Summary: Miss C complained about the quality of care her late father received at the care home in which he was a resident. She also complained the Council completed a safeguarding enquiry which was a waste of time. We find there was some fault in the care home’s consideration of what preventive measures to implement to reduce Mr D’s risk of falls. The care home also failed to follow its own observation policy. The Council’s safeguarding enquiry addressed the concerns about the preventive measures and recommended service improvements. However, it wrongly concluded the care home followed its observation policy. The Council has agreed to our recommendations to address the injustice caused by fault.

The complaint

1. Miss C complained about the quality of care her late father, Mr D, received at the care home in which he was a resident. Miss C says she raised concerns about several incidents where she believes her father was neglected. She adds the Council completed a safeguarding enquiry which was a waste of time and nothing was done about the neglect she reported.
2. Miss C says is has affected her mental health. She also believes the neglect Mr D suffered led to his death.

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The Ombudsman’s role and powers

3. 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)
4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)

5. 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)
6. 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, section 30(1B) and 34H(i), as amended)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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How I considered this complaint

8. I considered information Miss C submitted with her complaint. I made written enquiries of the Council and considered information it provided in response.
9. Miss C and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

10. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The CQC has issued guidance on how to meet the fundamental standards below which care must never fall.
12. Regulation 12 says that care and treatment must be provided in a safe way for service users.
13. Regulation 17 says care providers should maintain an accurate, complete, and contemporaneous record in respect of each service user.

Safeguarding duty

14. The Care Act 2014 and the Care and Support Statutory Guidance 2014 (updated 2017) set out the Council’s safeguarding duties towards adults who require care and support.
15. Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:

• Has needs for care and support.
• Is experiencing, or at risk of, abuse or neglect.
• Is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

16. If the section 42 threshold is met, then the Council must make enquiries. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by whom.

What happened

17. Mr D was a resident at Sherwood Lodge Care Home. The Council arranged and partly funded Mr D’s care. Mr D sadly died in May 2020.
18. The care home completed a pre-admission assessment of Mr D before he became a resident. It noted he had a high risk of falling.

Incident one

19. The care home’s records show care staff helped Mr D to the toilet. They left him alone and told him to press the call bell if he needed any help. After some time, another resident told care staff that Mr D was screaming. A member of staff returned to Mr D and he said he was going to fall off the toilet. The member of staff called for help, positioned Mr D on the toilet and told him to sit back. Mr D kept moving forward and he fell off the toilet.
20. Mr D suffered a skin tear to his knuckles. The care home called the District Nurse to dress Mr D’s wound. It also updated its accident and incident report form on the same day. Care staff said they would continue to monitor Mr D’s mobility and report any concerns. They also referred Mr D for physiotherapy support.
21. The care home also completed the safeguarding concern checklist and concluded the safeguarding threshold was not met. It said it had taken appropriate action by referring Mr D for physiotherapy and it would continue to ensure he always had his call bell.

Incident two

22. Miss C says she found Mr D soiled in his bedroom. The care home’s records show care staff gave Mr D a full body wash and that he had his call bell if he needed any help.

Incident three

23. Miss C says she found Mr D soiled on two further occasions. She says the family pressed the buzzer and no one came to help.
24. The care home’s records show Mr D had all his care needs met. The records also show that Mr D had his call bell and care staff regularly checked on him.

Incident four

25. Mr D told care staff he was experiencing pain in his arm and wanted a doctor. The medication records show care staff gave him two paracetamols in the morning and at teatime.

Incident five

26. A carer found Mr D on the floor in his bedroom. The carer raised the emergency alarm and Mr D was admitted into hospital as he had a cut on his head. The care home completed its accident and incident report form on the same day. It said Mr D was trying to stand up and fell forward.
27. Mr D had his wound cleaned up at the hospital and returned to the care home. Care staff encouraged him to sit in the communal area.
28. They observed him at 1:55pm, 3:30pm, 4:52pm, 7:04pm, 8:45pm and 9:30pm.

Incident six

29. Mr D had a further fall on the same day as incident five. A carer found him at around 9:30pm lying on his bedroom floor with his head against his wardrobe. Mr D had a head injury and there was blood on the floor. Staff called 999 and Mr D went to hospital. He was diagnosed with a fracture to his ribs and neck.

Safeguarding enquiry

30. The care home made a safeguarding referral to the Council after incident six. The manager that completed the form said Mr D had full capacity and would not always ask for help when required.
31. The Council spoke to the care home, a nurse at the hospital and Miss C. The nurse said there was no evidence the care home had put safety measures such as sensor mats in place. Miss C questioned why staff closed his bedroom door when he had an earlier fall on the same day. The Council decided to progress the matter and make further section 42 enquiries.
32. The Council gathered information from the care home. The care home explained it would not routinely put a sensor mat in place for people with capacity. It also said Mr D's previous falls were when he was in his chair. Rather than taking a step, he would fall forward, so the sensor mat would not pick his falls up.
33. The Council also spoke to Miss C. She said it was not good enough for the care home to only check Mr D every hour, and it should have been checking him every 15 minutes.
34. The Council completed its safeguarding enquiry. It found that the allegation of neglect was inconclusive. This was because:

• Mr D did not always want to ask for help and that he had attempted to stand without assistance before previous falls.
• The care home took some action to reduce the risk of falls.
• The care home sought medical attention and followed its own policy on head injuries.
• Mr D previously had a sensor mat before his admission to the care home. There was no evidence to suggest that Mr D’s views were sought about the implementation of a sensor mat and there were missed opportunities to consider a sensor mat before his falls.
• Mr D had suffered significant harm, but as the fall was unwitnessed, it was not possible to find out whether the fall would have been prevented if the sensor mat was in place, or whether Mr D would have consented to the mat.

35. It made the following recommendations to the care home:

• To discuss decisions whether to implement/not implement preventive measures with the service user and accurately document all decision making.
• In the absence of a manager, staff should communicate with the service user and/or family to identify and implement preventive measures.
• Pre-admission assessments should consider all relevant and available information to enable safe management of risk before the placement starts.
• For it to undertake supervisions with its staff regarding preventive measures following falls and the importance of record keeping.

Complaint

36. The Council spoke to Miss C and provided her with the outcome of the safeguarding enquiry. She said she was unhappy as the care home should have been checking on Mr D more regularly.
37. Miss C complained to the Council about incidents one to six. She also said was unhappy the Council had done nothing about the neglect she reported, and she had not received a copy of the safeguarding outcome.
38. The Council issued its response to Miss C’s complaint. It said:

• It had reviewed the safeguarding enquiry and the outcome was correct.
• Incident one – The care home acted appropriately. It contacted the district nurse and completed a safeguarding checklist form.
• Incident two – Mr D had a full body wash and he had access to his call bell.
• Incident three – Mr D had a full body wash, and no concerns were reported.
• Incident four – It gave Mr D paracetamol for the pain he reported in his arm.
• Incident five –The care home observed Mr D as per its policy and sought medical attention.
• Incident six – Mr D was found on the floor and care staff sought medical attention by calling 999.
• It sent her the outcome of the safeguarding enquiry on two occasions to her home address.

39. Miss C remained unhappy with the Council’s response and referred her complaint to the Ombudsman.

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Analysis

40. There is no evidence to suggest incident one could have been avoided. The daily records show that care staff tried to position Mr D back on the toilet, but he kept moving forward and ended up falling. The care home also took appropriate action after the incident. It called the District Nurse, completed its accident and incident form, and completed the safeguarding alert checklist form.
41. In relation to incidents two and three, there is no evidence that care staff left Mr D soiled. The daily records show Mr D had a full body wash and had access to his call bell if needed any help.
42. When Mr D complained about a pain in his arm, the care home gave him paracetamol. There is no evidence he complained about pain in his arm the following day and so I am satisfied it took the appropriate action in the circumstances.
43. Mr D’s fall from incident five was unwitnessed. When care staff found him, they took the appropriate action and called 999.
44. The care home’s policy on head injuries says care staff should observe residents:

• Every 15 minutes for one hour.
• Every 30 minutes for two hours.
• Every hour for four hours.
• Every four hours until 48 hours observation has been completed.

45. Mr D was found on the floor at 9:50am. A member of staff went to the hospital with him and so he was under constant observation. The observation records show he returned to the care home at 1:55pm. Therefore, the care home met the 15 and 30 minutes criteria.
46. The care home should have been observing Mr D every hour from 12:50pm to 4:50pm and then every two hours from 4:50pm to 0:50am. He returned from hospital at 1:55pm, and then was observed at 3:30pm and 4:52pm. Therefore, the care home failed to complete the hourly observation and adhere to its own policy. This is fault.
47. The care home says Mr D returned from the hospital at lunchtime and then sat in the communal areas, where a member of staff was present. Therefore, it says Mr D was observed every hour.
48. The care home’s policy makes it clear that observation following a head injury must be continued and recorded for a minimum of 48 hours following the incident. Therefore, regardless of whether Mr D was in the communal area, it still should have been recording its observation of him as per its policy. Accurate record keeping is vital to the delivery of safe and effective healthcare.
49. The Council concluded in its safeguarding enquiry that the allegation of neglect was inconclusive. It acknowledged that the care home missed opportunities to discuss the implementation of a sensor mat with Mr D, but that as the fall was unwitnessed, it was impossible to know whether a sensor mat would have prevented the fall.
50. I agree with the Council’s view that the care home failed to properly record why it was not implementing a sensor mat when it knew Mr D had a risk of falls. It also failed to ask Mr D for his views on whether he wanted a sensor mat. This is fault.
51. The Council also concluded in its safeguarding enquiry that the care home followed its own policy regarding observation after a head injury. I have explained in paragraphs 44 to 48 why this is incorrect.
52. The Council made appropriate service improvements to the care home about preventive measures which I welcome. However, I also recommend that the care home should ensure it adheres to its own policy after a resident has suffered a head injury. The Council needs to also ensure it is thoroughly checking all documents when it completes a safeguarding enquiry.
53. I cannot say what the outcome would have been if the care home had sought Mr D’s views on a sensor mat. Even if the care home had put in place a sensor mat, this may not have prevented Mr D’s fall. I also cannot say if the outcome would have been any different if the care home had followed its observation policy.
54. However, because of the care home’s fault, Miss C will always have a lingering doubt as to whether Mr D’s fall could have been prevented. The Council also provided her with inaccurate information when it completed its safeguarding enquiry, and this leaves her with further doubt. The Council should apologise and pay her £200 for this injustice.

Agreed action

55. When a council commissions another organisation to provide service on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found some fault with the actions of the care home, I made recommendations to the Council.
56. To remedy the injustice caused by fault, by 4 June 2021 Council has agreed to:

• Apologise to Miss C.
• Pay Miss C £200.
• Provide evidence the care home has implemented the service improvements from its safeguarding enquiry.

57. By 2 July 2021:

• Using this case as an example, ensure all care staff are reminded of the importance of adhering to its observation policy after a resident has suffered a head injury.
• Using this case an example, ensure staff conducting safeguarding enquiries thoroughly check all documents before sharing the outcomes with relevant parties.

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Final decision

58. I have found fault by the Council, causing an injustice to Miss C. The Council has agreed to my recommendations and so I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman