Summary: Mrs X complained a care home did not act quickly following her mother’s fall, resulting in her condition deteriorating and causing distress. We found no fault in the Council’s actions to support Mrs X but we found fault because it did not keep care records secure. We have recommended it provides an apology and takes action to address this.

The complaint

1. Mrs X complains on behalf of her mother, Mrs Y:
• Seahaven care home (the “care home”) did not act quickly following her mother’s fall;
• The Council investigated the actions of the care home but not the NHS ;
• The care home has since provided a wheelchair to her mother without completing an assessment and it had not ensured her mother’s clothes were changed.

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What I have and have not investigated

2. I have investigated the complaint above, save matters that were premature at the time Mrs X contacted the Ombudsman. This includes complaints about her mother’s wheelchair and clothing.

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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. The law says we cannot normally investigate a complaint unless we are satisfied the council knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the council of the complaint and give it an opportunity to investigate and reply (Local Government Act 1974, section 26(5))
5. 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.
6. 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)

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How I considered this complaint

7. I reviewed documents provided by Mrs X and the Council.
8. I gave Mrs X and the Council an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

CQC Fundamental Standards

9. Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 says providers must securely maintain accurate, complete and detailed records in respect of each person using the service.
10. Regulation 12 says providers must manage risks that may arise during care and treatment. Guidance on this regulation says:
11. “Incidents that affect the health, safety and welfare of people using services must be reported internally and to relevant external authorities/bodies. They must be reviewed and thoroughly investigated by competent staff, and monitored to make sure that action is taken to remedy the situation, prevent further occurrences and make sure that improvements are made as a result. Staff who were involved in incidents should receive information about them and this should be shared with others to promote learning. Incidents include those that have potential for harm”.

What happened

12. Mrs Y entered a care home in August 2021.
13. She suffered a fall on 29 April 2022. She was taken to hospital and stayed until discharge on 6 May 2022.
14. In May Mrs X complained about the delay in Mrs Y’s treatment following the fall.
15. In response, the Council outlined the actions taken by the care home. It concluded there was no delay by the care home, rather the delays arose due to a lack of ambulance capacity and inaction by 111. In summary it said:
• Upon finding Mrs Y on the corridor floor staff called for help.
• Two carers helped Mrs Y into a wheelchair and then took her to see the District Nurse.
• Staff then contacted the Acute Intermediate Care Team who confirmed they should call 111.
• They called 111 who said an ambulance would attend within the hour.
• Just under an hour later the ambulance service advised they were delayed due to capacity pressures.
• A few hours later 111 called to check on Mrs Y. It agreed to send a doctor but to keep the ambulance on standby.
• The care home later called the doctor, as Mrs Y was starting to deteriorate. He advised he had not heard from 111. Upon an update of Mrs Y’s condition the doctor advised they call 999 for an ambulance which they did.
• Care home records could have been more comprehensive and it had asked care home to improve care planning and record keeping.
16. Mrs X complained to the Ombudsman. She was concerned the Council had not recognised the impact the fall had on her mother or investigated the actions of NHS staff. She said the day prior to the fall staff had agreed her mother needed additional care. And an alarm should have been in effect so staff knew her mother was out of bed. She also raised matters that had not yet completed the Council’s complaints process.
17. In response to enquiries the Council provided statements taken from care home staff on 12 and 16 May outlining the actions taken on 29 April. I note these mirror the chronology within the Council’s complaint response.
18. I asked the Council for a copy of any care assessment and care plan in effect on 29 April. The Council provided various assessments but no care assessment. It also provided monthly evaluation reports showing staff reviewed a care plan in place, but no copy of this plan.
19. I asked the Council for a copy of any daily care notes made on 29 April. The Council provided notes covering other dates. It said the care home confirmed it held records on 29 April but could not now locate them. The care home could not explain this but said the Council and family had access to the file.
20. The Council provided professional visit records. These record the actions of the District Nurse on 29 April. I note this supports the chronology within the Council’s complaint response.
21. The Council provided hourly check records. These show staff checked Mrs X’s whereabouts each hour, including on 29 April.
22. The Council provided a copy of the action plan produced in response to the complaint. This required the care home to include more information alongside hourly checks; to include more detail in documents in general and; to ensure staff record specific times of incidents rather than estimated.
23. In comments on a draft decision the Council:
• Provided a copy of its review of Mrs Y’s care and support plan, completed on 27 April 2022. Of relevance this says:
1. Mrs Y is at very high risk of falls. She continues to mobilise indoors with a Zimmer frame. Assistance and supervision of one recommended all times to minimise potential risks of falls.
2. Mrs Y requires assistance, encouragement and monitoring of one. staff member with most aspects of her care and support needs. This includes: Mobility / transfers.
3. There were no changes to her current plan in regards to the support provided to minimise the risk of falls.

• Provided a copy of an incident report form completed on 29 April 2022. I note this supports the chronology in the Council’s complaint response.
• Said Mrs Y was no longer staying at Seahaven.

24. In comments on a draft decision Mrs X said:
• She remained unhappy with the actions of care home staff; they should have called 999 first not 111;
• Mrs Y suffered another unwitnessed fall prior to leaving Seahaven;
• She was unhappy key records were missing;
• She was unhappy with the draft decision; she held the care home responsible. Her mother had deteriorated following the fall and this would not have happened if they had either prevented the fall or acted more quickly following the fall.

Findings

25. The Council is responsible for the actions of the care home and has a duty to investigate complaints about the care home. It is not responsible for the actions of the NHS. Mrs X would need to raise a complaint directly to the NHS.
26. Care records show Mrs X was able to mobilise with a zimmer frame though she needed assistance and supervision. There is no mention of an alarm being in place to alert staff Mrs X had left her room. However, records show staff carried out hourly checks on her. Care home staff did not have to do more than this; there is no evidence of fault.
27. The Council has been unable to provide daily care notes for 29 April 2022. This is a breach of the Fundamental Standards and is fault. As daily care notes are available for other dates this appears to be an issue with the security of files, rather than a lack of records. The lack of records has added to Mrs X’s distress. This is injustice. I will also make a recommendation to ensure processes are in place to keep records secure, to prevent injustice to others.
28. The Council reviewed the care home records and the actions taken by staff on discovering Mrs Y had fallen. The Council found no evidence of undue delay by the care home. The hourly check records, incident report form, professional visits record and statements of staff support the Council’s findings. I find no evidence of fault.
29. I recognise Mrs X’s concern about her mother’s health deteriorating following the fall, however I cannot say this was due to any delay or fault by the care home on 29 April.
30. I acknowledge Mrs X’s concerns about the checks made of Mrs Y following her fall. However, I consider it was appropriate for care home staff to rely on any instruction and advice from medical professionals including the District Nurse, 111 and ambulance service.
31. I have not investigated any new or ongoing matters. This is because the Council should have the chance to investigate and reply first as explained at paragraph 4. I am therefore unable to comment on Mrs X’s concerns about a further fall.

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Agreed action

32. To remedy the injustice set out above I recommend the Council carry out the following actions:
33. Within one month:
• Provide an apology to Mrs X for the fault identified;
34. Within three months:
• Ensure the care home takes action to ensure it is storing care records securely.
35. The Council should provide us with evidence it has complied with the above actions.
36. The Council has accepted my recommendations.

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Final decision

37. I found fault by the Council because it did not keep records secure causing distress. The Council has accepted my recommendations and I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman