Summary: There is evidence of fault by the care provider. There are inconsistencies in the records of a fall Mr Y had in a care home. There was a delay in providing Mr Y’s family with care records pertaining to the fall. The Care Provider failed to investigate the complaint and failed to respond to Mr Y’s family. There is no evidence to suggest Mr Y received poor care, or that his fall could have been prevented

The complaint

1. Mr X complains about the care provided to his late father, Mr Y, at St Michaels’s Care Home. The home is owned and operated by Prime Life Limited (Care Provider)
2. Mr Y had a fall at the care home, from which Mr X says, Mr Y never recovered. Mr X says the care home left Mr Y unsupervised. Care staff gave differing accounts of the circumstances of the fall. Mr X says the care home and Care Provider failed to investigate the accident properly.
3. Mr X also complains the Care Provider failed to respond to his complaints about the above.

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The Ombudsman’s role and powers

4. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34H(3) and (4), as amended)

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How I considered this complaint

5. I have:

• considered the complaint and discussed it with Mr X;
• considered correspondence between Mr X and the Care Provider including the Care Provider’s response to the complaint;
• made enquiries of the Care Provider and considered the responses;
• taken account of relevant legislation;
• offered Me X and the Care Provider an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

6. 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.
7. One of the fundamental standards (regulation 9 of the regulations for service providers and managers) is about person-centred care. Each person should receive person-centred care and treatment, based on their individual needs.
8. Standard (regulation 12) is about safety. Care providers should not put people receiving care at risk of harm that could be avoided. It says care providers should be able to show they have taken all reasonable steps to ensure the health and safety of those receiving care.
9. Standard (regulation 16) is about complaints. This says staff must know how to respond when they receive a complaint, and this can be verbal. Care providers must thoroughly investigate complaints. This includes keeping records of complaints and actions taken.
10. Standard (regulation 17) is about good governance. This includes keeping accurate, complete and detailed records about people receiving care, including records of care provided and decisions made relating to care.
11. Standard (regulation) 20 is about duty of candour. This says registered persons must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users. A culture of openness and honesty should be encouraged at all levels.

Background

12. Mr Y was discharged from hospital to the care home on 23 December 2017. I have seen a copy of the hospital discharge letter which says Mr Y had been admitted to hospital in October 2017 with acute confusion. Whilst in hospital a CT scan of his head showed “suspicion of a small subarachnoid hemorrhage”. Whilst an in-patient Mr Y became increasingly confused and agitated and a CT scan was repeated. This showed “appearances suggestive of hemorrhage” related to a medical condition of the brain. Amongst other needs, Mr Y was reported to need two to mobilse.
13. Mr y was deemed not well enough to return home so went to the care home for a period of respite care.
14. On the day Mr Y arrived at the care home a ‘Respite Care Support Plan’ was completed. I have seen a copy of this document. It records Mr Y needed assistance with personal care, and that his mobility was poor. He was reported to need two carers to assist with mobilising. The support plan identified the risk that Mr Y may attempt to mobilise without assistance. To manage this risk “staff to ensure [Mr Y] has 2 carers to walk and he doesn’t mobilise without assistance”.
15. In the early hours of 15 January 2018 Mr Y fell at the care home. He was admitted to hospital. The records show a ‘bleed on the brain and is diagnosed with dementia”. Mr Y remined in hospital until he sadly passed away on 10 February 2018.
16. Mr X says care home staff initially told Mr Y’s wife Mr Y had fallen by the side of his bed. This later changed to him been found on the dining-room floor by carers at 00.40am, and changed again, when carers reported seeing him fall. Mr Y was still his day clothes. Mr X is concerned by the inconsistencies.
17. Mr X says Mr Y always retired to bed very early, so being up so late was out of character for him. He also says Mr Y did not watch television because he had glaucoma. He says the Care Provider has not answered his queries about this.
18. Mr X says when he, and other family members asked for the care home’s complaints procedure, they were told the care home did not have one. The Care Provider disputes this. It says the complaints procedure is clearly displayed around the care home. Mr X says when he later submitted a complaint to the Care Provider he had to chase a response. He received an unsigned, undated document which does not address the points he raised.

The care home’s records

19. As part of this investigation I considered the care home’s records for two weeks prior to Mr Y’s fall. The records show carers assisted Mr Y with all personal care and mobility. Checks were made at least twice during the night. Mr Y was reported to be settled, that he usually went to bed early evening and slept well.
20. On 3 January 2018 there is an ‘evaluation sheet’ which records that Mr Y had unwitnessed falls on 3 and 5 January 2018, no injuries were reported, and an accident report was completed. These falls are not documented in Mr Y’s daily care records.
21. On 13 January 2018 a carer reported at 04.50am that Mr Y “had been using the urine bottle overnight. He has been in and out of his bed. On 14 January 2018, a carer reported at 12.30am, that Mr Y had been using the urine bottle and walking to the toilet independently.
22. An entry in the care records at 6pm on 14 January 2018 records Mr Y’s family had visited, and after they left carers asked Mr Y if he wanted to go to bed, he declined. Mr Y was reported to be sat in the lounge with other residents.
23. The next entry at 00.30am – 15 January 2018, records Mr Y to be still sat in the lounge with other residents. He had some supper and was asked if he would like to go to bed when he had finished eating. Mr Y declined. The next entry at 01.20am records Mr Y had fallen onto the dining room floor at 00.40am. A carer telephoned the emergency services and an ambulance arrived at 00.50am. Mr Y was taken to hospital at 01.10am.
24. A carer completed an accident report at 01.20am on 15 January 2018. This records Mr Y had an unwitnessed fall at 00.40am and was ‘found’ on the dining room floor.
25. A carer telephoned Mr Y’s wife at 01.10am, The call was unanswered, there was no message facility. The carer telephoned again at 05.45am, again Mr Y’s wife did not answer. The carer spoke to Mr Y’s wife around 6.30am and explained the events, and that Mr Y was in hospital.
26. The records show Mr Y’s family contacted the care home ‘a few times’ to express their concerns, and that the manager had spoken to them. I have seen no records which detail conversations that took place. The family informed the care home Mr Y would not be returning on 21 January 2018.

Safeguarding

27. The Council received a safeguarding alert from the hospital on 19 January 2018. It commenced initial safeguarding enquiries. It contacted the care home manager to make enquiries about the circumstances of Mr Y’s fall.
28. The care home manager provided a report to the Council’s safeguarding team by email on 26 January 2018. I have seen a copy of the report. The manager said, after Mr Y’s family had been to visit, he declined to go to bed saying he was not tired. As he was at high risk of falls, he was assisted into the dining room so staff could keep an eye on him. The manager reported there were two carers present in the dining room when Mr Y rose from his chair and fell to the floor, and “that a staff member was already on their way to assist [ Mr Y] at the time…”.
29. An officer from the Council’s safeguarding team sent an email to the care home manager on 6 February 2018 to say no further action would be taken and the safeguarding enquiry would be closed. The officer asked the care home manager to inform Mr Y’s family. The care home manager did not do so.
30. Mr X contacted the Care Quality Commission (CQC) to report his concerns. Following this an inspector from CQC sent an email to the care home manager on 10 April 2018 asking if Mr Y’s family had been notified of the outcome of the safeguarding investigation. I have seen no evidence the care home manager did so. Mr X says the first he knew there had been a safeguarding investigation was, when I informed him.

What Mr X says

31. Mr X says a carer initially told Mr Y’s wife that Mr Y had been found on his bedroom floor at 00.40am. The family found this not to be correct after obtaining information the paramedics had supplied to the hospital.
32. Mr X was concerned about the circumstances surround the fall. Mr Y usually retired to bed early and did not watch television so Mr X could not understand why Mr Y would be in the lounge watching television at midnight in his day clothes. Mr X asked the care home for a copy of the accident report but initially the care home refused, saying it did not have to provide him with a copy. Mr X says obtaining the accident report was “a lengthy process”. When he received a copy, Mr X had concerns about inconsistent reports of the circumstances and timings of the fall.
33. In the weeks after Mr Y was admitted to hospital his wife, Mr X and other family members went to the care home to speak to the manager to discuss their concerns. On each occasion they were told the manager was out of the building or dealing with an emergency. On one occasion Mr X was told the manager was out of the building he saw her in her office.
34. When Mr X did speak to the manager he asked for the complaints procedure. Mr X says the manager said there was no complaints procedure. Mr X received an undated, unsigned copy of a document describing the events of the fall. This says Mr Y was sat in the dining room when his family left and that two carers were present and witnessed the fall. Mr X says the information conflicted with the accident report which says Mr Y had an unwitnessed fall and was ‘found’ on the dining room floor.
35. Mr X submitted a formal complaint to the Care Provider in March 2018. He received no response so contacted the company to chase a response, following which he received an email in June 2018 saying the matter was ‘being looked into’. Mr X heard nothing more, to date, he has not received a formal response to his complaint.

Analysis

36. It is not the Ombudsman’s role to determine a cause of death, that is the role of the Coroner. The Ombudsman’s role is to determine of there is evidence to suggest poor care, and if the Care Provider kept accurate records, and handled Mr X’s complaints properly.
37. After considering the daily care records for Mr Y I have seen no evidence to suggest Mr Y received poor care. However, there is evidence of fault in the events that followed Mr Y’s fall.
38. Mr X says the care home has not explained why on the day in question, Mr Y was up late into the evening when he usually retired to bed early evening. The records I have seen show that Mr Y did on all, but this occasion retire to bed early. Carers recorded he declined offers of assistance to go bed on more than occasion. It is not possible to understand why Mr Y changed his routine. Carers respected Mr Y’s choice, offered him food and ensured he was sat in the lounge with other residents who were watching television so he would have the company of others. This was appropriate to the circumstances. There is no evidence of fault here.
39. Mr Y’s care plan records he needed assistance to mobilise. The care records I have seen show Mr Y was assisted by carers when mobilising. However, Mr Y was able to move independently and there was a risk he would attempt to do so without assistance. Care records show he did sometimes get up in the night and move around without support. He was at risk of falls. Mr Y was not in receipt of 1-1 care, and carers could not ‘shadow’ Mr Y constantly.
40. The care records show Mr Y had two falls on 3 & 5 January 2018 and that he was not injured. There is no fault in the recording of these incidents, but I have seen no evidence Mr Y’s family were informed about this. This is fault.
41. On the night of 14/15 January 2018 carers reported Mr Y to be settled in the lounge with other residents for some hours. Carers could not have predicted that he would attempt to stand and mobilise without assistance. There is no evidence to suggest the fall was due to poor care, it was sadly, an unfortunate accident.
42. I have seen no inconsistencies in any of the records about the timings of Mr Y’s fall.
43. Mr X is concerned about the inconsistent reports about the circumstances surrounding the fall. I share his concern. The carers on duty at the time reported Mr Y had an unwitnessed fall and was ‘found’ on the dining room floor. Carers also reported that prior to the fall Mr Y was sat in the lounge. The care home manager’s record conflicts with this, her report says Mr Y was sat in the dining room with two carers present, and the carers saw Mr Y fall.
44. The care home manager was not present, so she could only rely on the carers reports. It is difficult to understand why her account differs from the carers. On balance, and given they were present, it is likely the carers account is correct. The care home manager’s account of events was provided to the Council’s safeguarding team and to the CQC.
45. Care homes have a duty to maintain accurate records, good record keeping is a regulatory requirement. The care home manager had a duty to provide Mr X, the Council and the CQC with accurate information. She failed to do so. This is a breach of ‘Regulation 20’ of CQC’s fundamental standards. The aim of this regulation is to ensure providers are open and transparent with people who use services and other ‘relevant persons’ (people acting lawfully on their behalf) in relation to care and treatment.
46. The care home, and later the Care Provider failed to deal with Mr X’s complaints properly. The care home manager told Mr X there was no complaints procedure. The Care Provider refutes this saying information about its complaint procedure are displayed around the care home. However, it acknowledges, that in this case, its complaints procedure was not followed. This is fault. Regulations state that every care home must have an efficient procedure for dealing with complaints and must have a complaints procedure that a resident/relative can ask to see. As part of the complaint process a resident/relative can ask to discuss their concerns informally with a care home manager. The records show Mr X and his family contacted the care home on a few occasions. Mr X says they were told the care home manager was not available. If the care home manager was not available, she should have contacted the family and arranged to meet with them.
47. Mr X says the care home manager initially refused him a copy of the accident report and obtaining a copy was a lengthy process. People have a right to access information about them. Care records should be made available to residents and suitable representatives. The delay in providing this information caused the family unnecessary frustration.
48. Mr X contacted the Care Provider to complain about the care home. The Care Provider failed to investigate the complaint properly. Had it done so; it is probable it would have discovered the inconsistent reporting. People have a right to have their complaint investigated properly and to receive a full and prompt response. This did not happen in this case. This is fault.

Summary

49. There is no evidence to suggest Mr Y received poor care, or that his fall could have been prevented
50. There are inconsistencies in the records about the fall. There was a delay in providing Mr Y’s family with records pertaining to the fall.
51. The Care Provider failed to follow its complaints procedure. It failed to investigate the complaint and failed to respond to Mr Y’s family.
52. The failings by the care home and the Care Provider caused Mr X and his family uncertainty and distress.
53. Under the terms of our ‘Memorandum of Understanding’ I intend to copy of the final decision statement to the Care Quality Commission.

Agreed action

54. To remedy the injustice caused, the Care Provider will within one month:

• provide Mr X with a written apology for the failures highlighted above
• make a payment of £250 to acknowledge the uncertainty caused by inconsistent record keeping, and poor complaint handling
• make a payment of £250 for his time and trouble pursuing the complaint with the Care Provider and the Ombudsman.

Within three months:

• consider staff training in relation to record keeping and complaint handling
• robustly review the complaints procedure
• provide a copy of the final decision statement to Lincolnshire County Council safeguarding team.

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Final decision

55. There is evidence of fault in this complaint. The recommendations above are a suitable way to remedy the injustice caused.
56. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman