Summary: Mr X and Mrs Y complain about the care their mother Mrs A, received from a care home. The Ombudsman upholds part of the complaint against the care home for the delay in answering a call bell. This caused Mr X and Mrs Y uncertainty as to what may have happened if staff had attended to Mrs A on time. The Care Provider has agreed to apologise to Mr X and Mrs Y and make a financial payment.

The complaint

1. Mr X and Mrs Y complain on behalf of their (late) mother, whom I shall call Mrs A. Mr X and Mrs Y complain that Porthaven Care failed to:
2. a) appropriately handle a fall by Mrs A on 17 April 2018. Mr X and Mrs Y said that:

• staffing levels in the home were inadequate and the fall could have been prevented if staff were available to respond to the call bell;
• the care home did not inform the family that Mrs A had fallen;
• the care home refused to refund Mrs A when her room was unoccupied for the period of time she spent in hospital; and
• a meeting with the care home did not take place until May 2018.

b) inform them of Mrs A’s decline in health, during the last 24-48 hours of her life;

c) contact them throughout the complaint process.

3. Mr X and Mrs Y say this caused them considerable distress, frustration and uncertainty.

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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 an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. 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, section 30(1B) and 34H(i), as amended)
7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

8. I have considered the information provided by Mr X and Mrs Y and discussed the complaint with them. I made enquiries of the Care Provider and considered the information it provided in response. I sent Mr X and Mrs Y and the Care Provider a copy of my draft decision and considered all the comments I received before issuing my final decision.

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What I found

Relevant law and guidance

9. The Health and Social Care act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance). We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
10. Of relevance to this complaint I find:

• Regulation 12 – “Safe care and treatment”. Providers must assess the risks to people’s health and safety during any care or treatment and make sure that staff have the qualifications, competence and skills and experience to keep people safe.
• Regulation 16 – “Receiving and acting on complaints”. Providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints from people using the service, people acting on their behalf or other stakeholders. All complaints must be investigated thoroughly, and any necessary action taken where failures have been identified.
• Regulation 18 – “Staffing”. Providers must provide sufficient numbers of suitably qualified staff, competent, skilled and experienced staff to meet the needs of the people using the service at all times.

Relevant Care Provider Policies

11. The Care Provider gives residents and/or their representatives a copy of its terms and conditions. These say that “any part of the day of arrival or departure constitutes a full day’s residence at the home and fees remain payable in the case of temporary absences, such as short hospital stays or family visits”.
12. The Care Provider’s complaints policy says “Home managers operate an open-door policy to encourage feedback from residents and their relatives. The first stage of the complaint procedure is that users should make their complaint in writing to the Home Manager. If this does not resolve the complaint, then the Regional Manager will investigate and respond. If the complaint is still not resolved after stage two, users are asked to refer the complaint in writing to the Chief Executive, who will respond within 20 working days.
13. The Care Providers “Management of Falls or an Injury” procedure says that if a resident sustains a minor or major injury, then staff should inform relatives and document the discussion. Where there is no apparent injury, the procedure does not require staff to inform relatives.

What happened in this case

14. This chronology includes key events in this case and does not cover everything that happened.
15. Mrs A moved into the care home in June 2017.
16. The Home completed a care plan for Mrs A. The care plan included:

• The call bell must always be in Mrs A’s reach to alert staff that she needs help;
• Mrs A would require two carers to get her up from the floor;
• Mrs A has full mental capacity;
• Mrs A wishes to spend her last days at the care home surrounded by her family;
• Family if possible, to be with Mrs A at the end of her life.

Fall on 17 April 2018

17. On 17 April 2018, Mrs A had a fall and she was found on the floor by a member of staff at 17:30. Mrs A told staff that she had rang the call bell, but no one came to answer so she went to the bathroom alone. At 17:40 staff rang 999 and called for an ambulance. They were advised it would take up to two hours for the ambulance to arrive. The Home says that Mrs Y arrived to visit her mother just after staff had called for an ambulance. The ambulance arrived at 19:30 and Mrs A was taken to hospital escorted by her daughter, Mrs Y.
18. Staff at the care home completed an accident and incident report form. The form stated that Mrs A was assisted back to bed and was resting whilst awaiting transfer to hospital. It is recorded that Mrs A’s next of kin, Mrs Y was aware of the fall. The body map completed by the staff stated that no visible injury or bruising was apparent.
19. The Home’s records show that the call bell was not answered within the expected response time of three minutes. Mr X and Mrs Y allege that staffing levels in the Home were inadequate and the fall could have been prevented if staff were available to respond to the call bell. The Care Provider has responded to this and said that staffing levels are based upon the dependency of the residents. At the time of the fall there were two nurses and two care assistants for fourteen residents and therefore the home was adequately staffed. The Care Provider accepts that there was a delay in answering the call bell. It said this was because:

• one nurse had left the care home to pick up medication from a GP;
• one nurse was carrying out wound care and treatment to another resident;
• two carers were already attending to other residents when the Mrs A rang the call bell.

20. Due to the fall, Mrs A had fractured her right hip. She spent over a week in hospital and returned to the care Home on 26 April 2018.
21. On 29 and 30 April 2018 Mrs Y spoke to the Clinical Lead Nurse about the incident. On 2 May 2018 Mr X contacted the Home Manager and asked for a copy of the investigation report into Mrs A’s fall. He said that on receipt of the report, both him and Mrs Y would like to meet with her to review their mother’s care. The Home Manager responded on the same day and said that she would prefer to see them personally and asked Mrs Y to send some dates for a meeting. Mrs Y responded back on the same day and said her brother, Mr X would ring the Home’s reception to arrange a meeting. She also said that she was going through a really busy period with work and family and would be in touch “towards the end of next week”.
22. On 4 May 2018 Mr X sent another email to the Home Manager. He said he understood that she was going to call him but was disappointed not to have received a telephone call. Mr X said that he would be visiting Mrs A the next day around 16:30 and could talk to someone from the home then. Mr X said if that was not possible then a telephone conversation could be arranged for the following week. Mr X said this would be three weeks after his mother fell.
23. The Home Manager responded to Mr X’s email on 7 May 2019. She apologised for not calling him on 4 May 2018. She explained that she had told Mrs Y that she would be busy with interviews but would try her best to call Mr X. She also said that she had told Mrs Y that the Deputy Manager would be available at the Home on Saturday and Sunday and that she would be at the Home on the bank holiday.
24. On 9 May 2018 Mrs Y sent an email to the Home Manager and asked if she was available to meet with her on Thursday or Friday afternoon that week. The Home Manager responded on 11 May 2018 and said she was available on the following dates:

• 15 May 2018 12:00 to 14:00;
• 16 May 2018 10:00 to 12:00 or 14:00 to 17:00; and
• 17 May 2018 09:30 to 16:30.

The Home Manager said she was on annual leave on 18 May 2018.

25. Mr X responded on the same day and said that the proposed dates were not feasible as he was out of the country. On 13 May 2018 Mrs Y asked the Home Manager if she could meet with her on 17 May 2018 at 16:00. This was agreed and confirmed by the Home Manager.
26. A CQC inspection report from December 2017 found that the “service was safe and there were sufficient staff employed with the right skills and knowledge, to meet people’s needs”. CQC rated the home as good.

The Care Provider’s contact with the family on 26 and 27 December 2018

27. Sadly, Mrs A passed away on 27 December 2018. Mr X and Mrs Y complain that the Home did not tell them that there had been a decline in their mother’s health.
28. The Care Provider has sent me copies of care records for 26 and 27 December 2018. These records show that staff checked on Mrs A 18 times between 26 December 2018 at 05:32 to 27 December 2018 at 10.11. The records show that Mrs A was either asleep or resting and comfortable in bed, for the majority of time. The records also show that staff regularly repositioned Mrs A and attended to her personal care.
29. The Care Provider confirmed that Mrs Y had visited her mother on 26 December 2018, in the afternoon. She spoke with staff about Mrs A’s health at the time. Mrs Y then left the home and was called by the nurse at 22:30 informing her that Mrs A’s condition had not changed. Mrs Y said that the home could contact her at anytime day or night. Mrs A passed away the next morning.

Complaint Handling

30. On 13 March 2019 Mr X and Mrs Y emailed the Chief Executive and raised a formal complaint about their mother’s care. The Chief Executive responded by letter on 14 March 2019 and explained that the complaint would be investigated by a senior member of staff. He explained that the investigation would involve a review of, Mrs A’s care records, communication between Mr X, Mrs Y and the Home and staffing levels. The letter stated that a formal response to their complaint would be provided within 20 working days. The Care Provider completed its investigation and wrote to Mr X and Mrs Y with the outcome on 9 April 2019.
31. Mr X and Mrs Y complain to the Ombudsman that the Care Provider did not contact them during the investigation into their complaint.

Analysis

32. The Care Provider confirmed that call bells should be answered within 3 minutes. In its response to the complaint the Care Provider acknowledged that it there was a delay by the Home in responding to Mrs A’s call bell. The Care Provider has provided me with information about its staffing levels. I have also seen two statements by staff which explain why they could not attend to the call bell at the time. I am satisfied that staffing levels were adequate at the time. However, the delay in answering the call bell is fault which meant that Mrs A went to the bathroom alone and this is when she fell.
33. The Home’s records show that it called for an ambulance at 17:40 and that Mrs Y arrived shortly afterwards. When staff found Mrs A on the floor, there were no obvious signs of injury and she was transferred to bed. In accordance with the Home’s, Management of Falls and Injury policy, staff did not consider it necessary to contact Mrs A's next of kin. When Mrs A complained of pain in her right leg, the Home called for an ambulance and Mrs Y arrived shortly afterwards. I am satisfied that the Home acted in accordance with its procedure and there was no delay in informing Mrs Y that her mother had fallen.
34. I have seen the communication between Mr X, Mrs Y and the Home following the fall and the request for a meeting. I appreciate that this was a difficult time for Mr X and Mrs Y, and they wanted to discuss their concerns face to face with the Home Manager. The evidence shows there was frequent communication between the Home, Mr X and Mrs Y. The Home Manager provided dates and times of when she was available to meet with them. I note that Mr X says this was prompted by him. I also note that when Mrs Y visited the Home she spoke with a senior member of staff about the fall. I appreciate that Mrs Y disagrees and say that this conversation did not address her concerns. However, I am satisfied that the Home Manager tried to arrange a meeting with Mr X and Mrs Y.
35. The Care Provider’s agreement “Contract of Residence” signed by Mrs Y on 22 June 2017, states “Any part of the day of arrival or departure constitutes a full day’s residence at the home and fees remain payable in the case of temporary absences, such as short hospital stays or family visits”. Therefore, there is no fault in the Care Provider’s explanation that it was unable to offer a refund for the period Mrs A was in hospital.
36. From the 26 December 2018 to 27 December 2018 the Home’s records show 18 separate entries, where staff checked on Mrs A and attended to her needs. It is recorded that Mrs A appeared frail and sleepy. The records show that staff continued to monitor Mrs A’s condition. I have also seen a statement from a member of staff which explains that Mrs A showed no immediate clinical signs or concerns, that required action or intervention. I have no reason to doubt this statement. Mrs Y visited her mother on 26 December 2018 and staff provided her with an update on Mrs A’s health. Mrs Y would have been aware of Mrs A’s frail condition. Whilst I appreciate that Mr X and Mrs Y feel differently, I do not find that the Home failed to make them aware of Mrs A’s condition.
37. I have considered the Care Provider’s investigation into Mr X’s and Mrs Y’s complaint. The Care Provider says that it had “sufficient evidence from the family emails and the electronic care plan documentation to answer the concerns that had been raised”. I find that Care Provider acted in accordance with its Complaints and Concerns Procedure. Furthermore, the Chief Executive’s letter dated 14 March 2019 explained how the complaint would be investigated and did not state that Mr X and Mrs Y would be contacted during the investigation. Whilst this may have been good practice, I find no fault with the actions of the Care Provider.
38. The Ombudsman does not recommend providing a remedy for distress or harm to somebody who is deceased in the same way as we might for someone who is still living. But my view is that the delay in answering the call bell caused Mr X and Mrs Y an injustice, notably in uncertainty as to what would have happened if staff had attended to Mrs A on time. The fault caused further distress to Mr X and Mrs Y at having to witness Mrs A suffering with a fractured hip. I therefore consider Mr X and Mrs Y’s injustice is limited to their frustration, uncertainty and the time and trouble they have had to go to pursuing this complaint.

Comments on draft decision

39. Mr X and Mrs Y commented on my draft decision and I made further enquiries of the Home. I carefully considered all the comments I received and found that they did not affect my view of the complaint and therefore my decision is unchanged.

Agreed action

40. To remedy the injustice set out in the decision statement the Care Provider has agreed to my recommendations. Within four weeks of the decision the Care Provider will:

• Apologise to Mr X and Mrs Y for failing to attend to Mrs A on time;
• Pay them £500 for the injustice caused.

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Final decision

41. I have completed my investigation as I have found fault leading to injustice. The Care Provider had agreed to remedy the injustice cause to Mr X and Mrs Y.

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Investigator's decision on behalf of the Ombudsman