Summary: We will not investigate this complaint about the actions of a care provider in relation to a fall in which the complainant’s mother sustained an injury to her head. This is because there is nothing that investigation by the Ombudsman could add to those carried out by the Care Provider and by Council B’s safeguarding procedures.

The complaint

1. The complainant, who I refer to here as Miss M, says that the Council did not take appropriate action when she complained about the Care Provider for her mother, Mrs M. She says that the Care Provider failed to:
• Prevent Mrs M falling and cutting her head, necessitating hospital treatment;
• Document and explain fully what happened;
• Ensure a Safeguarding Investigation was carried out; and
• Explain why Mrs M was wearing a head scarf that she did not own and that was distressing her, shortly after the incident.

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The Ombudsman’s role and powers

2. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome.

(Local Government Act 1974, section 24A(6))

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How I considered this complaint

3. I considered information provided by Miss M and by the Council.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. Mrs M was placed by the Council in a Residential Care Home. The Home is located in Council B.
6. Following an incident in which Mrs M fell and cut her head, the Care Provider asked Council B’s Safeguarding if the matter should be reported to Safeguarding. Council B advised it did not, as the fall would be considered unavoidable as the care plan was being followed and this was a one-off fall.
7. The Care Provider investigated the matter internally and provided a response explaining what had happened.
8. This included an account of why Mrs M was wearing a headscarf that did not belong to her. It was said to have been used to try to discourage Mrs M from rubbing her injured head. The Care Provider accepted this was not appropriate and apologised.
9. Miss M remained dissatisfied with the overall response, and raised a concern to Adult Safeguarding, as the family felt the fall should have been prevented.
10. Council B explained that the Section 42 trigger was not met as Mrs M was not in danger of immediate harm due to being moved out of the Care Home, but it undertook a non-statutory investigation to review practice and identify any risk reduction measures needed.
11. The investigation found that although the Care Provider’s records said the Care Plan was being followed and Mrs M fell and hit her head, and it provided a clear record of what happened thereafter, there was a lack of detail and analysis regarding the circumstances of the fall and how such incidents would be prevented in the future.
12. Recommendations were made to the Care Provider, and the safeguarding report details the actions taken by the Care Provider in response.

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Final decision

13. I will not investigate this complaint because is nothing that we could add to the investigations carried out by the Care Provider Council B, and we could not achieve a different outcome.

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Investigator's decision on behalf of the Ombudsman