Summary: Mrs B says her mother was found with a broken hip in the care home and there is no record of what happened. The Ombudsman has found fault and the Home has agreed to pay Mrs B £500 to reflect the injustice she has suffered.

The complaint

1. Mrs B complains on behalf of her mother, Mrs C. She says Mrs C was found with a broken hip at Manorhey care home in Manchester and nobody has been able to say what happened.

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

5. I have discussed the complaint with Mrs B. I have considered the documents that she, the Home and the council have sent and Mrs B’s and the Home’s comments on the draft decision.

Law, regulations and policies

Care Quality Commission

6. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve.
8. The CQC has issued guidance on how to meet the fundamental standards below which care must never fall. This says that:
• The care and treatment must be provided in a safe way for service users. (regulation 12).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17).

The Home’s Protocol

9. The Home has an Accident and Incident Management and Record Protocol which sets out what action staff should take when there has been an incident or accident.
10. Staff should (among other things):
• Call for assistance from a colleague.
• Ensure the person is thoroughly checked by an appropriately trained person. They should observe them for signs of pain, injury, bruising and breaks to the skin.
• Arrange emergency first aid by a qualified person or dial 999 if life threatening.
• ‘Where a service user has been found on the floor/un-witnesses fall the staff must automatically treat them as having sustained a head injury and central nervous system observations must be carried out using the Glasgow Coma Score.
• ‘Where there is any doubt regarding sustained injury the Medical Practitioner must be called without delay and the resident must not be moved if this movement is likely to make their condition worse.’
• ‘Where the fall is un-witnessed then the staff must consider that the person could have sustained a head injury and the appropriate protocol for head injury must be followed.’
• Next of kin should be informed.
• A written record should be made and staff should inform the manager as soon as possible.
• If a person does not need to go to hospital, then in any case of a fall/found on floor/unwitnessed fall, the post-falls protocol must be implemented.
• The post-falls protocol says there should be a 24 hour post fall observation log.
• Any injury through accident requiring removal of the person from the home via emergency services is RIDDOR (reporting of injuries and dangerous occurrences regulations 2013) reportable.

What happened

11. Mrs C is an elderly woman who suffers from dementia. She lacks capacity to make decisions about her care. Mrs B holds a Lasting Power of Attorney in respect of Mrs C’s property and finance. Mrs C has been living at the Home since March 2018.
12. The care plan said Mrs C had problem forming words and had a limited understanding of information given. She could understand others some of the time. She had significant hearing loss in both ears.
13. At the time of the incident, Mrs C’s care plan said she was able to walk with a walking frame. She was at risk of falls so she had to sleep on a low profile bed with the left bedrail up. There was a sensor mat to the right side so, if Mrs C got out of bed, staff would be alerted. I understand staff were meant to carry out two hourly checks during the night.
14. Mrs C was found in the morning of 15 May 2019 after the alarm bell was triggered. She was found lying on the bed with her right leg hanging off the bed. Mrs C was in pain. The staff member alerted the nurse. Mrs C was unable to bear weight on the leg. The GP was called and she advised that Mrs C should be taken to hospital.
15. Mrs C was taken to hospital where it was confirmed that Mrs C had a fractured right hip.
16. The manager spoke to Mrs B on 17 May 2019 and Mrs B said she had been informed that the fracture appeared to be the result of a fall / impact.
17. The Home completed an incident report and informed the Council and the Care Quality Commission of the incident. It also made a RIDDOR referral. The Council started a safeguarding investigation.
18. The Home’s records showed that Mrs C’s pressure mat was activated twice during the night triggering the call bell, at 02:33 am and at 05:02 am. The electronic call bell records showed that the call bell was turned off on both occasions from inside Mrs C’s room which meant that somebody went into Mrs C’s room and switched off the call bell. However, there was no record of who attended those two calls or what actions they took.
19. Mrs C could not say what happened because of the dementia.
20. Staff attended at 02:00 and 04:20 and found Mrs C asleep.
21. The carers and the nurse who were on duty that night all provided statements of their movements. The assistant manager then interviewed each person separately and the regional director held a further meeting with the staff present.
22. There were some discrepancies in the staff’s statements, particularly about what happened around 5:00 am. The investigation was made more difficult by the fact that there was a handover of staff carrying out one-to-one observations at 5:00 am and the fact that two alarm bells were going off at the same time at 5:00 am.
23. When questioned, all the night duty staff denied assisting Mrs C during the two calls when the alarm was activated.
24. The Council held a safeguarding planning meeting on 7 June 2019 where a 13-point safeguarding plan was agreed to keep Mrs C safe if she returned to the care home. This included:
• Hourly checks during the night.
• Bed to be moved against the wall and a crash mat to be placed next to the bed.
• Bed rails on both sides of the bed.
• Tag alarm.
• A named person to be allocated to Mrs C on each shift.
• Staff to be reminded of the importance of accurate and timely recording when responding to a sensor mat alert.
• The falls assessment and protection plan to be updated.
• Unannounced spot checks to be carried out.
25. Mrs C returned to the Home on 10 June 2019.
26. The Council concluded its safeguarding investigation on 27 June 2019 and said the allegation of neglect had been substantiated. This was based on the fact that the records showed Mrs C’s call bell went off twice during the night but ‘there was no evidence to suggest that a member of staff dealt with the bell, therefore neglecting [Mrs C’s] needs’.
27. The Council said the Home had fully cooperated with the safeguarding enquiry and the Home had implemented the safeguarding plan and updated Mrs C’s care files. The Council had carried out unannounced visits to the Home and no concerns had been raised as a result of those visits.
28. The Home wrote to Mrs B on 16 September 2019 and apologised for the unwitnessed accident which resulted in a fractured right hip.

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What I found

29. I agree with Mrs B that this is a concerning incident. Unfortunately, it will never be clear what happened to Mrs C during the night of 15 May. Nobody can say how Mrs C broke her hip.
30. I have investigated whether the Home’s actions caused an injustice to Mrs C or Mrs B.
31. I note that the care plan which was in place dealt with the risk of falls. The Home alerted the correct authorities once the incident had been discovered. I also note the Home fully cooperated with the council’s safeguarding investigation and implemented the safeguarding plan. These are all positive actions.
32. However, I agree with Mrs B that there was fault in the Home’s actions. It is not disputed that staff went into Mrs C’s room twice during the night so there should be a record of those visits. The Home has a clear policy of what actions staff should follow when there has been an incident and what information should be recorded. There is no evidence that this was followed and there is no record of the visits. That is fault.
33. However, the fault goes further as the staff members were asked repeatedly, after the event, whether they went into the room but they all denied doing so. This was further fault as somebody was not telling the entire truth of what happened that night. That is concerning.
34. I cannot say, with certainty what the injustice was to Mrs C as I cannot say what happened that night. The main injustice to Mrs B is that she will never know what happened to Mrs C. She will always be concerned about what the staff’s involvement was in Mrs C’s injury or whether Mrs C could have been helped sooner if staff had acted in accordance with the Home’s policies.

Agreed action

35. I note the Home has implemented a safeguarding plan. This included a service improvement to remind staff of the importance of accurate and timely recording when responding to a sensor mat alert and a number of other measures to keep Mrs C safe. Therefore, I do not propose any further service improvements.
36. This was an incident which led to a serious injury. The Home’s staff’s failure to record matters properly and to be open and transparent about the incident increased Mrs B’s concerns. I note the Home has already apologised to Mrs B. The Home has agreed to pay Mrs B £500 to reflect the injustice she has suffered as a result of the fault.
37. Under our information sharing agreement, we will share this decision with the CQC.

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Final decision

38. I have completed my investigation and have found that the Home’s actions have caused an injustice. The Home has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman