Summary: Mr X complained on behalf of his deceased mother, Mrs Y about the standard of care provided by Fairways Care Home and about an investigation completed after she fell. We find the Care Home delayed in responding after Mrs Y activated her sensor mat. That has caused Mr X avoidable uncertainty of how long his mother was on the floor after she fell and may have caused an injustice to Mrs X. Care Plus Group has already made recommendations for service improvements following the fall, it has also agreed to apologise to Mr X for the avoidable uncertainty caused.

The complaint

1. Mr X complained on behalf of his deceased mother, Mrs Y about the standard of care provided by Fairways Care Home (the Home). He said she was left unattended for two hours after activating the call bell for assistance; and a staff member had shouted at her to make her walk. He said when he reported this as a concern to the manager, they failed to address it.
2. Additionally, he is unhappy with the investigation completed by Care Plus Group (the Group) after his mother fell. He said the Group failed to communicate the findings of its investigation to him and it has been unable to confirm how long his mother was on the floor before care staff found her.
3. Mr X said his mother did not receive the level of care she should have received.
4. Mr X wants the Home to increase its staffing and to improve its care to the people it looks after.

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The Ombudsman’s role and powers

5. 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)
6. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
7. 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. (section 26A or 34C, Local Government Act 1974)
8. 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 30(1B) and 34H(i), as amended)

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How I considered this complaint

9. I discussed the complaint with Mr X.
10. I asked Care Plus Group questions about what happened and considered the evidence it provided.
11. Mr X and the Care Plus Group 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

How the Home investigate incidents

12. The Home is part of the Care Plus Group (the Group). The Group has a Quality, Regulation and Improvement Team that are responsible for investigating any incidents that take place in the Home. This is to ensure it is independent and objective.
13. The Group’s information about how it completes its investigations states it will meet with the person, or their family to discuss any events in the lead up to the incident. Once it has completed its investigation, it will provide a report of its findings and any proposed changes to practice.

What happened

14. Mrs Y moved into the Home at the start of 2020. The Home completed moving and handling risk assessments of Mrs Y in January, May and October 2020. It completed falls risk assessments alongside these. In the October 2020 assessment, the Home assessed Mrs Y as able to mobilise independently with the use of a walking frame. The Home assessed Mrs Y as being at medium risk of falling. The Home placed a sensor mat in her bedroom to alert staff when she was mobilising so that staff could attend to “ensure she is safe”.
15. Mrs Y had an unwitnessed fall in her bedroom in February 2021. She was found by care staff after she activated the sensor mat. As Mrs Y had a large bump to her head the Home called for an ambulance, who took her to hospital. The hospital admitted Mrs Y as she had a bleed on the brain. It discharged her later that month.
16. The Home reported the incident to the Care Quality Commission. An Officer from the Group wrote to Mrs Y at the start of March 2021. They said that they would be completing an investigation into what had happened. They said they hoped to complete that investigation by the end of May 2021.
17. Around this time, Mr X complained to the Group about the overall care the Home provided his mother. He said that when he had visited Mrs Y the previous year, he had found her in her bedroom in the dark. He believed she had been left like that for a few hours. He said on a recent visit to his mother she had activated the call bell, but staff did not respond to it for ten minutes. Mr X said he was concerned about whether staff would attend promptly if his mother had another accident.
18. In the Group’s response to Mr X’s complaint, it said it could not comment on Mr X’s complaint about Mrs Y being left unattended in her bedroom in the dark because of the length of time passed. In respect of the recent response to the call bell, it said it had checked its call bell records and that it took 13 minutes to respond to Mrs Y’s bell. It apologised for that delay and said staff were helping other residents. It said that staff knew that he was visiting his mother. The Group also explained the call bell was not an emergency bell, but an alert bell used to ask staff for assistance.
19. The Homes Occupational Therapist assessed Mrs Y in March 2021 following her return to the Home. That assessment said staff were to encourage Mrs Y to complete independent transfers and start mobilising short distances.
20. The case records show Mr X visited his mother in April 2021. On that visit he asked to speak to the Manager stating his mother had said staff were bullying her. After Mr X left, the Manager spoke to Mrs Y on her own about the allegation of bullying. The case records state Mrs Y did not identify a specific member of staff, but said it was when staff were trying to make her walk. She said she felt that she could not walk. The Manager explained staff were trying to encourage her to remain mobile. Following that conversation and at Mrs X’s request, the Home said it moved Mrs Y to a smaller room, to reduce the distance she needed to walk between her bed and ensuite.
21. The Group sent Mrs Y a copy of its investigation in June 2020. By this time, Mrs Y had moved to a different care home. The investigation report said Mrs Y’s sensor mat had activated at 9:20 on the morning she fell. Staff members activated the emergency alarm at 9:50. A senior staff member checked Mrs Y before contacting an ambulance. They described Mrs Y as being confused and distressed and unable to report what had happened.
22. The investigation report said it was not possible to confirm the time Mrs Y fell as the Home had explained she often activated the sensor mat by sitting on the edge of the bed and waiting for staff to attend. It reviewed the care records for Mrs Y. It found the Home had checked on her regularly the night before and there was no evidence of Mrs Y being unwell before the fall. It noted that she fell rarely, and that the Home reported she usually pressed her alarm and waited for staff to assist her.
23. The investigation found that the Home had followed the correct procedures following an unwitnessed fall. It did not identify that the Home could have done anything further to prevent the fall. However, it noted the Home had not reviewed Mrs Y’s falls risk assessment for over three months as per policy. It completed an action plan that involved notifying the Home of its duty to review risk assessments every three months. It also noted the Home could improve its operational procedures to include what should happen when a resident activated their sensor mat and to communicate that to staff.
24. Mr X was unhappy with the findings of the investigation and complained to the Ombudsman.

Care Plus Groups response to my enquiries

25. The Group said Mr X had not previously complained that Mrs Y had activated a call bell and staff had not responded for over two hours. It said there was no evidence from the Group’s perspective of a bell ever having been left unattended for two hours and that it completes regular audits of call bells.
26. It said as Mrs Y had capacity it shared all correspondence about the investigation directly with her. It said it was her choice to share that with family members. It said it could not arrange meetings with Mr X about his mother, without her consent. It said it asked Mr X to discuss this with his mother, but that did not happen.

My findings

27. Mr X is unclear when the Home had allegedly failed to respond to Mrs Y’s call bell for two hours. The Group states there is no evidence of this happening. Because of the lack of evidence and clarity about when this took place, I cannot investigate this part of Mr X’s complaint further.
28. After Mr X said staff were bullying Mrs Y the Manager spoke to Mrs Y about this allegation. The Home took appropriate action to explore the concerns with Mrs Y. There was no injustice caused to Mrs Y.
29. Mr X believes the Group should have met with him about its investigation into his mother’s fall. As Mrs Y had capacity, I am satisfied with the Group’s decision to communicate its investigation findings with Mrs Y directly.
30. Mr X is dissatisfied with the Group’s investigation as it has not identified the amount of time Mrs Y was on the bedroom floor. I have reviewed the investigation report and am satisfied it considered all available information. It is not possible to establish the amount of time Mrs Y was on the floor. It was an unwitnessed fall and Mrs Y could have activated the sensor mat before falling.
31. However, I am critical of the 30-minute delay between Mrs X activating the sensor mat and staff activating the emergency alarm. Even allowing staff a short period to assess the situation before pressing the emergency alarm, my view is the staff delayed in responding to the sensor mat activation. Mrs Y had a sensor mat because she was at risk from falling and the Home’s risk assessment stated the purpose of the mat was to alert staff so they could “ensure she is safe”.
32. Although it is not possible to identify how long Mrs Y was on the floor, the delay between her activating the sensor mat and staff responding has caused avoidable uncertainty to Mr X, and may have caused Mrs Y an injustice, as she may have been on the floor longer than necessary.
33. The investigation report identifies that staff response to the activate of sensor mats is not in the Home’s operational procedures and has recommended this as an area for improvement. That will help prevent a recurrence of the fault therefore I have not made further recommendations.

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Agreed action

34. Within one month of my final decision, Care Plus Group has agreed to write to Mr X to apologise for any avoidable uncertainty caused by the delay in responding to the activation of Mrs Y’s pressure mat.

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Final decision

35. There was a delay in the Care Home responding to a sensor mat. It has already suggested Service Improvements to prevent a recurrence of the fault. It has also agreed to apologise to Mr X for any avoidable uncertainty caused. Therefore I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman