Summary: Mrs X complained that Anchor Hanover Group (the Provider) failed to prevent her mother, Mrs Y, from falling and breaking her hip. We found fault with how the Provider assessed the risks to Mrs Y and how it handled Mrs X’s complaint. However, this did not contribute to Mrs Y’s fall, so did not cause the distress Mrs X claims. The Provider has apologised for the distress caused by how it handled Mrs X’s complaint and made service improvements. We consider this is a suitable remedy so we have completed our investigation.

The complaint

1. Mrs X complained that Anchor Hanover Group (the Provider) failed to adequately supervise her mother, Mrs Y, or to follow the advice of the falls team. As a result, she said her mother fell on 12 March 2020, breaking her hip, and later died. Mrs X said this caused significant distress to her and her family, particularly because she was unable to visit her mother in hospital due to COVID-19 restrictions. Mrs X said the care provider did not take the incident seriously or investigate properly, causing her further distress.

Back to top

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))
4. 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)
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. I am satisfied Mrs X is suitable to bring the complaint on behalf of Mrs Y. (section 26A or 34C, Local Government Act 1974)

Back to top

How I considered this complaint

6. I considered the information Mrs X provided and discussed the complaint with her.
7. I considered the Provider’s comments on the complaint and the supporting information it provided.
8. I considered the relevant law and guidance.
9. Mrs X and the Provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.
10. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

What I found

Law and guidance

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 Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
12. Regulation 9 says that care provided must be person-centred. This means it must be appropriate and meet their needs. It also means that assessments of a person’s needs should be reviewed regularly and whenever needed throughout their care.
13. Regulation 12 says that care must be provided in a safe way for residents. This includes assessing and as far as possible mitigating risks, safe care planning, ensuring premises and equipment are safe and safe management of medicines.
14. Regulation 16 says that providers must investigate complaints and necessary action must be taken in response to any failures identified.

What happened

Mrs Y’s fall

15. Mrs X’s mother, Mrs Y, was a resident at the Provider’s West Hall Care Home from 2015. Mrs Y had dementia and was at risk of falling.
16. To help reduce the risk of falls the Provider produced a fall prevention plan for Mrs Y. This included seeking advice from the local NHS falls service, who last saw Mrs Y in June 2019.
17. The provider identified Mrs Y was at a high risk of falling and, due to her dementia, she was not aware of this risk. It said that she would “often stand up and start walking…, being very wobbly and unsteady on her feet” and that she “requires supervision on standing up from a sitting position and walking around indoor[s]”. The plan required Mrs Y to have a chair sensor for the chair she usually occupied in the lounge. The plan said staff should not use the chair sensor on other chairs due to the attached lead being a trip hazard.
18. In late September 2019, Mrs Y’s GP prescribed a sedative medication because Mrs Y had become increasingly agitated in the past few months. Staff could give this medication, as needed, when Mrs Y became agitated.
19. In October 2019, Mrs Y had several falls. Paramedics and her GP examined her after these falls. The Provider also referred Mrs Y again to the falls service which advised it felt there was nothing further it could add to the advice it gave in June.
20. The Provider reviewed Mrs Y’s fall prevention plan in early November. This review referred to the previous advice from the falls team and Mrs Y’s last medication review. However, the question about whether Mrs Y was on any medication that might cause drowsiness or dizziness was ‘No’. Given the side effects of Mrs Y’s sedative medication, this answer appears to be wrong.
21. In early March 2020 Mrs Y’s GP saw her again for a post fall check-up. The Provider’s records state the GP had no concerns and decided no further action was necessary. The Provider again reviewed Mrs Y’s fall prevention plan, but again answered ‘No’ to the question about medication that might cause drowsiness or dizziness.
22. On the day of the fall in mid-March, the Provider’s records state staff gave Mrs Y her prescribed sedative medication around 7:40am before she had her breakfast a few hours later.
23. Around midday, Mrs Y was sitting on a chair in the dining room with two other residents. A member of care staff supervised the dining room while preparing the room for lunch.
24. The statement from the staff member says they noticed Mrs Y trying to stand and they moved towards her to offer support. However, they could not reach Mrs Y before she fell. The Provider says its manual handling training advises staff not to try to catch falling residents to prevent the risk of more injuries.
25. After Mrs Y fell, the care home manager checked her for visible injuries, found none, and care staff transferred Mrs Y to a wheelchair.
26. After a few minutes, Mrs Y became agitated, so the care staff called for paramedics and transferred Mrs Y to bed. Paramedics took Mrs Y to hospital for checks which discovered that Mrs Y had broken her leg.
27. Mrs Y went into hospital for surgery. Mrs X says due to COVID-19 restrictions, she could not visit Mrs Y in hospital, which caused extra distress to both Mrs X and Mrs Y.
28. Mrs Y left hospital and moved into another care home in early April 2020. Mrs Y has since died.

