The Ombudsman's final decision:
Summary: Mr X complained that a care provider failed to properly assess his mother’s needs and should not have accepted her as a resident. He complained about aspects of the care provided. We found no fault in the care provider’s decision to accept her as a resident or its decision that it could meet Mrs X’s needs. We found there was a failure to carry out a risk assessment, but this caused no significant injustice.
- Mr X complains that The Radley Care Home did not properly assess his late mother’s nursing care needs when it accepted her into the home. He complains that had his mother’s weight loss been managed better, and if she had the correct nursing care it could have reduced pain, suffering and loss of dignity. Mr X says his mother should have been assessed for full Continuing Health Care (CHC) funding. Mr X says he wants answers to his questions about Mrs X’s initial assessment.
The Ombudsman’s role and powers
- 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)
- If we are satisfied with a care provider’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)
- 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.
How I considered this complaint
- I considered the information Mr X provided. I asked the care provider for information and I considered its response to Mr X’s complaint.
- Mr X and the care provider had an opportunity to comment on my draft decision. I considered the comments received before making a final decision.
What I found
- Mrs X was referred to the Radley Care Home in May 2018 following an assessment of need completed by a local council. The assessment took place on 24 May and determined Mrs X needed a residential dementia care placement.
- On 31 May a representative of the Radley Care Home met with Mrs X’s daughter to carry out a pre-admission assessment. This took place at a nursing home where she had been receiving respite care.
- The pre-admission assessment noted Mrs X’s likes, dislikes and her care needs. It noted Mrs X had dementia and it noted her degree of comprehension and communication. It noted her daughter was advocating for Mrs X and held a Lasting Power of Attorney. The assessment stated “Currently in nursing placement – has high needs but residential”.
- Under eating, drinking and nutrition the assessment at first stated “Good appetite but then noted “No allergies known/Poor Appetite.” Mrs X’s weight was not recorded at the pre-admission assessment.
- The assessment document noted Mrs X had a history of falls and she had poor mobility and needed assistance. The assessment stated Mrs X was very needy and tended to wander at night in search of company. It also took account of Mrs X’s medication.
- The transfer information provided by the nursing home contained notes about how Mrs X presented, her sleep pattern and medication she received. It recorded that Mrs X was mobile but needed assistance and used a frame and walker. It stated her falls risk was high. The transfer information made no mention of any issues with eating and drinking. A transfer summary form completed by the nursing home stated Mrs X weighed 60.4kg as at 11 May 2018.
- Mrs X was admitted to The Radley Care Home on 11 June. She weighed 51kg on admission.
- On 12 June 2018 Mrs X fell out of bed. Mr X was concerned that no bed rails were used to prevent this.
- The care home provided a copy of its policy on the use of bed rails. This is based on guidance from the Medicine and Healthcare Products Regulatory Agency (MHRA). The policy notes that bed rails are not intended to restrict the movement of a resident (i.e. prevent them leaving their bed). Rather, they are to prevent people falling from bed and sustaining injuries. The guidance indicates bed rails are not used as a standard, but when a risk assessment indicates it is appropriate. The factors that should be considered include the likelihood that the person will fall from bed, whether bed rails are the most appropriate solution and what other options there are to deal with the risk. The policy notes that dementia patients are amongst those with greater risk of entrapment in bed rails.
- The MHRA guidance notes there are significant risks associated with entrapment, suffocation and falls from greater heights (when people climb over bed rails to leave their bed). It advocates a risk-based approach to deciding when bed rails are utilised.
- In response to our enquiries, the Radley Care Home told us there was nothing in the transfer information from the nursing home to indicate that Mrs X was at risk of falls and this was not something her daughter raised. So, no risk assessment was completed. The home had since become aware Mrs X had one fall in the past year. They told us, had they been aware of this, they would have completed a risk assessment. However, the home stated, because Mrs X was mobile on admission, she was known to wander at night, and because she had dementia, they would not have used bed rails. This was because there were risks associated with their use. They considered Mrs X may have climbed over the bed rail and fallen from a greater height, or she may have become trapped.
- The care home stated the notes provided by the nursing home did not indicate any concerns around Mrs X’s food or fluid intake. They were told Mrs X had a soft diet and she ate independently. The home stated Mrs X enjoyed eating sweet food during the first few days at the home.
- The care home told us that it referred Mrs X to a GP on 14 June because she had an unsettled night and staff became concerned. She was referred to the GP again on 17 June and 19 June. The home spoke to Mrs X’s daughter on 19 June as they felt Mrs X was reaching the end of her life. Mrs X was admitted to hospital on 19 June. Sadly, she passed away on 24 June.
Was there fault by the Radley Care Home
- I found there was no fault in the way The Radley Care Home decided to accept Mrs X as a resident or in the care home’s decision that it could meet her needs. I say this because, Mrs X had been assessed as needing a residential dementia placement for a person with high needs. I recognise Mr X’s view that Mrs X spitting out food could be an indicator of late stage Alzheimers, so Mrs X should have received end of life care at a nursing home. While it is clear that Mrs X’s health was declining, and had been for some time I found the decision the care home made that it could accommodate Mrs X was a professional judgement which took account of needs Mrs X had. The decision was based on all the information that the care home had been provided with. There was no fault in the decision it took to admit Mrs X.
- In terms of diet, Mrs X’s daughter had made the Radley Care Home aware that she had a poor appetite. However, the transfer information provided from the nursing home did not explain their concerns about Mrs X’s food and fluid intake. Because the nursing home had not weighed Mrs X since admission, Mrs X’s weight loss between 11 May 2018 and 11 June 2018 was not documented, so the extent of these concerns were not known to the residential home when assessing Mrs X for admission and after admitting her. The care home told us Mrs X had eaten sweet foods well in the days after admission, but it provided no detailed records of Mrs X’s food and fluid intake. It does not appear any detailed monitoring of this were carried out by the residential care home but I am conscious that, unfortunately, Mrs X was admitted to hospital just over a week after admission which would not have allowed staff much time to evaluate Mrs X. In the absence of the more detailed background information I do not find fault by the residential care home in respect of the monitoring of Mrs X’s food and fluid intake.
- Although the transfer information from the nursing home could and should have better explained issues surrounding Mrs X’s diet and weight loss, a residential home would be able to manage issues with eating and drinking. This is not in itself a reason why a placement at a residential care home would be inappropriate. I have commented further on the nursing home’s actions in a separate complaint investigation.
- However, the care home’s response to our enquiries told us there was no indication that Mrs X was at risk of falls. This is not correct. Both the home’s own pre-admission assessment and the information from the nursing home recorded that Mrs X was at risk of falls. So, the care home should have carried out a risk assessment that included consideration of bed rails. The lack of a risk assessment constitutes fault by the care home.
- Although a risk assessment should have been carried out, it does not automatically follow that this would have led to the use of bed rails or that Mrs X’s fall from bed on 12 June would have been prevented. There are significant risks associated with the use of bed rails. On balance I do not consider it likely that the risk assessment would have resulted in the use of bed rails in this situation. As a result, I do not consider the lack of a risk assessment led to a different outcome.
- I would not have expected the Radley Care Home to have arranged for a CHC checklist or Decision Support Tool (DST) assessment to be carried out. This is because the assessment that led to Mrs X being admitted to the home had recently been conducted and this included an assessment for CHC.
- I recommend the care home reviews its procedures for assessing whether new residents are at risk from falls and, as part of this, whether bed rails are appropriate or not. It should ensure any such risk assessments are documented on the resident’s files.
- There was some fault by the care home. However, I do not consider this led to injustice to Mr X or his family.
Investigator's decision on behalf of the Ombudsman