Summary: We have found fault with the Council for the actions of the care provider it commissioned. The care provider did not properly monitor Mrs X’s pain after she suffered a fall and moved her into an unsuitable room following her discharge from hospital. This caused avoidable distress. To remedy the injustice caused, the Council agreed to apologise, make a payment, and ensure the care home provides staff with training in pain management and keeps proper records of pain monitoring.

The complaint

1. Mrs Y complains about the way the care home acting on behalf of the Council dealt with her mother, Mrs X, after she experienced a fall. She also complains about how Mrs X was moved back to the care home after she left hospital.

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What I have and have not investigated

2. Mrs Y also raised concerns about Mrs X being locked in her room. I have not investigated these concerns as Mrs Y has not raised a complaint to the care home or Council about this. It would be appropriate for Mrs Y to complain in the first instance so that the care home or Council has the opportunity to respond to the allegations.

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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. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
6. 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)
7. 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

8. As part of this investigation, I considered the information form Mrs Y. I discussed the complaint with Mrs Y over the telephone, I made enquiries with the Council and considered the information received in response. I sent a draft of this decision to Mrs X and the Council for comments.
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

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
11. Regulation 13 says service users must be safeguarded from abuse and improper treatment, including neglect.
12. Regulation 17 says records relating to the care and treatment of each person using the service ‘must be kept and be fit for purpose. Fit for purpose means they must: Be complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable.’
13. 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

14. Mrs X lives in a care home. On 13 August 2022 at 13:00, Mrs X suffered a fall which was witnessed by care home staff. Care home staff checked Mrs X for injuries and then said she was supported to walk to her bedroom and onto the bed for a more detailed examination.
15. Care home staff said Mrs X expressed pain in her lower back when in bed. Mrs Y arrived at the care home and staff told her about Mrs X’s fall. Following this Mrs Y approached care home staff and said Mrs X was in pain.
16. At 13:22 the care home called an ambulance for Mrs X. At 14:46 a paramedic contacted the care home to ask for further details about Mrs X’s fall. This included the area of pain on Mrs X’s back. The paramedic told the care home a specialist paramedic or paramedic practitioner would visit Mrs X.
17. At 16:49, the ambulance arrived and Mrs X was assessed by a paramedic. The paramedic thought Mrs X had a pulled muscle and recommended Mrs X stay at the care home and to seek medical attention if the pain continued for more than three days. The paramedic told the care home to keep Mrs X moving but she would likely get worse before she got better.
18. Care home staff said Mrs X was still in pain on 14 August 2022 and 15 August 2022. On 15 August 2022, care home staff called a GP for pain relief cream and were waiting for a call back from the GP about this. At around 13:30 on 15 August 2022, Mrs Y arrived at the care home and had concerns about Mrs X’s pain and demeanour. After telling the care home Manager about these concerns, the care home Manager asked staff to call an ambulance for Mrs X.
19. When the ambulance arrived, paramedics took Mrs X into hospital. Paramedics had to give Mrs X morphine to enable them to transfer her downstairs from her room as she was experiencing pain. Once Mrs X arrived in hospital it transpired she had suffered two fractures in her back.
20. Mrs Y said she discussed Mrs X’s return to the care home with doctors who recommended a ground floor room. Mrs Y said she contacted the care home about this and spoke with a care assistant who told her she would make enquiries about a downstairs room however she did not hear anything back. The care home was also in contact with the hospital who advised staff not to move Mrs X when she returned to the care home until a physiotherapist had assessed her.
21. On 26 August 2022, the hospital discharged Mrs X. The care home placed Mrs X into a downstairs room. This was because the paramedics were unable to transfer her up the stairs to her first floor room. The care home advised this was the only available room and was not up to the standard expected as it was scheduled for redecoration.
22. On 2 September 2022, Mrs Y made a complaint to the care home about its actions following Mrs X’s fall and its actions when Mrs X was discharged back into the care home.
23. On 12 September 2022, the care home responded to Mrs Y’s complaint. The care home said:
• The judgement of the staff member on 15 August 2022 was wrong and Mrs X needed to be seen in hospital for an x-ray.
• It apologised for a staff member not returning calls to Mrs Y and for not seeking further advice about a downstairs bedroom when arranging for Mrs X to return to the care home.
• The room Mrs X was placed into after her return from hospital was the only room available. The care home said it had clean bedding but there were issues with the washing machine which could have contributed to the smell on the bed linen.
24. The care home said it would give Mrs Y the direct email address of the manager for future concerns and queries. It would also arrange training for clinical observations and pain management for all care staff and address communication issues between staff in the next staff meeting.
25. Mrs X was moved back into her original room on 13 September 2022 as it was felt she was well enough to transfer.
26. Mrs Y raised a safeguarding concern with the Council in September 2022, about how the care home handled the incident on 13 August 2022 and how Mrs X was transferred back into the care home.
27. The Council carried out a safeguarding investigation. The Council recommended the care home should ensure it informed and updated Mrs Y on any medical or medication changes and that the care home asks visiting professionals to ring Mrs Y directly to give her a courtesy call to update her.
28. The safeguarding investigation did raise some points over the care home’s recording and management of Mrs X’s pain after her fall.

Analysis

29. Following Mrs X’s fall on 13 August 2022, paramedics were called and advised Mrs X should remain at the care home, but should her pain worsen to seek medical attention. It was not clear from the information provided how care home staff monitored Mrs X’s pain following this advice or how details about her level of pain were recorded. This was fault.
30. In response to Mrs Y’s complaint the care home said that the staff member who called the GP, made the wrong judgement and it was apparent Mrs X needed to be seen in hospital as she was in a lot of pain. This was also fault.
31. On 15 August 2022, the care home did call an ambulance but this was only after the intervention of Mrs X after she contacted the care home Manager. It is not possible to say whether Mrs X was properly monitored from 13 August 2022, or when the pain which led to an ambulance started to increase as there are no clear records of this from the care home.
32. This has caused distress and uncertainty to Mrs Y as she did not know whether Mrs X received proper monitoring at this time and whether an ambulance could have been contacted sooner. The care home’s admission that a staff member made the wrong judgement about Mrs X on 15 August 2022, suggests an ambulance should have been called sooner.
33. When Mrs X moved back into the care home she was placed into the only available ground floor room. The care home said this room was not up to the appropriate standard as it was scheduled for redecoration. During the period Mrs X was in hospital there were missed opportunities by the care home to arrange a suitable room. This was fault.
34. Had the care home returned Mrs Y’s calls or made enquiries about reserving a downstairs room, Mrs X could have been moved into a more suitable bedroom.
35. I recognise the care home acknowledged some of these failings and said it would arrange training for staff on pain management and speak to staff about the communication issues in this case, however I do not consider this remedies all of the injustice caused.

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Agreed action

36. 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.
37. Within one month the Council agreed to carry out the following:
• Apologise to Mrs Y for the faults identified.
• Pay Mrs Y £300 for the distress and uncertainty she experienced as a result of the care homes failings.
• Remind staff at the care home of the need to have proper records of any pain monitoring, especially when recommended by medical advice.
• Provide evidence to the Ombudsman the care home has in fact provided care staff with training in pain management and addressed the communication issues with its staff.
38. The Council should provide us with evidence it has complied with the above actions.

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Final decision

39. I have completed my investigation and found there was fault in the way Mrs X was dealt with following her fall. This caused injustice. The Council has agreed to carry out the above actions to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman