Summary: We do not uphold Ms B’s complaint. There was no water on the bathroom floor when Mr B fell and the Care Provider responded appropriately by seeking medical help for Mr B, by updating his care plans and by referring him to the falls team.

The complaint

1. Mrs B complains about her late husband Mr B’s care in one of Healthcare Homes Group Ltd’s (the Care Provider’s) care homes. She complains Mr B fell due to water on the floor of the bathroom caused by a leak which had not been fixed.

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The Ombudsman’s role and powers

2. 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)
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

4. I considered Mrs B’s complaint to us, the Care Provider’s response to her complaint, documents from the Care Provider set out below and documents from the local authority. I discussed the complaint with Mrs B. Both parties received a draft of this statement and I took comments into account.

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What I found

Relevant law and guidance

5. 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.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
6. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
7. Regulation 12 of the 2014 Regulations says care must be provided in a safe way including assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks. A care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
8. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)
9. Action taken by a council under section 42 of the Care Act is often called ‘safeguarding’.

What happened

10. Mr B had Parkinson’s disease. He went into Beaumont Park (the Care Home) for respite care at the end of April 2019.
11. A senior carer completed an accident form on 19 May. This said:
• She went to Mr B’s room after he pressed the call bell.
• He was on his knees in the bathroom near the toilet.
• Mr B said he had slipped on some water on the bathroom floor.
• There was a deep cut to his right brow.
• Staff called an ambulance and Mr B went to hospital for stitches and contacted Mrs B to tell her.
12. Carer A, who responded to the emergency bell said in a statement that she attended to Mr B immediately after his fall, and found him kneeling on the floor by the toilet. She helped him to stand, noting he had a cut to the brow. She called 999. Carer A said there was no water on the floor.
13. A report completed the day after the fall said the domestic worker checked the floor after Mr B fell and reported it was dry and she had not cleaned the bathroom floor before he fell. A small leak had been found at the back of the cistern and the plumber fixed this on 21 May.
14. The records indicate staff did follow up checks on Mr B after the fall once he had returned from hospital.
15. A member of staff spoke to Mrs B on 20 May and said the cleaner had not mopped the floor before Mr B fell. The member of staff advised Mrs B that the floor in the bathroom was non-slip and Mr B may have splashed water or urine on it. She said the GP nurse would remove Mr B’s stitches after a week.
16. A member of staff spoke to Mr B’s GP on 22 May and asked for a referral to the falls team. The nurse practitioner from the GP visited on the same day, checked Mr B and made the falls team referral.
17. The Care Home’s care plans for Mr B said:
• He was independent with strip washing and needed help with showering and shaving. He liked to be as independent as possible but would ask for help if needed.
• He had tremors, stiffness of the muscles and could be unsteady
• He walked independently, needed help to get up first thing but once up and moving could walk well
• He had a history of falls. The care plan was updated after the fall on 19 May and he was on hourly checks. After a second witnessed fall on 3 June, Mr B grazed his knee and the care plan was updated to reflect Mr B was on checks every 30 minutes. In July, the care plan was updated again to reflect that Mr B had seen the falls team who suggested he use a walking frame, but Mr B did not want to use the frame
• He wore a pendant alarm round his neck when in the garden due to a risk of falls. He would tell staff when he left the building
• He had no problems communicating
• He used the toilet independently in the day. At night, he used a convene attached to a leg bag. Care staff helped him apply and remove the convene.
18. The Care Home did a falls risk assessment each month. The risk of falls was low on Mr B’s admission but increased after the fall and he was placed on hourly checks. After another fall, this was increased to checks every half hour and Mr B also had a sensor alarm.
19. Mrs B raised concerns about Mr B’s care with the local authority. The local authority looked into the fall and other concerns Mrs B has not raised with us, under safeguarding procedures. The record of the local authority’s investigation indicated one of its social workers visited Mr B two months after the fall in July and found water on the floor in Mr B’s bathroom and a sign on the door saying ‘do not use’. The local authority did not conclude there was neglect by the Care Provider.
20. Mrs B sent us photos of Mr B and of his toilet which she said she took two days after the fall. There is a towel placed at the back of the cistern which appears slightly wet. There is no picture of the floor.
21. The Care Provider’s response to the complaint explained:
• The carer on duty and the domestic worker both said there was no water on the floor. Staff noticed a leak after. This may have been due to Mr B hitting his head on the toilet when he fell.
• The local authority investigated the matter and there was no evidence to suggest the floor was wet
• In future it would try to contact relatives a second time after a first phone call.
22. The Care Provider told us:
• The Care Home had a maintenance worker who identified and fixed the leak in Mr B’s bathroom in Mr B’s on 21 May.
• The water on the floor in July was because of a leak from the room above Mr B’s and the water supply to that room was switched of and a plumber fixed it the following day after it was reported.

Findings

23. Mr B told the carer who attended him after the fall that the bathroom floor was wet. But, Carer A who attended Mr B after the fall reported there was no water on the floor. And the cleaner confirmed what Carer A said. There is not enough evidence to suggest Mr B slipped on a wet floor. And, even if he did, it would not indicate any failing by the Care Provider because Mr B was independent using the toilet and his care plan did not say he required supervision. So I do not uphold this complaint.
24. I am satisfied the Care Provider took appropriate action in response to the fall and in line with Regulations 9 and 12 of the 2014 Regulations by:
• Seeking urgent medical help for Mr B
• Telling Mrs B about the incident
• Carrying out checks on Mr B after the fall
• Updating his falls assessment and care plans to include additional checks
• Referring him to the falls team.

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Final decision

25. I do not uphold this complaint. There was no water on the bathroom floor when Mr B fell and the Care Provider responded appropriately by seeking medical help, updating his care plans and referring him to the falls team.
26. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman