Summary: Mrs C complained about the care her (late) mother received at the care home she lived. The Ombudsman found the care home should not have given Mrs M strawberries, which she was allergic to. However, the care home has already apologised for this, as well for two incidents that involved another resident. This was an appropriate remedy for the injustice that occurred.

The complaint

1. The complainant, whom I shall call Mrs C, complained to us on behalf of herself and her (late) mother, whom I shall call Mrs M. Mrs C complains about the care her mother received at Heather View care home where she lived. Mrs C says:
• The care home failed to notice, on three occasions, that her mother needed to go to hospital, resulting in delays.
• Her mother fell out of bed regularly and on some occasions her crash mat was not in the correct position.
• On two occasions, the sensor pad was not connected, which should alert staff when her mother tries to get out of bed.
• A male resident showed inappropriate sexual behaviour towards her mother.
• Staff gave strawberries to her mother on several occasions, even though she had told the staff repeatedly not to do this because she was allergic.
• Staff failed to prevent her mother from falling on 5 April 2019.

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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))

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How I considered this complaint

4. I considered the information I received from Mrs C and the care provider. I also interviewed the manager of the home. I shared a copy of my draft decision statement with Mrs C and the care provider and considered any comments I received, before I made my final decision.

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What I found

Relevant Legislation and Guidance

5. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
6. Regulations 12 says care and treatment must be provided in a safe way for service users. This includes the need to:
• assess the risks to the health and safety of service users of receiving the care or treatment;
• do all that is reasonably practicable to mitigate any such risks. They must adopt control measures to make sure the risk is as low as is reasonably possible.
• ensure that equipment is properly maintained and used correctly and safely.
• ensure that the equipment used by the service provider for providing care or treatment to a service user is used in a safe way;
7. Regulation 13 requires a care provider to prevent people using the service from being abused by staff or other people they may have contact with when using the service.
8. Regulation 17 requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

What happened

The alleged failure to refer her mother to hospital on 3 occasions

9. Mrs M moved into Heather View care home in November 2018, because she needed 24-hour care due to her complex medical needs. Mrs M had Alzheimer’s but could express her needs and preferences. Mrs C says that, after some time, the family was not happy anymore with the home and moved Mrs M to another home in April 2019
10. Mrs C says the care home failed to notice, on three occasions, that her mother needed to go to hospital. This resulted in delays going to hospital.
11. Incident one (December 2018):
• Mrs C says that staff failed to notice her mother had been unresponsive. She asked staff to organise an ambulance, because her mother was unresponsive. However, the staff totally ignored this. It took 40 minutes for staff to call an ambulance, because the home decided that a nurse first had to do several tests. Mrs C says the staff should have first called an ambulance and then started doing the tests. Had she not insisted on an ambulance being called I dread to think what would have happened.
• The care provider’s records from that day state that:
1. Mrs M’s daughters were concerned about Mrs M’s physical health as Mrs M had been very sleepy. The daughters came to visit her and were very concerned as Mrs M was not responding to them. The home manager and Clinical Lead reviewed Mrs M. She presented as unconscious, with an unhealthy pale appearance, she was cold to the touch and unresponsive to verbal comment. Staff took vital measures and reassured the family.
2. The care home called an ambulance as the family insisted on this. The ambulance crew advised they would take Mrs M to hospital for review, as the family was very concerned. The hospital could not see anything wrong with Mrs M and returned her to the home.
12. Incident two (February 2019):
• Mrs C said that: staff had just left her mother slumped over a table. She told the team leader that her mother looked unwell and asked them to call 111. The team leader did not do anything, saying her mother was ‘just tired’. She took her mother to her room and laid her on her bed. She again asked staff to call 111. When staff eventually called 111, there had been a one-hour delay from when she first asked. Staff told 111 that she was ‘worrying over nothing’. She subsequently decided to dial 999. An ambulance arrived 10 minutes later, which took her mother to hospital with Pneumonia. Her mother had to be kept in hospital for over a week. We had difficulty convincing the team leader how serious it was and were made to feel a nuisance.
• The records state that:
1. Mrs C raised a concern at 10.30 about her mother being very sleepy and a suspected UTI. The home said it would carry out regular observations and see whether she needed a GP. However, Mrs C was adamant her mother needed the Out of Hours GP. The home checked Mrs M’s temperature and she did not have a fever. It subsequently called the Out of Hours GP.
2. The care home manager says it spoke to a health advisor to try and do an assessment over the phone. It was not possible to collect a urine sample because Mrs M was very sleepy. The health advisor was unable to rule out a problem and also spoke to Mrs C. One of the health doctor advisors would contact the home to say what the plan would be.
3. An out of hours doctor subsequently contacted the family and said they would arrange paramedics to come and check on Mrs M. They arrived at 3.15pm and decided with the family to admit Mrs M to hospital to administer IV fluids. However, Mrs C told the manager that she did not want her mother to go into hospital.
• The home manager told me that staff could not have known that Mrs M had Pneumonia, because she did not have a temperature, was not coughing and did not present different than otherwise.
13. Mrs C told me she did not say that ‘that she did not want her mother to go into hospital’. She wanted her mother to go into hospital.
14. Incident three (April 2019):
• Mrs C said: she visited her mother at Easter at breakfast time and found her clearly unwell and took her to bed. Staff told her she had a bad night. She left the home, asking the carers to monitor her. When she later returned in the afternoon, her mother was still unresponsive. The staff had not carried out any monitoring checks on her mother (there was no equipment in her room), even though the carers knew she was unwell. The home’s nurse came and found that her mother’s BP was 69/47. She insisted the home should call an ambulance. Again, valuable time was lost before an ambulance was called, and it was only called due to her alerting staff, rather than staff noticing her mother was unwell and properly escalating this. She was taken to hospital and was found to have had pneumonia and a possible minor heart attack.
• The records state:
1. The day before: regular references to ‘no concerns’ during the day. Family visited as well and did not raise a concern that day.
2. The day itself: Asleep throughout the night till 10am. With family from 11.30 onwards. Assisted with lunch at 12.30. Mrs C came while Mrs M was assisted with her lunch. However, Mrs M was not eating much so her daughter took her out of the dining room and upstairs. Mrs M was feeling tired, so her daughter took her to bed. The records do not state that Mrs C raised a concern at this point in time, and the care home denies Mrs C asked staff to monitor Mrs M. Mrs C confirmed to me she asked a staff member to monitor her mother, which the staff member failed to record.
3. 3pm remains in bed. She is unresponsive when trying to wake her. Mrs M appeared drowsy so nurse came to took the observation and blood pressure. Called ambulance. Paramedics decided to take Mrs M to hospital to check her chest and possibly give IV antibiotics.
15. Analysis
• The records show that Mrs M’s was often sleepy, drowsy and slow to respond at times. They also show that staff regularly involved the GP and asked him to review Mrs M. On occasion, the family raised a concern about a possible chest infection. However, a subsequent GP visit did not support this. The home regularly updated the family about Mrs M’s health and the outcome of visits.
• The care home manager told me that it is usual practice that, if a concern is raised about the health of a resident, the clinical lead and/or home manager is called to assess the resident first, before this is potentially escalated.
• There is a difference between the way Mrs C and the way staff have recollected certain aspects of the incidents. I have considered both versions of events and care records made at the time. However, there is insufficient evidence to conclude if: the staff rather than the family should have noticed there was a concern, and/or if the staff themselves should have realised a call should be made to 111/999 (earlier), because:
1. Incident 1: It is not possible to determine when Mrs M’s presentation deteriorated, or to what extent her presentation was such that it was clear she should be admitted to hospital as a matter of urgency. If a nurse is available, it would be usual practice for her to assess the resident first. There is insufficient evidence to conclude the symptoms Mrs M showed were such that it should have been clear she needed immediate hospitalisation.
2. Incident 2: It is not possible to determine when Mrs M’s presentation deteriorated, or to what extent her presentation was such that it was clear an out of hours GP needed to become involved. There is insufficient evidence to conclude she showed symptoms that were such that it should have been clear enough that she may have Pneumonia.
3. Incident 3: According to the records, no concerns were identified by Mrs C or the home until 3pm. There is insufficient evidence to determine when exactly Mrs M’s presentation deteriorated. However, when a concern was raised at 3pm, the nurse came and an ambulance was called.

Mrs C’s complaint about her mother falling out of bed and the equipment to deal with that

16. Mrs C says her mother fell out of bed regularly. Furthermore:
• On some occasions her crash mat was not in position, as a result of which her mother could have hurt herself more as she would have done with the mat in place. She sustained skin tears to her arms and bleeding elbows. Twice these injuries needed attention from the district nurse.
• On two occasions, the sensor pad was not connected. Furthermore, on one morning, the batteries had been removed. This meant that, on those occasions, an alarm would not have gone off if her mother was to leave her bed.
17. The care provider says that:
• Its falls risk assessment concluded Mrs M was at high risk of falling. She was able to mobilise a short distance, with assistance, but was mainly confined to her chair or bed.
• Mrs M had a tendency to stand up from her chair without asking for assistance.
• She displayed a tendency to roll out of bed when repositioning herself.
• A crash mat was risk assessed to be an appropriate support measure to prevent injury when rolling out of bed. A sensor mat was also in place to alert staff if this happened. The mat next to her bed would also alert staff when Mrs M would try to get out of bed unaided. There was also a mat next to her chair in her room. Her bed was set to the lowest hight.
• Staff carried out hourly welfare checks when Mrs M was in her room and repositioned her when needed; the records show regular checks every 30 to 60 minutes during the day and at night.
18. The care provider also said that it had not been able to find any record of:
• The sensor mat not being connected twice. Mrs M’s family did not raise this as a concern at the time.
• The Batteries had been removed on one occasion. Again, while investigating this, we saw no evidence of this having happened.
• Despite a request, Mrs C did not provide the dates when the above allegedly happened.
19. Mrs C says she would have expected the staff to make a record when they notified the staff of these incidents.
20. Mrs C told me her mother rolled out of bed less frequently after she moved to another home. She believes, this may be because staff monitored more frequently, her bed was wider and the new home put pillows on either side to prevent her from rolling.
21. The care home manager told me that a home should not put cushions on an air mattress next to a person who is at risk of pressure sores. All required equipment was in place at the home to manage the risk, including a hospital bed which was put in the lowest position possible. Mrs M was not suitable for bed rails
22. Analysis
• On the balance of probabilities, I found that the incidents as described by Mrs C in paragraph 16 1&2 did take place. However, they did not result in an injustice / fall at the time.
• The care home took appropriate measures to reduce the risk, and the potential harm, of Mrs M’s falling out of bed.

Alleged inappropriate sexual behaviour towards Mrs M

23. Mrs C complains a male resident (Mr X) who was known to show inappropriate sexual behaviours, was allowed on many occasions to wander around in and out of rooms without supervision. This was witnessed by family and put her mother at risk. The resident showed inappropriate sexual behaviour towards her mother on two occasions.
24. The care home manager told me that, after the first incident, the male resident was always supervised, whenever he would leave his bedroom. As such, a staff member would always be there in the communal areas to monitor him and intervene immediately when necessary.
25. The care provider told Mrs C in its complaint response that:
• Dementia can alter behaviours in different ways, and people living with the disease are unable to understand their actions.
• On 29 January 2019, Mr X was found in the dining room. He was standing close to Mrs M when he exposed himself. Staff immediately distracted him and moved him away from Mrs M.
• On 16 March 2019, Mr X was leaning towards Mrs M’s leg in a communal area. The team immediately intervened and escorted him away. The home reported this as a near miss.
• All these incidents were well-recorded, and raised as safeguarding incidents. The home had involved the GP and the Community Mental Health Team to treat the male resident’s behaviour.
• It was sorry for any distress that Mrs C or her mother experienced due to these incidents.
26. According to Mrs C, staff told her that the incident on 29 January 2019 took place in her mother’s bedroom.
27. The care home’s incident record say that: He walked into the dining room as staff member was about to monitor the dining and lounge area. She witnessed that the male resident pulled his trousers down. He was near to Mrs M. Staff immediately shouted his name and distracted his attention. He is currently on half hourly safety checks. GP reviewed his medication. Contacted Community Psychiatric Nurse for an urgent review. Next of Kin of both families informed and aware.
28. Analysis
• The care home put reasonable measures in place in response to the first incident, so as to monitor the male resident’s behaviour in communal areas and intervene when needed. It has apologised for the distress the two incidents caused, which was an appropriate remedy for any distress experienced.

The complaint that Mrs M received food she was allergic to

29. Mrs C says she told the home at the pre-admission assessment, and repeatedly afterwards, that her mother was allergic to strawberries. However, staff gave strawberries to her mother on (at least) two occasions. On speaking to the staff, none of them were aware that mum was allergic to strawberries.
30. The care provider says the family did not mention this food allergy at the pre-assessment visit and it is therefore not included in its pre-admission assessment form, which mentions:
• Known allergies: ‘penicillin’
• Food allergies: none known.
31. Mrs M’s care plan said in different sections (Nutrition; Meaningful lifestyle) that (On receipt of life history - it is noted that Mrs M is) ALLERGIC TO STRAWBERRIES.
32. There were two incidents in the records when staff gave strawberries to Mrs M (a strawberry custard and a strawberry fool). The care provider has told me that the GP has no record of this allergy. Furthermore, the family has said that it only results in an upset stomach. Mrs M did not have an allergic reaction following both incidents. However, the care home did apologise for the incidents happening.
33. The care home manager told me it now has a very solid system in place for resident’s diets to ensure this does not happen again. The home uses a Specialist Diet Log form, which would clearly record if someone had an allergy to any food or drink. A copy of the completed diet log is given to the kitchen team, on the relevant unit, and a copy saved on the T-drive. Any allergy is also documented on its electronic care recording system, and included in the eating and drinking care plan, on the M.U.S.T assessment, and on the e-mar medication records.
34. Analysis
• Despite the allergy having been mentioned in the care plan, Mrs M received strawberries on two occasions. However, they did not result in an allergic reaction and the care home has apologised. The care home has also explained the changes it has put in place to avoid a reoccurrence.

The allegation that staff failed to prevent a fall

35. Mrs C says the home failed to prevent her mother from having a fall in April 2019. She told me that: Her mother was trying to stand up in the dining room from a recliner chair, even though she was unable to mobilise independently. She fell straight to the floor cutting her eye and bruising her arms and elbows, because there was no staff present in the room to prevent her from trying to mobilise.
36. The pre-admission assessment identified that Mrs M was at high risk of falls.
37. Mrs M’s care plan states: She is at high risk of falls due to her frailty and poor mobility, along with restlessness. Mrs M can stand safely with 2 staff members and understands instructions. Her coordination is poor, but she will try and get up herself. This is usually when she becomes very unsettled.
38. The care provider told Mrs C in its complaint response that:
• Mrs M’s care records show she was in the communal lounge at 8:20pm. She tried to stand up from her chair unaided, lost her balance and landed on the floor. The carer who was present witnessed the fall, pressed the emergency bell, and staff called 999.
• Staff completed detailed records of the incident. All required documentation was completed, and assessments were updated.
• The home was sorry the incident happened.
39. The risk assessment said that Mrs M has sensor mats on her chair and a crash mat to ensure staff are always alerted of her movements. The home also put a half hourly observation chart in place.
40. Analysis
• The care home had correctly assessed and identified Mrs M’s risks of falling and had put measures in place to try and manage the risk. According to the records, a staff member was in the same area (lounge) as Mrs M when the incident happened. However, the staff member was unable to avoid the fall. Based on the available evidence, I am unable to conclude the home should have done something different that would have avoided this specific incident from happening.
• The care home has already provided an apology.

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Final decision

41. For reasons explained above, I found there was fault with regards to the home giving Mrs M strawberries. The care home has already provided an apology for this, which was an appropriate remedy.
42. The home also apologised for the two incidents that involved a male resident, and for her mother’s fall.
43. I am satisfied with the actions the care provider took to remedy the above, and have therefore decided to complete my investigation and close the case
44. Under the terms of our Memorandum of Understanding with the Care Quality Commission, I will send it a copy of my final decision statement.

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Investigator's decision on behalf of the Ombudsman