Summary: Mrs C complained about the way in which the care home, where her father had been placed by the Council, dealt with her (late) father’s repeated falls. There was fault that two measures were not considered that could potentially have reduced the risk of Mr F falling. The Council has agreed to apologise for any distress this may have caused Mrs C.

The complaint

1. The complainant, whom I shal call Mrs C, complained to us on behalf of her late father, whom I shall call Mr F. Mrs C complained:
• Her father had five unwitnessed falls in June 2019. The care home failed to take sufficient steps to try and reduce the chance of another fall happening again.
• Even though she told the care home several times to fix the leaking toilet in her father’s bathroom, because the leaking water was a slip / falls risk, the care home had failed to do this as of 21 June 2019, which resulted in her father having a fall and breaking his hip.

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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. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, if we find fault with the actions/service of the Care Provider, we make recommendations to the Council.

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How I considered this complaint

5. I considered the information I received from Mrs C and the Council. I shared a copy of my draft decision statement with Mrs C and the Council and considered any comments I received, before I made my final decision.

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What I found

The way the care home responded to Mr F’s falls

6. In January 2017, Mr F went into hospital following an unwitnessed fall at his home. He went into the care home in May 2017.
7. At the care review in April 2019, the records state the family agreed the placement was going well: ‘The family tell me that Mr F has settled well (…) and that the staff are 'very caring'.’ The family raised concerns that Mr F appeared to be drowsy when they visited, but not that he was always in his room and should be taken out more often.
8. The care home reviewed Mr F’s falls risk assessment every month. It recorded in April 2019 that Mr F had become unsteady on his feed and had issues with his balance. It said Mr F had a high risk of falling, due to his medication, his visual impairment, and his cognitive issue that could impact his risk perception.
9. Mrs C says his risk of falls was mainly due to the type of dementia her father had.
10. On 1 May 2019, the GP saw Mr F with regards to some recent falls he experienced.
11. On 12 May 2019, staff suspected that Mr F had an “unwitnessed fall”. Staff found him on the lounge floor leaning against the wall. Before that, staff saw him walking around the unit. As a result, the home advised staff to be present as much as possible in communal areas.
12. On 22 May 2019, the home referred Mr F to a Physiotherapist for a mobility assessment. The referral said Mr F had some falls at night and the staff and Mrs C were wondering whether he would need a walking aid. He tried a walking frame and walked independently saying he felt safe. The Council ordered a walking frame that he could use in the evening when he was less steady on his feet. He received this early June 2019. It also ordered a chair raiser for him.
13. The GP carried out a medication review with Mr F on 23 May 2019 as he would get dizzy when standing up.
14. Mr F also had a Falls Action Plan, which the home reviewed every month. On 23 May 2019, it included an extensive review of his fall risks and any environmental risks. Mr F’s Plan said that:
• His mobility fluctuates day by day.
• He was largely independent but needed support and supervision often.
• Staff should regularly check on him and ensure his environment is clutter free.
15. The following care records are relevant to the falls that occurred:
• 1 June 2019: Mr C had an unwitnessed fall in his room at 11:55am. Staff found him on the floor, collapsed and calling out. No injuries noticed. Assisted back into chair. Action to avoid reoccurrence: added to GP medication review list.
• 12 June: The home called the GP to say they found Mr F on the floor last night. There were no apparent injuries.
• 18 June: Mr F had an unwitnessed fall at 3.30am, when staff found him on the floor. No injury observed. It said that: Due to his reduced cognition, there is no way of preventing him from falling again.
• 21 June: Mr F had an unwitnessed fall at 4.40pm. It says “he was found on his bedroom floor by a care assistant on duty. Mr F was unable to verbally recall what caused his fall.” The fall resulted in a broken hip and hospital admission. The home raised a safeguarding alert and notified the Care Quality Commission. He becomes more confused late afternoon and evening.
16. Mrs C says her father had many unobserved falls during a short time. As such, the care home failed to recognise it should have tried to ensure that (as much as possible) he would sit in areas where staff could observe / monitor him.
17. Two out of the five falls during May and June 2019 happened when Mr F was in his room and were unobserved as such. The care home records show that, during the month of June 2019, Mr F was spending most of his time in his room, but he would come out for meals. The care home says that this is what he wanted.
18. The Council’s care review of Mr F held on 23 April 2019 noted that “although Mr F likes to go in the garden, he tends to be a private man and prefers his own company rather than sitting with others”.
19. Mr F had a sensor mat in his room. However, staff were not asked when Mr F’s fall risk increased to put a sensor mat in front of his chair during the day. This would have alerted staff when Mr F would leave his chair and would have better enabled staff to monitor and observe his movements.
20. Mrs C said that:
• There is a lack of evidence to show that staff would, as a minimum, encourage Mr F to leave his room every day and spend more time in communal areas etc. When he moved to another home, he spent most of the time in the communal area with other residents.
• There were (falls) risk attached to being in his room alone, and her father did not have capacity to make the decision that he wanted to stay in his room despite these risks. As such, Mrs C said the care home failed to assess / consider Mr F’s capacity to make this decision and failed to make a best interest decision with regards to this.
21. The Council says:
• The care home took steps to try and manage Mr F’s increased risk of falls. It tried to ensure, as much as possible, that Mr F would spend time in communal areas during the day. It is standard practice for staff to offer and encourage residents to join other residents in the communal areas and take part in group activities. However, Mr F would often decline.
• Mr F had his bedroom door open during the day and liked staff to ‘pop in to see him’. When Mr F was in his room staff would regularly check on him and were able to observe him as his bedroom door would remain open.
• The risk of falls would have remained high, even if he had been in the communal areas at all times.
• There were no concerns by the care home, or the social workers involved in his case, that Mr F was unable to make day to day decisions about his care. This included decisions whether or not to stay in his room, join in with activities or sit in the lounge. As such, there was also no need to make such a best interest decision.
• In conclusion, it appears there were many factors that may have contributed to Mr F falling, which were acted on by the care home. The care home was in contact with Mr F’s GP at the time of the falls and had put adequate precautions in place to try to minimise the risk.

Analysis

22. The care home reviewed Mr F’s Falls Risk Assessment and his Falls Action Plan every month.
23. When the care home noticed that Mr F’s risk of falls had increased, it took the following actions: it organised two reviews by his GP (including one of his medication), a physiotherapy assessment, provision of additional equipment, and told staff to regularly check up on him. As such, it is clear the care home responded to Mr F’s increased risk and pursued various options to reduce this.
24. However, Mrs C says her father’s falls were unwitnessed and, as such, the home should have encouraged her father to be more in communal areas where staff would be present. The care home acknowledged at the time that staff should try and observe Mr F as much as possible. I agree the care home could have considered to regularly encourage Mr F to spend more time in a communal area, as a possible strategy to try and reduce the risk. Even though the Council said the staff had regularly tried to ensure that Mr F would spend time in communal areas during the day, it provided insufficient evidence to me to support this.
25. Furthermore, while Mr F had a sensor mat next to his bed to alert staff when he would try to get out of his bed, there is no evidence the care home considered to have a sensor mat in front of Mr F’s chair to alert staff when he would try to get up and mobilise. In my view, the care home should have considered this.
26. Two out of the five falls happened in Mr F’s room during the day. I am unable to conclude, on the balance of probabilities, that the two measures above would have reduced the number of falls Mr F experienced.

Mr F’s fall on 21 June 2019

27. Mrs C said that:
• Her father had a leaking toilet that had not yet been fixed. She had been at the home shortly before the fall, when the toilet had not been fixed yet and there was water on the floor.
• She believes her father slipped in the bathroom on 21 June 2019, because there was water on the bathroom floor. Furthermore, a staff member who called her on 21 June 2019 said she was with her dad in the bathroom where he slipped.
• However, the home later said her father did not fall in the bathroom, but in his room.
28. In response to my request, the care leader involved that afternoon stated that Mr F was not found in his bathroom, but in his bedroom.
29. The care provider has said the toilet was fixed on 19 June 2019, two days before Mr F fell. A copy of the care home’s Maintenance Records state that Mr F’s daughter reported a leak on 18 June 2019. Underneath ‘ACTION TAKEN’ the handyman reported ‘NO LEAK’, which indicated he carried out a check.
30. The care provider told Mrs C in March 2020, as part of its complaint response, that:
• The incident report on 21 June 2019 documents that staff found Mr F on his bedroom floor.
• The Home Manager and the Care Leader both confirmed that it is their recollection that Mr F was in his bedroom near to the bathroom door.
• It is sorry for the miscommunication or misunderstanding about the location of the fall at the time it happened.
31. The Council has told me there was a toilet leak in April 2019, which was fixed in the presence of Mrs C’s sister. After a further report that the toilet was leaking in June 2019 this was checked by the care home’s maintenance person on 19 June, who found no leak. There was no leaking water in Mr F’s bathroom. Mr F did not slip on water and did not fall in the bathroom. This was not the cause of the fall.

Analysis

32. According to the available evidence, Mr F did not fall in the bathroom and the toilet was not leaking at the time.

Agreed action

33. When a council commissions another organisation to provide services on its behalf, in this case a care home, it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the care provider, I have made recommendations to the Council.
34. I recommend that, within four weeks of my decision, the Council provides an apology that the care home failed to put in place, or at least consider, two measures that could have reduced Mr F’s risk of falling.
35. The Council has told me it has accepted my recommendations.

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Final decision

36. For reasons explained above, I found there was some fault with regards to the actions complained about. I am satisfied with the actions the Council will carry out to remedy this and have therefore decided to complete my investigation and close the case.

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Investigator's decision on behalf of the Ombudsman