Oxfordshire County Council (19 008 326)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 18 Mar 2020

The Ombudsman's final decision:

Summary: Mrs X complained about an incident that occurred at a Council commissioned care home which she says led to her father’s death. There were faults by the care home, acting on the Council’s behalf, which the Council identified through its safeguarding investigation. The care provider has already taken appropriate action to learn from the faults identified and to make improvements to its service.

The complaint

  1. The complaint concerns the Council commissioned care provided to Mrs X’s late father Mr Y at Yarnton Residential and Nursing Home.
  2. Mrs X complains the care home failed to properly assess a new resident to the care home, and to manage the risk posed by the resident, who pushed her father over, leading to a broken hip which led to his death.

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The Ombudsman’s role and powers

  1. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
  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. We cannot investigate a complaint about the start of court action or what happened in court. (Local Government Act 1974, Schedule 5/5A, paragraph 1/3, as amended)
  4. 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)

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How I considered this complaint

  1. I have considered the information provided by Mrs X in writing and on the phone. I have considered the Council’s response to my enquiries.
  2. I gave Mrs X and the Council an opportunity to comment on a draft of this decision and considered any comments I received in reaching this decision.
  3. 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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What I found


  1. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014).

What happened

  1. Mr Y had dementia. He had poor mobility and used a walking frame. He had lived at the care home since December 2017. In early December 2018 an incident occurred where another resident (Resident B), who had recently moved into the care home, pushed Mr Y over. The care provider called 999 and an ambulance attended. The paramedics decided Mr Y did not need admitting to hospital and assisted him to his room.
  2. The next day, staff were concerned Mr Y could not weight bear or stand up and called his GP who referred him to hospital.
  3. Later that day Mr Y was discharged from hospital. X-rays found no obvious injury. He was prescribed antibiotics for a chest infection.
  4. Mr Y was in pain and so the care provider contacted the GP who prescribed pain relief. Mr Y’s condition did not improve. Following discussion between the GP and family it was agreed Mr Y would remain at the care home rather than undergo any further investigations at hospital. The GP prescribed increased pain relief.
  5. Mr Y died at the care home nine days later. This was reported to the police. The care provider raised a safeguarding alert with the Council.
  6. The Council undertook a safeguarding investigation into what happened. It reviewed evidence from the care home’s last quality monitoring visit and spoke with the care home manager, the GP, the hospital, the police and the family. It looked at the care home records.
  7. In January 2019 Mrs X submitted a complaint to the care provider. The care provider responded in March 2019. It explained Resident B was assessed prior to their admission and information was sought from other professionals at the time. It advised that in future, it would ensure it considered the needs of existing residents when new residents were assessed. Mrs X remained unhappy and the care provider responded at stage two of its complaints’ procedure in June 2019. It explained as Mr Y could mobilise independently with a walking frame and Resident B could mobilise independently, neither had 1:1 supervision when they left the dining room. It confirmed a staff member stayed with Mr Y after his fall. It said the home had taken appropriate steps when Resident B was identified as having challenging behaviour. The care provider said it had contacted the social worker about the incident but at that point no injury was identified. It had later raised a safeguarding alert.
  8. The Council’s safeguarding investigation found the care provider was raising concerns with the Council about Resident B and had requested the Council look for a more suitable environment for Resident B before the incident occurred. It provided 1:1 support when Resident B was clearly agitated and aggressive but not at other times. This plan was not clearly recorded and was a reactive rather than proactive response to Resident B’s behaviour. There was not a clear risk management plan written in the records.
  9. It found a lack of handover between staff regarding the frequency of aggressive incidents by Resident B. It found carers logged challenging behaviour by Resident B but the manager was not always alerted to this. The Council considered, had the manager known they may have been able to put more effective risk management in place.
  10. It found when Mr Y was on the floor after the incident awaiting the paramedics, Resident B was still nearby trying to kick away Mr Y’s pillow. Staff prevented any harm to Mr Y but did not call management for back up support.
  11. It considered even if Resident B had 1:1 support this might not have prevented the incident as it only takes a moment to push someone.
  12. The Council concluded the safeguarding investigation in early July 2019. It found the allegation of neglect partially substantiated. There was a lack of handover between staff related to the aggressive incidents and staff failed to call management for support in the aftermath of the incident. It recommended:
    • the care home undertake (where possible) a more in-depth pre-admission assessment to ideally include a visit from the potential new resident to the care home for lunch/a couple of hours. This would allow both parties to assess each other and would potentially provide an opportunity for any challenging behaviour to be recognised and considered.
    • the care home consider taking a proactive, not reactive, approach especially in situations of challenging behaviour. Although Resident B’s behaviour was largely unpredictable, a proactive approach would have encouraged carers to expect the unexpected.
    • clear communication and escalation within the care team at the care home when there are incidents of concern, including calling on management support earlier, especially when staff are struggling to manage someone’s behaviour.
    • training for care home staff around person centred dementia care and de-escalation techniques for challenging behaviour.
    • improved communication at the care home with families of residents especially when incidents occur.
  13. The coroner reached a narrative verdict in June 2019. They concluded Mr Y died due to a bone fracture and worsening of an underlying health condition. They said Mr Y sustained the fracture “as a result of an unprovoked shove by another resident causing him to fall to the floor”.
  14. The Care Quality Commission inspected the care home in May 2019. It rated the care home as good in all areas. Its findings included:
    • There were sufficient staff deployed to meet people’s needs.
    • The service was well-led by a manager who was making positive changes.
    • The staff culture had significantly improved, and this had resulted in the provision of good care.
    • Care plans reflected individual needs with clear guidance for staff to follow to ensure person centred care.
    • The management team ensured people’s needs and any changes were communicated effectively among staff.
  15. In June 2019 the Council also carried out a quality monitoring visit at the care home. During the visit it reviewed the care home's admission procedures and support for service users with dementia. It rated these areas as good.


  1. The circumstances leading to Mr Y’s death were the subject of a coroner’s inquest and it was for the coroner to determine the cause of death and any link between poor care and the cause of death. I cannot comment on the coroner’s investigation. The Council carried out a thorough safeguarding investigation and I have found no fault in the way the Council conducted this. I have therefore not reinvestigated what happened as I cannot add to the investigations already undertaken.
  2. The Council’s safeguarding investigation found failings in the care provided. The care provider failed to ensure effective staff handover after incidents of aggression and staff failed to seek support from management after the incident occurred. This is fault. Although the investigation did not find the care provider failed to properly assess Resident B on their admission, it did highlight the need to ensure risk management plans are drawn up and shared with staff promptly where individuals exhibit challenging behaviour. It also noted that the need to provide 1:1 support to Resident B when they were agitated was not clearly recorded. This was fault.
  3. There were faults by the care provider but I cannot say, even on balance, what the outcome would have been had the faults had not occurred. Mr Y has died so I cannot provide any remedy for him. However, Mrs X is seeking assurance that the same thing will not happen to anyone else.
  4. The Council made recommendations which the Coroner accepted were appropriate. The care provider has provided evidence to demonstrate the actions it has taken based on the Council’s recommendations. This includes:
    • Potential new residents having lunch/activity visits prior to their admission;
    • Staff have attended training on behaviour and communication and dementia and a number of staff are now studying for NVQs;
    • Staff are aware of the need to raise potential safeguarding issues and it has provided evidence to show this has happened recently;
    • There has been a significant reduction in staff absence and the need for agency staff leading to more consistency in staffing; and
    • Positive feedback from relatives following a recent relatives and residents meeting.
  5. The CQC has since inspected the home and rated the care provided as good, as did a recent Council quality inspection. I am satisfied suitable action has been taken to ensure the necessary improvements were undertaken by the care provider.
  6. There was a delay in the care provider raising the safeguarding alert. Initially it believed no harm was caused to Mr Y. However, after Mr Y’s admission to hospital it should have raised an alert. This is fault. However, it did raise an alert later and this was properly investigated so this delay did not cause a significant injustice.

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Final decision

  1. I have completed my investigation. There was fault by the care provider, acting on behalf of the Council. It has taken appropriate action to learn from the faults identified and to make improvements to its service.

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Investigator's decision on behalf of the Ombudsman

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