Summary: Mrs Y complains about the care her father, Mr B, received during a two month stay at a care home. The Council arranged the placement. Mrs Y says failings in his care led to a deterioration in Mr B’s health and admission to hospital following a fall. The Ombudsman finds fault in how the Home managed Mr B’s risk of falls, notified his family and followed up on concerns about urine infections. We also find fault in the Home not ensuring a DNAR was in place.

The complaint

1. The complainant, who I refer to as Mrs Y, complains on behalf of her father, Mr B. Mrs Y says failings in Mr B’s care during a two month stay at a care home (“the Home”) led to his health deteriorating and him suffering a serious fall. Mrs Y also complains the Home did not put in place a do not attempt resuscitation (“DNAR”) form and badly handled the situation when it served an eviction notice on Mr B. Mrs Y says Mr B never properly recovered from his fall, which led to a hospital admission. She wants the Council to write off Mr B’s contribution to the Home’s fees, due to the concerns she has about his care.

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The Ombudsman’s role and powers

2. 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)
3. 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)
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

5. I reviewed the information Mrs Y provided and spoke to her about the complaint. I then made enquires of the Council and the Home. I spoke to a member of staff who responded to Mr B’s fall. I sent a copy of my draft decision to Mrs Y and the Council for their comments.

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What I found

Home Policies

6. The Home’s ‘Prevention and Management of Falls’ policy says a falls risk assessment should be completed within 48 hours of admission. Staff should update this monthly or more often if needed. It says the person in charge should report all falls to relatives as soon as possible.
7. The policy has a flow chart that sets out the steps to take if a resident has a fall. It says: ‘Reassess falls risk status – Review circumstances of fall, refer to relevant staff to review, update care plan and implement falls prevention strategies’.
8. The Home’s falls risk assessment form includes three categories of risk: ‘low’, ‘medium’ or ‘high’. The resident’s risk status is based on scoring from several factors (low: 0-11, medium: 12-16, high: 17-22). One of the factors is their history of falls, which is scored as follows:
• No history of falls – 0
• Dizziness in last 6 months – 1
• Has fallen 1 or 2 times before, but not in the last 48 hours – 2
• Has fallen more than twice, but not in the last 48 hours – 4
• Has fallen in the last 48 hours – 6
9. The policy says staff must produce a falls care plan if the resident is at a high or medium risk of falls. Staff should make a referral to the falls team if the person has a had three falls in the last 12 months, has balance or gait deficits and/or requires medical attention after a fall.
10. The policy sets out various measures staff can use to manage a person’s risk of falls, such as:
• Footwear
• Mobility aids
• Sensor mats
• High low beds
• Wedges and crash mats
• Bed rails
• Straps and harnesses
11. Not all these will be suitable in every circumstance and some are a last resort.

Background

12. Mr B was diagnosed with vascular dementia in around 2015. He also suffered from diabetes and other health conditions. Until 2017 Mr B primarily lived at home with his wife, Mrs B, who was his main carer. He stayed in a care home during periods of respite for Mrs B.
13. In early 2017 Mr B’s needs became more challenging and Mrs B developed health problems of her own. It was therefore decided to find Mr B a residential placement. The Council completed a needs assessment and financial assessment for Mr B in around March 2017. It arranged a placement for Mr B at the Home and calculated his contribution to the care costs.
14. Mr B stayed at the Home until June 2017, when he was admitted to hospital following a fall. Mrs Y raises the following concerns:
• The Home did not put in place a DNAR for Mr B
• The Home did not do enough to stop other residents entering Mr B’s room
• The Home did not complete adequate falls assessments for Mr B and did not refer him to the falls team early enough
• The Home allowed Mr B access to a razor and toiletries and did not complete 15-minute observations, which may have contributed to his fall in June 2017
• Mr B’s health deteriorated significantly while he was at the Home
• The Home poorly managed serving a notice of eviction on Mr B
• The Home produced a signed deed of guarantee that is dated after Mr B left the Home

DNAR

15. On admission the Home discussed Mr B’s care with his family, including Mrs Y. The family agreed to put in place a DNAR. Mrs Y says this was a very difficult decision. The family accepted a DNAR due to the risk that, if Mr B was resuscitated, it could cause permanent damage and he may suffer a poor quality of life.
16. A doctor from the Home’s GP surgery visited Mr B two weeks later. A record in Mr B’s care file shows the doctor was going to contact Mr B’s family about the DNAR. The Home says it does not have any record of staff following up on this.
17. Mrs Y says that when paramedics arrived to take Mr B to hospital, following the fall in June 2017, they asked for Mr B’s DNAR. The paramedics needed to take this with Mr B to hospital. However, staff could not find any record of Mr B’s DNAR. Mrs Y says that, had Mr B needed resuscitation, paramedics would have had to resuscitate him because of the lack of a DNAR.
18. The hospital arranged for a DNAR to be put in place the following day. Mrs Y says she later contacted the GP, who said she did not receive a request for a DNAR from the Home.

Residents entering Mr B’s room

19. Mrs Y says she raised concerns with the Home several times about other residents entering Mr B’s room and taking his things. She said this caused Mr B a lot of distress.
20. The Home says it accepts residents did enter Mr B’s room. It says Mr B also went into other residents’ rooms and it tried to manage this by placing Mr B and another resident on 15-minute observations. It also moved Mr B to another room in what it says was a quieter area. However, the problems continued. Mrs Y says the new room was no better than the last.
21. The Home says it found Mr B’s behaviour difficult to manage. It completed behaviour charts that record incidents of Mr B acting aggressively towards staff and other residents throughout his stay at the Home. It says it eventually served a notice of eviction on Mr B because it did not feel the Home could manage Mr B’s behavioural issues.
22. Mrs Y says Mr B would get upset because of residents entering his room. She says the Home should have done more to stop this happening.

Falls assessments and referral

23. Mr B’s pre-admission assessment says he had one fall two years before entering the Home. Mrs Y says he had become less steady on his before going into the Home. He mobilised using a walking aid.
24. There is no record staff completed a falls risk assessment within 48 hours of Mr B’s admission. The first risk assessment took place on 12 May 2017, more than a month after the admission.
25. Mr B had a fall on 2 May 2017. No staff witnessed the fall. At first Mr B told staff he fell off the bed, then that he fell off the chair. Staff checked Mr B and found no injuries. Staff did not complete an updated risk assessment until 12 May 2017, ten days after the fall. That risk assessment said Mr B had no history of falls. It found Mr B was at low risk of falls, with a score of 11. There is no record the Home told Mr B’s family about this fall.
26. Mr B fell again on 25 May 2017. No staff witnessed the fall. The incident form records staff finding Mr B and another resident having fallen. It says Mr B was in an agitated state. It says there was no evidence of any injuries to Mr B. There is no record that staff reviewed Mr B’s risk of falls. The professional communication record shows the Home notified the family of this fall.
27. Mr B had another fall on 30 May 2017. No staff witnessed the fall. The incident form records that staff found Mr B next to his bed shouting. There is no record of what might have caused the fall and no record the home then reviewed Mr B’s risk of falls until several days later. There is no record the Home told Mr B’s family about this fall. Mrs Y says she did not know Mr B had three falls in May 2017.
28. Staff made a referral to the falls team on 4 June 2017. The Home says they did so because Mr B had fallen three times and his risk of falls had increased to medium. However, staff did not review Mr B’s risk of falls until 5 June 2017. At this point in time staff recorded that Mr B had fallen more than twice but not in the last 48 hours. This increased his risk score to 15, so medium risk. There is no record that staff put in place a falls care plan.
29. Mr B fell again on 6 June 2017 and was admitted to hospital. The fall caused bruising, but Mr B did not suffer any fractures. Mrs Y says Mr B was very unwell at the time of the fall, following constant infections while he was at the Home. I have gone into Mrs Y’s concerns about the Home’s general care in more detail at Paragraphs 39 to 49. Mrs Y says he never properly recovered from this fall and continued to have regular infections.

Access to toiletries/Observations

30. Mrs Y says staff telephoned her at around 19:00 on 6 June 2017. The observation records say Mr B was sitting in his chair at 19:15. Mrs Y says the record is not accurate and does not believe staff were conducting the 15-minute observations.
31. The Home’s incident form lists the time of the incident as 19:15. It says Mr B was found on the bedroom floor and had hit is head. His head was bleeding. He also had a bruise on his back.
32. Mrs Y lived close to the Home so went straight there. Mrs Y says when she arrived Mr B was still on the floor and was incontinent. She says there was toothpaste and shaving foam all around his mouth and over the floor. She believes Mr B was trying to shave and the toiletries could have contributed to him slipping and falling. Mrs Y says the state of his room also leads her to believe staff did not complete 15-minute observations.
33. The incident form does not record the presence of a razor or toiletries. Under ‘Did any aids / furnishings / equipment contribute to the accident?’ it says: ‘Unknown’.
34. I spoke to a former senior carer who responded to Mr B’s fall. The carer told me he remembered Mr B having shaving foam around his mouth and believes Mr B may have been trying to shave. He did not remember anything being on the floor. He said this is not unusual and if residents can shave themselves carers would encourage them to do so for their independence. However, he was not directly involved in Mr B’s care so could not comment on whether Mr B would shave himself.
35. Mrs Y says she asked a staff member why Mr B had access to a razor and toiletries. The staff member told her they did not like residents to lose their independence. Mrs Y says she understands this but in Mr B’s condition it was not safe for him to have access.
36. In its response to the complaint, the Home said its formal policy is to lock toiletries in cupboards. It does not have a specific policy on this but says it is consistent with its general policies.
37. Paramedics attended and took Mr B to hospital. He did not have any fractures. However, Mrs Y says he did not recover and was then placed on an elderly mentally infirm ward before moving to another care home.

General care and deterioration in health

38. Mrs Y raises concerns about a general deterioration in Mr B’s health as a result of poor care by the Home. She says Mr B suffered from frequent urine infections. She says she repeatedly asked the Home to refer him to the GP about this, but it did not.
39. I can see the pre-admission assessment notes that Mr B has a history of urine infections. It also notes that he has cellulitis on his legs. It says he has various medical conditions including dementia, diabetes, a tumour and a serious lung disease.
40. The Home’s multidisciplinary records show several healthcare professionals visited Mr B throughout his time at the Home. At the end of April 2017, the Dementia and Intensive Support Team (“DIST”) assessed Mr B. The DIST then arranged to visit Mr B three times a week.
41. On 10 May 2017 the daily progress notes record that Mr B had a rash on his chest. It says Mr B was frustrated as a nurse had not yet seen him. On the same day, the multidisciplinary record shows a GP matron visited to check the rash. It says the nurse will send a cream.
42. On 14 May 2017, the daily progress notes record that Mr B has an infection in his legs and eye. The following day the matron visits. The notes say the matron sent antibiotics and drops.
43. The multidisciplinary record shows that on 19 May 2017, the Home called 111 as the family were concerned that Mr B was confused and breathing fast. The note says, ‘test sugars again and get urine sample but its most likely due to his legs infection’.
44. The matron visited again and prescribed a further course of antibiotics for his legs on 23 May 2017. On the same day the Home referred Mr B for pressure screening due to redness on his skin.
45. The matron visited on 26 May 2017, due to a burst blood vessel in Mr B’s eye.
46. On 30 May 2017, the multidisciplinary record says the matron visited again due to Mr B being wheezy and breathless. The matron said she would arrange a blood test.
47. A district nurse took the blood test on 2 June 2017. On the same day the Home telephoned the GP regarding the redness on Mr B’s legs. The record says, ‘Possibly cellulitis so antibiotics prescribed and started’.
48. The next records concern contact with the hospital following Mr B’s fall.

Eviction Notice

49. Mrs Y says the Home told her it was giving 28 days’ notice of eviction in possibly around the end of May 2017. The Home’s records show staff discussed this with Mrs Y on 2 June 2017. I have not seen evidence of a written notice served at this time.
50. Mrs Y says the notice came out of nowhere. She had raised persistent concerns with the Home about Mr B’s care and the Home kept saying he was fine. She says it then told her about the eviction right before a bank holiday, when she could not do anything about it. She says this caused a great deal of distress.
51. The Home says it gave notice because it could not manage Mr B’s behavioural needs and it was concerned about the impact on and safety of other residents.

