Summary: Mrs C complained about the way the care home responded to her mother’s falls. We found with the care provider’s actions. The care provider has agreed to apologise to Mrs C and her mother and pay each of them a financial remedy for the distress they experienced. It will also share the lessons learned with its staff.

The complaint

1. The complainant, whom I shall call Mrs C, made a complaint to us on behalf of her mother, whom I shall call Mrs X. Mrs C complained her mother had seven falls at her care home within a short timeframe. More specifically, Mrs C says the care home:
• Failed to do enough to try and prevent these falls from continuing to happen.
• Failed to inform the Council’s safeguarding team about the falls.
• Should not have moved her mother from the floor onto a bed when she had broken her hip following a fall.

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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))
4. If we are satisfied with a care provider’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 34H(i), as amended)

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How I considered this complaint

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

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What I found

Relevant legislation and guidance:

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the 2014 Regulations (the Fundamental Standards). We consider the 2014 Regulations and the Fundamental Standards, as well as a provider’s policies and procedures, when determining complaints about poor standards of care. The following regulations are relevant to this complaint:
• Regulation 12. This requires care providers to provide care and treatment in a safe way. This includes that assessments, planning and delivery of care and treatment should be based on:
1. risk assessments that balance the needs and safety of a resident with their rights and preferences,
2. include arrangements to respond appropriately and in good time to people's changing needs, and
3. are carried out in accordance with the Mental Capacity Act 2005. 
7. The care provider’s Falls Prevention and Management Policy says that:
• All falls are properly recorded and investigated, and the outcomes of all investigations are updated on Datix.
• Care Plans and Risk Assessments are reviewed and updated.
• Each Care Home has a ‘Falls Team’ responsible to the Home Manager / Designated Person in Charge. This team will meet on a quarterly basis to review all falls incidents and ensure appropriate actions are planned and taken to reduce the risk of falls.
8. The care provider’s Falls Prevention Home Managers Guide says that:
• Residents identified as ‘at risk’ must have a full monthly review, or more frequently as the resident’s condition dictates.
• When a resident falls it is important that they are assessed and examined promptly to see if they are injured. This will help to inform decisions about safe handling.
• As soon as possible after the fall an incident report must be completed and the incident should be logged on Datix. The incident report should be comprehensive and give a clear picture of what happened and what immediate action was taken.
• Even if a fall is minor and causes no injury, you must still investigate and try to prevent it happening again. An increasing number of minor falls is likely to result in a more serious fall in the future.

What happened

9. Mrs X had to move into Winters Park Care Home in February 2020. As such, the care home completed a pre-admission assessment. It said:
• No concerns about comprehension, mood or anxiety
• Walks with frame.
• Has had one fall.
• Mrs X had Parkinson’s disease and was no longer aware of her falls risk.
10. Mrs X went into the care home two days later. The care home completed a 7-day care plan, which said she needed a wheeled trolley to mobilise, she could be unsteady on her feet and was at risk of falls.
11. The care home’s falls assessment and plan said:
• Mrs X would often mobilise without her wheeled trolley.
• Mrs X would like staff to remind her as she often forgets.
• The intervention in place at the time was: monitoring Mrs X and reminding her to walk using her walking aid.
12. In March 2020, the “Safer people handling risk assessment and care plan” said Mrs X did not have any recent falls. It said: she managed mobilising well herself. Has a Zimmer trolley, but will often walk unaided. At times she appears confused. Staff to be vigilant. She can consent or refuse verbally. Often will walk unaided; she is aware of her abilities. It also included other risk minimisation strategies such as appropriate fitting footwear, clutter free environment, dry floors in the bathroom, the use of a shower chair and bath hoist, one member of staff to assist when bathing and use of a wheelchair when outside the home.
13. The “Sleeping and Rest care and support plan” from March 2020 said that a sensor mat, clutter free environment and having the call bell close at hand, were the risk minimisation strategies in place overnight.
14. Mrs X did not have any falls during the first month of her stay at the home. Mrs C says her mother spent a lot of time in her room, which perhaps prevented her from falling. She started to walk more after that. The home updated the falls assessment and plan of care on 25 March 2020. It said Mrs X could be confused and restless, pacing around the home due to her cognitive impairment. Falls reduction plan updated.
15. Mrs X subsequently started to experience the following falls:
• 21 March fall (8:50pm): A staff member found Mrs X sitting on the floor in the lounge. Minor injuries. The care provider acknowledged the home manager failed to update the falls diary on this occasion, as this fall is not mentioned in there. However, it is mentioned in the Datix Incident & Accident reporting form. It said a resident was laying down and Mrs X sat next to him. Mrs X said she had tripped over him.
• 25 March: According to the daily care records Mrs X was walking without her walker that morning. As such, staff encouraged her at 10:30am to walk with her walker. However, she would not walk with it. Later that morning, staff found Mrs X on the floor at 11:40am, as she was “walking without walking aid”. Mrs X had a cut to her eyebrow, a nose bleed, and her hand hurt. Action taken: monitor and encourage to walk with walking aid.
• 4 April fall: Mrs X had another fall in the corridor at 5:15pm, because she had been “walking without her walking aid” again. Staff had given her the walker to walk with. However, Mrs X put the walker to the side and continued to walk unaided. She then lost balance and fell, reopening the wound to her eyebrow.
• 8 April: This time she fell in the ‘sitting area, because she was trying to sit on her trolley but slipped and ‘banged her arm’. The care provider acknowledged the home manager failed to update the falls diary on this occasion, as this incident was not mentioned in there.
• 10 April: Mrs X fell in the reception area at 10:25am as she was “walking without her walker” again. Mrs X said she lost balance and fell to the side. Action taken: “No apparent injuries. She got herself up. Need to be vigilant and get her walker if she is not using it”.
16. On 13 April 2020, the care home updated Mrs X’s “Review Form: Care and support plans / Risk assessment”. It said: Mrs X has a history of falls and sometimes forgets to use her trolley. Staff to ensure she uses walking aid and that her room is clutter free.
17. The care home recorded in Mrs X’s “Safe Environment Care and Support Plan” on 16 April 2020, that:
• Mrs X’s capacity can fluctuate. She does not have capacity to understand most safety risks.
• She has a trolley but does not use it most of the time. She is at high risk of falls and has frequent falls within the home due to losing her balance when walking unaided.
• Staff to encourage her to use the trolley.
• She has a sensor mat in place at night and when she is alone in her bedroom. Staff to ensure it is plugged in and in good working order. At times she can walk around the mat or unplug it.
18. However, Mrs X continued to experience falls:
• 2 May: Mrs X fell in the corridor area at 5:30pm, while “without walker”. Mrs X said she thought she was getting into bed while in the corridor and fell forward. She did not have any injuries and staff reminded her to walk with her walker.
• 3 May: Mrs X was found on the floor next to her bed at 5am. She said she rolled out of bed.
• 6 May: Staff found Mrs X on the floor in the corridor.
19. This meant Mrs X fell 8 times, within less than two months, five of which were due to Mrs X not using her walking frame.
20. The care home said it introduced the following measures to try and manage Mrs X’s risk of falling:
• The home would review Mrs X’s falls risk assessment after each fall and update accordingly.
• A sensor mat was in place in her room to alert staff when she would get up and start to mobilise, so staff could responsive and check if she was using her walking frame. However, Mrs X would sometimes unplug the sensor or walk around it.
• Staff reminded Mrs X of the importance of using her trolley.
• Staff customised her trolley, to try and make her use it more.
• Staff ensured her trolley was always close at hand.
21. When asked, the care home acknowledged that it should have discussed and considered the use of a door sensor as an additional measure to alert staff if she left her room, as Mrs X would not have been able to walk around that.
22. The care provider mentioned in its complaint response to Mrs C that it did not refer the falls to the Council’s safeguarding team, because there is a threshold for the type of incidents that should be referred. It said none of Mrs X’s falls met this threshold. However, it has acknowledged that the Council’s Safeguarding Adults Threshold Tool says that a care home should refer to, or at least discuss with, the safeguarding team if there are repeated incidents and preventative measures are not working.
23. The care provider also acknowledged in its complaint response to Mrs C that, on reflection, it should have referred Mrs X to the Council’s Falls Team / GP, due to her repeated falls within a short timeframe.

Analysis

24. The care home was in a difficult situation where Mrs X was refusing to use her walking frame, which significantly increased her risk of falls. As staff could not force Mrs X to use her frame, the home concluded it could only put measures in place to alert staff when Mrs X was mobilising, so staff could check if she was using her frame and, if not, encourage her to use it. It carried out falls risk assessments and reviewed these when needed. There was no fault with regards to this and this was in line with Regulation 12 of the Health and Social Care Act.
25. However, the care home failed to:
• Update the Falls Diary on two occasions
• Consider installing a door sensor, as Mrs X would try to avoid triggering the floor mat sensor.
• Refer Mrs X to the Falls Team, via the GP.
• Discuss Mrs X with the Council’s safeguarding team.
26. This was fault and not in line with Regulation 12 of the Health and Social Care Act.
27. However, while I am unable to conclude on the balance of probabilities, that the above actions would have prevented some of the later falls, including the one on 6 May 2020 which resulted in a broken hip fracture, there is a possibility it may have prevented this. This uncertainty has been distressing to Mrs C.

The way staff dealt with the fall on 6 May 2020

28. Mrs C says the care home should not have moved her mother when she fell on 6 May 2020. She was clearly in pain and it was possible she had broken a bone or experienced a significant head injury. As such, the staff’s action put her mother at risk.
29. The care home’s records state that staff found Mrs X on the floor in the corridor. A senior staff member checked her over before moving her. Mrs X said she had bumped the back of her head. There were no signs of any lumps, but she said her right knee was sore to touch. Three staff members helped Mrs X into a wheelchair. Mrs X said she had pain on the left side of her hip. Staff put Mrs X into bed and carried out a further check. Staff noticed that one leg was shorter than the other, which indicates a hip fracture. Staff contacted the GP.
30. The care home told Mrs C as part of its complaint response, that Mrs X was trying to get up off the floor and did not want to remain on the floor whilst staff assessed her injuries. Staff did not initially suspect that Mrs X had a fractured hip and felt that assisting Mrs X to get up would reduce her distress.
31. The care provider told me that staff would have ideally not moved Mrs X, and would have fully examined her where she fell. However, Mrs X was trying to get herself up off the floor, so staff supported her up. By not supporting her, this could have caused further injury, particularly if she was to fall again.

Analysis

32. The care provider acknowledged that staff should not have moved Mrs X if they suspected she could have had a serious head injury or had a fracture.
33. Mrs X mentioned she had bumped her head, and that her knee was in pain. Furthermore, I found it would have been more likely than not, that staff would have noticed the hip fracture (for instance that one leg was shorter than the other) if they had carried out a comprehensive check while Mrs X was still on the floor.
34. The home later said that this was not possible because Mrs X was making attempts herself to get up and it would have been dangerous not to support her with that. However, there is no reference to this important information in any of the records related to the incident, that were made at the time. Nor is there any reference to staff having tried to encourage Mrs X to remain on the floor a bit longer to complete the checks.
35. As such, I found that staff failed to carry out a sufficiently comprehensive check of Mrs X before they moved Mrs X. However, there is no evidence to indicate this resulted in an actual significant injustice to Mrs X.

Agreed action

36. I recommended that, within four weeks of my decision, the care provider:
• Provides an apology to Mrs C and Mrs X for the faults above and any distress these have caused them.
• Pay Mrs X and Mrs C each £200 for the distress they experienced.
• Share the lessons learned about responding to falls and escalation to external stakeholders with relevant staff within the care home.
37. The care provider has told me it has accepted my decision.

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Final decision

38. For reasons explained above, I have upheld the complaint.
39. Under the terms of our Memorandum of Understanding with the Care Quality Commission (CQC), I have shared a copy of my final decision statement with the CQC.

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Investigator's decision on behalf of the Ombudsman