Summary: Mrs X complains the Council’s care home, Cranmer House, failed to look after her husband properly when he stayed there for respite care and the Council failed to address her concerns about this properly. Cranmer House failed to protect Mr X from harm, resulting in minor injuries when he fell out of bed. The Council’s safeguarding enquires were also delayed, which added to Mr & Mrs X’s distress. The Council needs to take action to remedy the injustice it has caused and to make sure Cranmer House has implemented the improvements it asked it to make.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council’s care home, Cranmer House, failed to look after her husband properly when he stayed there for respite care and the Council failed to address her concerns about this properly.

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What I have investigated

2. I have investigated the action of the Council and Cranmer House.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)
5. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

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How I considered this complaint

6. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries; and
• shared a draft of this statement with Mrs X and the Council, and invited comments for me to consider before making my final decision.

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What I found

What happened

7. Mr X needs support mobilising, having had two strokes and. He lives at home with a package of care. He needs a gluten free diet.

Respite arranged at Cranmer House

8. The Council arranged for Mr X to stay at Cranmer House for two weeks from 3 September 2018 to give Mrs X some respite. It sent Cranmer House a copy of Mr X’s March 2018 reassessment. Cranmer House did a pre-admission assessment with Mrs X over the telephone on 28 August. She explained that Mr X needs a gluten free diet and had been prescribed thickened drinks but won’t drink them. She said she would bring in his Speech and Language Therapy assessment. She said Mr X has a crash mat beside his bed at night and did not always sleep well.
9. Mrs X says she told Cranmer House her husband needed a bed which went low to the ground, as he had previously fallen out of bed. She gave Cranmer House a copy of the letter her husband’s Speech and Language Therapist sent to his GP. It includes recommendations which say Mr X needs:
• positioning upright at 90o for oral intake and for 30 minutes afterwards;
• soft foods;
• thickened drinks;
• 1:1 supervision when eating and drinking;
• monitoring for coughing, choking, chest infections.
10. However, the letter also says Mr X:
• does not tolerate the diet and fluid recommendations;
• lacks the capacity to decide whether to follow the recommendations;
• could only be encouraged to follow the recommendations;
• was therefore at risk of aspiration pneumonia.
11. On 1 September Cranmer House did a risk assessment over Mr X’s diet. It says:
• he would not follow the Speech and Language Therapist’s recommendations;
• to observe Mr X closely at mealtimes.
12. Mrs X says Cranmer House did not observe her husband closely at mealtimes but left him with food in his room.
13. On 3 September Cranmer House did a falls risk assessment and action plan for Mr X. This says to use crash mats and an ultra-low profile bed kept in its lowest position. Mr X stayed in room 7.
14. Cranmer House produced a night care and support plan for Mr X which says:
• he is “to be checked through the night”;
• to use a hoist for transfers, while noting he used a stand aid at home and would sometimes try to stand and walk on his own;
• he has a crash mat by his bed at night.
15. On 6 September Cranmer House did a risk assessment over not using bedrails. It says to do regular checks during the night.
16. Cranmer House kept daily records of the care provided for Mr X. I refer to the key contents.

Meals

17. The records show Mr X had a poor diet. He often refused or ate little of the food offered, preferring to graze on food brought in by his family (biscuits, crisps, chocolate and grapes). The same applied to drinks, but Mr X would drink a bottle of beer most days.
18. Mr X spent most of his time in his room watching television. He occasionally went to the dining room for lunch, at his request.

Falls

19. The records say the crash mat was put in place on 3, 4, 7, 10, 11, 12, 14 and 15 September. They do not mention the crash mat on the other six days.
20. After Mr X went to bed on 6 September staff visited him three times: at 20.00 to give him cocoa; at 21.00 to change his sheets; and at 22.35 when he asked to have his head lowered.
21. At 00.30 on 7 September Mr X fell out of bed. He had a mark on his left elbow, although he was found lying on his right side. The records say the crash mat was under the bed. Mrs X says the bed could not have been lowered, as there would not have been space for the crash mat if it had. At 01.30 Mr X complained of a headache and said he may have hit his head when he fell out of bed. Although there was no mark, Cranmer House called an ambulance to have Mr X checked over. When the Paramedics arrived at 04.20, they decided to take him to hospital. Cranmer House tried calling Mrs X at 05.30. The incident report form says Mr X was in room 21. It includes these recommendations by the Team Leader:
• “make sure that the bed is as low as it can be, make sure crash mat is out and when [Mr X] goes to bed that he is near the wall and put a pillow in place near the edge of the bed and check regular”.
22. A Manager added this recommendation:
• “Client to be moved to another room with bedsides and low-lying bed”.
23. When Mrs X visited Cranmer House on 7 September her husband was still in hospital. She said he had bedrails at home. Cranmer House told her it was using a bed that goes to the floor, having moved him to room 32 to facilitate this. It said it was concerned about entrapment if bedrails were used.
24. Mr X returned to Cranmer House later that day.
25. At 02.35 on 8 September Mr X fell out of bed gain. He had a bruise on his right forehead. Mr X said he had been pushing himself away from the wall until the bed moved. An ambulance arrived at 03.45 and took him to hospital. The incident report form says he was in room 32. It includes these recommendations by the Team Leader:
• “Frequent safety checks. Crash mat on the floor. Remind [Mr X] to ring for assistance”.
26. A Manager added these recommendations:
• “Decision made by staff on duty 9/9/18 to move to a different room (from 32 to 21) to allow time for bed brakes to be checked – request made … 10/9/19. Following discussion within team, felt it safer to move to a lower level bed, so moving from room 21 to 24, where a low-level bed is available now”.
27. Cranmer House updated Mr X’s risk assessment. It says: “Moved [Mr X] to room 24 once last client went home as this bed is ultra-low. The lowest we have in the building. To lower the risk further”.
28. When Mrs X visited on 10 September, she raised concerns about the use of an inflatable overlay mattress (used to promote skin integrity), suggesting this could cause her husband to overbalance and fall out of bed. According to Cranmer House’s records it decided to remove the overlay mattress and told staff to check Mr X’s pressure areas. Mrs X says Cranmer House refused to remove the overlay mattress. Cranmer House moved Mr X to a room with an “ultra-low” bed to reduce the risk from falling out of bed. The daily notes say he moved from room 21 to 24. After speaking to Mrs X, Cranmer House noted the need to turn the bed controls off at night to prevent Mr X from using them.
29. On 11 September a GP arranged for a District Nurse to fit a catheter as Mr X was not passing urine. Mrs X says Cranmer House should have consulted her about this.
30. At 07.30 on 13 September Mr X rolled out of bed again. This time he landed on the crash mat and suffered no injuries. The falls diary says Mr X was in room 24. The incident report form includes this recommendation by the Team Leader: “Remind [Mr X] to ring for assistance”. A Manager recommended checking on Mr X as often as time allowed at night, recording any changes or problems.

Safeguarding and complaints

31. On 21 September the Council told Mrs X it was making formal safeguarding enquiries into the events at Cranmer House.
32. The Council’s safeguarding records say:
• On 7 September Mr X “was on a low profile bed, but one that didn’t go right down to the floor. A crash mat was placed beside the bed, but when he was found on the floor, the crash mat was under his bed. It is unknown as to how the crash mat was found to be under the bed and not beside it”. Mr X “was then moved to another bedroom for his safety, as the new room had a profiling bed that went lower to the floor. A crash mat was situated beside the bed and the other side was against the wall where a pillow was placed near the edge of the bed”.
• On 8 September Mr X “had been moved to a different room (room 32) where the bed could go even lower to the floor and a crash mat was placed beside the bed and the bed was against the wall, with the brakes applied”. “Bed brakes were found to have play in them and the bed was taken out of use until serviced” (last service was in April 2018).
• On 13 September Mr X was on a lower profiling bed and rolled onto the crash mat without injuring himself, so all preventative steps from the second fall had mitigated the risks.
33. On 17 October the Council visited Mr & Mrs X. Its record of the visit says it was to discuss the “outcomes” of the enquiry. The Council advised them that Cranmer House was to “conduct an internal investigation, staff training and ensure processes and adherence to professional advise as appropriate”. It also told them the complaints would be logged with the Council’s Quality Assurance Department for further investigations. Mrs X understood the purpose of the meeting was to take a statement. She subsequently e-mailed pictures of Mr X’s injuries. She heard nothing further, despite trying to contact the Officer whom she had been told would respond to the complaint.
34. The Council says it asked Cranmer House to make improvements relating to: checking beds; record keeping; procedures for the use of crash mats; and the processes for raising safeguarding concerns. However, it accepts it has not checked to make sure Cranmer House has made the required improvements.
35. The Council closed its safeguarding enquiries on 9 January, having carried out a risk assessment on 2 January. It decided the allegations were “partially substantiated”, because the crash mat was under the bed when Mr X fell out of it on 7 September.
36. Mrs X complained to the Council about the care her husband received at Cranmer House on 7 January 2019. The Council wrote to Mrs X on 10 January saying it would put her complaint on hold while it completed its safeguarding enquiries into the concerns she had raised.
37. When the Council wrote to Mr X on 21 March, it said it had concluded its safeguarding enquires. It said Cranmer House had acted appropriately in response to the events that occurred. The Council accepts it delayed in writing to Mr X and did not communicate properly about its findings.
38. The Council wrote to Mrs X on 5 April responding to her complaint. It said
• it could not explain why the crash mat was under her husband’s bed when he first fell out of it;
• he may not have injured himself if it had been beside his bed;
• Cranmer House had taken appropriate steps in moving Mr X to another room with “an even lower bed”;
• the second fall was due to a faulty brake on the bed, which meant Mr X could push the bed away from the wall and he fell on the wall side of the bed;
• Cranmer House removed the bed, which had been checked in April 2018, and was advised to check the safety of all the beds;
• Cranmer House carried out the plan to keep Mr X safe and minimise risks, so he did not injure himself on the third fall.

Is there evidence of fault by the Council which caused injustice?

39. I cannot find fault over the fact Mr X fell out of bed or over the decision not to use bedrails, which can be a risk for some people.
40. There is no dispute over the fact that the crash mat was not beside Mr X’s bed on the night of 6/7 September. That was fault for which the Council is accountable (see paragraph 4 above). There is no evidence to support the claim that the crash mat was put in place at the side of Mr X’s. If it had been in place this should have been recorded in the daily notes, as it was on most other days. Besides, it seems likely that if the mat had been placed beside the bed, the carers pushed it under the bed when they changed the sheets at 21.00 and did not put it back. The Council needs to make sure Cranmer House has made the improvements it asked it to make following its safeguarding enquiries.
41. There is contradictory information in Cranmer’s House’s records about the rooms Mr X occupied. Nevertheless, it is clear that, despite identifying the need for an ultra-low profile bed on 3 September, Cranmer House did not provide him with one until after he fell out of bed on 7 September. That was also fault.
42. However, Cranmer House was not at fault over the fall on 8 September. It was not to know the bed was faulty and that Mr X would be able to push it away from the wall. The bed had been checked within the last six months.
43. The Council delayed in drawing its safeguarding enquiries to a close. It had reached a conclusion when it visited Mr & Mrs X on 17 October 2017 but did not write to Mr X until 21 March. There should have been no reason to put Mrs X’s complaint on hold, but she had to wait until 5 April 2019 for a response. This was also fault by the Council.
44. The faults caused injustice to Mr X as Cranmer House failed to protect him from harm. This also caused distress to both Mr & Mrs X and put Mrs X to the time and trouble of pursuing the complaint.

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Agreed action

45. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of Cranmer House, I have made recommendations to the Council.
46. I recommended the Council:
• within four weeks write to Mr & Mrs X apologising for the faults I have identified and pay them £300 for the failure to protect Mr X from harm, the distress caused and the time and trouble they have been put to in pursing the complaint;
• within eight weeks check and provide evidence that Cranmer House has implemented the improvements identified by its safeguarding enquiries; and
• within eight weeks review its process for safeguarding recording and communication, make the necessary changes and communicate them to staff involved in safeguarding enquires
• within eight weeks consider what action it needs to take to improve the timeliness of safeguarding enquiries.

The Council has agreed to do this.

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Final decision

47. I have completed my investigation as the Council has agreed to take action to remedy the injustice it caused to Mr & Mrs X.

Parts of the complaint I did not investigate

48. I have not investigated the actions of the NHS as they fall within the remit of the Parliamentary and Health Service Ombudsman.

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Investigator's decision on behalf of the Ombudsman