Summary: Care provided to Mrs Y in a residential care home was below an acceptable standard. The care home failed to keep Mrs Y safe, and consequently she sustained a serious injury. The Care Provider has accepted failings in its practice; however, it has not offered an appropriate remedy for the distress caused.

The complaint

1. Mrs X complains the Care Provider failed to properly investigate and acknowledge the poor care provided to her late mother, Mrs Y.

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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. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4).

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How I considered this complaint

5. I have;

• considered the complaint and discussed it with Mrs X;
• considered the supporting information supplied by Mrs X, including the Care Provider’s response to the complaint;
• considered relevant legislation;
• offered Mrs X and the Care Provider an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

6. 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.
7. Regulation 12 concerns safe care and treatment. This requires Care Providers to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm.
8. Providers must do all that is reasonably practicable to mitigate risks. Incidents that affect the health, safety and welfare of people using services must be reported internally and to relevant external authorities.

What happened

9. Mrs Y was in her nineties. She had lived in the care home for eight months.
10. On 9th April 2021 one carer transferred Mrs Y from her wheelchair to a chair and reported her legs gave way and that she was supported to the floor. Mrs X says the carer dropped Mrs Y. In its complaint response letter dated 7 July 2021. the Care Provider acknowledges two carers “should have been present to support the transfer” This resulted in a left leg break under her knee.
11. Mrs X says two days prior to this, on 7 April 2021, a similar incident occurred. Mrs Y sustained grazes to both upper arms. A team leader from the care home telephoned Mrs X the same day to inform her about the incident.
12. The Care Provider has confirmed the matter was reported to the Health & Safety Executive on 9 April 2021 and provided the report reference details to this office.
13. Mrs X says she met with the care home manager and the deputy manager on 14 April 2021 to discuss the incidents and other issues relating to Mrs Y’s care. Mrs X says there were numerous occasions when the care provided to Mrs Y was inadequate. She says the manager informed her the incident had been reported to the Health & Safety Executive, and that it would be visiting the following day. The Care Provider says it has no evidence to show this meeting took place. Mrs X provided a copy of an email she exchanged with the care home manager requesting the meeting, and the care home manager’s agreement
14. Mrs X says that during the meeting the manager confirmed that only one carer had been present when Mrs Y was transferred from a wheelchair to a chair, and that two carers should have been present. Mrs X says she was told Mrs Y’s care plan had recorded the need for two carers, and that this had been communicated to carers in handovers.
15. Mrs Y sadly died on 3 May 2021.
16. Mrs X says the Care Provider’s complaint response letter, dated 7 July 2021, stated the care plan had not been communicated to care staff. She says this contradicts what she was told by the care home managers on 14 April 2021.
17. I have had sight of the Care Provider’s complaint response letter dated 7 July 2021 written by the care home manager. The manager acknowledged that two carers should have been present when transferring Mrs Y, and the absence of such resulted in a fracture to Mrs Y’s leg. The manager went on to say Mrs Y’s care plan reflected the need for two carers, but this had not been communicated to care staff, and consequently, the care home had failed to keep Mrs Y safe.
18. Mrs X believes the Care Provider has failed to take full responsibility for its failings.

Analysis

19. People in care homes must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Care Providers must assess the risks to a persons’ health and safety during any care or treatment and make sure their staff have the qualifications, competence, skills and experience to keep people safe.
20. In this case the Care Provider failed to do so. It did not follow the practice required by the fundamental standard on keeping people safe.
21. The Care Provider acknowledged that only one carer was present during the transfer of Mrs Y on 9 April 2021, when there should have been two. Whether Mrs Y fell or was lowered to the floor as the Care Provider suggests, she sustained a serious injury. It is difficult to see how such an injury could occur had Mrs Y been lowered to the floor in a controlled manner.
22. Mrs Y suffered a tangible injustice. As a direct result of the Care Provider’s failings, she sustained a serious injury. Whilst we cannot say with certainty that this contributed to Mrs Y’s death, it will have caused her significant distress.
23. The Care Provider has no record of the meeting held on 14 April 2021, on the balance of probability I find that it more likely than not that the meeting took place and the care home manager omitted to record it. This is fault.
24. Sadly, Mrs Y had died, so it is not possible to provide a remedy. Where a person has died we will not normally seek a substantive remedy 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 that would enrich a person’s estate.
25. However, Mrs X has also suffered an injustice. She has been left with the uncertainty about whether the fall contributed to the Mrs Y’s death, and the distress at witnessing her mother’s injury and subsequent suffering.
26. The Care Provider’s final complaint response was inadequate. A complaint as serious as the one Mrs X presented should have been investigated and responded to by head office, not the care home subject to the complaint.
27. Whilst the care home manager acknowledged failings in the care provided to Mrs Y and the resulting injury, she failed to give sufficient detail about lessons learnt and the action/changes implemented as a result. She also failed to offer an appropriate remedy for Mrs Y’s distress, neither had it recommended action.

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Agreed Action

28. The Care Provider will within four weeks of the final decision offer Mrs X a written apology for its failure to:

• adhere to Mrs Y’s care plan;
• keep Mrs Y safe from falls;
• provide adequate urostomy care;
• provide an adequate complaint response.

29. In addition, the Care Provider should:

• pay Mrs X £1,000 to acknowledge the distress caused by the events, and a further £250 to acknowledge her time and trouble pursuing the complaint with the Care Provider and this office;
• provide evidence of changes implemented to practice as a result of the incidents;
• confirm if any training needs were identified, and when this was carried out;
• confirm if any action was taken against staff members;
• confirm if the care home now has an adequate staffing ratio;
• confirm if the matter was reported to the Council’s safeguarding team;
• provide evidence of the above to this office.

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Final decision

30. There is evidence of fault by the Care Provider. It failed to adhere to Mrs Y’s care plan in moving and handling, which resulted in a fall and Mrs Y sustaining a serious injury. It also failed to provide adequate urostomy care, causing Mrs Y significant discomfort.
31. The above recommendations are a suitable way to settle the complaint.
32. It is on this basis; the complaint will be closed.
33. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

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Investigator's decision on behalf of the Ombudsman