Summary: Mrs X complained the Council-commissioned care home failed to provide her late mother, Mrs Y, with suitable care. She says the poor care caused her mother to have a fall which resulted in a hospital admission. She also said the care home’s record keeping was inadequate. The care home, acting on behalf of the Council, is at fault. There is no evidence poor care caused Mrs Y’s fall, but there is evidence of poor record keeping and poor communication. This caused Mrs X uncertainty over what happened and whether Mrs Y was receiving appropriate care. The care provider will write to Mrs X to apologise for the faults and for the uncertainty and distress caused.

The complaint

1. Mrs X complained the Council-commissioned care home, Yarnton Care Home, failed to provide her late mother, Mrs Y, with suitable care. Mrs X says the poor care caused her mother to have a fall which resulted in a hospital admission. She also said the care home’s record keeping was inadequate. She wants the care provider to apologise for the poor care provided to her mother and the Council to ensure the care home improves its practices.

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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)
5. 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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How I considered this complaint

6. I considered the information Mrs X provided in her written complaint and on the phone.
7. I considered the Council’s response to our enquiries.
8. Mrs X and the Council had the opportunity to comment on the draft decision. I considered their comments before making my final decision.

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What I found

Background information

The Fundamental Standards

9. The Health and Social Care Act 2008 (regulated activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The fundamental standards include minimum standards for:
• Person-centred care
• Maintaining accurate and complete records
• Safeguarding from abuse
• Duty of candour.
10. 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.
11. When investigating complaints about the standards of care in a care home, the Ombudsman considers if the 2014 regulations and the fundamental standards have been met. If they have not, we consider whether any identified faults have resulted in injustice.

Adult safeguarding procedures

12. 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 him 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

13. In 2019, Mrs X’s mother, Mrs Y, lived in a care home. Mrs Y was unable to walk and required a hoist to transfer between her bed and chair.
14. In March 2019, Mrs Y had a fall. The care records are unclear about exactly how the fall happened, but somehow Mrs Y slipped or fell out of her chair. When staff found Mrs Y, they re-positioned her on the floor then hoisted her into her bed. The night nurse on duty, nurse A, did not complete an incident form.
15. The following morning nurse A told the day nurse, nurse B, about Mrs Y’s fall. However, during the morning management meeting, nurse B did not tell care home managers about Mrs Y’s fall. Instead they queried whether Mrs Y had sepsis and said they had called Mrs Y’s GP to request a visit.
16. Mrs Y’s GP visited that afternoon. The GP was told about the fall and was concerned Mrs Y may have sustained a fracture. They arranged for her to be admitted to hospital for further investigations. The care home rang Mrs X to tell her about the fall and that Mrs Y was being admitted to hospital.
17. Mrs X was unhappy the care home had not contacted her earlier to tell her about the fall.
18. Mrs Y returned to the care home that night. The hospital investigations showed she had an un-displaced fracture in her right leg. She was discharged with a leg splint for support and pain relief.
19. The following day, Mrs Y reported she was still in pain. The care home contacted the GP who advised she should return to the hospital for further tests. Mrs Y was re-admitted that evening.
20. Mrs Y returned to the care home again the following day, but her condition deteriorated, and she was re-admitted 8 days later. Hospital notes recorded the reason for this re-admission was drowsiness, lethargy, low mood and decreased oral intake.
21. A few days later, Mrs Y died in hospital.
22. Mrs X raised a safeguarding alert with the Council. She also complained to the care home. She complained about the fall, several issues related to poor care, poor communication with families and poor record keeping.
23. The Council decided to investigate the safeguarding concerns. It contacted the care home to request information and carried out its investigation.
24. In October 2019, the Council completed its safeguarding investigation and issued its report. It found:
• there was poor reporting and recording of Mrs Y’s fall. Records were not consistent, and there were no details about what happened and when.
• Staff did not complete an incident form.
• At the morning meeting, staff did not inform management about Mrs Y’s fall.
• Staff delayed in contacting Mrs Y’s family.
• When Mrs Y returned from hospital, staff did not complete a falls assessment or a return from hospital assessment.
25. Because of these issues, it substantiated the allegation of poor falls management. It said the care home had accepted failings related to the fall and acted to improve its practices going forward. It did not substantiate other elements of Mrs X’s complaint related to poor care. It wrote to Mrs X to tell her of its findings.
26. The care provider also responded to Mrs X. It said it accepted the failings identified in the safeguarding investigation, that its documentation and recording of the incident was poor, and it had badly handled the incident. It said the Council’s safeguarding investigation had not substantiated other elements of her complaint about poor care and it also had found no evidence to support these parts.
27. Mrs X remained unhappy and brought her complaint to us. She told us she wanted the care provider to apologise for the poor care her mother received whilst at the care home.

My investigation

28. In its response to my enquiries, the Council said when it was alerted to the safeguarding concerns, it acted in accordance with its policies and procedures by completing a robust safeguarding investigation.
29. It said the care provider had accepted the investigation findings and had put several measures in place to improve its practices. These included:
• Additions to the electronic system to prompt staff about recording and reporting of incidents, body maps, return from hospital assessments and communication with family.
• A more robust induction process and support for agency staff concentrating on recording and reporting.
• More effective handovers between staff and a strong management team committed to positive culture change.
30. It said it completed monitoring visits in June and September 2019 which showed the care home had made improvements to its practices.
31. It said it wished to offer its condolences to Mrs X, and the care provider also offered its sincere apologies to Mrs X that overall, the service fell below the high standards of care they should expect.

My findings

32. I have reviewed the evidence and am satisfied the Council appropriately investigated Mrs X’s safeguarding concerns. It considered each aspect of Mrs X’s complaint, and its conclusions were logical and based on the available evidence. The investigation found no evidence that poor care caused Mrs Y’s fall. I have reviewed the evidence and have also found no evidence to support this.
33. The safeguarding investigation found there was poor recording and reporting at the care home, and that following her fall, the care home delayed in contacting Mrs Y’s family. The evidence supports these findings. The fundamental standards include the need to keep accurate, complete, and up to date records. The failure to meet the fundamental standard is fault. The fault caused Mrs X distress as the care home could not confirm how the fall happened, and left Mrs X with an enduring sense of uncertainty over whether Mrs Y was receiving appropriate care and support. The delay in contacting Mrs X following the fall is likely to have added to her distress and uncertainty.
34. Since Mrs X’s complaint, the Council has acted appropriately by working with the care provider to improve the quality of care at the care home. I am satisfied the actions taken by the care home are appropriate and the Council has worked with the care home to monitor and improve the standard of care provided and to learn from the faults identified.
35. Mrs X has told us she wants an apology from the care provider. In its enquiry response, the Council has told us the care provider has offered an apology for the identified failings, but I have seen no evidence the care provider has written directly to Mrs X to offer this. It should now do this.

Agreed action

36. Within one month of the final decision the Council will instruct the care provider to write directly to Mrs X to apologise for the poor management of Mrs Y’s fall, including poor incident reporting, inadequate record keeping and poor communication with the family. It will acknowledge the uncertainty and distress caused to Mrs X by these faults.

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Final decision

37. I have completed my investigation. I have found fault and agreed action to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman