Summary: Mr C says a care home, acting on behalf of the Council, failed to provide any recompense for rings it lost, failed to explain how Mrs B had sustained a head injury and failed to recognise Mrs B had a urinary tract infection. The care home, acting on behalf of the Council, failed to follow its procedures for storing valuables and for dealing with falls and failed to complete records properly. An apology, payment to Mr C, liaison with the care home and Mr C to see whether an agreement can be reached on recompense for the rings and training for care staff is satisfactory remedy.

The complaint

1. The complainant, whom I shall refer to as Mrs B, is represented by her nephew, whom I shall refer to as Mr C. Mr C complained the care home, acting on behalf of the Council:
• failed to offer a payment for the rings it lost, despite admitting responsibility;
• failed to explain how Mrs B sustained a head injury; and
• failed to recognise Mrs B had a urinary tract infection when she was admitted to the care home and failed to take action to resolve that.
2. Mr C says those failures show the care home failed to provide the basic level of care or treat Mrs B with dignity.

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The Ombudsman’s role and powers

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 an organisation’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)
5. 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 care provider, I have made recommendations to the Council.
6. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

7. As part of the investigation, I have:
• considered the complaint and Mr C's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
8. Mr C and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

What should have happened

10. The home’s belongings procedure (the procedure) says personal items brought into the home should be documented and kept in a clean and presentable condition. They must be uniquely identified with the name of the owner and logged appropriately on the resident’s property record. Anything handed to the care team for safekeeping should be logged in a hardbacked safekeeping book to be kept in the office. A receipt should be issued and the receipt number noted. The envelope containing the belongings should have the date, the owner’s name and a brief description of the contents.
11. The procedure says while the care provider will make every effort to provide a secure environment it is not responsible for loss or damage to belongings and discourages people bringing items of high value into the home unless absolutely necessary.
12. The care home has a falls prevention and management policy (the policy). This says any unexplained bruising following a fall should be reported to the home manager/designated person in charge. If the unexplained bruising could be attributed to a fall the person’s care plan must be reviewed and reassessed as a priority.
13. The policy says where an injury is sustained this will be detailed on the full body diagram and where a head injury is suspected the home must seek immediate medical advice.

What happened

14. Mrs B was in hospital following a fall. The Council arranged a care home placement at Ashton View Care home in Wigan (the care home). Mrs B moved in at the end of January 2022. When she moved in the care home carried out a moving in assessment which identified Mrs B was suffering from dementia and could become anxious, shout and throw things. The assessment recorded Mrs B needed a sensor mat in the room. The initial intention was for Mrs B to remain in quarantine due to COVID-19 restrictions which would have required half hourly observations. However, as this became unmanageable Mrs B was not kept in quarantine and was instead on two hourly observations during the night.
15. When Mrs B entered the care home she had two rings with her. The deputy manager of the care home locked those rings in her drawer as she did not have access to the safe at the time. The deputy manager moved offices and gave the rings to a member of staff working on the community in which Mrs B was living. Those rings have been lost.
16. On several occasions during Mrs B’s time in the care home care staff found her on the floor in her room where she appears to have placed herself by choice. Mrs B also regularly moved the sensor mat. Mrs B had a minor fall on 4 February. When care staff found her on the floor at 4.10am on 7 February though she had a head injury. Care staff assisted Mrs B back into bed. Later that morning care staff contacted 111 for advice and Mrs B was taken to hospital by ambulance. The hospital discharged Mrs B back to the care home later that day. Mrs B was readmitted to hospital on 9 February where she later sadly died.
17. When responding to Mr C’s complaint the care home apologised for the loss of the rings as well as some other items of clothing. The care home reimbursed Mr C for the cost of the clothing lost.
18. As a result of the learning from this complaint group supervision has taken place at the care home to reinforce the procedure for managing a resident’s belongings. The care home also now has falls files on all units with step-by-step guides on what to do in the event of a fall. Supervision sessions with staff have also covered falls and how they should be responded to.

Analysis

19. Mr C says the care home failed to offer payment for the rings it lost, despite admitting responsibility. Mr C is referring here to the findings the care home reached when considering his complaint. In that complaint response the care home agreed it had not followed its procedure for safeguarding belongings as it had not secured the rings in the home’s safe. The care home, when responding to my enquiries, accepts it would be reasonable to offer an amount for the rings if both sides can agree what that amount should be.
20. The first point to make here is that the Ombudsman does not have jurisdiction to consider liability. In this case I have exercised discretion to investigate this part of the complaint because the care home accepts responsibility for the loss of the rings. Failure to follow the procedure is fault and means the care home is now unable to identify what has happened with the rings. It seems likely if the right procedure had been followed the care home would have been able to identify the point at which the rings had gone missing and it is also possible those rings would not have been lost as they would likely have been placed in the safe. Given the care home accepts it was at fault here I have considered what financial remedy is appropriate.
21. As I have made clear earlier in this statement, the complaint is against the Council as the Council arranged the care provision. I can therefore only make a recommendation for the Council, rather than the care home. It is not the Ombudsman’s role to establish the value of the rings and the Ombudsman would not normally consider a remedy for loss of belongings as that would be a matter for the courts. I therefore recommended the Council apologise to Mr C and facilitate a discussion between Mr C and the care home about an amount that would be appropriate to reflect the likely value of the rings. The Council has agreed to my recommendation. If an agreement cannot be reached though Mr C will need to consider taking the case to court as only a court can definitively decide liability and a value for the loss of the rings.
22. Mr C has also raised concerns about why the care home sent him photographs of rings to see whether they were the ones belonging to Mrs B when it had already admitted responsibility for their loss. I do not see those two things as contradictory. The care home accepted it had not followed the right procedure and, because of that, had been unable to establish what had happened with the rings. The care home had also made clear though it would continue to look for the rings which is why it contacted Mr C to provide him with photographs of rings it had found to see whether those were the missing rings.
23. Mr C says the care home, acting on behalf of the Council, failed to properly investigate or explain how Mrs B sustained a head injury. Mr C says as Mrs B was supposed to be receiving half hourly observations as she was in quarantine the home should have been able to identify the reason for the head injury. Mr C also questions whether the care home completed a falls risk assessment when Mrs B entered the care home.
24. In terms of the documentation completed by the care home when Mrs B moved in, there is no evidence a falls risk assessment was carried out at the outset. While there is a falls assessment and plan of care on the file, that is dated 7 February 2022, which is after the fall in question. I therefore consider it likely, on the balance of probability, the care home had not completed a falls assessment on Mrs B’s admission.
25. I am, however, satisfied the moving in assessment identified the need for Mrs B to have a sensor mat and crash mat in the room at night with the bed left on low due to Mrs B’s difficulty mobilising. I am therefore satisfied the care home had in place a process for managing any issue with falls, despite the fact a formal falls assessment was not completed on admission. In those circumstances I do not consider it likely failing to complete a falls assessment on admission resulted in any additional risk to Mrs B, although it is fault not to complete it.
26. I do, however, have some concerns about the documentary records kept by the care home. The care home has provided a copy of the close observation record for Mrs B. That document has various boxes that require filling in. One of those boxes is to record how frequently observations should take place. With the exception of two forms, none of those records indicate how frequent observations should take place. The two records that do refer to the frequency of observations say they should take place every two hours. That is also the time period recorded in the deprivation of liberty safeguards paperwork. Failure to keep proper records detailing the frequency of observations to be undertaken on the close observation records is fault.
27. It is also clear from some of the close observation records that care staff did not always carry out observations every two hours. That again is fault. Mr C’s main concern is, of course, the observations that were undertaken on the night Mrs B sustained a head injury. I have a copy of the records for that evening/early morning. The record for the early hours of the morning is not legible and it is not clear whether the first a.m. observation took place at 1:53am or 2:53am. Whichever is the case, that observation did not take place within two hours of the previous observation and the observation at 4:10am, which is when Mrs B was found to have a head injury, could have been more than two hours after the previous observation. Failure to carry out observations in accordance with the two hour timeframe the care home accepts was in place at the time is fault. I understand Mr C’s concern about that. However, I could not say if two hourly observations had taken place Mrs B would not have fallen or suffered a head injury as I cannot speculate about the timing of the incident and whether a member of the care staff would have been present. I therefore consider Mr C’s injustice is limited to his frustration that records are not clear and observations were not carried out as often as they should have been.
28. In reaching that view I recognise Mr C believes the care home should have carried out half hourly observations. However, half hourly observations would only have been necessary if Mrs B had remained on quarantine due to COVID-19 regulations. The evidence I have seen satisfies me Mrs B was not kept on quarantine and instead was using the communal areas during the day. In those circumstances and given the recordings in the deprivation of liberty safeguards paperwork I see no reason why the home would have had to carry out half hourly observations.
29. I am concerned though with what happened immediately following the fall. The care home’s policy, which I refer to in paragraph 13, says where a head injury is suspected the care home must seek immediate medical advice. I have seen no evidence to suggest the care home sought immediate medical advice. Rather, the documentary records I have seen suggest the care home did not contact 111 until much later in the day. Failure to follow the policy is fault.
30. In addition, the post injury observations form completed by the care home for a different fall notes that observations should be increased to every 15 minutes for the first hour after a fall, followed by an observation 30 minutes later, then one hour later and then two hours later. I have not been provided with any evidence to suggest those checks took place in relation to the fall which happened in the early hours of 7 February 2022. That again is fault. I do not consider it likely delay seeking medical advice or failing to carry out additional checks on Mrs B following the fall is likely to have resulted in any specific injustice though. I say that because the hospital identified no issues and sent Mrs B home later the same day. I therefore do not make any recommendation for a personal remedy for Mr C. However, I recommended the Council ensure the care home has carried out a training session for care staff and managers so they are aware of the policies and procedures in place when a resident falls and to ensure those procedures are followed in future. The Council has agreed to my recommendation.
31. I recognise Mr C wants some answers about what happened on the night Mrs B fell and injured her head. However, I cannot see that the care home can provide Mr C with any further detail about that as no members of care staff were present at the time. Mrs B also had dementia and would therefore likely not have been able to describe what happened. I therefore do not criticise the care home for any attempts to speculate about what might have happened, in the absence of any definitive evidence.
32. Mr C says the care home, acting on behalf of the Council, failed to recognise Mrs B had a urinary tract infection when she was admitted. Mr C says the behaviour Mrs B was exhibiting at the care home was out of character for her and the care home should therefore have identified the possibility of a urinary tract infection and contacted the GP for advice.
33. The evidence I have seen satisfies me Mrs B was admitted to the care home from hospital. I am satisfied the care home completed a moving in assessment on the same day and there is nothing in that assessment to suggest the hospital had sent Mrs B there with a urinary tract infection. I am also satisfied the moving in assessment referred repeatedly to issues with Mrs B’s behaviour as identified in hospital. That included confusion, becoming disruptive and throwing things around. Those are also the types of behaviours identified in the daily care notes. Given this was the description of Mrs B’s presentation when discharged from hospital I do not criticise the care home for failing to consider the possibility of a urinary tract infection. From the care home’s point of view the behaviours Mrs B was presenting with matched the behaviours she had shown in hospital and there is no evidence the hospital had identified a urinary tract infection.
34. So, I have found fault in the actions of the care home, acting on behalf of the Council. I have found that the care home failed to consider offering a payment for the rings lost, failed to follow its procedure for storing valuables, failed to complete paperwork properly and failed to follow its policy on falls. As I have made clear, I do not consider it likely those failures affected what subsequently happened in terms of Mrs B’s care. Nor would it now be possible to remedy any injustice to Mrs B given she has sadly died. However, I consider Mr C has suffered an injustice as he has had to go to time and trouble to pursue his complaint. I also consider he has suffered understandable distress as the care home did not follow its procedures properly. As remedy for that I recommended the Council apologise to Mr C and pay him £300. I further recommended the Council discuss with Mr C and the care home the possibility of a payment for the missing rings. The Council has agreed to those recommendations. As I have made clear though, if both sides cannot agree a suitable financial remedy Mr C will need to seek any remedy through the courts.

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Agreed action

35. Within one month of my decision the Council should:
• apologise to Mr C and pay him £300;
• liaise with Mr C and the care home to see whether an agreement can be reached on a suitable amount to be paid for the lost rings.
36. Within two months of my decision the Council should provide evidence to the Ombudsman of the actions taken by the care home to ensure staff are aware of the procedure to follow with residents belongings and when a fall takes place.

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Final decision

37. I have completed my investigation and uphold the complaint.

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Investigator's decision on behalf of the Ombudsman