Summary: There was fault as the care home’s full records cannot be found. From the evidence that the Ombudsman has seen, there was fault as the records do not show how the care home properly reviewed the risk of falls and changed the care plan appropriately. There was an incident where Mrs C was left on her own following a fall. The Council has agreed to apologise to Mrs C’s daughter and pay her £150.

The complaint

1. Mrs B complains on behalf of her mother, Mrs C who has passed away. Mrs B complains about the fact that Mrs C suffered three falls while she was at the care home she was living in and was left on her own during one of the falls.

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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. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
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 and the Council have sent and both sides’ comments on the draft decision.

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What I found

Regulations

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 of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• 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).

What happened

9. Mrs C was an elderly woman who had needs for care and support. She went to live at the care home after she was discharged from hospital on 23 June 2017. Sadly she passed away in September 2017.
10. Mrs C’s care plan/risk assessment said:
• Mrs C was able to walk short distances with a little uncertainty. She might not always lift her feet high enough off the ground to avoid stumbling over uneven ground or small obstacles. Mrs C used a folding frame wheelchair to move from place to place. She also had a walking frame.
• Mrs C required guidance from care staff. She needed reminding to use her mobility aids safely and effectively and may attempt to move without assistance when assistance was required.
• Mrs C was at high risk of falls.
• One carer should support Mrs C during transfers and aids should be used during transfers. Areas where the aids were used should be free from obstacles. Mrs C should have the support of a staff member when moving because of her history of dizziness and blackouts.
• An alarm mat was in place when Mrs C was in bed to alert staff when Mrs C got up so that staff could give her assistance when she was walking.
11. I note the following entries regarding the falls Mrs C complained about:
• 5 July 2017. Mrs C was found on the floor at 19.07. She had a lump on her forehead and cuts on both hands. The Home called 999 as Mrs C was on warfarin (a medication that thins the blood) and had hit her head. Mrs C was taken to hospital and the Home rang Mrs B to inform her. Mrs C returned to the Home the following day.
• 2 August 2017: Mrs C’s pressure mat was activated. Staff found Mrs C sitting on the floor. Mrs C could not move her right leg and complained of pain while moving it. The staff called an ambulance and informed Mrs B. Mrs C returned to the Home the following morning. She had a small fracture in her ribs.
• 18 August 2017. Mrs C’s pressure mat was activated. Mrs B was lying on the floor. She had a bruise on her left hand and a bruise around the left eyebrow. The Home called 111 for further advice and because Mrs C was on warfarin. She was taken to hospital and returned to the Home on the next day.
12. I note that there were nine other incidents when Mrs C was found on the floor.
13. Mrs B made the first complaint in May 2018. I have summarised the complaint and the Council’s responses. Mrs B said:
• Mrs C suffered 3 falls while she was at the Home. One fall happened when she was at high risk of haemorrhage due to the administration of a too high dose of warfarin.
• The ambulance crew who attended Mrs C on 2 August 2017 made a safeguarding referral to the Council as they found Mrs C on her own in her room. Mrs C said she had been left on her own for hours before the ambulance crew arrived
14. The Council carried out a safeguarding investigation into the matter. The Council’s safeguarding investigation took place more than a year after the events (October 2018). The social worker carrying out the investigation said he had read the care plans and risk assessments. There was some information on body maps. However, he said that most of the information required for the safeguarding enquiry was in the Home’s day to day notes (handwritten at that time) and the incident/falls reports which were seen in a separate enquiry.
15. The social worker said that finding the paper copies of the records of the falls had not been possible. He said that there had been a change in ownership and management and the new management had been unable to locate the documents.
16. He concluded that:
• Mrs C had multiple falls whilst at the Home.
• Medical advice was sought appropriately after these falls.
• There was evidence of a reassessment of risk (for example, lowering bed and introducing a crash mat) but no reference of referral to the falls team.
• The recording was somewhat task focussed, but he did not consider that there was evidence to say the Home had been neglectful.
• There were known risks associated with warfarin which meant that the falls could have led to significant injury but felt that the actions taken by the Home were effective in managing the risk.
17. The Council replied to Mrs B’s complaint in May 2019 and sent further replies in June and September 2019. The Council said:
• Mrs C had several falls but the care plans were appropriate and risk assessments were carried out. Crash mats and bed rails were in place. The community nurses visited regularly with regards to warfarin. The Home was in regular contact with the community nurses and the GP and called the emergency services when needed.
• In response to the concerns raised by the ambulance service, the Home said a member of staff sat with Mrs C when she fell and a member of staff was with her when the ambulance arrived. It was the Home’s policy not to leave residents unattended following a fall.
• There had been a change in ownership of the Home since Mrs C stayed there and the Home now had a new management team and a new recording system. Some of the staff had also left.
• It said there had been internal errors in passing on her complaint which led to the long delay in its reply. It apologised for the delay.

My investigation

18. The Council has been unable to provide me with the Home’s full records on Mrs C. Unfortunately, as the Home’s ownership has changed, Mrs C’s records have not been found.
19. I have read the Home’s care file / risk assessment for Mrs C. There is no evidence in the risk assessment or care plan that this document was reviewed or changed following an incident. I do not know if there are other care plans or risk assessments.
20. The only reference in the electronic daily notes that I found about a change in the care plan following a fall was a note dated 18 August 2017. This suggested staff should remove Mrs C’s small bed rail and put a crash mat in place as this would lessen the danger to Mrs C as most of her falls were from her bed.
21. I have also read the ambulance service’s safeguarding referral for the incident on 2 August 2017. This said: ‘When crew were taken by staff into patient’s room they found her lying on her side on the floor with no staff present with her in the room. The patient said she had been left alone since she fell at 15.30.’
22. The Council received the referral and contacted the Home’s manager. The Home said a member of staff had sat with Mrs C after she fell and she was ‘not left alone for any length of time’. She was puzzled by the ambulance referral as a member of staff was with Mrs C when they arrived. She confirmed that it was the Home’s policy that residents were not left alone following a fall. The social worker was meant to visit Mrs C on 15 August 2017 but this visit was postponed. The Council did not carry out a safeguarding investigation following the referral.

Analysis

23. The Council has already acknowledged there was fault in the delay in its complaint response and has apologised. I agree there was fault.
24. I have not been able to carry out a full investigation into the complaints as the records have been lost. I have based my investigation on the records I have seen.
25. In an investigation such as this one, I would consider the Home’s policies on incident reporting and falls prevention. I would then check whether the Home had followed its own policies. Generally speaking, most care homes would expect staff to complete an incident report when an incident has happened. There may also be a review of the falls risk assessment as a result of the incident and then possibly a change in the care plan if this was indicated by the review risk assessment.
26. I note that the Home carried out an initial risk assessment and there was a plan in place to minimise risk. This was that Mrs C should be supervised and assisted whenever she was walking around and that there should be an alert mat next to her bed. I also note that the Home took Mrs C to hospital on those occasions when she suffered visible injuries from the falls and that it did so partly because of the concern about the effect of the warfarin. Those are positive measures.
27. However, from the records I have seen, I am concerned about the frequency of the falls and the lack of evidence to show that the Home properly assessed the risk after a fall and adapted the care plan accordingly. This should have happened and the failure to document that it has happened was fault. The only change in care plan that I have seen relates to action taken after the fall on 18 August 2017 which was the 10th incident in the case notes. I question why this or other changes in the care plan were not considered earlier.
28. I have considered the complaint about the incident on 2 August 2017. I have read the ambulance crew’s safeguarding referral and they clearly say they found Mrs C alone in her room when they arrived. The Home denies this.
29. I do not think the ambulance crew would have made a safeguarding referral and would have lied about finding Mrs C on her own. I do not know why they would have done that. I can make a decision on the balance of probabilities and therefore I am of the view that the ambulance crew was speaking the truth and found Mrs C on her own when they arrived. This was in breach of the Home’s own policy and was fault.
30. I know Mrs C said she was left alone for the entire time, but Mrs C suffered from cognitive problems and lacked the mental capacity to make decisions. Therefore, it is impossible to say how long Mrs C had been left on her own when the ambulance crew arrived.
31. I have considered the injustice caused by of the fault. The injustice is the distress caused by the the uncertainty of not knowing whether the risk was properly assessed and whether the care plan was sufficiently reviewed after each incident and whether this would have made any difference to the care plan.

Agreed action

32. Sadly, Mrs C has died so any injustice to her cannot be remedied.
33. 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 care home, it is the Council which will provide the remedy.
34. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise in writing to Mrs B for the fault.
• Pay Mrs B £150 in recognition of the distress caused by the fault.

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Final decision

35. 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