Summary: Mrs X complained the Council commissioned care home, failed to provide her mother, Mrs Y, with appropriate care and support which led to a hospital admission and the Council failed to carry out a safeguarding investigation about this. The care provider was at fault for poor record keeping. The Council was also at fault for poor communication, failure to undertake a formal safeguarding investigation and delays in responding to Mrs X’s complaint. This caused Mrs X and Mrs Y distress, frustration and uncertainty. The Council has agreed to apologise, make a payment and provide evidence it has undertaken further staff training in safeguarding.

The complaint

1. Mrs X complained the Council commissioned care home, Stamford House Residential Home, failed to provide her mother, Mrs Y, with appropriate care and support during a temporary stay at the care home which led to a hospital admission. In addition, the Council failed to investigate the concerns under its safeguarding procedures or to respond to her complaint. This caused Mrs X and Mrs Y distress, uncertainty and frustration.

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The Ombudsman’s role and powers

2. 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)
3. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), 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)

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How I considered this complaint

5. I considered information provided by Mrs X and discussed the complaint with her on the telephone. I considered information provided by the Council in response to our enquiries and the relevant law and guidance.
6. I gave Mrs X and the Council the opportunity to comment on a draft of this decision. I considered any comments I received in reaching a final decision.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Relevant law and guidance

The role of CQC

8. CQC is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of the fundamental standards and prosecute offences.

Safeguarding

9. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

10. In September 2021 Mrs Y had a fall at home which led to a hospital admission. She had a fracture which limited her mobility. At a meeting between the District Nurse and council officer the council officer noted Mrs Y was at high risk of falls. They noted that whilst in hospital the occupational therapist (OT) had recommended that Mrs Y remain in bed but she continued to try and get up. The District Nurse recommended the care home install equipment to alert staff members when Mrs Y did this. Mrs Y was discharged to the care home while her long term care options were assessed.
11. The daily care notes show Mrs Y was still regularly trying to get up out of bed.
12. In late September 2021 the council officer met with Mrs X at the care home. The care home advised Mrs Y was receiving all her care in bed. The care home reported Mrs Y was often trying to get up in the night and it had put a crash mat in place in case she fell. As she was repeatedly trying to get up, two staff were supporting her to use the commode. The council officer had concerns about Mrs Y’s transfers to and from bed and so the moving and handling team agreed to carry out a review.
13. An OT visited Mrs Y in early October to complete a moving and handling visit. They spoke to a District Nurse who advised a sensor mat was requested due to Mrs Y wandering and that staff had advised the care home not to use the commode. The OT made a referral to the falls team. A referral was also made for physiotherapy. The care notes show Mrs Y was often found sitting up on the side of the bed. The care home says it has no record of being advised a sensor mat was recommended.
14. In late October one entry recorded Mrs Y was unsettled, had got out of bed and wandered to the door.
15. In late October 2021 the council officer carried out a review of Mrs Y’s care. They noted Mrs Y had seen the physiotherapist and had exercises to do. She was managing to sit on the edge of the bed. The care home reported Mrs Y was up and down in the night sitting on the edge of the bed. The council officer noted Mrs Y was sometimes confused and requested a mental capacity assessment of whether Mrs Y had capacity to decide her care needs.
16. The council officer spoke with the physiotherapist in early November who reported Mrs Y was struggling to follow instructions. The physiotherapist reported the specialist bed in the care home was not working and this was required to assist with getting Mr Y from the bed to the wheelchair. The physiotherapist reported that when they visited Mrs Y was in the lounge. They asked care staff to demonstrate how they had moved Mrs Y. Staff showed how they held Mrs Y under her arms to lift her from the bed to the wheelchair which was the incorrect way to do this. The physiotherapist said they had showed staff the correct way to do this but they were worried about Mrs Y’s ability to follow instruction. They advised they planned to visit again with someone from the moving and handling team.
17. An officer from the moving and handling team visited with the physiotherapist and assessed Mrs Y successfully using a rota stand (a type of transfer aid) with the assistance of two staff members.
18. Mrs X says she received a call on 4 November that Mrs Y had fallen, bumped her head and cut her lip. The care home has no record of a fall on 4 November.
19. The care home notes refer to an incident on 6 November when staff had found Mrs Y on the floor in the lounge and assisted her up. No incident report was completed.
20. The daily care notes of 7 November state Mrs Y ‘has come out of bed and scraped her shoulder. Everything seems fine.’ No incident report was completed.
21. The care home completed an incident report at 1.15am on 10 November 2021 which noted Mrs Y had fallen, bruised her head and cut her lip.
22. The care home manager submitted a ‘provider report for safeguarding enquiry’ about the incident of 10 November to the Council. This stated night staff had found Mrs Y on the floor in her bedroom. She had a bruise on the right side of her head and a small cut to her lip. It stated it had told the family. The action plan stated she was being kept under close observation. The GP was contacted, the care provider ordered a sensor mat and the care plan was reviewed and updated.
23. An advanced nurse practitioner from the rapid response team visited the care home. They found Mrs Y was alert and able to talk in full sentences. They noted she had no apparent injuries and could move herself from lying on the bed to sitting.
24. The care home records include a second accident report at 18:30 also dated 10 November. This stated ‘found [Mrs Y] on the floor behind the bedroom door’. It stated that no injuries were apparent at the time.
25. The council officer spoke to the care home. The manager advised they had moved Mrs Y to a more comfortable room with a carpet. There was a crash mat in place and they had ordered a sensor mat.
26. On 12 November 2021 a physiotherapist from the rapid response team visited Mrs Y. They noted Mrs Y was unable to follow instructions. They noted she was able to sit up herself but was unsafe to stand or move independently due to general weakness and lack of balance. They advised she should continue to use the transfer aid for safe transfers.
27. On 18 November 2021 Mrs X visited Mrs Y. Mrs X says Mrs Y was slumped in her wheelchair, grey in colour and in pain. Mrs X told staff who administered paracetamol.
28. The care home notes record Mrs Y was crying and complaining of back pain whilst getting dressed on 19 November. On 24 November the records noted Mrs Y was more settled and talking to staff and other residents about her family.
29. On 24 November 2021 Mrs X says Mrs Y was still in pain so she asked the care provider to contact the GP. It said it would monitor Mrs Y over the next few days and would call the GP on the Monday (29 November) if she had not improved. Mrs X also called the Council as she was concerned Mrs Y’s previous fracture may need an x ray. The council officer agreed to contact the GP and care home. The council officer emailed the GP for advice.
30. Mrs X says that on 29 November 2021 she insisted the GP was called. The GP referred Mrs Y for a follow up x ray.
31. In early December 2021 Mrs Y was taken to hospital and got an x ray which found she had broken one hip and dislocated the other. Mrs X spoke to the council officer who agreed to contact the care home to enquire if there were any unreported falls and to gather information regarding how the injuries were sustained. The officer noted the care home manager had reported Mrs Y tried to get out of bed but the officer was only aware of one fall.
32. The council officer spoke to the care home manager. They said there had only been one fall, on 10 November, and the rapid response team had said Mrs Y was fine. The manager said Mrs Y had first started complaining of pain on 8 November and so they had contacted the GP to get paracetamol to help with the pain. The manager advised there were no other falls. The officer spoke to a third party officer who shared a falls report of another fall on 6 November 2021.
33. Mrs X spoke to the council officer and said she wanted to raise a safeguarding concern. She was concerned about how the injury had occurred and why it was not discovered sooner. She did not want Mrs Y returning to the care home and was concerned it had neglected her.
34. The family submitted a formal complaint to the Council.
35. The council officer spoke to the care home manager regarding the fall Mrs Y had on 6 November. The care home manager was not aware of this incident. Mrs X asked the Council to raise a safeguarding concern. The care home manager later contacted the council officer about the fall on 6 November. However, the information they provided was inconsistent with the falls report.
36. In late December 2021 Mrs Y was discharged from hospital to a nursing home.
37. The council officer contacted Mrs X in early January 2022. Mrs X said she had requested some of the care notes from the care home but had not got a response. The council officer spoke to the care home manager about their concerns that the incident forms and care notes were poorly documented. They explained the need to document falls correctly and to follow the correct pathway to seek medical advice. The manager advised they would complete training with staff.
38. In late March 2022 the Council held a safeguarding meeting. At the meeting the Council said it was not possible to pinpoint the exact date and time of the falls which caused Mrs Y’s injuries. It also said the family had not been informed of the actual fall which caused the injuries. It found discrepancies in record keeping about the times and nature of Mrs Y’s falls.
39. The Council found there was poor recording of incidents, poor practice and communication. It did not find that abuse or neglect occurred so decided there was not enough evidence to conduct a section 42 safeguarding enquiry.
40. In September 2022 Mrs X complained to us. The Council asked for the opportunity to respond to the complaint which it did in February 2023.
41. It found:
• During Mrs Y’s stay at the care home Mrs Y needed a mental capacity assessment to establish Mrs Y’s capacity to agree to her long term care needs. This was delayed due to a shortage of staff.
• From the available evidence it was not possible to know when Mrs Y obtained her injuries. Notes by care home staff did not indicate any trauma sustained by Mrs Y.
• When the Council received the family’s complaint it should have raised a safeguarding concern to allow appropriate enquiries to be made including a decision as to whether to conduct a s42 safeguarding enquiry.
• The Council had undertaken enquiries with the care home which found poor record keeping which was inconsistent with staff accounts. By that time Mrs Y had moved care homes so was deemed safe.
42. The Council accepted it should have maintained regular communication with the family regarding the incident and the safeguarding process should have been investigated fully and the process followed. It advised that refresher training would be provided to staff on safeguarding to improve its responses in future.
43. It apologised for the distress caused to Mrs Y and the family and offered to reimburse to Mrs Y the £1397.97 she had paid towards her short term care charges. Mrs X says they had not paid the charges in any case.

The Care Quality Commission (CQC)

44. In late 2021 the CQC carried out an inspection of the care home and found the care home in breach of four regulations. Its report, published in January 2022, rated the care home inadequate. The CQC contacted the Council about its concerns and the Council raised a multi-agency concern. The care home suspended all new placements.
45. The CQC inspected again in May 2022 and again rated the care home inadequate, in October 2022 it rated it as requiring improvement and in January 2023 it rated it as good.
46. The Council’s quality assurance team visited the care home twenty times in 2022 and monitored improvement in a number of areas including accidents, incident and safeguarding reporting, care planning and risk assessment.

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Findings

47. The Council commissioned care provider could not explain how and when Mrs Y received her injuries. After Mrs Y fell in the early hours of 10 November it took appropriate action and sought medical help. At that time the injuries found following Mrs Y’s x-ray were not apparent. In the case notes there is reference to a further fall later that day but not to any additional injuries. A physiotherapist did not raise any concerns when they visited a couple of days later. There were other earlier falls which were not properly recorded. The care provider’s failure to properly record falls was fault. However, even on the balance of probabilities I could not say when Mrs Y’s injuries occurred or if she had a later unrecorded unwitnessed fall. Nor could I say the actions of the care provider led Mrs Y to fall. The records show Mrs Y was at high risk of falls and regularly tried to get up unaided. However, the poor record keeping leaves Mrs X with a sense of uncertainty and distress about the length of time Mrs Y may have had the undiagnosed injuries.
48. The Council followed up the concerns and collated information from the care home. It raised concerns about poor case note recording and record keeping and asked the care home to address this. However, it should have initiated a formal safeguarding enquiry and investigation. Failure to do so was fault.
49. The Council failed to keep Mrs X updated with the actions it was taking to investigate her concerns between December 2021 and January 2022 and it did not hold a safeguarding meeting until late March 2022. This delay and poor communication was fault and left Mrs X with sense of uncertainty over what was happening and whether had it investigated matters sooner it may have been possible to get a clearer picture of what happened.
50. The purpose of safeguarding is to remove from harm or the risk of harm. Following her hospital discharge Mrs Y moved to a different care home and so was safe. Between January and March 2022, the Council was actively involved in monitoring the care home and ensuring action was taken to make improvements in a number of areas highlighted as concerns by the CQC, including record keeping, risk assessments and incident reporting. So although no formal safeguarding took place I am satisfied the Council has taken action to address the care home’s performance which will prevent a recurrence of the same fault affecting others. The CQC, as the statutory regulator of care services was also heavily involved in monitoring the care home.
51. From Mrs Y’s admission to the care home, records show Mrs Y repeatedly tried to stand and get up independently. The care home did not order a sensor mat until after Mrs Y’s fall on 10 November. The failure to consider getting one sooner is fault. I cannot say this would have prevented Mrs Y from falling, and the notes record Mrs Y had a crash mat in place, However, a sensor mat would have alerted staff sooner to Mrs Y attempting to get up.
52. The Council failed to respond to Mrs X’s complaint of December 2021. It did not provide a response until after Mrs X had complained to us. This was fault and added to Mrs X’s distress and frustration. In its response the Council advised that refresher training would be provided to staff on safeguarding to improve its responses in future. This is appropriate to prevent a repeat of the fault in future.
53. When we have evidence of fault causing injustice we will seek a remedy for that injustice which aims to put the complainant back in the position they would have been in if nothing had gone wrong. When this is not possible, we will normally consider asking for a symbolic payment to acknowledge the avoidable distress caused. But our remedies are not intended to be punitive and we do not award compensation in the way that a court might. The Council agreed to cancel the short-term care charges to Mrs Y which was appropriate to acknowledge the impact the faults had on her. However, this does not remedy all the distress and uncertainty caused to Mrs X and Mrs Y. I have therefore made a further recommendation for symbolic payments.

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Agreed action

54. Within one month of the final decision the Council has agreed to:
1. apologise to Mrs X and Mrs Y and pay them £500 each to acknowledge the distress, frustration and uncertainty caused by the care provider’s poor record keeping, the Council’s failure to carry out a safeguarding investigation and the delay in responding to the complaint.
2. provide evidence to show safeguarding refresher training has been provided to relevant staff.
55. The Council should provide us with evidence it has complied with the above actions.

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Final decision

56. I have completed my investigation. There was evidence of fault causing injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman