Summary: Mrs X complains about the care given to her Mum, Ms Y, at Appleby Court Care Home. We find fault with the Home causing distress and frustration to Mrs X. We have made recommendations to the Council to remedy the injustice caused.

The complaint

1. Mrs X complains about the care given to her mother, Ms Y, at Appleby Court Care Home (the Home).
2. Two carers took Ms Y for a bath. She had an “assisted fall” onto the floor. She was checked over and put back to bed. Four days later she went to hospital where it was discovered she had suffered two fractured ankles and a fractured toe.
3. Mrs X has now lost confidence in the Home and wants to ensure the same thing does not happen again.

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The Ombudsman’s role and powers

4. 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)
5. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. (section 26A or 34C, Local Government Act 1974)
7. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
8. 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.
9. 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

10. I spoke with Mrs X about her complaint and what she wanted to achieve. I asked the Council questions about the care provided. I considered -
• Ms Y’s case records, care plans and risk assessments;
• Complaint correspondence;
• Relevant legislation and guidance.
11. Mrs X, the Home and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Legislation and Guidance

Fundamental standards of care

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the fundamental standards those registered to provide care services must achieve.
13. The Care Quality Commission (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 fundamental care standards and prosecute offences.
14. The CQC has issued guidance on how to meet the fundamental standards below which care must never fall. The relevant regulations here are:
15. Regulation 9 on personalised care. The CQC’s guidance on the regulations says:
• “Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be”.
16. Regulation 10 is about dignity and respect. “When people receive care and treatment, all staff must treat them with dignity and respect at all times. This includes staff treating them in a caring and compassionate way.”
17. Regulation 12 sets out the requirement for care and treatment to be provided in a safe way for service users. This says a registered person must, amongst other requirements, do the following:
• assess the risks to the health and safety of service users of receiving the care or treatment;
• do all that is reasonably practicable to mitigate any such risks;
• ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.

Record keeping

18. Care providers should keep records relating to the care of each person, including an accurate record of all decisions taken in relation to their care. (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17)
19. When a complaint or allegation of abuse is made, all agencies should keep clear and accurate records of the issues and any action taken. In the case of providers registered with the CQC, these records should be available to the CQC so they can take any necessary action. (Care and Support Statutory Guidance, Section 14)
20. Care providers should ensure:
• all care records are accurate, honest and comprehensive;
• all staff are familiar with the recording system used;
• records are updated with the new information in a timely way.

(Good Record Keeping Guide for Care Providers, Local Government and Social Care Ombudsman, February 2023)

Complaints about care

21. There must be policies and procedures in place for anyone to raise concerns about their own care or the care of people they care for or represent. The policies and procedures must be in line with current legislation and guidance, and staff must follow them. (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12)
22. The Care Provider’s complaints procedure sets out its process for handling complaints from residents or their representatives. This says there is a two stage complaint procedure. Once a complaint is submitted it will be acknowledged within three days, and a resolution sought within 28 days from receipt of the complaint. If the response is unsatisfactory it can go to stage two. A response from a complaints investigator will be given within 28 days. After this complaints can be brought to the Ombudsman.

Council responsibility

23. When a council commissions another organisation to provide services on its behalf it remains responsible for those services. It also remains responsible for the actions of the organisation providing them.
24. As commissioners of the care, it is the Council’s responsibility to ensure the care provider completed a formal robust investigation.
25. If a person raises concerns with the Council about the quality of care provided by a commissioned care provider, the Council must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. Care Act 2014 S.42

What happened

26. Ms Y has dementia, is non-verbal and bed bound. She entered the Home in February 2019.
27. In February 2022 her carers prepared to give Ms Y a bath. She was taken to the bathroom in a wheelchair.
28. The carers were about to hoist Ms Y into the bath when she slipped out of her wheelchair. Two carers held her as she fell to the ground in an “assisted fall”, to prevent any head injury.
29. The carers raised the alarm bell and put Ms Y back into her wheelchair after she was checked for injury, then they put her back to bed.
30. The next day a nurse from the Home called the GP requesting a visit to look at Ms Y. She said Ms Y “fell out of her shower chair yesterday, injured her right toe, very swollen”.
31. The GP notes say Ms Y’s leg fell out of the hoist and she stubbed her toe on the shower seat, “slight bruising and not tender”. The GP advised the care staff to observe Ms Y.
32. Four days later an ambulance took Ms Y to hospital and it was confirmed she had fractured both her ankles and her toe.
33. The ambulance crew raised a safeguarding enquiry as they were concerned how long it had taken for Ms Y to get checked at hospital after her fall, and the lack of communication between care staff.
34. The ambulance crew were told that Ms Y had slipped out of her hoist whilst being moved in the bathroom. Care staff said they tried to guide her fall whilst holding her head up. However due to positioning her feet got most of the impact.
35. The Manager of the Home told Mrs X of the fall by telephone six days after the fall, when she returned from annual leave. She informed Mrs X that she had self-referred to the CQC and she would be able to see a copy of the report but it could take up to eight weeks.
36. Mrs X was worried Ms Y may have been in pain for days before receiving treatment. She was thinking of making a complaint to the Home so she spoke with Ms Y’s GP on 18 March.
37. Mrs X raised an alert for neglect with the CQC in May about the fall and other issues. She knew about the referral filed by the ambulance crew which added to her distress.
38. In late May Mrs X made a formal complaint to the Home about the fall and various other issues.
39. Mrs X spoke to the Manager on 9 June. She wanted a copy of the Home’s investigation report but the Manager said she could not share it. Mrs X was still not clear how Ms Y fell out of her wheelchair as she is not mobile.
40. Mrs X had to chase the Home for a response on 4 July and then received one not specific to her concerns. She raised a stage two complaint on 18 July and the Home then formally responded on 1 August apologising for the delay and added distress this caused.
41. The Home had mixed up Mrs X’s complaint with one from Mrs X’s cousin. In the first response to Mrs X the Home addressed the cousin’s complaint. Mrs X felt frustrated that she had to keep chasing the Home for a response, and felt that she was not being listened to or taken seriously. She told me it seems like the Home has no complaint procedure in place.
42. The complaint response described in detail what had happened to Ms Y and the action taken after her fall. It says the carers were using the hoist to transfer Ms Y from her wheelchair to the bath. As they raised the hoist, one carer felt that it needed to be adjusted. Ms Y was lowered back down into her wheelchair and the carers started to adjust the sling. Ms Y then slipped out of the wheelchair as it was wet with urine. The carers supported Ms Y to the floor which was safer than trying to stop her fall.
43. It also accepted the initial information the agency nurse gave the GP was misleading. “She should have said Ms Y slid from the chair and not the hoist sling on it.”
44. The Home carried out its own investigation and made a report dated 8 March 2022. This reviewed all Ms Y’s documents, care plans, risk assessments, daily booklet and case notes, with interviews and statements from staff.
45. The investigation report also describes the events leading to the fall, and the actions taken by care staff afterwards. The key issues and lessons learnt section said when reviewing her care sheets it was clear Ms Y has only had bed baths since December 2020 and has not been transferred during this time.
46. The report says the bruising was not documented as soon as it was noticed, however it is clear when interviewing staff that no bruising was evident until three days after the fall.
47. The conclusion of the Home’s investigation was the care plan did not reflect Ms Y’s needs and has been updated with a moving and handling plan. The staff members involved were up to date with their training but were given refresher courses.
48. The Council held a Strategy Meeting on 14 June to discuss the safeguarding referral from the ambulance crew and the concern raised by Ms Y’s family member. Mrs X attended the meeting.
49. The meeting raised other issues, but of those relevant to this complaint it clarified that Ms Y fell from her wheelchair and not the hoist in the bathroom. Her care plan had not been updated to say she is bed bathed only now, which is why the two new carers took her for a bath. The plan has now been updated.
50. Further the carers removed Ms Y’s incontinence pad in the bedroom and transferred her with no pad to the bathroom. The pad should not have been removed as reflected in the care plan.
51. Both carers were new to the home but were experienced carers and received moving and handling training the week before Ms Y’s fall. One carer has now left, the other has had refresher training and has gone through managers supervision.
52. The Manager disclosed an agency carer did not give correct information about the fall to the GP. This has been highlighted to the agency and they are doing their own investigation. The Manager confirmed she would not be using the same agency worker again.

Analysis

53. Ms Y suffered severe injuries after an assisted fall in the Home on 23 February 2022.
54. The carers acted quickly after her fall, and were following her care plan, which, unfortunately, had not been updated by the Home. This is fault.
55. The carers were up to date with all the relevant training, but were both new to the Home and were not aware of Ms Y’s history.
56. There are a few different versions of what happened on the day. This has since been clarified by the Home but should have been communicated to Mrs X before she had to bring a complaint. This is fault by the Home. I have recommended action for the Home to ensure concise and accurate records are kept.
57. Although Ms Y’s injuries were not noted for four days following the fall, appropriate pain scores were carried out by staff and she was kept under review. However when further bruising was noted and Ms Y started showing signs of being in discomfort, this should have been acted on immediately rather than the following day.
58. In the Strategy meeting it was noted the Manager felt when she is not at the Home things can lapse. The summary says there is a reliance on the Manager and the Home are in the process of hiring a deputy manager / clinical lead which is hoped will improve things.
59. The Home mixed up the complaints brought by Mrs X and her cousin. This is fault, and Mrs X had to chase a response to her complaint. Although the Home did apologise for this in the final complaint response to Mrs X, she does not think this was sufficient for the distress caused. The Home failed to follow the timelines in its own complaint procedure. This is fault.
60. The Home failed to signpost Mrs X to the Ombudsman in the complaint response. This is fault. Mrs X was told to bring her complaint to the Ombudsman by Ms Y’s social worker.

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Recommended action

61. 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 we found fault with the actions of the Home, we have made recommendations to the Council.
62. Within one month of the final decision the Council should:
1. write a personal apology to Mrs X for the faults we have identified;
2. pay Mrs X £200 to recognize the avoidable distress and upset caused by its actions;
3. pay Mrs X £100 for the time and trouble caused by having to chase her complaint response and bring a complaint to the Ombudsman.
63. Within three months of the final decision the Council should check the Home has made a review of its policies and procedures for the following:
1. note and record keeping. Ensure staff know when, where and how to document any incidents or accidents accurately, and that care plans are updated regularly;
2. complaint procedure. Ensure relevant staff know the appropriate timelines complainants should be responded to, and amend standard letters or templates to signpost complainants to the Ombudsman.
64. The Council should provide us with evidence it has complied with the above actions.

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Final decision

65. I find fault with the Home and have made recommendations to the Council for the injustice caused to Mrs X.

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Investigator's decision on behalf of the Ombudsman