Summary: There was fault as the Home failed to monitor the call bell response times and failed to provide appropriate records relating to two falls Mrs C suffered. The Home gave contradictory explanations on how one of the falls occurred. The records also say that Mrs C’s call bell and mat were unplugged on one occasion. The Council which commissioned the Home has agreed to apologise to Mrs C’s son and pay a financial remedy.

The complaint

1. Mr B complains on behalf of his mother, Mrs C, who has sadly passed away. He complains about the care provided by Elizabeth House residential home in Benfleet. He says Mrs C suffered two falls while at the Home and that the staff sometimes unplugged Mrs C’s call bell so that she was unable to call for help.

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The Ombudsman’s role and powers

2. 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)
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. 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

5. I have discussed the case with Mr B. I have considered the documents that he, the Council and Council 2, which carried out the safeguarding enquiry, have sent and Mr B’s and the Council’s comments on the draft decision.

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What I found

Regulations, guidance and policies

Regulations

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards for those registered to provide care services must achieve.
7. The CQC has provided guidance on the regulations. This says that:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. (regulation 12).
• Care providers must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17).

The Home’s Call Bell Policy

8. The Home’s call bell policy says:
• An emergency call must be responded to within one minute and all other calls, within four minutes.
• Under no circumstances should support mechanisms such as call bells and sensor mats be removed from residents or unplugged. Staff who do this may face disciplinary action.
• The care home has a duty to regularly monitor call bell response time. This can be done by analysing a printout of all call bells and/or doing daily checks to see how long it takes for call bells to be answered on the various units.

The Home’s Falls Prevention Policy

9. The Home’s falls prevention policy says staff should take the following actions, among others, when a resident has had a fall:
• Complete an accident form.
• Investigate how the incident occurred and identify any lessons learned.
   

What happened

10. Mrs C was an elderly woman who had restricted mobility. She moved into the Home on 26 August 2020.
11. The Home assessed her needs and provided a care plan which said:
• Mrs C was able to mobilise with her wheeled rollator frame for short distances but needed assistance from one care worker for longer distances.
• Mrs C was at high risk of falls, especially at night as she used the toilet a few times at night.
• Mrs could express her need to use the toilet by using the call bell.
• Mrs C had a floor sensor mat to address the risk of falls. The mat was positioned to the right side of the bed when Mrs C was in bed and in front of her chair when she was in the chair.
• Staff should monitor Mrs C at night to ensure that she maintained a safe environment.
12. The following is a chronology of what happened based on the care records.

Fall - 10 September 2020

• Mrs C was checked at 15:59 and she was awake and ‘very happy’.
• Mrs C’s call bell was ringing at 16:18. The care worker went to Mrs C’s room and found her sitting on the floor, near the bathroom. She was not in any pain and had been able to move enough to reach the call bell. She had a minor tear on her right shin.
• The fall was added to the care plan and the care plan made reference to an ‘accident form’.

23 September 2020 (Wednesday)

13. Mr B rang the Home at 10:38. He said staff continued to remove Mrs C’s call bell at night and ignored her. The manager said it was unacceptable to take the call bell away and she would check the call bell herself in case there was a loose connection.
14. A care worker recorded, at 13:50: ‘Went into [Mrs C’] bedroom this morning to find her call bell and sensor mat was unplugged from the wall.’

24 September 2020

15. Mrs C’s social worker contacted the Home. She said Mr B had told her that Mrs C’s call bell was pulled out of the wall Tuesday night. The manager said:
• She went to Mrs C’s room with the night staff, but Mrs C could not remember the nights the call bell was pulled out from the wall.
• The manager had never observed the call bell being pulled out of the wall.
16. The care package was commissioned and funded by Nottingham City Council, but the Home was not in Nottingham but in a different local authority, which I will call Council 2. Therefore any safeguarding duties lay with Council 2, not Nottingham City Council.
17. Mrs C’s social worker made a safeguarding referral to Council 2. Council 2 requested further information from the Home to try to establish whether the referral met the threshold for a safeguarding enquiry, but the Home did not respond.

Fall - 30 September 2020

18. Mrs C had food and tea in her room at 17:07.
19. The daily record said: ‘At 17:30, [Mrs C’s] call bell was going and [Mrs C] sitting in the floor in her ensuite between her toilet and the wall. I asked [Mrs C] how did she fall she said she was trying to get up from the toilet.’
20. The call bell monitoring system said the response time for the call was 1 minute and 28 seconds.
21. Mrs C was taken to hospital where it was discovered that she had a fracture at the bottom of her spine.
22. Sadly, Mrs C passed away on 17 October 2020.

1 October 2020

23. Mr B called Council 2 on 1 October 2020 and informed them of the fall.

13 October 2020 – start of the safeguarding enquiry

24. Council 2 started a safeguarding enquiry into the two referrals.
25. The form relating to the allegation that the call bell had been unplugged said: ‘I have spoken to [Mrs C]. She said that ‘last night was ok (Wednesday 23 September) but it was the night before and the night before’, so 21 and 22 September. Mrs C said she wet the bed on Tuesday night through to Wednesday morning and no carer came to her.’

Complaint - 4 December 2020

26. Mr B made a complaint about the falls Mrs C suffered and said they were caused by lack of supervision and the fact that the staff, in particular the night-time staff, did not answer Mrs C’s calls when she pressed the call bell to go to the toilet. Mr B said he had alerted the Home on two occasions that the night staff had unplugged the call bell so Mrs C could not call.

The Home’s complaint response to Mr B

27. The Home responded (undated letter) and said:
• On 10 September 2020 Mrs C was trying to go to the toilet. She walked over her sensor mat which activated the alarm. When the care staff attended her care bell, they found Mrs C sitting near her ensuite. The accident happened at 16:10 and before that, Mrs C was checked at 15:59.
• On 30 September 2020, Mrs C was found in the ensuite when the staff attended her call bell.
• Mrs C would frequently say to care staff that her call bell was unplugged.
• ‘There was not one occasion when the call bell was unplugged.’

The Home’s response to the CQC – 7 December 2020

28. The CQC became involved and the Home responded to the CQC on 7 December 2020 and said the following about the 30 September 2020 fall:
• ‘The service user’s call bell was activated which prompted staff to check them in the bedroom and it was then that the service user was found in the ensuite on the floor.’

The safeguarding enquiry

29. Council 2 completed its safeguarding enquiry on 18 February 2021. The report said:
• In relation to the allegation that the call bell had been unplugged, the Home said Mrs C’s call bell was working on the nights of 21 and 22 September 2020 but its call bell monitoring system was not working, so it could not provide evidence to the response times to the call bell.
• Council 2 checked the daily records for the night of 21/22 September and the night of 22/23 September (until 07:45) and confirmed that Mrs C had had regular checks and toilet access during those two nights.
• The call bell monitoring system was not working on 21 and 22 September 2020 but the Home had taken measures to undertake hourly observations. Steps were taken to ensure residents were safe in the absence of the call monitoring system.
• There could have been better manual recording of the call bell being pressed.
30. Council 2 made these observations about the 30 September 2020 fall in the safeguarding enquiry report:
• At 17:30 Mrs C’s call bell was going off and the staff came to check her. Mrs C was found sitting on the floor in her ensuite. She said she was going to the toilet but fell.
• The Home said: ‘During the 17:31 call, the staff member answered the call bell and assisted [Mrs C] to go to the toilet. [Mrs C] said that once she was finished she would press the buzzer again. The carer who assisted [Mrs C] to go to the toilet was on her way back to check on [Mrs C] and this was the time that the emergency alarm got activated and she found [Mrs C] with the call bell around her wrist and already on the floor.’ Following this response from staff, the call bell was activated a further six times but the Home said the later calls were caused by staff dealing with the emergency walking over the alert mat.
31. Council 2 completed its enquiry and said the allegation of neglect was ‘unsubstantiated’.

Complaint response – March 2021

32. The Council relied upon Council 2’s investigation in its response complaint. It said there were no concerns about the care provided at the Home and it did not uphold Mr B’s complaint.

Failure to respond

33. I tried to obtain the following information from the Home:
• The incident reports relating to the falls and any investigations/ assessments carried out after the falls.
• The call bell monitoring records.
• When did the call bell monitoring system stop working and when did it start working again?
• Why did the Home give different versions of events about the fall on 30 September 2020?
34. The Home failed to respond to the Council and to the Ombudsman’s enquiries. The Council and the Ombudsman chased the Home on many occasions both by email and telephone over several months. There was no response.
35. I have made a decision based on the information I have.

Analysis

Unplugging of the call bell

36. I wanted to speak to the Home about the record which stated that the call bell and mat were unplugged on 23 September 2020 and whether there was any other explanation for this record. The Home has not returned my calls.
37. Therefore, on the evidence I have, I uphold Mr B’s complaint that the Home unplugged Mrs C’s call bell on at least one occasion. This was fault. This put Mrs C at risk of harm as she could not call for help when she needed help. It also put Mrs C at greater risk of falls as she could not walk safely without assistance.

Fall on 10 September 2020

38. Mrs C had a fall on 10 September 2020. Unfortunately, the Home said that the call bell system was not working on that day so it could not say whether Mrs C had been waiting for her call bell to be answered when she went to the toilet and had a fall.
39. I asked the Home when the monitoring system stopped working and when it started again, but it did not answer my query.
40. The Home also failed to provide the incident/accident report or any record relating to the investigation it carried out to find out what happened (risk assessment). I note that there is a reference to an accident form in the care plan which suggests the form was completed, but the Home should have provided the forms.
41. There was fault in the Home’s failure to monitor the call bell. The Home’s own policy says the call bell system should be monitored to ensure that the staff respond within the required times. I note the Home said it provided hourly monitoring of residents, but that would not have fully addressed the issue. The correct response would have been to keep a manual record of the call bell response time and the Home failed to do this.

Fall on 30 September 2020

42. The call bell monitoring system was working on that day but there is again, no incident/accident report of the fall which the Home should have provided.
43. I am concerned about the different versions of events the Home has provided both to Mr D and the Council. From the call records, the call bell was attended at 17:31.
44. In its initial complaint response to Mr B, the Home said that the call bell was ‘going’ and the care worker went to Mrs C’s room and found Mrs C on the floor near the toilet. This is also what the Home told the CQC.
45. However, the Home then changed its story and told Council 2, in response to the safeguarding enquiry, that the care worker had assisted Mrs C in going to the toilet and then left her there. The care worker was on her way back and triggered the mat and then found Mrs C.
46. This is concerning as it suggests that there was no proper record of the incident or a proper investigation at the time of the incident. There should not be two versions of the same event. This was fault.

Injustice and remedy

47. Sadly, I cannot remedy the injustice Mrs C has suffered as a result of the fault, as she has passed away.
48. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate.
49. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a token payment to them as a remedy for their own distress.
50. I do not underestimate the distress Mr B has suffered in worrying about Mrs C and what happened. The poor record keeping, the contradictory communications about the fall on 30 September 2020 and the failure to engage with the Ombudsman’s investigation have made matters worse.
51. In the draft decision, I recommended that the Council paid Mr B £300 as a symbolic payment, in the draft decision. In its response to the draft decision, the Council said it accepted the Ombudsman’s findings and agreed to pay the £300. In addition, the Council said that, now it had been made aware of the Home’s failings, it would waive any outstanding charges for the care fees.
52. Mr B said that one of the outcomes he wanted to achieve from going to the Ombudsman, was to ensure that no other family had to go through what he did. The CQC is best placed to address any service issues within the Home and I shall share this decision with the CQC.

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Agreed action

53. 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, although I found fault with the actions of the Home, I have made recommendations to the Council.
54. Under our information sharing agreement, we will share this decision with the Care Quality Commission.
55. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise to Mr B in writing for the fault.
• Pay Mr B £300.
• Waive Mrs C’s outstanding charges for the fees.

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Final decision

56. I have completed my investigation and found fault. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman