Alysia Caring Limited (19 005 101)

Category : Adult care services > Residential care

Decision : Not upheld

Decision date : 18 Dec 2019

The Ombudsman's final decision:

Summary: Mr B complained about the action taken by a Care Provider in response to a fall by his mother Mrs C. We cannot find fault with the action the Care Provider took.

The complaint

  1. Mr B compains on behalf of his mother, Mrs C that Alysia Caring Limited (the Care Provider) failed to notice or take action for two days, to address the fact she had broken her hip following a fall.

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The Ombudsman’s role and powers

  1. 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)
  2. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

  1. I have considered the complaint and the documents provided by the complainant, made enquiries of the Council and considered the comments and documents the Council provided. I have written to Mr B and the Council with my draft decision and considered their comments.

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What I found

‘I Stumble’ Algorithm for help

  1. This procedure produced by the health service details the checks to be made after a person falls and the signs which indicate a 999 call should be made. The first checks relate to vital signs such as breathing, airways and pulse. The second set of checks follow the acronym, I STUMBLE:
    • Intense pain
    • Suspected collapse
    • Trauma to head/neck
    • Unusual behaviour
    • Marked difficulty in breathing/chest pain
    • Bleeding freely
    • Loss of consciousness
    • Evidence of fracture.
  2. If no one of these signs are present it says the resident should be lifted from the floor either manually or with a lifting aid, reassessed and observed regularly for changes in condition.

What happened

  1. Mrs C had been living in a home run by Alysia Caring Limited since 2018. She is very elderly, has short-term memory problems and is at risk of falling. The GP visited Mrs C on 7 April 2019. He noted Mrs C was able to move all her limbs in the air, roll from side to side and sit up. He had no concerns.
  2. Her case records note she ate and drank very little on 7 April 2019 and had an upset stomach later in the day. On 8 April 2019 she had a settled day and ate better. She declined assistance with personal care. Her daughter visited.
  3. A note was made that she came out of her room requesting assistance early on the morning of 9 April 2019, but she settled back into bed. At 10 am a carer found her lying on the floor. She said she had fallen on her way back from the bathroom.
  4. The accident record says she was checked over immediately and the Deputy Manager was present: she was able to move and bend all her limbs and roll from side to side. She said she was not in any pain or discomfort when asked. Staff helped her to wash and dress and she was transferred back into bed with a hoist.
  5. Mrs C remained in her room for the rest of the day. She ate and drank well. Her daughter and Mr B visited.
  6. On 10 April 2019 staff assisted Mrs C with washing and dressing. They noted her mobility was not 100% but said she was able to walk to and from the bathroom. She ate and drank well at breakfast. But declined to do any activities and stayed in her room.
  7. On 11 April 2019 Mrs C complained to staff of pain on her right side. A senior member of staff checked her over but could not find any bruising. Mrs C complained of pain in her right side. She ate reasonably at breakfast, declined assistance with going to the toilet and enjoyed spending time with her son. A nursing specialist examined her in the early afternoon and recommended she went to hospital for an x-ray.
  8. When the St Johns ambulance crew arrived, they assessed Mrs C and considered she could transfer to a wheelchair herself as she was not saying she was in pain. But she then changed her mind and the crew used a slide to transfer her on to a stretcher. Mrs B telephoned the home later in the evening to inform them that Mrs C had been admitted to hospital with a broken hip.


  1. Mr B complained to the Care Provider on 17 April 2019. He said Mrs C had fallen on 8 April 2019, was unsteady and had a bruise on her arm. She was confused after she fell on 9 April 2019. Staff minimised her reports of pain and tried to get her to walk and sit in the chair, despite her obvious discomfort. He also said the home did not contact the doctor after Mrs C’s fall and did not make a serious attempt to identify any damage. The practice nurse only checked her over because she was there for other reasons and due to the lack of action Mrs C endured two days of pain and possible further damage to her hip.
  2. He said Mrs C was going into a nursing home for two weeks to convalesce and decide if she wished to return to the home.
  3. The Care Provider responded in May 2019. It said there was no evidence of a fall on 8 April 2019 and staff had not noticed a bruise on her arm. It recounted the circumstances in which she was found after the fall on 9 April 2019 and the action staff took. It noted she had seemed fine for the rest of the day, eating and drinking and not complaining of pain.
  4. On 10 April 2019 it said one member of staff assisted Mrs C to the bathroom, with the use of a wheelchair. It said Mrs C did not complain of pain. When Mr B visited, she got back into bed as she said sitting was painful, but she declined paracetamol. Staff told Mr B she would be put on the list to see the nurse practitioner the following day. Mr B says two carers helped her to the bathroom.
  5. On 11 April 2019 Mrs C was complaining of pain in her leg. A senior member of staff checked her and could not find any bruising or signs of dislocation. But given that Mrs B was complaining of pain they decided to check with her GP rather than send her to the hospital without a referral. However, before this could happen the nurse practitioner saw Mrs C and recommended she went to hospital for an x-ray.
  6. It said all staff followed the ‘I Stumble’ procedure, asked for a second opinion where appropriate and often made a GP referral rather than going straight to A&E which may involve a long wait.
  7. Mr B continued his complaint stating that staff had not acted on Mrs C ‘s reports of pain so she was left in unnecessary discomfort for two days.


  1. I understand it was distressing for Mrs C and her family to discover she had broken her hip. However, I cannot find evidence of fault in the actions the Care Provider took which cause her an injustice.
  2. It took action in response to her fall on 9 April 2019, checking her over and assisting her back to bed with a hoist. Staff could not identify any concern or injury and Mrs C was not complaining of any pain or distress. There was no reason to take any further action at this stage and none of the signs in the ‘I Stumble’ procedure were noted.
  3. When she complained of pain during the evening of 10 April 2019, she was offered painkillers which she refused and was put on the list to see the nurse practitioner. The following morning a senior member of staff checked her and then sought a second opinion from the nurse practitioner.
  4. Mr B disagrees that appropriate action was taken quickly enough but on the basis of the evidence provided I consider the Care Provider followed its procedures and acted when Mrs C complained of pain.

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Final decision

  1. I have completed my investigation into this complaint as I am unable to find fault causing injustice in the actions of the Care Provider towards Mrs C

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Investigator's decision on behalf of the Ombudsman

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