Summary: the late Mrs X, and her daughter Mrs A, suffered injustice due to a failure to carry out a risk assessment for falls when Mrs X was admitted to Richmond Village Witney for a short respite stay. After Mrs X fell out of bed, staff did not complete a risk assessment, review the Care Plan or put in place measures to mitigate the risk of further falls. She had a further fall and suffered extensive bruising. Mrs A’s complaint was not considered in accordance with BUPA’s complaints procedure. BUPA accepts our findings and has agreed to provide a suitable remedy.

The complaint

1. Mrs A complains about events that happened while her mother, Mrs X, was staying in Richmond Village Witney for one week’s respite care. Richmond Village Witney is part of the BUPA group.
2. Mrs A made the complaint on behalf of her mother and with her consent. Sadly, Mrs X passed away after we began the investigation. Mrs A asked us to continue and we agreed to do so.
3. Mrs A complains that her mother sustained bruising and a black eye following two falls in the care home. She says staff on duty did not seek medical advice when they found Mrs X after the first fall. Mrs A is concerned that the falls happened because staff did not carry out regular night-time checks as required in her mother’s care plan. She also complains that the call bell in her mother’s room had been disconnected and the care home manager could not explain why this had happened. Mrs A believes staff in the care home tried to cover up what happened.

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The Ombudsman’s role and powers

4. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34H(3) and (4), as amended)
5. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
6. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)

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How I considered this complaint

7. I have spoken to Mrs A and considered all the information she provided. This includes her photographs of Mrs X on the day she was admitted to the care home and later ones showing the bruising caused by the falls she had in the care home.
8. I contacted the care provider and considered the records and correspondence it provided. Some of the key records could not be found.
9. Mrs A and the Care Provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.
10. Under our information sharing agreement, we will share our final decision with the Care Quality Commission (CQC).

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What I found

The Fundamental Standards of Care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
12. Regulation 12 deals with the need to provide safe care and treatment. The CQC guidance says the purpose is to prevent people from receiving unsafe care and treatment and to prevent avoidable harm or risk of harm. 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, skills and experience to keep people safe. (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12)

The care provider’s procedures for recording incidents and injuries and deciding whether to seek medical advice

13. The care provider says a member of staff should inform the Senior Care Expert when they find a resident following an incident. In the event of a fall, or an unwitnessed fall, the staff member should use a falls summary form to decide on the seriousness of the incident.  Using the prompts on that form, it may be appropriate to call the NHS 111 number.  If there is a suspected head injury or fracture, the resident would be left in situ, made comfortable, and kept warm until emergency services arrived. A member of staff should remain with them and a family member should be informed.
14. The member of staff should complete an incident reporting form immediately after any incident.  Agency staff do not have access to an electronic recording system so they should complete a paper form and pass it to the department lead, Administrator or Head of Care to upload to the system. The following steps should then be taken:
• the resident’s care plan should be updated;
• a falls diary completed;
• a falls risk assessment and additional plan of care should be undertaken;
• staff should be briefed and a handover form updated. 
• the Care Home Support Service should have been contacted to arrange a review. This would lead to care recommendations which the team would input into the care plan and follow as directed.     
   

The events of this complaint

15. Mrs X was in her eighties when she was admitted to Richmond Village Witney for one week’s respite care in March 2019. She stayed in the wing for residents with dementia. This was the first time Mrs X had stayed in a care home or respite provision. She was usually cared for at home by Mrs A and her sister. The respite was a planned break to allow Mrs A’s sister to take a holiday.
16. Mrs X had Parkinson’s disease and associated dementia and a history of cardiac problems. She could mobilise indoors using a walking frame with help from one person. She had ramps outside her home and could still walk a short distance to the car. Her mobility was gradually deteriorating due to the Parkinson’s disease. Mrs X had had a couple of falls at home before she went into Richmond Village Witney.
17. Mrs A says a registered nurse visited Mrs X at home to complete a pre-admission assessment. Mrs A’s sister was present.
18. Mrs A’s sister says she told the nurse about Mrs X’s history of falls and showed him the equipment she used to reduce the risk. Mrs X slept on the ground floor of the house and used a profiling bed. Mrs A’s sister had set up a motion sensor, fixed to Mrs X’s bed, with a pager alarm next to her own bed, and a baby monitor, to alert her if Mrs X tried to get out of bed in the night. The motion sensor was positioned to detect leg movements and to alert Mrs A’s sister. Mrs A’s sister says she showed the nurse all the measures she had put in place to ensure he had a clear understanding of the risk level.
19. While she was at home, Mrs X also had several falls during the day, two of which resulted in fractures requiring hospital admission. Mrs A’s sister said Mrs X found it difficult to adjust to her limitations and was getting progressively weaker and more unsteady due to the Parkinson's disease. She had five falls in the previous 12 months. Two falls happened when Mrs X was trying to mobilise on her own using her Zimmer frame. Mrs A’s sister said she told the nurse in the pre-admission home visit about these falls. She says he took notes during the visit and she felt reassured he had understood the risks.
20. The Care Provider cannot find its pre-admission assessment notes for Mrs X. It is therefore not clear whether it had assessed the risk of Mrs X having falls and the need for measures to prevent or mitigate the risks to Mrs X.
21. Mrs X went into the care home on 25 March. The Care Provider says it cannot find Mrs X’s Care Plan. It has no records to indicate whether a body map was completed at the time of admission.
22. Mrs A visited Mrs X every day. She took a photograph of Mrs X on the day she went into the care home. There were no marks or bruises on Mrs X’s face.
23. The care provider’s records include an incident report form dated 27 March. A senior care assistant (SCA) from an agency was on duty. He found Mrs X on the floor in her room next to the bed. Under the heading “details of injuries sustained” he said there were no visible injuries or marks. The form does not record whether any action was taken (for example, administering pain relief medication or contact with the NHS 111 line for advice).
24. The care provider says it seems the SCA did not follow the procedure in paragraph 13 after he completed the incident form. The sections of the form used to record action by management and to log the incident on the care management system are blank. Accordingly it seems the incident did not lead to a falls risk assessment or a review of Mrs X’s Care Plan.
25. Mrs A was not informed of the fall at the time. She says she noticed a small dark mark near her mother’s eye when she visited on the evening of 29 March. Mrs X was sitting in the residents’ lounge. On previous visits, Mrs X had been in her room. Mrs A asked the staff to give Mrs X some paracetamol. By the following day, the mark had developed into a black eye. Mrs A asked her mother what had happened but Mrs X could not explain.
26. On 30 March 2019 Mrs X fell out of bed for a second time during the night. The same SCA found her lying on the floor when he carried out a routine check after midnight. He completed an incident report form. He said Mrs X told him she had fallen while trying to turn over. The SCA noticed bruising on her left shoulder. He called 111 for medical advice and was advised to give Mrs X paracetamol. The sections of the form to record action taken by management, and to confirm the form had been uploaded to the electronic care records, were not completed.
27. The SCA called Mrs A’s sister to inform her about the fall. Mrs A says this ruined her sister’s holiday. Mrs A says she had made it clear that she should be the first point of contact while her sister was on holiday. She says the care home had her contact number and staff should have checked the Care Plan before making the call. She believes staff only made contact on this occasion because she had previously expressed concern about the failure to call 111 and inform her about the first fall.
28. The care provider could not trace Mrs X’s daily care records. The only other contemporaneous records available are brief entries in the daily handover notes when the staff changed shifts. These record the times when the SCA found Mrs X on the floor in her room. For the first fall, there is a discrepancy between the date on the incident report form and in the handover notes. The handover notes say it happened on 28 March at 6:15 am. However the incident report form says it happened on 27 March at 6:15 am.
29. The care provider says that, as far as it knows, neither fall was reported to the Head of Care.  The Head of Care left the organisation in June 2019. 
     
30. Mrs A sent me three photographs of Mrs X’s injuries. These show extensive bruising around Mrs X’s left eye, hip and upper arm.
31. On the day of the second fall, Mrs A removed Mrs X from the care home. This means she returned home one day earlier than planned. Mrs A did not feel it was safe for her mother to stay any longer.
32. Mrs A says her mother took a long time to recover after she returned home. She lost confidence in mobilising and had very painful bruising. She says her mother also developed a severe urinary tract infection immediately after she came home which required four or five courses of antibiotics. Mrs A says she cannot prove the infection was caused by poor personal care in the care home. She says Mrs X asked not to go back to the care home.
33. Mrs A says Mrs X was also dehydrated. She had noticed during her daily visits that staff sometimes left drinks out of Mrs X’s reach. We asked the care provider for the fluid intake charts for Mrs X’s stay but it could not find these records.
34. Mrs A says she noticed the call bell in her mother’s room was disconnected when she made the final visit on 30 March. The care provider sent us the call bell records for Mrs X’s room. These list all the dates and times when the call bell was used by Mrs X and staff response times. The call bell was used several times between 6:00am and 10:35 am on 30 March.
35. The care provider says staff are expected to respond to call bells within five minutes. On 30 March staff took 12 and 31 minutes to respond to two of Mrs X’s calls. It says the IT team cannot run a report to determine whether the call bell was unplugged.    
36. Mrs A and her sister continued to look after Mrs X at home. They cancelled a further week’s respite care they had booked at the care home for April 2019. Mrs A says she had to juggle full-time work with looking after her mother.
37. The fees for Mrs X’s one week stay was £1,300.

Mrs X’s complaint

38. BUPA Care Homes has a two stage complaints procedure. At the first stage, the complaint is handled locally in the care home and a response should be sent within 20 working days. If the person is not satisfied with the care home’s response, they can contact the Quality & Compliance team to request a review by a member of the senior management team. The investigator then conducts a review of the way the complaint was handled at Stage One and makes any further enquiries necessary. A final Stage Two response should be sent within 20 working days.
39. On 4 April Mrs A made a complaint about the quality of her mother’s care. She wanted to ensure the care provider learned from what went wrong. She also considered the care provider should make a payment to her mother as a goodwill gesture and refund one night’s care. The letter of complaint was passed to the manager of the care home and the Head of Care.
40. On 25 April the manager contacted the agency which employed the care assistants who had been working in the home during Mrs X’s stay. He sent the agency details of Mrs A’s complaint and asked the agency to take statements from these staff.
41. On 1 May the agency sent the manager a written statement from the SCA who had been on duty on the two nights when Mrs X had falls. This SCA had completed both incident report forms.
42. In his statement, the SCA said the first fall happened on 26 March in the early morning. He said he had contacted 111 and noted this in the care records. He had also put a crash mat and sensor mat on the floor as a precautionary measure.
43. The SCA said he met Mrs A on the evening of 27 March when she was visiting Mrs X. He noticed then that Mrs X had a black eye. Mrs A told him she had seen bruises on Mrs X’s body when she was showering her. The SCA then completed a body map and said he made a record in Mrs X’s Care Plan and communication book. He said it was known that Mrs X had had falls at home but there was no falls risk assessment and no preventative measures had been put in place to protect her during her stay.
44. On 8 May the manager of the care home replied to Mrs A’s complaint. He said he had spoken to the Head of Care and they agreed there were some areas where the service had fallen below expected standards. In particular, he noted the lack of detailed recording of information and poor communication. He authorised a refund of £185.71 for one night because Mrs X left the care home one day earlier than planned.
45. He said it was not normal practice to contact 111 when a resident has a black eye. But he accepted that staff should have carried out more regular checks on Mrs X during the night. He said that had been agreed with care home staff. He could not explain why the call bell in Mrs X’s room had been disconnected.
46. He apologised for staff contacting Mrs A’s sister when the notes clearly said Mrs A should be the first point of contact. He arranged for the charge for the final night to be removed from the invoice. He did not explain how Mrs A could take her complaint to the next stage of the BUPA complaints procedure if she was not satisfied with his reply.
47. On 11 May Mrs A informed the manager she was going to seek further advice. On 17 May the manager invited her to meet him and the Head of Care at the care home. Mrs A replied on 24 May to suggest some dates. Mrs A and her sister attended the meeting on 10 June. On 24 June the manager sent Mrs A an email to say he was waiting for some further information before sending a further response to her complaint.
48. On 4 July the manager sent his final response to Mrs A’s complaint. He made the following points:
• appropriate levels of care and observations were undertaken when the mark was identified on Mrs X’s face;
• The SCA contacted 111 following Mrs X’s fall on 30 March;
• Crash mats were provided in the bedroom;
• He could not explain why the call bell had been disconnected;
• There is no way to prove that Mrs X’s urinary tract infection, which started after she left the home, was a consequence of the care she received;
• He accepted that detailed information, obtained mainly in the Pre Admission Assessment, such as emergency contact details and the need for regular night- time observations could have been handed over more efficiently;
• The team has implemented additional handovers and briefings for new residents to learn from these mistakes;
• information recorded in the Care Plan could have been more thorough and robust. Since this incident more regular and enhanced auditing of care plans has been implemented by the Clinical Governance Manager;
• further training has been delivered and weekly visits to the home are being made to check on the quality of recorded documentation continues.
49. The letter did not say it was a Stage Two response nor did it inform Mrs A that she could complain to the Ombudsman if she was not satisfied. The manager says this was an oversight on his part.

Service improvements since Mrs X’s stay

50. In his final response to Mrs A’s complaint, the manager said many improvements had been made since Mrs X’s stay. I asked for details. The care provider provided the following information:
• it had recruited new care staff in the last six months to reduce the use of agency staff;
• it only uses agency staff who have worked at the care home before and who know the residents; 
• the Head of Care now carries out pre- admission assessments to ensure correct information is captured consistently. The document is then passed on to the Senior Care Experts before admission to give staff time to prepare the resident’s Care Plan;
• it has introduced a new handover process between the day and night teams to ensure consistent communication; 
• it delivered a leadership course for Senior Care Experts to give them greater confidence in decision-making, delegation skills, team leadership, empathy and understanding of families;   
• a new Head of Care has been in post since September 2019. This has provided stronger leadership, increased visibility to residents and families and improved communication;
• it has improved the relationship with the Care Home Support Service which provides additional training for the team;
• it has recruited a Village Trainer to ensure compliance with mandatory training and to create bespoke training plans.

Analysis

51. The care provider could not find several of the key care records. In the records it did provide, there were some inconsistencies. The dates entered for Mrs X’s falls on the incident report forms did not correspond with the dates on the daily handover notes. The failure to retain all the care records, and the quality of record-keeping, fell below acceptable standards. That is fault.
52. Although a pre-admission assessment was carried out, the care provider cannot find it. So it cannot produce any evidence to show that a falls risk assessment was completed before Mrs X was admitted to the care home. The statement from Mrs A’s sister confirms she discussed Mrs X’s history of falls with the nurse during the pre-admission meeting. Furthermore, the agency SCA stated in his 1 May statement he had not seen a falls risk assessment and no preventative measures had been put in place. This was a significant omission which put Mrs X at risk.
53. After Mrs X’s first fall on 27 March, there is no evidence that managers acted on the incident report form completed by the SCA. They should have assessed the risk of falls, reviewed and updated the Care Plan, and ensured appropriate measures were put in place to prevent or mitigate the risk of further falls. If that action had been taken promptly, it may well have prevented the second fall on 30 March or Mrs X may not have suffered such extensive bruising.
54. There were also failings in the way the care home considered Mrs A’s complaint. The care home manager replied at both stages. When Mrs A made it clear she was not satisfied with his 8 May response, he should have escalated the complaint to the Quality & Compliance team for a review at the second stage of BUPA’s complaints procedure. Instead the local manager continued to deal with the complaint. Furthermore, Mrs A was not given information about the Ombudsman in the final response of 4 July. The manager did not follow BUPA’s complaints procedure and that was fault.
55. The care provider has explained the steps it has already taken to review procedures, improve training and implement staffing changes to address the failings in Mrs X’s care. I made one further recommendation about record-keeping and the retention of records.
56. Mrs A believes there was a deliberate attempt by staff in the care home to cover up Mrs X’s first fall. I found no evidence to support this view. The agency SCA completed an incident report form to record the first fall and his immediate response. There was then a failure by management to take the necessary steps to complete a risk assessment, review Mrs X’s Care Plan and put measures in place to reduce the risk of further falls. There was also a failure to inform Mrs A of the first fall. These were significant failings but, on the available evidence, I cannot say there was a deliberate attempt by staff to conceal what had happened.
57. Mrs A’s photographs, and the incident report forms, confirm Mrs X suffered extensive bruising following the first fall. These injuries may have been prevented if there had been proper care planning, a risk assessment and measures put in place to mitigate the risks from the start of Mrs X’s stay. Sadly, Mrs X has passed away so it is too late to achieve a remedy for her.
58. I therefore considered the impact the care provider’s actions had on Mrs A. Naturally she was very distressed to see her mother’s injuries. As her mother had fallen out of bed twice in six days, she decided to remove her from the home one day earlier than planned. That was an understandable reaction to protect her mother from further falls. This disrupted Mrs A’s plans and caused her some inconvenience because she had to juggle her work and caring responsibilities. She was also put to some time and trouble in pursuing a complaint.

Agreed action

59. Within one month, the care provider will:
• arrange for a senior manager to apologise in writing to Mrs A;
• pay £300 to recognise her distress and inconvenience;

It has already implemented the following recommendations:

• reviewed its procedures for retention of former residents’ records to ensure they are available for Ombudsman investigations;
• ensure managers complete the relevant sections of incident report forms to record action taken;
• remind local care home managers that complaints must be escalated to the second stage of BUPA’s complaints procedure if they cannot be resolved locally at the first stage;
• confirmed that the final response from the Quality & Compliance team signposts complainants to the Ombudsman.
3. I have completed the investigation and found the late Mrs X suffered injustice due to the care provider’s actions. Sadly, it is too late to provide a remedy for her. The care provider has agreed to provide a remedy to recognise Mrs A’s distress and inconvenience.

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Investigator's decision on behalf of the Ombudsman