Summary: Mr X complains the care home, in which the Council placed his mother, failed to look after her properly, resulting in her having two falls and permanently reducing her mobility. The evidence does not support the claim that the care home was responsible for Mrs Y’s injuries.

The complaint

1. The complainant, whom I shall refer to as Mr X, complains the care home, in which the Council placed his mother, failed to look after her properly, resulting in her having two falls and permanently reducing her mobility.

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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. 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, sections 30(1B) and 34H(i), as amended)
4. 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)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mr X;
• discussed the complaint with Mr X;
• considered the comments and documents the Council has provided in response to my enquiries; and
• shared a draft of this statement with Mr X and the Council, and invited comments for me to consider before making my final decision.

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What I found

What happened

6. The Council arranged for Mr X’s mother, Mrs Y to move to the care home, Holme Lea, in January 2018 when he could no longer meet her needs at home. Mrs Y has dementia and other age-related medical conditions. She needed help with personal care and mobilising, as she was at risk of falls. The care home noted Mrs Y was “wandersome” and prone to “put herself on the floor”. She had a sensor mat by her bed, to alert staff if she got out of bed.
7. On 3 March Mrs Y had an unwitnessed fall in her bedroom between 09.00 and 09.30. According to the incident and accident reporting form, staff were alerted to this by the sensor mat. No injuries were found and Mrs Y was “happy to get up”. Staff helped her wash and dress and monitored her in the lounge. The body mapping record says Mrs Y’s skin was intact. According to statements made by staff later, Mrs Y said she was not in pain. After the fall she spent time walking around and had a nap on a sofa with her legs up. At tea-time Mrs Y again confirmed she was not in pain. The daily record says Mrs Y was quiet during the night.
8. On 4 March Mrs Y appeared unwell. She did not want to get out of bed or have breakfast. She complained of lower abdominal pain and did not want to walk. The care home called an ambulance, which took Mrs Y to hospital where she was found to have fractured her right hip.
9. On 7 March The care home contacted the Council about the fall on 3 March. The Council expressed concern about the failure to seek medical attention on the day Mrs Y fell. The care home agreed with this but noted staff had checked Mrs Y over. The Council noted injuries could not always be seen. It also noted it was not clear what monitoring and checks were put in place after the care home found Mrs Y on the floor.
10. The Council completed its safeguarding enquiries on 16 March. It decided the safeguarding concern was “partially founded” because the care home had not put Mrs Y on 24-hour observations after the fall.
11. Mrs Y left hospital and returned to the care home on 4 April.
12. On 11 April Mrs Y had another unwitnessed fall in her room. The incident and accident review form says staff came when Mrs Y called out “I am on the floor”. checked Mrs Y and noted no injuries. She had no pain and could mobilise as normal. The body mapping record says her skin was intact.
13. On 3 May Mrs Y was found on the floor in front of the chair she had been sitting on. Mrs Y said she was not in pain. According to the body mapping record completed on 4 May, no new injuries were found following the fall. The care home told Mr X about the fall and said staff would monitor her regularly. The care home monitored Mrs Y for 24 hours from 19.20 and no concerns were raised. The care home completed an incident and accident review form which says the date of the incident was 6 May.
14. Mrs Y’s medication administration records show a GP had prescribed paracetamol to be taken when needed (two tablets up to four times a day). They also say Mrs Y did not take any paracetamol between 14 May and the day she left the care home. However, other records say Mrs Y was given paracetamol on 21 May for a temperature.
15. The care home’s daily notes indicate Mrs Y got up as normal each day after her fall until 20 May when she ate very little, although she still spent time in the lounge. On 21 May she was very sleepy and over dinner became unresponsive. An ambulance took Mrs Y to hospital at 15.10. She was found to have a urinary tract infection and to have fractured her left hip. Mr X says the hospital told him his mother must have fractured her hip a week before as the injury was starting to calcify.
16. On 23 May the hospital called the care home. It said Mrs Y was in pain on 22 May and an x-ray showed she had a broken hip. It said it would be raising a safeguarding concern against the care home. The care home question this as there had been no sign of a fracture when Mrs Y left Home Lea on 21 May.
17. On 7 June the care home visited Mrs Y in hospital and decided it could no longer meet her needs due to poor diet and fluid intake, which meant she would be dehydrated if readmitted.
18. On 18 June the hospital told the Council Mr X did not want his mother to return to the care home, which also felt it could no longer meet her needs. It said an assessment of Mrs Y’s nursing needs was required.
19. On 21 June the care home told Mr X it could not take his mother back.
20. On 22 June Mr X visited the care home. He asked how his mother had broken her hip. The Manager told him she did not know, as they sent her to hospital with suspected sepsis. She said Mrs Y had not had a fall since 3 May and had mobilised normally afterwards.
21. On 25 June Mr X raised safeguarding concerns over the fact his mother had fractured her hips twice in three months. The Council’s safeguarding records say his desired outcome was for the Council to hold a meeting into his concerns but he did not want to be involved in this. The records say this was “fully achieved”. When the Council completed its enquiry on 2 July it recorded the outcome was “unsubstantiated”.
22. The Council assessed Mrs Y’s needs on 27 June. It noted her mobility had reduced significantly. Although she could weight bear, her balance was very poor, so she needed a full hoist and two care workers.
23. On 19 July Mrs Y went to live in a nursing home.
24. HC One, which runs the care home, replied to a complaint from Mr X on 29 November. It said the Council had held a safeguarding meeting on 2 July which found the concerns to be “unfounded and the home had not contributed to” Mrs Y’s fall. However, it accepted that when he visited his mother on 4 April:
• her commode should have been emptied;
• the lamp should have had a bulb in it;
• soiled pads should not have been in her bed;
• her name band should have been removed when she returned from hospital;
• her room should have been checked before she returned.

HC One apologised.

The care home’s risk assessments, and care and support plans

25. Mrs Y’s 28 January the care home safe environment care and support plan says she:
• was at high risk of falls;
• was not always aware of her personal limitations and could not assess risks;
• became anxious in unfamiliar surroundings (e.g. outside her room);
• liked to walk about during the day and staff would need to orientate her if she could not find her room;
• had a sensor mat to alert staff to assist her.
26. Mrs Y’s 28 January risk assessment for “placing herself on the floor” says Mrs Y:
• could lie down and get herself up independently, but this put her at risk of injury;
• staff were to encourage her to get up and move somewhere more suitable.

The care home reviewed the risk assessment on 28 February, 11 April and 19 May but made no changes.

27. Mrs Y’s 29 January falls care and support plan says:
• staff were to help her when mobilising and remove potential hazards;
• to ensure the sensor mat was in place at all times and switched when she was in bed;
• to ensure she wore well fitted footwear, as she liked to take her shoes off;
• she was putting herself at risk by sitting on the floor to lie down, despite being able to get herself up.

The care home reviewed the plan on 28 February and 18 May and made no changes.

28. Mrs Y’s 11 April risk assessment for a sensor mat says she:
• was at risk of slips and trips if the sensor mat was not used correctly;
• could not walk independently;
• could become anxious and push herself to the edge of the bed, which could result in falling
• the sensor mat was to be in place all the time in her bedroom and plugged in. This reduced the risk score from 15 to 12.
29. Mrs Y’s mobility care and support plan dated 11 April says:
• due to her recent falls, Mrs Y “can become very agitated and anxious. So she needs assistance from one member of staff. Staff need to be careful of her emotional status because she can push herself to the floor.”
• she needed help from one member of staff and a wheelchair when moving from place to place.
30. The care home reviewed the plan on 19 May. It noted Mrs Y had raised no issues and staff had no concerns so there were no changes.
31. Mrs Y’s falls risk assessment, completed on 4 May, refer to falls on 11 April and 3 May. It also says she fractured a hip in November 2017. It does not refer to the fall on 3 March or the fractured hip. The care home reviewed the risk assessment on 19 May but made no changes.

Is there evidence of fault which caused injustice?

32. The care home identified that Mrs Y was at risk of falls and took steps to reduce the risks by placing a sensor mat by her bed and from 11 April by identifying the need for help when mobilising. But that does not mean it could stop Mrs Y from falling when she got out of bed or when she slipped off the chair. No one was to blame for the falls Mrs Y had while she was at the care home.
33. The fall Mrs Y had on 3 March resulted in her fracturing her right hip. The care home was at fault for not monitoring Mrs Y for 24 hours after the fall. However, there is not enough evidence to say this caused injustice to Mrs Y. Given that she did not complain of pain and had a settled night, it seems unlikely she would have been sent to hospital any sooner if monitoring had been in place.
34. There is not enough evidence to say the fall Mrs Y had on 3 May was the cause of the broken left hip discovered nearly three weeks later on 22 May. There is nothing to suggest Mrs Y complained of pain until she was in hospital on 22 May. Indeed, she appears to have carried on as normal until she contracted an infection earlier in May.

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Final decision

35. I have completed my investigation as there is not enough evidence to say the Council’s actions caused injustice which warrants a remedy.

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Investigator's decision on behalf of the Ombudsman