Summary: Mr B complains that his father broke his hip while he stayed at a care home. We have not found fault with the way the Council carried out a safeguarding enquiry into the incident, not its investigation into alleged discrepancies in the documents. However, there was some fault in the care home’s communications with the family, record keeping and consideration of the care plan. The Council’s safeguarding enquiry already addressed these concerns with recommended service improvements. We do not recommend any other service improvements but the Council should apologise to the family for the fault.

The complaint

1. Mr B complains on behalf of his father, Mr C, who has sadly passed away. Mr C broke his hip while he was staying at Thorncliffe Grange Nursing Home in Denton, Manchester. Mr B says there is conflicting information about what happened during the night of the incident and there has not been a satisfactory explanation on how the fracture happened. He says the Home failed to put in a pressure mat and says the Council’s investigation into the incident did not provide the necessary answers.

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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. 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)
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 Mr B. I have considered the documents that he and the Council have sent, the relevant law, guidance and Council policies and both sides’ comments on the draft decision.

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What I found

Law, guidance and policies

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 CQC has provided guidance on the regulations. This says that the care and treatment must be provided in a safe way for service users. (regulation 12). This means care homes should, among other things:
• Assess the risk of health and safety of residents receiving the care and treatment.
• Do all that is reasonably practicable to mitigate any such risks.

Safeguarding duty

8. The Care Act 2014 and the Care and Support Statutory Guidance 2014 (updated 2017) set out the Council’s safeguarding duties towards adults who require care and support. The Council also has its own policies.
9. Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:
• has needs for care and support
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
10. If the section 42 threshold is met, then the Council must make enquiries or cause others to do so. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by whom.

What happened

11. Mr C was admitted to the Home on 30 August 2018 for two weeks respite care. He had a diagnosis of dementia. Mr C broke his hip on 7 September 2018.
12. I will set out what the documents say about Mr C’s care planning and the events of the day when the incident happened.

Council’s assessment

13. The Council carried out its assessment of Mr C’s needs in July 2018. The social worker said was becoming increasingly more difficult for Mrs C to be Mr C’s full time carer.
14. Mr C needed assistance in all aspects of his care such as washing, showering, getting dressed, meals, medication and so on.
15. Mr C got up numerous times during the night and, because of his dementia, he was not be able to find the bathroom so Mrs C had to help him and this led to her sleep being disturbed. Mr C was sometimes doubly incontinent which was greatly distressing to Mrs C and meant she spent a lot of time changing clothes, bedding and doing laundry. Mrs C was not able to leave Mr C on his own.
16. Mr C had a respite break in the past and the Council agreed that he should have a further respite break.

Home’s assessment and care plan

17. The Home’s manager carried out a pre-admission assessment of Mr C on 13 August 2019. The Home’s deputy manager carried out a further assessment on the day of admission, 30 August 2019.
18. The documents show the following:
• The Home’s mobility dependency assessment said Mr C scored a 2 in terms of mobility which meant he needed the assistance of one person to mobilise.
• Mr C’s moving and handling care plan said Mr C was mobile but may need the assistance of one carer.
• The Home scored Mr C’s social dependence as 4 which meant he was unable to manage alone and was at risk. In terms of his behaviour, he scored a 2 which meant that he wandered by day and by night.
• The Home assessed Mr C’s risk of falls. It said he was at medium risk of falls. Some of the risk factors were the fact that his mobility status was unknown or he appeared unsafe/impulsive. He was disorientated in terms of his environment, for example between his bed and the bathroom and had accidents in terms of his continence. The action plan said Mr C ‘needs directing, needs assistance of one carer due to cognitive impairment.’
• The personal safety/falls risk care plan said Mr C was at risk of falls although he had only had one fall at home. It said Mr C was unable to use a nurse call bell due to his cognitive status. Staff had to check Mr C 2 to 3 hourly overnight as he was known to get up at night.

Incident report - 7 September 2018

19. The incident report said the care workers went into Mr C’s room at 6:00 am to assist him with personal care. Mr C shouted: ‘Hello’ as the care workers walked in. The care workers said Mr C did not sound upset or stressed but said it looked as if he had tried to get out of the bed as he was half in and half out of the bed. His bedsheet was wet and his continence pad was on the floor. When the care workers assisted Mr C to stand, he shouted: ‘My knee.’ His knee then seemed to give way. The care workers then guided Mr C to the floor and an ambulance was called.
20. At the hospital it was determined that Mr C had broken the neck of his femur (thigh bone).

Ambulance crew’s safeguarding referral

21. The ambulance crew made a safeguarding referral to the Council on 7 September 2018. The referral said:
• This was an unwitnessed fall and it was not clear how Mr C sustained the injury.
• The carers said they were unaware that the patient had a fall.
• The carers said Mr C had been checked every hour, however in the documentation there was an hour blank which suggested that Mr C may not have been checked on.

Hospital transfer form

22. The hospital transfer form said: ‘Stood to get washed, said his knees was hurting, went down onto knees. Knee very painful.’

Other information

23. Mr C was supported to bed at 22:30 and the nightly checks form showed Mr C was checked at 22:55, 01:15, 04:05 and 6:00 (when he was found.)
24. Mr C sadly died in hospital on 30 October 2018.

Council’s safeguarding enquiry

25. The Council received two safeguarding referrals, from the ambulance service and from the Home on 7 September 2018.
26. The social worker visited the Home on the same day to start pre-safeguarding enquiries. The Home’s manager said a crash mat was not in place for Mr C as Mr C was not identified as a high falls risk.
27. The social worker also spoke to a consultant at the A&E department who said the injury must have been sustained from a fall and that it was unlikely that Mr C would have transferred himself into bed without help.
28. The social worker spoke to the family on 10, 17 and 25 September 2018 and had a meeting with them on 19 September 2018. She visited Mr C at the hospital on 28 September 2018.
29. The decision to start a formal safeguarding enquiry was taken on 11 October 2018 and the strategy meeting took place on 16 October 2018.
30. The safeguarding manager spoke to the staff nurse at the hospital on 16 October 2018 who said it would be difficult for a person who sustained a fracture to return to bed, but could not say that it was impossible.
31. The investigating officer said in the report dated 24 October 2018:
• ‘It is documented that …[Mr C] was able to walk independently with no aids or equipment.’
• As Mr C was not a high falls risk, a crash mat was not used as this would have been a trip hazard.
• Due to the layout of the rooms, staff had to pass Mr C’s room to observe a resident next door who was checked hourly. Staff had full view of Mr C’s room and noticed nothing unusual. The last check on the other resident’s room was at 5:20 am.
• The care workers who assisted Mr C at 6 am both gave written statements about the incident with drawings to show where Mr C was when they found him.
• The hospital told the investigator that it would be difficult for Mr C to return to bed unaided, after suffering the fracture, but could not say that it was impossible. All the evidence suggested that Mr C was trying to get back onto the bed as he was face down on the bed with his right leg bent on the bed.
• The ambulance crew’s statement that there was an hour gap in monitoring contradicted the evidence the investigator saw. There was no requirement to check Mr C hourly as the care plan said he should be checked two to three hourly. The ambulance crew probably referred to the informal checks which were done while checking Mr C’s neighbour and misunderstood the information.
32. The conclusion of the safeguarding enquiry was:
• Inconclusive.
• The investigator could not determine how the injury occurred.
• It was likely that Mr C got out of bed, suffered a fall and attempted to get himself back on the bed but this could not be said with any certainty.
• There was no negligence on behalf of the staff involved as the nightly checks were carried out and staff sought medical intervention at the earliest opportunity.
33. The recommendations of the enquiry were:
• To use a bed sensor for any other residents in similar circumstances.
• To ensure that documented information was accurate and consistent.

