Summary: Mr B complains about the care his mother, Mrs C, received while resident at the Home. He says Mrs C had large number of falls, including three within the space of two days that saw her hospitalised twice. He complains the Home readmitted Mrs C from the hospital during the earlier hours when it could not meet her needs. The Ombudsman does not find fault.

The complaint

1. The complainant, who I refer to as Mr B, complains about the care Mrs C received at the Home between December 2017 and March 2018. He says the Home did not do enough to prevent her frequent falls, which led to injuries and hospitalisation. He says the Home should not have admitted Mrs C back to the Home following a serious fall, when it could not prevent her falling again.

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The Ombudsman’s role and powers

2. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves, or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. Part 3A covers complaints about care bought directly from a care provider by the person who needs it or by a representative, and includes care funded privately or with direct payments under a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
3. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
6. If we are satisfied with a 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)

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How I considered this complaint

7. My colleague assessed the case and spoke to Mr B about the complaint. I then reviewed the information provided and made enquiries of the Home. I sent a copy of my draft decision to Mr B and the Home for their comments.

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What I found

Background

8. Mrs C was resident at the Home from early December 2017 to late March 2018. Mrs C had dementia and the Home assessed her as at high risk of falls on admission.
9. Mrs C had two falls on consecutive days in late December 2017. A GP visited and advised staff to move Mrs C’s walking frame as, when she saw it, she was more inclined to want to stand without help. Mrs C fell again later that evening. The GP visited the following day, found her blood pressure dropped when she stood up and organised an x-ray. The next day the GP stopped one of her medications.
10. A few days later Mrs C had another fall, causing a skin tear to her arm. Several days after that, the Home placed a sensor mat in her room. Staff would place the sensor mat in front of her bed or chair, depending on where she was, so it would alert staff if she moved. Mr B says when he visited Mrs C the sensor mat was often under the bed, so not in use.
11. During Mrs C’s stay staff reported she developed challenging behaviours, including agitation and aggression. The Home referred Mrs C to the metal health team. A doctor visited and stopped several of her medications but believed the behaviours were linked to her dementia.
12. In early February 2018, Mrs C had another fall. A GP visited Mrs C three days later and prescribed Lorazepam PRN for agitation and aggression. Another three days after this, Mrs C had two falls on the same day. That week the GP visited again to assess her ongoing health concerns and found all observations were fine. Mrs C had a further fall around two weeks later.
13. In mid-March 2018 the Home replaced Mrs X’s bed with a profiling bed, which it could lower to the floor, because of her increased number of falls.
14. The following day staff found Mrs C on the floor in the early hours of the morning. The falls log says staff found no injuries. That afternoon staff found Mrs C on the floor again. This time her head was bleeding, and Mrs C was taken to hospital. The Hospital discharged Mrs C back to the Home in the early hours of the next morning, at around 02:00. Before mid-day Mrs C had another fall. She had a skin tear on her arm and was taken to hospital again.
15. Mr B raised concerns about his mother’s care. He was concerned about the number of falls and said a doctor at the hospital felt the Home had over administered Lorazepam. The local authority safeguarding team held a meeting with Mr B and the Home the next day. It investigated and found the Home had only administered Lorazepam PRN on a few occasions so did not uphold that it had misused this. However, it partially upheld the allegation as it considered the home should have had more comprehensive paperwork around Mrs C’s falls risk assessment and there was no clear handover from the hospital to the Home on discharge in the early hours.
16. The Home says that normally the hospital will call the Home to say the person is fit for discharge. The Home can then ask for a reassessment or carry out an assessment on the phone and decide whether to accept that person back. It says on this occasion the hospital did not call so it did not have an opportunity to do this. It says it could not have turned Mrs C away when she arrived at the Home in the early hours, after a potentially distressing journey.
17. Mrs C moved to a different care home on discharge from the hospital, two days after the fall. Mrs C passed away around a month later. Mr B says the frequent falls and poor care at the Home contributed to Mrs C’s deterioration in health. He says the Home could not have observed Mrs C properly or she would not have fallen three times in the space of two days. He also said the Home should not have accepted Mrs C back in the early hours, when it did not have enough staff to keep Mrs C safe. Mr B also questions why the Home did not use bed rails to prevent falls and says the sensor mat was not in place when Mrs C fell in mid-March 2018.
18. The Home did not complete a formal bed rails assessment. It says bed rails can present a greater risk of injury where residents might attempt to climb over them or become trapped in the rails. The Home says it did not consider bed rails as an option because of Mrs C’s behaviour and her ability to move independently. It says it was a high probability that she would try to climb over them.

Findings

Falls Risk Assessments

19. I do not find fault with the Home’ management of Mrs B’s risk of falls. It is clear from the documentation that Mrs C had a high number of falls while she was at the Home. However, I can only consider whether the Home completed and followed the proper risk assessments and care plans to reduce Mrs C’s risk of falls, in line with its procedures.
20. I understand the safeguarding investigation found the Home should have had more comprehensive risk assessment paperwork. It is not clear from the case conference report what additional information safeguarding expected to see in the risk assessments.
21. I can see from the documentation provided the Home completed regular falls risk assessments, including after every fall. It identified that Mrs C was at very high risk of falls and had a clear care plan in place, setting out how staff would manage her mobility and risk of falls. From February 2018 onwards this included the use of a sensor mat and in mid-March a lowered profiling bed. Before this, the Home raised the problem with the GP on more than one occasion, who made recommendations and changes to Mrs C’s medication.
22. Mr B says he often found the sensor mat was not in place. The Home’s records and its response suggest it was always in place. This is a conflict in the evidence I cannot resolve, so cannot make a finding on this point.

Bed Rails

23. On balance, I do not find fault in the Home not completing a formal bed rails assessment. If the Home considered placing bed rails might decrease Mrs C’s risk of falls, then it may have been good practice to at least complete a formal risk assessment and decide whether bed rails could be used safely.
24. However, it could only use bed rails to stop Mrs C accidently falling from her bed. They are not intended as a restriction on movement and can pose a greater risk if the person is able to mobilise and might attempt to climb over them. Risks include falling from a greater height or becoming trapped in the rails.
25. It is clear from the Home’s response and the care records that staff believed Mrs C’s falls often resulted from her trying to mobilise independently. I therefore understand why the Home did not formally consider the use of bed rails or complete an assessment. Instead, the Home changed Mrs C’s bed to a profiling bed as it could lower this to the floor, to reduce the risk of Mrs C falling from height.

Discharge from Hospital

26. I do not find the Home at fault for accepting Mrs C back in the early hours of the morning. It is unusual for a patient to be discharged and transferred from hospital at this time and the Home accepts it should not have happened without it first assessing whether it was safe for her to return. However, if the hospital did not call ahead, I understand why the Home could not have turned Mrs C away on its doorstep.
27. The care records show the Home completed an up-to-date falls risk assessment for that day, which showed Mrs C was at very high risk of falls. The records also show staff completed all observations on its 24-hour observation sheet for after a fall.
28. I understand Mr B was concerned about the number of staff on duty on the night shift. There are no regulations that give specific requirements about the number or ratio of staff that must be on duty. CQC regulations say providers must deploy enough qualified, skilled staff to meet people’s needs, but again do not give specific numbers.
29. The Home has assessed the number of staff it needs, and I cannot question its decision. I could only find fault if there was evidence it had not met its assessed safe staffing levels. There is no indication that is the case here. The safeguarding investigation considered this matter and did not substantiate any concerns about staffing levels. If Mr B has concerns about staffing levels at the Home, the CQC is the body best positioned to consider this as part of its routine inspections.
30. I also note that Mrs C’s subsequent fall happened during the morning, in day shift hours, when more staff would have been on duty.

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Investigator's decision on behalf of the Ombudsman