Mrs X’s complaint

29. Mrs X complained about the fall to the Provider, who assigned one of its regional managers, Manager A, to investigate the complaint.
30. Mrs X objected to Manager A’s involvement and asked that a different manager investigate her complaint.
31. Manager A issued a response to Mrs X’s complaint two weeks after Mrs X complained. Manager A said the Provider did not use chair sensors in the dining room, because it only used sensors in residents’ rooms. Mrs X knew this was not true and asked the Provider to reinvestigate the complaint.
32. Manager B reviewed the complaint and again told Mrs X the Provider did not use chair sensors outside residents’ rooms. Mrs X was not satisfied with this response and sent the Provider photographs showing Mrs Y’s chair sensor on her lounge chair. Mrs X says this shows the Provider did not investigate her complaint thoroughly.
33. A director reviewed the responses to Mrs X’s complaint and apologised for the wrong information about the use of chair sensors.

Improvements made by the Provider

34. In response to my draft decision, the Provider explained improvements it has already made in response to Mrs X’s complaint.
• It has reviewed its processes for reviewing fall risk at its West Hall Care Home. This includes the following.
1. Managers checking correct recording of medication which could contribute to the risk of falls and ensuring this is reflected on the care plans and risk assessments.
2. An information sharing session with staff who are responsible for completing these documents to ensure a better understanding of what has been asked.
3. Holding weekly clinical risk meetings with team leaders and the general manager holding monthly clinical risk meetings. Falls are discussed at these meetings and care plans checked to ensure that they reflect the required information.
4. The senior manager completing a monthly falls analysis audit to identify any trends in falls and putting action plans in place accordingly.
• When investigating future complaints, it will ensure more specific, detailed questions are asked of care home managers and documents are checked robustly when preparing investigation reports.

My findings

Mrs Y’s fall

35. The evidence shows the Provider assessed the risks to Mrs Y, including those from her being liable to falling. It reviewed these assessments after Mrs Y’s GP prescribed the sedative medication, sought further advice and updated Mrs Y’s fall prevention plan in early March 2020. However, not all the reviews recognised Mrs Y’s prescribed medication could cause drowsiness. Therefore, I consider the reviews were not as person-centred and accurate as they should have been in accordance with Regulations 9 and 12. This was fault.
36. On the day Mrs Y fell, she was sat in the dining room and supervised. There was no chair sensor because Mrs Y’s care plan says this is only for her chair in the lounge. A staff member noticed Mrs Y trying to stand but could not reach her in time to prevent her falling. So, even if a chair sensor had been used, it is unlikely this would have alerted staff sooner or prevented Mrs Y from falling.
37. Although there were flaws in the assessments, I am satisfied this did not contribute to Mrs Y’s fall. There is no evidence the sedative medication she was given that morning played a part in her fall around lunchtime. Mrs Y was supervised at the time. Therefore, I am satisfied that:
• the Provider was unlikely to have been able to prevent Mrs Y’s fall, even if there were no flaws in the assessments; and
• any flaws in the assessment did not cause the fall and distress Mrs X complains of.

Mrs X’s complaint

38. The Provider’s first two responses to Mrs X’s complaint wrongly stated it did not use chair sensors outside of residents’ rooms. This was despite Mrs Y’s care plan stating that her chair sensor was used in the lounge.
39. Mrs X had to raise this point with the Provider twice and provide photographic evidence before it corrected the mistake.
40. The evidence shows the Provider did not investigate Mrs X’s complaint properly at the first stage and did not properly consult Mrs Y’s care records. This was fault, contrary to Regulation 16. Therefore, I am satisfied this caused Mrs X avoidable uncertainty in the thoroughness of the Provider’s investigation and added to her distress.
41. The Provider has apologised to Mrs X for the mistakes in its complaint responses. I am satisfied this is a suitable remedy.

Improvements made by the Provider

42. I am satisfied the improvements the Provider has already made are an adequate response to the faults I have identified. I have therefore not made further recommendations.

Final decision

43. I have completed my investigation and uphold parts of Mrs X’s complaint. There was fault by the Provider and this caused an injustice to Mrs X. I am satisfied the Provider’s apology to Mrs X remedies the injustice to her. I am also satisfied with actions the Provider has taken to prevent similar faults in future.

Back to top

Investigator's decision on behalf of the Ombudsman