Summary: Mrs F complained on behalf of her father Mr G, that the Care Provider took inadequate action to care for Mr G when he fell in a residential care home. We noted the Care Provider accepted some fault and has taken action to improve its procedures. But we consider it should pay Mrs F and Mr G £300 for the distress and uncertainty caused by the failings. The Council has agreed to our recommendations.

The complaint

1. Ms F complains on behalf of her father, Mr G, that Handsale Ltd (the Care Provider):
• failed to take adequate precautions to prevent Mr G falling again after two falls in April 2020;
• failed to seek medical advice, carry out a proper assessment of Mr G’s injuries or inform the family after two further falls in June 2020;
• has given contradictory accounts of how the falls happened;
• failed to call an ambulance after the second fall and left Mr G all night with a broken hip;
• failed to attend to Mr G’s personal care adequately: he was left unshaven for long periods and he was left without both sets of teeth; and
• failed to ensure Mr G had the means to receive or make video calls to Ms F during the pandemic.

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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, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

4. I have considered the complaint and the documents provided by the complainant, made enquiries of the Council and considered the comments and documents the Council provided. Mrs F 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

5. Mr G is elderly with a number of health issues including dementia. He is non-verbal. He was living in his own flat with a package of care but due to a deterioration in his condition and ability to look after himself, in March 2020 he went to live in Bierley Court Care Home (the Home) run by the Care Provider.
6. His social care assessment identified he was at risk of falls. His care plan said his mobility was variable: he needed assistance from two people most of the time but on bad days required a hoist.
7. On 6 April 2020 Mr G fell out of bed. He was not injured and the Home informed Mrs F. On 10 April 2020 staff found him on the floor having fallen out of bed again. A senior member of staff checked him over and noted he had no injuries. The Home informed Mr G’s son in the morning and he asked whether bed rails or an alarm could be provided. The Home said it did not use alarms and it was up to the manager to decide about bed rails. Mrs F telephoned the Home to query the bed rails: she said he was discharged from hospital with a special bed designed to use bed rails. The manager said before using bed rails staff should put Mr G’s bed on the lowest setting, move it against the wall and place a sensor mat on the other side. This was done and the care records show evidence that the mat was checked regularly.
8. The Council’s case records note that in mid-May 2020 that Mr G had settled into the Home well and his mobility was improving. The family were sad they could not visit him due to the pandemic but had done video calls and seen him from outside the building. There were no concerns and the Council closed the case.
9. On 8 June 2020 the Home reviewed Mr G’s assessments and concluded he was at high risk of falling. His sleep plan required two hourly checks throughout the night, to ensure his bed was on the lowest setting and against the wall with a sensor mat on the other side, due to the previous incidents.
10. On 11 June 2020 Mr G had an unwitnessed fall. At 15:53 he was assisted to his room and at 16:30 staff found him on the floor of his room. They activated the emergency call alarm and fetched a senior member of staff, who checked Mr G and found an injury on his head. The Home contacted the district nurse service remotely for advice. They said the injury was just a graze and needed dressing, Mr G did not require pain relief. Staff carried out checks at 17:30 and 18:30, saying he was fine. The Home informed Mrs F of the fall around 18:00.
11. Mr G had a second unwitnessed fall in the evening. The Home said staff checked on him around 20:10 and he was fine. At 20:15 a member of staff heard a thud and found him on the floor on his right side; he had fallen out of his chair. The member of staff pressed the emergency call alarm. Two senior staff attended and checked him for injuries but couldn’t find any. They assisted Mr G back into his chair and said he seemed fine. Checks through the night indicated he was fine and content.
12. The care records make no mention of the fall until the following morning at the shift handover. The morning records indicate he was fine with no reported discomfort or concerns. Mrs F rang at around 09:00 expressing concern about his second fall and wanting to know what extra preventative measures were being put in place. At 10.07 the records say Mr G was assisted to get into bed due to pain. No other concerns were noted until 11:00 when a member of staff was concerned that one of Mr G’s legs appeared shorter than the other and was swollen. Mr G also appeared to be in pain. The member of staff rang 999 and they sent an ambulance for him. He went to hospital at 12:30 and the Home informed the family. Later that day the hospital informed the Home that Mr G had broken his hip.
13. Mrs F complained to the Home about the falls and a number of other issues regarding Mr G’s care, including video calling. The family also gave notice for Mr G to leave the Home.
14. The Home responded to the complaint on 10 July 2020. It explained what had happened regarding the falls in April and was satisfied that appropriate action was taken to prevent Mr G falling out of bed.
15. In respect of the two recent falls, it was satisfied that the correct procedure was followed after the first fall: calling for help, immediate first aid, calling for medical attention and obtaining medical advice. Staff also checked on Mr G throughout the night.
16. In respect of the second fall, it said that three carers helped Mr G to get dressed at 06:50 on 12 June 2020, but when he tried to walk he groaned in pain. A senior member of staff was called, who arrived after 15 to 20 minutes but took no action. The deputy manager arrived at 07:45 and was called to see Mr G straight away. Mr G was rubbing his leg and the deputy manager noted his right foot was swollen. They contacted Mrs F to find check a medical detail and then called 999.
17. The Home said night staff were instructed to call Mrs F but had not done so. It concluded that Mr G had not received appropriate care and attention once he showed signs of distress on the morning of 12 June 2020. It identified the following faults:
• Medical advice was not sought following the second fall.
• Correct procedures were not followed when senior staff were informed Mr G was in pain and unable to walk.
• Information given to Mr G’s family about the falls was inconsistent and unclear: for example whether he had fallen from his bed or chair.
• Staff did not contact Mrs F about the fall.
• Records relating to both falls were insufficient and did not meet the record-keeping expectations.
18. The Home apologised and said it would:
• Ensure that staff who did not follow the Home’s falls and injury procedure were subject to the organisation’s human resources procedures.
• Ensure all staff have refresher training on the falls and injury procedure; and
• Recommend that the Home reviews its admissions policy to ensure all people due for admission are considered for ‘as needed’ pain relief’.
19. In respect of the video calls, the Care Provider explained that the Home’s tablet broke in May 2020 and due to lockdown, staff were unable to get it repaired and the Care Provider was unable to offer help to repair or replace it. The device had now been repaired but the Care Provider accepted this meant Mr G had not been able to video call his family for a couple of months. It apologised for the distress this caused.
20. The Home also gave an explanation over the missing dentures (it found them after Mr G went into hospital) and apologised for the failure to ensure they were sent to him. It apologised for the omission which compromised Mr G’s dignity and respect.
21. The Home said Mr G had last had a shave on 8 June 2020 and was due another one on the morning he went into hospital (12 June 2020). Prior to that he had been shaved on 4 and 6 June 2020.
22. Mrs F made a further complaint about several points in the first complaint and the Care Provider sent a second response on 23 July 2020 clarifying the issues raised.
23. Mrs F then complained to the Council. The Council responded in August 2020. It said it had liaised with the Care Provider who had responded to the complaints and offered to meet the family, but they had declined. Mrs F and the Home had contacted CQC who had investigated the issue of falls in the Home. It had put together an action plan identifying improvements the Home should put in place. The Council did not consider it could achieve any more by further investigation. Mrs F then complained to us. She denies that the Care Provider had ever offered to meet with the family.

Analysis

failed to take adequate precautions to prevent Mr G falling again after two falls in April 2020

24. The Home carried out a further risk assessment after the falls in April, amended the sleep plan, pushed the bed against the wall and put a sensor mat on the other side. Mr G did not fall out of bed again and Mrs F did not raise any further concerns about these falls. I cannot identify any fault in the action the Home took.

failed to seek medical advice, carry out a proper assessment of Mr G’s injuries or inform the family after two further falls in June 2020, gave contradictory accounts of how the falls happened, failed to call an ambulance after the second fall and left Mr G all night with a broken hip

25. I cannot identify fault with the way the Home dealt with the first fall. It called senior staff, sought medical advice, informed the family and regularly checked on Mr G.
26. The Care Provider fully accepts that its actions following the second fall were inadequate. I agree with its conclusions detailed at paragraph 17: the Home failed to seek medical advice, failed to take immediate action the following day when Mr G was in discomfort, failed to inform the family, gave them contradictory information about the falls and failed to keep proper records of the incidents. This was fault which caused Mr G and the family, distress and uncertainty as to what had happened and why.
27. I understand it must have been very distressing for the family to learn that Mr G spent all night with a broken hip. However, I note there is no evidence he showed any discomfort until the following morning and he slept well.
28. The Care Provider has identified and implemented improvements in its procedures, both as a result of the complaint and the CQC involvement. It has also taken action in respect of a member of staff. I am satisfied it has taken the complaint seriously and improved its practice as a result.

failed to attend to Mr G’s personal care adequately: he was left unshaven for long periods and he was left without both sets of teeth

29. The Council has explained the frequency it shaved Mr G and I cannot conclude there was fault here. The Council has explained the issue with Mr G’s dentures and apologised for the failure to provide them in hospital.

failed to ensure Mr G had the means to receive or make video calls to Ms F during the pandemic.

30. The Care Provider accepts the tablet was broken for approximately two months which meant Mr G could not have video contact with his family. It has explained this was due to the pressures and circumstances raised by the lockdown and has apologised for the distress this caused Mr G and his family.

Agreed action

31. While I welcome the steps the Care Provider has taken to implement improvements and apologise to Mrs F and the family, I considered a financial payment is appropriate to recognise the injustice caused to Mr G and Mrs F.
32. I asked the Council (within one month of the date of my final decision) to pay Mrs F £300.
33. The Council has agreed to my recommendation.

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Final decision

34. I consider this is a proportionate way of putting right the injustice caused to Mrs F and I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman