Summary: Ms C complained on behalf of her father that care provided to him by Haversham House Limited was unsafe. Ms C complained that her father was neglected and suffered mental and physical distress. We found fault by the care provider in some aspects of his care. An apology has been agreed to acknowledge the resultant injustice.

The complaint

1. The complainant, whom I shall call Ms C, complained on behalf of her father, Mr B, that care provided to him when he was resident at Haversham House care home was unsafe. She reports that Mr B was neglected and suffered mental and physical distress.

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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 all the information provided by Ms C about this complaint. I made written enquiries of the care provider Haversham House Limited, and took account of all the information provided in response.
5. Ms C and Haversham House had an opportunity to comment on a draft of this decision, and I considered all comments received in response.

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What I found

Background

6. Mr B moved to Haversham House care home on discharge from hospital in mid May 2019, and he remained resident there until October 2019. Mr B paid for his own care: Ms C has Lasting Power of Attorney to deal with her father’s financial affairs.
7. It was noted by the hospital that he was at risk of falls, and the assessment of needs document completed on admission to the care home noted that he suffered from dementia, hypertension, and cataracts. He mobilised with the aid of a stick.

Falls

8. While resident at Haversham House, Mr B suffered several falls. Ms C considers that the home was negligent and failed to protect her father from harm because it did not prevent these falls.
9. As noted above, Mr B was known to be at risk of falls. The home says that Mr B was in the habit of walking unaided, and would walk upstairs using handrails, a risk it mitigated by allocating him a ground floor room. The home said Mr B was independently mobile and he chose to walk around the home and was not in immediate danger when doing so, often walking and coming to no harm. The home noted that it was a basic human right to choose to walk, and said it would not stop any resident from exercising such a right, unless there was immediate risk of harm. While possible staff did take extra care to watch Mr B when he chose to walk, but the home’s staff to resident ratio would generally be six to one, and Mr B’s care package did not include one to one care. Mr B would often refuse to use his walking aids despite encouragement from staff.

Evidence in respect of falls

10. The evidence in respect of falls includes falls logs which include such information as the date, time, and location of falls, whether they were witnessed or unwitnessed, any injury sustained, whether emergency services were called, which family member was notified, and any follow up action required or taken. In addition to the falls logs, there are body maps and professional visit records also include information about assessment by paramedics for example. There are also assessments of risk in respect of mobility and falls, plus professional visit records which include references to assessment by paramedics and physiotherapists.
11. Referral for assessment by a physiotherapist was made on 7 June 2019, because of falls. There was input from a physiotherapist thereafter. In June he noted Mr B was currently mobile with a walking stick but required prompting, and in August the forward plan was for assessment for a walking frame, and for staff to encourage Mr B with his mobility and to always use his stick. Subsequently Mr B was assessed for a walking frame, and this was provided in September. Records indicate that Mr B tended to leave aside his walking aids and that even when encouraged to use them he would not always do so.

Analysis

12. The care provider has a policy document setting out its post-fall procedure. Where a resident has an unwitnessed fall, the emergency services must be called; the next of kin must be informed; and an accident / incident form must be completed. Where a Resident has a witnessed fall, where there has been no immediate danger of head or spinal injuries and the fall was proportionate for the weight and the distance of the fall, staff may assist. However, if the resident has suffered any obvious injuries, complains of any significant pain or is on any medication that could compromise their health, staff must follow the guidelines for an unwitnessed fall, as above.
13. The evidence shows that on the occasions when Mr B suffered a fall, appropriate action was taken in line with this protocol. Other associated and appropriate actions included making referrals to other professionals such as the physiotherapist, district nurses or GP; the use of risk management aids such as the pressure sensor mat; and prompting and encouragement to Mr B to use his walking aids. The risk of falls could not be entirely removed. While staff could offer encouragement to Mr B to use his walking aids, they could not compel him to do so and he did sometimes refuse, and, as the home has explained, Mr B’s care package was not for one-to-one care at all times. The action taken in this case to mitigate risk of falls and to respond when falls occurred was proportionate and was not fault.