Deed of guarantee

52. The Council’s record show it completed a financial assessment for Mr B in early April 2017, when he went into the Home.
53. The Council has produced a deed of guarantee form, which is dated 15 June 2017. This is after the date Mr B signed the form. The form is signed by Mrs B. Mrs Y says it does not look like Mrs B’s signature, but she had been poorly and shaken up.
54. The Council says it visited Mrs B and Mrs Y on 15 June 2017 to assess Mr B’s contribution for the care he received at the Home. It says Mrs B signed the form. It says Mr B was still liable for his contribution to the care home fees. Mrs B says this did not happen.

Findings

DNAR

55. I find fault in how the Home managed Mr B’s DNAR request.
56. I understand a GP told Mrs Y the Home did not make the DNAR request. The note in the Home’s records about the GP visit, is brief and does not provide clear evidence of a formal referral from the Home to the GP. However, it does indicate the GP was aware Mr B needed a DNAR and was going to discuss this with the family. That did not happen.
57. For that reason, I cannot, on balance, say the Home did not make the referral. However, it is clear the Home did not chase up on this or ensure the GP acted on the referral. This is fault. The Home should have chased to ensure a DNAR was in place. It should not have allowed two months two pass without one.
58. It is difficult to establish the level of injustice this caused. The potential consequences of the fault were significant. It could, in a different situation, have led to paramedics resuscitating Mr B against the agreed wishes of his family. However, this did not happen. The paramedics did not need to resuscitate Mr B.
59. With that in mind, I cannot find the fault caused a significant injustice to Mr B. However, I do find it caused injustice to Mrs Y in the form of distress. Mrs Y attended the Home shortly after Mr B’s fall, in what would have already been a stressful situation. The fact the Home did not have a DNAR for paramedics to take with him to hospital, caused additional and avoidable distress to Mrs Y.

Residents entering Mr B’s room

60. I do not find fault in how the Home managed the situation of residents entering Mr B’s room.
61. I understand the distress this would have caused Mr B. However, the Home did take measures to address this. Its records show staff completed observations every 15 minutes. The Home recognised that other residents entering his room was a trigger for Mr B showing aggression. It included this in Mr B’s behaviour care plan, which said staff should try to engage Mr B in activities, encourage him to close his door and provide emotional support to him. The Home’s behaviour charts and other records, show evidence of staff doing this. Staff also moved Mr B to a different room.
62. This did not stop the incidents completely. However, it is a care home for dementia and there will be occasions of residents wandering. It may not be possible for staff to prevent this ever happening, without watching all residents at all times, which is not practical. When the Home reached the view it could not manage the issues involving Mr B, it served an eviction notice.

Falls assessments and referral

63. I find fault in how the Home assessed and managed Mr B’s risk of falls.
64. The Home did not fully assess Mr B’s risk of falls within 48 hours of admission. This is fault as it should have done so in line with its policy. It did not do so until a month after his admission, during which time Mr B had a fall.
65. The Home should have completed a risk assessment after each fall in line with the flow chart in its policy. It did not do so until 10 days after Mr B’s fall of 2 May 2017. It said in the risk assessment that he had no history of falls.
66. The falls policy is not clear on the timescale in which staff should review a resident’s risk, following a fall. However, the Home’s risk assessment form suggests the resident is at greatest risk of falling again over the following 48 hours. In the context of this and the flowchart, it would be surprising if the Home did not intend for this to happen as soon as possible after the fall, certainly not 10 days later. This is fault.
67. If the Home had recorded Mr B’s fall in the risk assessment on 12 May 2017, his score would have increased to 13, which is medium. If it had done the risk assessment within 48 hours of the fall, his score would have increased to 17, which is high. Either way, the Home should then have produced a care plan. This care plan should have considered whether any measures were needed to prevent further falls, such as those set out at Paragraph 10.
68. The same is true for the following two falls on 25 and 30 May 2017. The Home did not review Mr B’s risk of falls until 5 June 2017. This is even after it referred him to the falls team on 4 June 2017, so the Home clearly understood there was a problem. If it had reviewed his risk following either of these falls his risk score would have been high and again should have produced a care plan.
69. Mr B went on to have a more serious fall, where he hit his head and was admitted to hospital. I cannot say for certain that, had the Home properly risk assessed Mr B, produced a care plan or considered measures to manage his risk of falls, he would not have continued to fall or been admitted to hospital. However, it raises real concerns that, a week after his third fall in the space of a month, the Home had still not done any of these things. It causes significant uncertainty about what would have happened if it had. That uncertainty causes an injustice to Mrs Y.
70. My other concern is the lack of apparent investigation into what might be causing the falls. All the incident reports are brief and show little evidence the Home considered if any environmental factors, illnesses or infections that might have contributed.
71. The final incident report makes no mention of Mr B trying to shave or having foam or toothpaste around his mouth or on the floor. This is an environmental factor the Home should have recorded. Whether Mr B slipped because of shaving foam on the floor, or simply while trying to shave, that information would inform any risk assessment and care planning going forward.
72. As it happens, Mr B did not return to the Home. However, the person completing the incident form could not have known that at the time. It also raises questions about whether any relevant information was not included in the previous incident reports. This adds to the uncertainty about what difference it might have made were there no fault in how the Home managed Mr B’s risk of falls.
73. I also find the Home at fault for not notifying Mrs Y of the falls on 2 and 30 May 2017. The falls policy says staff should notify relatives of all falls as soon as possible. Mrs Y says she did not know about the falls. The family communication records do not provide any evidence staff notified her of the falls.

Access to toiletries

74. I find fault in how the Home managed Mr B’s access to toiletries.
75. If the Home’s policy on locking toiletries away is a formal policy, then Mr B should not have had access to a razor, shaving foam or toothpaste. On 6 June 2017, he did, and that is fault. I cannot say for certain whether it contributed to his fall. However, again, it adds to the uncertainty about what would have happened if the Home had strictly followed its policies.
76. The staff member I spoke to suggested carers may encourage residents to shave and look after their own personal care, if they are able. This is consistent with Mrs Y’s account of what the carer on duty told her. It would suggest residents may have access to toiletries in circumstances where it is appropriate.
77. The Home’s position therefore does not appear completely consistent. It is not clear whether staff should make decisions about the individual resident or apply a blanket policy. There is no written policy to clarify this.

Observations

78. On balance, I do not have enough evidence to find fault in how the care staff conducted observations.
79. Mrs Y says the Home called her at 19:00. She says she wrote the time down when it happened as she was keeping logs of everything. I do not dispute this. However, the Home’s incident form and professional communication record put the incident at 19:15. I cannot say for certain which is the correct time, so cannot make a finding on that point.
80. I note the carer has recorded at 19:15 that Mr B was sitting in his chair. This does raise some questions about the accuracy of the observation records, as the incident report says this is the time the carer found Mr B on the floor. However, it is possible there could have been some rounding up or down on either side. For instance, the carer could have checked on Mr B at 19:12, found him on the floor at 19:17, and recorded 19:15 for both.
81. Mrs Y and the staff member have given different accounts about the state of the room. I cannot resolve which account is more accurate. If there was shaving foam all over the floor, I would not be able to say how long it took Mr B to get into that state. I therefore cannot say the state of the room is evidence that staff did not complete observations.

General care and deterioration in health

82. I find some evidence of fault in how the Home responded to Mrs Y’s concerns about urine infections. I do not find evidence of fault in other aspects of Mr B’s general care.
83. The daily records and observation charts are fully completed and show carers providing personal care and a full diet. There were occasions Mr B refused care, but the records show staff continued to offer that care throughout the day.
84. Mr B did develop infections to his eye and legs. I cannot say what might have contributed to those infections, but the records show the Home contacted the GP and a matron attended regularly and prescribed treatment. I therefore do not find fault.
85. I cannot see any record of Mr B developing urine infections while he was at the Home. Mrs Y was clearly concerned he did and raised this with staff.
86. The Home’s intake/output charts have a section where carers can note if the person’s urine is concentrated, has a strong odour or contains blood. No concerns are noted in these sections. The note in the multidisciplinary record on 19 May 2017, suggest staff felt the infection to his legs caused his confusion rather than a urine infection. However, the note also refers to doing a urine test after it called 111.
87. There is no further reference to this in the multidisciplinary or daily records. It is not clear from the records whether the Home followed up on this, arranged for a urine test or received any results. There is no record the Home raised this with the GP or the matron when she visited. Her visits were instead focussed on the infection to his eye and legs.
88. I cannot say whether Mr B had urine infections while he was at the Home, or if this contributed to the deterioration in his health. However, I find fault as I would have expected to see some follow up on the urine test or evidence the Home raised this with the GP or matron.

Eviction notice

89. I do not find fault in how the Home managed the notice of eviction.
90. I understand Mrs Y is concerned about the Home’s communication and the timing. I have no doubt it caused her distress. However, I can see the Home did keep Mrs Y informed of incidents between Mr B and other residents and expressed its concerns about his behaviour. It may not have made clear it was considering eviction, so I understand why it took Mrs Y by surprise. However, it is not for me to say what warning the Home should have given. The Home is entitled to serve notice if it believes it is not suitable for a resident and this would always have caused some distress.

Deed of guarantee

91. I do not find fault in relation to the deed of guarantee.
92. I could not make a finding about whether the Council fraudulently signed the form in Mrs B’s name, as this would be a criminal matter. The Council is clear that she singed the form when it visited on 15 June 2017.
93. There may be some question about why the Council was assessing Mr B’s contribution to the care home fees in June 2017, when it completed a financial assessment April 2017. However, I have not looked into this further. Mrs Y has not raised concerns about the accuracy of the financial assessment. Mr B’s family would have known, when he went into the Home, the care was chargeable. Her concern is not about the contribution, but that Mr B should not be liable for his contribution when there was fault in his care. I have addressed this in the following paragraphs.

Consideration of remedy

94. The outcome Mrs Y wants is for the Council to write off Mr B’s contribution to the care home fees. The outstanding contribution is just over £1,000. I have not asked the Council to write off the full amount. However, I have recommended a financial remedy of £600 for the following reasons.
95. I have found fault in three areas:
• The Home did not properly assess Mr B’s risk of falls or put in place a care plan to manage that risk
• The Home did not notify Mr B’s family of the falls on 2 and 30 May 2017
• The Home did follow up on a urine test or raise the family’s concerns about a urine infection with health professionals
• The Home did not follow up to ensure Mr B had a DNAR in place
96. I cannot say for certain what impact the fault had on Mr B’s condition. It is clear he was very unwell when he entered the Home and his condition did get worse, but I cannot specifically link that to poor practice by care staff. The injustice in each case is the uncertainty and avoidable distress it caused Mrs Y.
97. We will normally recommend between £100 and £300 for distress, or more when the distress is very significant or caused by multiple failings.
98. I am of the view the uncertainty and distress caused was very significant. There is significant uncertainty around what impact proper falls risk assessment and care planning could have made. The fact a DNAR was not in place added avoidable distress to an already stressful situation. It also adds uncertainty about what would have happened, had Mr B needed resuscitation. It could have meant he was resuscitated against the family’s wishes, which is a serious consequence.
99. I have not found fault in all aspects of the Home’s care. The Home kept records of regular personal care and a full diet. It recorded timely interventions for the infections to Mr B’s eye and legs. I have taken this into consideration. However, the injustice caused by the four elements of fault remains very significant and, in my view, warrants the higher remedy. I therefore recommend the Council pay Mrs Y £600 to recognise the distress caused.
100. I considered whether to recommend the Council write this amount off from the outstanding care fees. However, my findings do not dispute that Mr B was legally liable to contribute to his care fees. Mr B has now passed away and any outstanding fees are a matter for his estate. I do not know who the beneficiaries are and will not get into any complications this might raise. The injustice I have identified is to Mrs Y, so I recommend the Council make the payment to her.
101. I have also found the Home’s policies were not clear on the timeframe in which staff should review risk assessments following a fall, and on when to lock away toiletries. I recommend the Home update its policies.

Agreed action

102. The Council has agreed to, within a month of this decision:
• Apologise to Mrs Y for the fault in the care her father received while resident at the Home
• Pay Mrs Y £600 to recognise the distress and uncertainty caused

It will also, within three months of this decision:

• Provide evidence the Home has updated its Prevention and Management of Falls policy to show a clear, specific timeframe in which staff should review a person’s risk of falls following a fall
• Provide evidence the Home has updated its policies to show that toiletries should be locked away from residents’ access and/or, in what circumstances residents can have access to toiletries

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Final decision

103. I find fault in how the Home managed Mr B’s risk of falls, notified his family, followed up on concerns about urine infections and for not ensuring a DNAR was in place.

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Investigator's decision on behalf of the Ombudsman