Mr B’s complaint

34. Mr B complained to the Council about the fall in February 2019. He wanted a full investigation into what happened and why.
35. The complaint went through the 2 stages of the complaints process and I have summarised the complaints and the Council’s complaints response.

The day of admission / failure to provide a crash mat

36. Mr B said:
• During their initial visit to the Home, he and Mrs C discussed with the assistant manager how Mr C could call for help at night.
• The deputy manager said there was an emergency button above the bed. Mr B explained that, because of Mr C’s dementia, he would not be able to use this button. The deputy manager agreed and removed the button immediately. She promised that a crash mat would be installed.
• The Home never installed the mat.
• The Home later said it would not have agreed a crash mat as this was a tripping hazard. However, the Home never explained how Mr C was meant to call for help if he was unable to use the call button and did not have a mat.
37. The Council’s assistant director responded to the complaint and said:
• There was no record within the assessment document of a discussion taking place regarding a crash mat. The assistant director spoke to the Home’s manager and she said she remembered a conversation with the family to advise them that a crash mat would not be considered as it would be a trip hazard.
• The documents showed there was a conversation on 10 September 2019 where the manager explained to Mrs C why it would not use a crash mat for someone like Mr C. The Council apologised if the Home’s recollection of the conversation was different from the family’s.
• None of the documents identified that the Home would provide a crash mat.
• The moving and handling plan said Mr C was mobile with no equipment needs and required the support of one carer. The falls risk assessment said he was at medium risk of falls.
• The care plan said Mr C was unable to use the nurse call bell so 2-3 hourly checks were to be carried out.
• As Mr C was unable to use the nurse call bell, alternative alerts could have been considered such as a bed exit sensor, which could have reduced the risk to him. This had been recommended as part of the safeguarding enquiry and had been communicated to the Commissioning Team who would monitor this.
• The Council had also recommended that any verbal conversations were recorded and highlighted the importance of thorough pre-admission assessments being completed and fully documented.

Discrepancies in the records and the Council’s responses

38. Mr B complained about the discrepancies he had noticed and said:
• The Council’s complaint response dated 5 April 2019 said Mr C was supported to bed at 11 pm and was checked by night care staff every 2-3 hours.
• The Council’s complaint response dated 4 February 2020 said Mr C was supported to bed at 22:30 and checked at 22:55, 01:15 and 04:05.
• The paramedics report said the care workers told the paramedics that Mr C was checked hourly but that there was a gap between 04:00 and 05:00.
• The hospital transfer form said: ‘[Mr C] stood to get washed, said his knee was hurting, went down onto knees, knee very painful.’ This contradicted the statements of the care workers who said they found Mr C half in and half out of the bed and assisted him to stand.
• The NHS triage report said: ‘Care staff deny had had a fall.’
• The hospital said it was unlikely that Mr C would have been able to get from the floor to the bed. The consultant surgeon also said this. If Mr C was unable to climb into the bed, then the statements by the care workers who said they found Mr C half in/half out of the bed must be false.
39. The Council said:
• The incident/accident report and the CQC notification confirmed what was found in the daily records. Mr C was supported to bed at 22:30 and checked at 22:55, 01:15 and 04:05. He was sleeping every time he was checked.
• Because of the lay out of the rooms, the night staff had to pass Mr C’s rooms, in order to observe a resident who was on hourly checks. Staff did not notice anything untoward in Mr C’s room during those checks.
• The writer had consulted with an occupational therapist who said that a crash mat may have posed a risk as a potential trip hazard.
• There was no indication that staff had been negligent in their duties on the night of the incident.

The Ombudsman’s investigation

40. In their complaint to the Ombudsman, Mr B explained that the discussion about the crash mats took place on the day of admission, 30 August 2018 and the conversation was with the assistant manager, not the manager. He said Mr C had stayed at a different care home in the past and this care home had provided Mr C with a pressure mat beside the bed to alert the staff if Mr C went wandering.
41. The Home’s manager made the following comments in response to the Ombudsman’s questions:
• She assessed Mr C a few days before his admission.
• Mr C was independently mobile. He walked around freely during the day and would also get up at night.
• A crash mat would not be used as these mats are thick and would increase the risk of falling.
• An alert mat would only be used if the resident was ‘unsteadily mobile’ and staff would need to be alerted to movement. This would require a best interest decision and a deprivation of liberty authorisation.
• Her observations of Mr C were that he was ‘steadily mobile’. For example, he was able to walk from the lounge to the lift and access the family’s car outside.
42. The Home’s deputy manager who assessed Mr C on the day of admission said the following:
• ‘I do not recall specifically saying that an alert mat would be put into [Mr C’s] room, it may have been discussed that if there was a problem overnight then an alert mat could be placed by the side of the bed.’

Analysis

Discrepancies in the records

43. Mr B has highlighted discrepancies in the records of the night of the incident and the Council’s complaint response and he is concerned that this means the Home is trying to hide something. The Council has investigated this as parts of the safeguarding and complaints processes and has not found any concerns.
44. I have read all the first-hand records, namely the daily records, the incident report, the CQC referral, the safeguarding referral and they are all consistent and clear. They all essentially say the same thing.
45. Mr C was assisted to bed at 22.30 and was then checked at 22:55, 01:15. 4:05 and 6:00. This is what the Council said in its complaints response dated 4 February 2020. I agree that the Council’s first complaints response was inaccurate as it said Mr C was supported to his room at approximately 11pm. However, I think that is human error by the person investigating the complaint and not an indication of anything more sinister.
46. The Council has explained that an hourly check was not needed for Mr C and the care plan confirms this. It has also explained that informal hourly checks were happening because Mr C’s neighbour needed hourly checks. It may be that the paramedics misunderstood the information they were given, but there was no fault in the Home not providing hourly checks. In any event, the care workers said they saw Mr C at 5:20 am and did not witness anything untoward so there is no indication that an additional hourly check would have made any difference.
47. There is no contradiction in the hospital transfer form and the care workers’ accounts of what happened at 6:00 am. Mr C went to stand to get washed and then told the care workers his knee hurt.
48. The hospital transfer form simply says the staff denied that Mr C had a fall. I think the word ‘denied’ may slightly confuse matters, but I think the hospital is saying that no fall had been witnessed so the Home could not say that a fall had happened.
49. Therefore, overall, I find no fault in the way the Council has addressed these discrepancies and I agree that there is no evidence that the Home’s records of the incident itself were incorrect.
50. I also agree with the Council that there is no indication, from the evidence I have seen, that the Home’s staff did not follow the correct procedures or did not follow Mr C’s care plan on the night of the incident.

The day of admission / failure to provide a crash/alert mat

51. Mr B says the Home promised him and Mrs C that a pressure mat would be provided. The Home said this was not the case.
52. The Home’s assessment of Mr C and his care plan do not mention any discussion about a mat or an emergency bell.
53. When the Council investigated this, the Home’s manager confused matters by saying she recalled a conversation with the family about the mats, but did not say when this conversation happened. There is only one record of a conversation about crash mats between the manager and Mrs C but this took place on 10 September 2018, after the incident.
54. The Council said in its complaint response to Mr B dated 4 February 2020 that ‘this recollection of the conversation contradicts your account’ but it was not clear what conversation the Council was referring to. Mrs C and Mr B agreed that the manager had a conversation with Mrs C about mats on 10 September 2018, but this was not the conversation their complaint related to.
55. Their complaint related to a conversation Mr B and Mrs C had with the deputy manager (not the manager) on the day of Mr C’s admission, 30 August 2018 (not 13 August 2018).
56. The deputy manager has now confirmed that she cannot remember a specific promise to place an alert mat, but says it may have been discussed to put an alert mat by the bed, if there was a problem overnight.
57. In its original complaint response, the Council did not uphold this complaint, but that was because the Council and the complainants were talking about different conversations.
58. I can make a decision on the balance of probabilities. As the deputy manager admits she may have promised an alert mat, but cannot definitely remember doing so and as Mr B and Mrs C have clear memories of the conversation, I can conclude that, on the balance of probabilities it is likely that the conversation took place.
59. If that was the case, the Home should have installed the mat or, if it later decided it was not appropriate for Mr C’s needs, it should have let the family know. Also, whatever the outcome, there should have been a record of the conversation and the decision. Therefore, there was fault in terms of poor communication with the family and poor record keeping about the decision making.
60. The Home’s manager has explained the difference between a crash mat and an alert mat. This is helpful as I note that the two terms have been used in the documents I have seen, but they are different things used for different purposes.
61. My reading of the letter is that a crash mat would prevent injury from a fall, presumably out of bed, and did not apply to Mr C. As he was mobile, it would have been a trip hazard. The alert mat is similar to a bed exit sensor in that it alerts staff that the resident is up and moving about and the staff can then go and attend to the resident.
62. One of the recommendations of the safeguarding enquiry was that the Home should use a bed exit sensor for any other resident in circumstances similar to Mr C’s. The Council also said in its complaint response that the Home could have considered a bed exit sensor as this could have reduced the risk. I agree with these findings.
63. A sensor should have been considered, not necessarily only because of the risk of falls, but because of the risks that Mr C’s dementia posed. Mr C was disorientated and the falls care plan said he needed assistance from one care worker ‘due to cognitive impairment’ when he was ‘wandering’ particularly at night. Also, Mr C had no mechanism to call for help as his call bell had been removed.
64. It was not clear how these concerns could be addressed by a 2-3 hourly check. Also, as mentioned above, the family had raised the issue and been promised an alert mat. Therefore, I am of the view that the option of some type of alert mechanism or sensor should have been considered at the care planning stage and any decision whether to install it or not should have been recorded.

The Council’s safeguarding enquiry - no satisfactory explanation for the injury.

65. I find no evidence of fault in the Council’s safeguarding enquiry. I understand how frustrated Mr B and the family are by the fact that they do not know how Mr C sustained his injury. However, the failure to find those answers does not mean there was fault in the way the enquiry was run. Sadly, if a person with dementia has an unwitnessed fracture, it may be that some questions will never be answered.
66. The enquiry was thorough. The investigating officer checked all the records from the Home and other agencies. The two staff who found Mr C were interviewed and supplied full statements. Their statements were accompanied by drawings of Mr C on his bed to ensure it was clear what Mr C’s position was on the bed when he was found.
67. I also note the social worker contacted the hospital nurse to obtain more information about the possibility of Mr C getting back on the bed unaided. The main reason why the family was worried there was something suspicious about the fracture was the fact that it was unlikely that Mr C had got back on the bed by himself. The nurse agreed it was unlikely, but not impossible and I do think it was important for the Council to clarify that.
68. The enquiry also considered whether the Home needed to take any action to reduce any risk in similar circumstances. I agree with the two recommendations the Council made in terms of installing sensors and proper recording of conversations and initial assessments. They were appropriate recommendations to address the risk that had been identified and to minimise the chance of this happening to another resident in the future.

Injustice

69. The fault I have found relates to the Home’s communication with the family and its failure to consider and record its decision regarding installing an alert mat or sensor.
70. I cannot say, of course, what the outcome would have been if the Home had considered it. I cannot say what Mr C’s care plan should have been. Also, even if the Home had put in place a sensor, this may not have prevented the fall as that was not its main purpose. A sensor may have contributed to the reduction of the risk of falls, but this was part of the wider purpose of addressing the concerns relating to Mr C’s dementia, wandering and his inability to use a call bell when he needed help.

Agreed action

71. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Home, I have made recommendations to the Council.
72. The Council has agreed to apologise to the family within one month of the final decision.
73. The Council has already identified the appropriate service improvements and I do not make further recommendation in that respect. Under our information sharing agreement, we will share this decision with the CQC.

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Final decision

74. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman