider Ms Y’s care needs, comply with medical professional advice after her fall or decision not to notify the Care Quality Commission.

The complaint

1. Mr X complains on behalf of his mother, Ms Y, about the care provided to her. He says the care provider failed to properly assess and protect her against the risk of harm from falls from her bed.
2. He further complains the care provider failed to appropriately respond to Ms Y’s fall in March 2018 by not calling an ambulance or reporting the fall to the Care Quality Commission. He says it did not tell him about the fall. He only found out about it when he visited. It then refused to call an ambulance when he visited two days later finding her mother in pain until he demanded it did so.
3. Mr X says these failures to take timely, appropriate action, avoidably led Ms Y to suffer considerable pain and worsened her ability to recover from the fall.

Back to top

The Ombudsman’s role and powers

4. 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)
5. 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)

Back to top

How I considered this complaint

6. I spoke to Mr X about his complaint.
7. I asked the care provider questions and considered its care records for Ms Y.
8. I considered the Care Quality Commission (CQC) fundamental standards and regulations regarding notification of incidents.
9. I wrote to Mr X and the care provider with my draft decision and gave them an opportunity to comment. I made further enquiries of the care provider because of questions raised by Mr X.

Back to top

What I found

10. The Care Quality Commission (CQC) sets out fundamental standards which are the standards below which care should never fall. These standards include the requirement for everyone to get person-centred care meeting their needs and preferences. The standards require all care providers to assess the risks to health and safety during any care or treatment. Providers should ensure their staff have qualifications, competence, skills and experience to keep people safe.
11. Care providers must tell the CQC if certain events occur affecting someone’s care. This includes any injury to a service user which, in the opinion of a health care professional, has resulted in:
• “an impairment of the sensory, motor or intellectual functions of the service user which is not likely to be temporary
• Changes to the structure of a service user’s body
• The service user experiencing prolonged pain or prolonged psychological harm or
• The shortening of the life expectancy of the service user”
12. Providers must also tell CQC if an event, in the opinion of a health care professional, requires treatment to prevent death or injury “which if left untreated would lead to one or more of the outcomes mentioned [in paragraph 10]”.
13. Associated CQC guidance says that reportable injuries include those that lead to, or if untreated are likely to lead to permanent damage, or damage that lasts, or is likely to last more than 28 days to bones (as well as other specified types of injury).

What happened

14. Ms Y went into the care home in 2016. She had a history of previous falls resulting in bone fractures. She had osteoporosis and dementia. Her support plan and risk assessment said she had a “high risk of falls”.
15. The care provider carried out a moving and handling risk assessment and developed a safe system of work for Ms Y. This gave carers advice on how to help move Ms Y. It set out how to help her get in and out of bed, shower and walk. It recorded Ms Y needed a pillow for support in bed and for carers to assist and elevate her from bed. There was no identified need for a specialist bed.
16. Its falls risk assessment said Ms Y was likely to get out of bed at night and so needed a pressure mat to alert staff. The care provider reviewed Ms Y’s falls risk assessment after falls in 2017 and 2018. It could not be certain whether these falls were from the bed or on the way to the bathroom.
17. It developed a falls support plan, based on the falls risk assessment. Ms Y’s room had a conventional bed without bedrails. This was because the care provider considered it was not appropriate for a patient with dementia to have bedrails because of the risk of climbing over rails with consequential increased risk of injury.
18. In March 2018 Ms Y fell out of bed during the night, triggering the sensor mat. Care staff attended, helping her stand up before getting her into bed. The accident form completed at the time of the fall says Ms Y was “assisted to stand after being checked.” The staff called the non-emergency 111 number. An out of hours doctor visited in the early hours. Their notes record Ms Y had been helped back into bed and had lower back pain and right hip pain. The doctor advised care staff about pain relief and was satisfied that, given Ms Y’s condition, she could stay at the care home. The care home filled out a near-miss form recording this.
19. Staff arranged for a home visit from Ms Y’s doctor and asked the doctor to prescribe stronger pain relief. The care provider also completed an accident report form setting out what happened and what action it had taken regarding medication and checks.
20. The care provider decided it was not necessary to call Mr X during the night. It says it intended to tell him the next day. Mr X visited his mother later the day after the fall. Ms Y complained of back pain. A carer told Mr X what had happened the night before. The care provider says it later reported the fall to the local safeguarding procedure as a low-level reporting concern. It did not report it to the CQC as it did not consider it met the criteria for notification.
21. The care provider completed a post fall monitoring record. This says Ms Y continued to have pain the day after and that pain relief medication was given.
22. Two days later, Mr X visited his mother as he had arranged to take her out for her birthday. He found her complaining of being in serious pain. The daily records say the care provider had already contacted Ms Y’s doctor because of the pain. It said it was awaiting the doctor’s visit when Mr X arrived. It said, “the directive at the time from NHS West Cheshire CCG was to refer to GP practice or 111 before telephoning 999”.
23. Mr X demanded the care provider call for an ambulance. Paramedics arrived and took Ms Y to hospital. The hospital admission form stated Ms Y had been admitted with back pain and was in severe discomfort. Later that day Mr X told the care home that Ms Y had a suspected spinal fracture. He contacted the following day to update that the hospital was making a further investigation. It says it understood, from what Mr X said that the hospital did not know where the pain was coming from so Ms Y would be in for a few more days.
24. Ms Y was later discharged into a nursing home. Mr X complained to the care provider about what had happened. He told the care home Ms Y had multiple spinal fractures due to Osteoporosis at the base of her spine.
25. The care provider says that this was not identified as the result of the fall but due to the chronic condition, Osteoporosis affecting Ms Y’s health. It says that because of this, the incident did not meet the criteria of statutory notification to the CQC.
26. Mr X told the home Ms Y would move into nursing care so her contract with the care provider ended in April 2018. He told me that after Ms Y left hospital, she was not able to bear weight because of the spinal injury she had suffered. This was a life changing issuing for her causing frustration.
27. He questioned whether Ms Y suffered another fall between the two incidents that had been reported. He provided a letter from the CQC to say it had been notified about injuries to Ms Y at the care home on three occasions before 2018. But it said it had no record of being informed about the incident in March 2018.

Mr X’s complaint to the care provider

28. The care provider replied to Mr X’s complaint. It said that after the fall it had monitored Ms Y’s condition, given her pain relief and requested a home visit from her doctor. Then, on the day Mr X visited two days later, it had contacted the doctor, rather than calling an ambulance. It said this was because in the senior carer’s opinion “it was not an emergency situation and the directive from the NHS West Cheshire CCG is to refer to GP practice first before ringing 999”. It said it had called for an ambulance as soon as Mr X had requested.
29. Mr X checked with the CCG (Clinical Commissioning Group) about its advice to care providers. It told him if anyone needed emergency medical attention then care providers should call 999. If the situation was less urgent then it could be appropriate to call a doctor. Mr X then complained to the Ombudsman.
30. Mr X told me he had checked with the care provider about their use of beds without bedrails when his mother was admitted. He could understand the risk from being caught up in rails when falling. He said he understood there were electric beds that allowed residents to be safely lowered to the level of the pressure mat. He said the manager had apologised for not telling him about the fall before he visited that afternoon.
31. He was very concerned that the care home had not informed the CQC about the fall. He said on the day of his visit for Ms Y’s birthday she was in very serious pain. He said the care provider told him it had called the out of hours doctor which was strange because it was during the day. He said staff ignored his request for an ambulance until he spoke to the deputy manager. He was concerned about the training in lifting and handling for some staff at the home.
32. He said the CQC had informed him the fall should have been notified to them as it appeared it fitted the criteria for notification.
33. The care provider told me it had not reported the fall to the CQC because it did not meet its criteria of a serious injury. It said Ms Y’s admission was the consequence of her underlying chronic Osteoporosis. It said it had minimised risk to Ms Y by using the sensor mat.
34. It provided an email from the CCG from March 2018, after the fall, sent to all care homes in the area in response to pressure on hospital bed space. This reminded care home staff that, where possible and safe, health concerns should be discussed first with a GP practice or through 111 or single point of access.

My findings

35. The care provider carried out risk assessments and put in place advice and procedures for staff caring for Ms Y. It reviewed its plans after Ms Y’s falls, putting in place the pressure mat. It explained why it did not consider a bed with safety rails was appropriate for Ms Y. Mr X strongly believes the care provider could have done more to ensure Ms Y’s bed was appropriate for her. There was no specialist (for example occupational therapist) requirement for Ms Y to have a specific type of bed. Because it considered her circumstances and kept them under review, I cannot question its professional judgement about what was appropriate for Ms Y’s care.
36. After the fall, records show the care provider manually lifted Ms Y back into bed. Mr X strongly believes this should not have happened. But there was nothing in her care plan to say this should not have happened. Her care plan refers to the importance of two carers assisting her back into bed. Care staff were therefore entitled to base their actions on the care plan. On the day of the fall the care provider contacted an out of hours doctor who attended and assessed the situation. The care provider has provided evidence of a subsequent reminder from the CQC about using GPs/111 where safe to do so. This is a reminder of normal practice. It was for the care provider to decide whether or not the situation was urgent enough to call for an emergency ambulance.
37. The doctor decided it was appropriate for Ms Y to stay at the home with pain relief. The Ombudsman cannot investigate the doctor’s actions and decisions. The care home complied with the doctor’s recommendations for treatment.
38. The CQC’s guidelines only require notification to it by care providers where an incident results in injury that is not temporary and/or where the service user is experiencing prolonged pain. The care provider was therefore entitled to decide not to refer the incident at that time as, based on the GP’s advice, it did not meet the requirements of the guidelines at that time.
39. On the day of Ms Y’s birthday, the care provider called Ms Y’s doctor because of her continued and worsening pain. It decided this was appropriate and that it was not an emergency requiring ambulance attendance. Because it considered Ms Y’s situation and previous medical advice from the GP, I cannot question the care home manager’s professional judgement deciding to call for the doctor, rather than immediately calling 999. After Mr X’s intervention, it called for an ambulance, so its decision did not make a significant difference to what happened.
40. The care provider decided Ms Y’s condition leading to the hospital admission did not meet the CQC’s criteria for notification because it understood the admission was the consequence of Ms Y’s underlying condition of osteoporosis. Mr X is sure the fall directly led to hospital admission and it significantly and permanent worsened Ms Y’s health.
41. The Ombudsman cannot say what the consequences were of Ms Y’s fall on her condition or comment on any causal relationship between the fall and the admission. We can only consider whether there was administrative fault in the care provider’s actions.
42. The provider considered what it knew about Ms Y’s situation, including her underlying health condition, in deciding whether or not to notify the CQC. Because it followed the correct procedure, considering relevant information to make this decision, we cannot question that decision. It was open to NHS staff carrying out further investigation into her condition to have made a notification if they had concerns that the incident met the criteria. We cannot investigate them.

Back to top

Final decision

43. I have completed my investigation. I do not uphold Mr X complaint.

Back to top

Investigator's decision on behalf of the Ombudsman