Incorrect administration of medication

14. Ms C has reported that the family was informed by the care home in May 2019 that staff had given Mr B an incorrect dose of medication.
15. The home accepts that a medication error occurred on 18 May 2019, and says that medical advice was sought, and the matter was reported to the local authority which was satisfied no harm had been caused to Mr B. The home refers to its policy of retraining and reassessing the competency of the relevant member of staff, and to keeping a record of the incident on file.

Evidence in respect of the medication error

16. The evidence in respect of this matter includes an entry in the professional visit record dated 18 May 2019 and timed at 13:40 hours, which shows a telephone call made to 111 for advice about the medication error, described here as ‘wrong dose given / insufficient dose given with three separate medications’. The professional advice received was noted as to continue as normal for the first two medications but for the third to monitor for dizziness, fainting, cold sweats, and falls in blood pressure. That record also shows a call was made at 15:00 hours to the local authority responsible for adult social care safeguarding to raise this issue as a safeguarding concern.
17. On the same date there is an entry in the record of ‘discussions with significant others’ showing a call to Ms C at 14:00 hours to explain about the errors occurring and about referral to safeguarding. The note records that Ms C, who is a medical doctor, also gave advice.

Analysis

18. Appropriate action was taken to seek prompt advice, to report to local authority safeguarding, and to notify the family. There is no requirement to report a medication error to the Care Quality Commission (CQC) unless the cause or effect of the error met the criteria to notify a death, injury, abuse, or an incident reported to or investigated by the police. The medication error itself was fault, however.

Incorrect medical history

19. Ms C reported there was incorrect medical information in Mr B’s care plan, including documentation about a knee replacement and glaucoma, neither of which he had. She also had concerns that her father was being offered a diet which was not appropriate for his diagnosis of type two diabetes.
20. The home has explained that the information about Mr B’s medical history came from the patient profile provided by the hospital when Mr B was discharged. The records noted he had type two diabetes controlled by medication and diet. The home confirmed that staff were properly aware that Mr B required a diabetic diet and that puddings offered contained reduced or no sugar. Responding to a question from Ms C about blood sugar monitoring, the home confirmed that this is not done unless a clinician advises it, in which case the district nursing team would assist.

Evidence and analysis

21. The document completed in May 2019 on Mr B’s admission to the care home did include incorrect information, and a later copy on file has the incorrect detail scored through reflecting Ms C’s correction. There are no grounds to criticize the home for noting information provided by the hospital, and in any event there appears to have been no injustice caused to Mr B as a result. The document also included other information about Mr B’s medical history and conditions which was correct, noting for example that he suffered from type two diabetes and was living with dementia.
22. In respect of diet the records show that it was duly noted that Mr B was diabetic, and reference is made to a sugar-free, high-fibre diet. Ms C says she wrote in the care plan that this was needed. Ms C also raised concerns about hydration, and the records for this reflect that Mr B did need some encouragement to drink at times but there were no substantiated concerns about his hydration. There is no evidence of fault by the home in respect of Mr B’s nutritional needs being met.

Assault by a member of staff

23. Ms C reported that the family was advised on the morning of 30 October 2019, the date Mr B moved to a different care placement, that the previous evening a member of staff had hurt Mr B’s arm, an incident which had been recorded on CCTV. The family was told the member of staff concerned had been dismissed, and that the matter had been referred to the safeguarding team.
24. The home has confirmed that the carer involved was an agency worker employed to support the night shift. The home has said there was no force used that would have caused Mr B any harm, and no harm was sustained. The agency staff member concerned was not allowed to return to the home to work. The CQC and the local safeguarding authority were informed. The home says that when the manager of the home spoke to the family member about the incident an apology was given.

Evidence and analysis

25. The referral to the CQC noted the detail of the event as follows:
    “Agency carer was observed by care staff to use incorrect and unsafe moving & handling technique. Staff overheard resident say to agency carer "please do not push me like that again". CCTV footage shows that carer moved resident's hand out of the way and held him in his wheelchair, preventing him from leaning forward. the resident appeared to push back in the wheelchair and the carer held him as though to reposition using incorrect manual handling. no apparent force was used. Agency was contacted and informed we do not wish to use this carer again and safeguarding authority was contacted”.
26. The care provider took appropriate action in response to this incident, including reporting it to CQC and safeguarding. However, the action of the agency carer was clearly fault, and that carer was acting on behalf of Haversham House when this incident happened.

Concerns about personal care

27. Ms C reported other concerns about the care afforded to her father while at Haversham House, in particular about his personal care, including hygiene and continence issues. She noted that on occasion Mr B was in public areas of the home without his incontinence pad, or was found with a heavily soaked pad in need of changing. She also had concerns about his oral care and showering.
28. The home said that Mr B was mobile and would occasionally remove his incontinence pad or decline to have assistance with his continence needs, and although staff would prompt him regularly he would not always be compliant or accepting of help. Similarly, with oral care and showering Mr B would often decline assistance, particularly in the early part of his stay at the home although he became more accepting of this later on.

Evidence and analysis

29. The home’s records note that Mr B needed help with washing, dressing, continence, and prompting to brush his teeth. But they also evidence that Mr B did frequently decline help with his personal care and the home was limited in what it might reasonably have done without Mr B’s consent. Records include for example notes that if he declined oral care then staff could try again later in the day or after meals, that he needed encouragement, and that he preferred a male carer but would accept older female carers. The records note a high risk of skin breakdown and that staff were to monitor this dally when Mr B permitted it, but he often refused this care. The evidence relating to reviews by health professionals did not reference any breakdown in skin integrity.
30. The home could not compel Mr B to accept care against his wishes. There is no evidence of fault.

Concerns about heating

31. Ms C reported that defective heating in Mr B’s room was not noticed by care staff until the family reported it. She had found him to be cold.
32. The home told Ms C that it opens windows to air bedrooms after cleaning when residents are elsewhere, but that keeping them shut would not be a problem. It said Mr B often removed his jacket, and while staff encourage him to put it back on it was his choice.

Evidence and analysis

33. The home’s response to Ms C did not address the claim that the heating was broken. In its initial response to my enquiries the home said that broken heating was not something it could have foreseen, and appropriate measures were taken to ensure Mr B was made warm and comfortable. It said the heating issue was resolved immediately by the onsite maintenance officer who would have sought support from an external engineer and placed a suitable portable heater within the bedroom. It said this was for less than 24 hours. In its subsequent response the home said that having discussed the matter with the maintenance officer it had established the heating was not broken but had been turned down at the thermostat due to the room being very warm, but the family requested it was turned back up and this was immediately done.
34. The responses provided by the home to my enquiries on this point are somewhat contradictory. I have not seen any reference to this matter in the daily care records and I have not been provided with any evidence of actions taken in respect of the heating either by the maintenance officer or any other staff. I cannot reach a safe conclusion about whether Mr B was without heating and if so what remedial action was taken and how quickly. There is however some apparent fault in the record keeping in respect of this matter.

Injustice caused by the faults identified

35. The medication error in this case and the actions of the agency care worker in his handling of Mr B caused unnecessary distress and concern. The poor record keeping in respect of the heating matter caused uncertainty about what exactly happened and how quickly it was remedied.
36. I noted that in her complaint Ms C referred to the home’s actions as negligent.
    My role however is to consider the complaint about how the care provider managed Mr B’s care. It is not to decide on matters of negligence: those are matters for the courts.

Agreed action

37. In recognition of the injustice referred to above, I recommended that within four weeks of the date of the decision on this complaint Haversham House Limited issues Mr B and Ms C with a formal written apology for the identified failings and their impact.
38. I further recommended that within three months of the date of the decision on this complaint:

• Haversham House takes action, if it has not already done so, to ensure compliance with its policy of retraining and reassessing the competency of the relevant member of staff involved in the medication error; and
• Provides the Ombudsman with evidence to show that all the above actions have been completed.

39. Haversham House Limited has agreed to my recommendations.

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Final decision

40. I have completed my investigation on the basis set out above.
41. 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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Investigator's decision on behalf of the Ombudsman