Summary: Mrs X complains about the quality of care her father, Mr Y, received from the Care Provider. There was fault in the Care Provider’s handling following several falls by Mr Y, the last of which resulted in his emergency admission to hospital. The Care Provider’s record-keeping and adherence to its own procedures could have been better. The Care Provider has already offered an appropriate financial remedy to address the injustice caused to Mr Y. It has now agreed to take further action to remedy the injustice caused to Mrs X and her brother and make service improvements to help avoid recurrence of the faults identified in this case.

The complaint

1. Mrs X complains about the quality of care her father (Mr Y) received from the Care Provider since his admission on 7 November 2021 to 22 April 2022. Mrs X says the Care Provider failed to notify the family each time her father suffered a fall at the Care Home and did not take appropriate action to prevent subsequent falls. Mrs X is unhappy with the Care Provider’s differing and contradictory accounts of what happened in its responses to her and her brother’s (Mr Z) complaints. She also feels the Care Provider has not taken sufficient steps to improve its service as a result of the issues highlighted by her father’s case. Mrs X also complains her father’s possessions were not kept safe and the Care Home did not follow proper procedures when it transferred Mr Y to hospital (Red Bag Process). Mrs X does not feel the monetary amount the Care Provider has offered sufficiently addresses the distress and injustice caused to her father and his family.

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The Ombudsman’s role and powers

2. The law says we cannot normally investigate a complaint unless we are satisfied the body knows about the complaint and has had an opportunity to investigate and reply. (Local Government Act 1974, section 26(5))
3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
4. 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)
5. 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

6. I have spoken to Mrs X and considered the information she has provided in support of her complaints.
7. I have considered the information the Care Provider has sent in response to my enquiries.
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. Mrs X and the Care Provider 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

Fundamental Standards of Care

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:

• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.

Hospital Transfer Pathway or Red Bag Scheme

11. Since 2018, the NHS Red Bag Scheme has been used to help with the transfer of care home residents to and from clinical settings such as hospital in emergencies.
12. The bags, which contain key paperwork, medication and personal items like glasses, slippers and dentures, are handed to ambulance crews by carers and travel with patients to hospital where they are then handed to the doctor. The information in the red bags can reduce the time a person has to spend in hospital, can speed up assessments for treatment, reduce the loss of key items and provide key information to care home staff on discharge.
13. Mr Y’s Care Home uses the Red Bag Scheme for hospital transfers and has an allocation of bags based on the number of residents in the care home.

Care Provider’s Falls Management Policy

14. The Care Provider’s policy states that all residents should be assessed for their falls risk on admission. The Care Provider’s policy also states falls risk assessments should be undertaken in the following circumstances:

• Has a history of 2 or more falls when mobilising/transferring within the last six months
• Is unsteady/unsafe when they try to walk alone
• Has a history of 2 or more falls from bed within the last three months
• Has not had medicines review in the last 12 months
• Has been referred for a falls assessment
• Is living alone
• Has a ‘lifeline’ (or another alarm/alert system)

15. The policy goes on to provide guidance for action post fall, which includes informing relevant persons/relatives of falls where there is a suspected injury to a person taking anticoagulant medication.

What happened

16. This is a chronology of key events and does not include everything that has happened.
17. Mr Y was a resident at Lansdowne Hill Care Home (the care home) from 7 November 2021 to 22 April 2022. Mr X was admitted for respite care following the sudden death of his wife. Mr Y has a diagnosis of vascular dementia. The day before admission, the Care Home completed a falls risk assessment for Mr Y and found him to be at low risk of falls.
18. In late November and early December 2021, Mr Y had four falls. Three of these falls were out of bed. The Care Home notified Mrs X (or her brother, Mr Z) about the three falls out of bed.
19. An Occupational Therapist (OT) assessed Mr Y on 13 December 2021. The OT recommended a bed lever, crash mat near his bed (for Mr Y’s head), for Mr Y’s bedroom to be rearranged and for a walking frame to help him get around safely. The Care Home completed Mr Y’s bedroom rearrangement on the day of the OT assessment and ordered the bed lever, crash mat and walking frame. Mr Y already had a sensor installed in his bed which notified Care Home staff when he was out of bed. Care Home staff were also completing hourly night-time checks on Mr Y since his admission.
20. The remaining equipment was delivered to the Care Home on 16 December 2021 and installed on 17 December 2021. The Care Home started including notes within its daily care records about whether the bed lever and other equipment was in place during hourly night-time checks made on Mr Y.
21. During Mr Y’s stay at the Care Home, he had a total of 16 falls. Ten of these were falls out of bed and the remaining six falls occurred in communal areas such as the toilets, reception or dining room. While the Care Home completed records of all of Mr Y’s falls, it only notified Mrs X and Mr Z of half (eight) of the falls. Mr Y was recorded of having some bruising, grazes or small cuts to his head and other areas following falls.
22. Mr Y received some form of hospital or clinical treatment following at least seven of these falls. After Mr Y’s first fall at the Care Home on 23 November 2021, Mr Y attended hospital for a CT scan, which did not identify any significant injuries to his head. Mr Y then attended hospital for an x-ray following a fall on 6 March 2022. On the remaining four occasions, the Care Home called for paramedics to attend and examine Mr Y and confirm no further action was necessary.
23. Mr Y’s stay at the Care Home ended following his last fall on 22 April 2022. Mr Y had been attempting to climb a flight of stairs at the Care Home with his walking frame when a Care Worker had seen him and tried to help him back down the stairs. Mr Y had slipped and suffered a head injury while climbing back down the stairs, which resulted in him losing consciousness. Mr Y was taken to hospital following this fall and spent some considerable time there before being transferred to another Care Home which provides nursing care as Mr Y now requires the use of a wheelchair.

Mrs X and Mr Z’s complaints

24. Mr Z complained to the Care Provider on 30 April 2022. He raised concerns about the way in which the Care Home had dealt with Mr Y’s repeated falls and its failure to notify Mr Z or Mrs X on every occasion this happened. Mr Z raised concerns that an earlier falls report prepared by the Care Home had not covered the whole period Mr Y had been a resident. Mr Z was also concerned about the action the Care Home had taken following each of his father’s falls and whether this had been in line with medical advice.
25. The Care Provider met with Mr Y and Mrs X on 12 May 2022. It followed up this meeting with an investigation into Mr Y’s falls at the Care Home. The Care Provider included a report which provided brief details of Mr Y’s mobility, his existing health conditions, what happened when Mr Y fell on the stairs on 22 April 2022 and the updates the Care Home had received from the hospital about whether Mr Y could be discharged.
26. Mr Z was unhappy with the Care Provider’s complaint response and requested escalation of his complaint on 9 June 2022. Mr Z raised the following concerns about the quality of the investigation:

• the date of his father’s admission to the Care Home was incorrect in the investigation report;
• the status of many of the falls within the Care Home’s incident reports remained open or not yet confirmed/required;
• the investigation report failed to identify the cause of Mr Y’s last fall at the Care Home as Mr Z had expected given the seriousness of the incident;
• there were inconsistencies in where Mr Y had been on the stairs when he had fallen – one account said Mr Y had fallen from near the top of the stairs and another said he had slipped off the last few bottom steps. The account also suggested Mr Y was holding on to rails on both sides of the staircase when this would not be possible due to the staircase width and Mr Y’s frailty;
• no evidence was provided to substantiate the statement that staffing levels at the Care Home during Mr Y’s last fall were appropriate;
• the Care Home’s refusal to allow Mr Y to be discharged back to it because of his limited mobility. This led to Mr Y spending longer than he needed to in hospital, contracting COVID-19 and chest infections causing a deterioration in his health;
• Mr Y’s last fall from the stairs had been preventable. Comments in the Care Provider’s investigation report about there never having been other similar incidents prior to Mr Y’s fall were inappropriate.

27. The Care Provider had a further meeting with Mr Z and Mrs X about their concerns and agreed to reinvestigate the matter.
28. The Care Provider sent a further investigation report and complaint response to Mr Z on 21 July 2022. It confirmed it had ended Mr Y’s contract at the end of April 2022 and was only billing him to that date. It explained it had received no indication from the hospital that Mr Y could be discharged. It had corrected dates within its falls report for Mr Y and concluded that while a stair gate could have prevented Mr Y’s fall, there had been no previous incidents to warrant installation of a stair gate. It also noted that the fall might have been avoided if the Care Worker that helped Mr Y down the stairs had instead helped him up the last few steps to then use the lift back down to the ground floor.
29. Mr Z and Mrs X remained unhappy with the Care Provider’s findings and had a further meeting with a Senior Manager on 31 August 2022. The Care Provider followed up with its final response to Mr Z on 30 September 2022, in which it confirmed a refund of care home fees (£4,960) for May 2022 and an offer of a goodwill payment of £5,440 in recognition of the findings following Mr Y’s care and falls at the Care Home.

Analysis

Failure to notify Mr Y’s family of falls

30. The Care Home notified Mr Y’s family about eight of the 16 falls he had while there. It is clear from daily care records and Mr Z and Mrs X’s complaints that they were both heavily involved in their father’s care and were keen to ensure he was safe and well. The Care Provider’s failure to inform them each time Mr Y had a fall, slip or trip was fault which caused injustice to Mr Y and his family. This failure was also contrary to the guidance in the Care Provider’s falls policy which states it will notify relevant people or relatives where a person on anticoagulant medication has a serious fall.

Not taking appropriate action to prevent subsequent falls

31. Mrs X complains the Care Provider did not do enough to prevent Mr Y’s falls. The Care Provider has not followed its own falls policy as it did not complete a further falls risk assessment of Mr Y following his two falls out of bed in early December 2021. The Care Provider did not complete a further falls risk assessment of Mr Y until 10 April 2022.
32. In my view, the professional advice from an Occupational Therapist (OT) shortly after Mr Y’s third fall in early December 2021 goes some way to mitigating the lack of falls risk assessment.
33. There does however remain fault in the Care Provider’s record-keeping. I have examined all daily care records for Mr Y’s stay at the Care Home. These include a standard section where staff can indicate whether bed rails or similar equipment are in place on hourly night-time checks.
34. This section of the daily care records only appears to have been completed on 17 days out of the 156 days of Mr Y’s stay. It is therefore not possible to determine if the OT’s recommendation to install a bed lever was consistently adhered to. Mr Y continued to have falls out of bed which leads to the conclusion that the bed lever was not typically in place as it should have been.
35. While I accept the bed lever would not have prevented falls Mr Y had elsewhere in the Care Home, this was one simple action the Care Provider could have taken that might have helped avoid further falls out of bed. Failure to adhere to the OT’s advice was fault which caused injustice to Mr Y and his family.

Care Provider’s differing and contradictory accounts of what happened

36. The Care Provider’s three reports on the falls Mr Y experienced give differing accounts of the incident on 22 April 2022 on the Care Home stairs. There are discrepancies in where on the staircase Mr Y was when the fall occurred.
37. The Care Provider’s records show it only took a statement from the Care Worker present when Mr Y fell on the stairs in late June 2022. The statement from the Care Worker is brief and understandably states they could not remember exactly what happened given the passage of time. Failure to obtain a timely statement of the incident has meant the quality of evidence the Care Provider could gather for its investigation has been compromised. The differing accounts of the incident in complaints responses have no doubt added to Mrs Z and Mrs X’s confusion and distress about their father’s care.

Care Provider has not done enough to prevent incidents like this in future

38. The Care Provider has completed a lessons learnt exercise following Mr Y’s fall and his family’s complaints. While I commend this action, I am concerned with the quality of this exercise. The Care Provider appears to have focussed on what it could not have prevented rather than what steps it might need to take to avoid incidents in future. There is also a lack of clarity on whether the Care Provider intends to install a stair gate.
39. The Care Provider has also reviewed its risk assessment of the staircases in the Care Home. Since Mr Y’s fall, the Care Home has installed a rope barrier to help prevent residents from accessing the stairs, while still making it easy for Care Home Staff to use them. The Care Home has reported no further incidents involving residents on the stairs since the rope barrier was installed, which is encouraging.
40. Mrs X told us she was aware of the rope barrier and continues to have concerns that this measure will not prevent other residents from falls. I can understand her concerns in this respect. I have recommended the Care Provider takes further action to reassure Mrs X below.

Failure to keep Mr Y’s possessions safe and not following procedures on transfer to hospital

41. It does not appear that this element of Mrs X’s complaint has been raised with the Care Provider previously. However, I have not seen any minutes or notes of the three meetings Mrs X, her brother and the Care Provider had to determine whether this was discussed during these meetings.
42. In response to my draft decision, Mrs X has indicated the specific item that had not been kept safe for her father. Mrs X has also told me she was concerned the Red Bag Scheme was not used when Mr Y was transferred to hospital on 22 April 2022.
43. In response to my enquiries, the Care Provider has explained that it had run out of its allocation of red bags when Mr Y was admitted to hospital on 22 April 2022. It had however sought to ensure all items that would be placed in the Red Bag were sent with Mr Y to hospital.
44. There is a lack of evidence or further information to show the Care Provider has been formally alerted about these elements of Mrs X’s complaint, which means I am unable to reach a view on what happened and whether there has been any fault by the Care Provider.

Financial remedy offered does not sufficiently address the distress and injustice caused to Mr Y and his family

45. The Care Provider has offered to refund care home fees and make a goodwill payment totalling £10,400 to Mr Y following Mr Z and Mrs X’s complaints.
46. This is a significant sum and is typically higher than the amounts we would usually recommend where we have identified faults with a Care Provider’s handling.
47. While I consider the amount the Care Provider has offered to Mr Y sufficiently remedies the injustice caused to him by the faults identified in its and our complaint investigations, there is scope for further action to remedy the injustice caused to Mr Z and Mrs X.
48. Mr Z and Mrs X have understandably been deeply distressed and worried about their father’s health and wellbeing given the number of falls, trips or slips he had while at the Care Home. They have spent a number of months making their complaints to the Care Provider about their concerns.
49. The lack of clarity in the Care Provider’s accounts of what happened has no doubt added to Mrs X and Mr Z’s concerns. I can understand their continued lack of confidence in the assurances the Care Provider has since given. My recommendation below seeks to address the personal injustice Mrs X and Mr Z have experienced as result of the Care Provider’s faults.
50. While it took longer than usual for the Care Provider to complete its complaint investigations into Mr Z and Mrs X’s concerns, I am satisfied this did not cause significant injustice to them. The evidence shows the Care Provider was actively engaging and interacting with Mr Z and Mrs X throughout this time and it appears to have been committed to providing suitable resolutions to the issues highlighted.
51. There do however appear to be aspects where the Care Provider’s handling could be improved. I have recommended some service improvements below to help address these issues.

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Agreed action

52. Within one month of my final decision, the Care Provider agrees to:

• make a written apology to Mrs X and Mr Z for the faults identified in this decision statement;
• provide Mrs X with details of whether and when the Care Home intends to install stair gates or an explanation why if this action is no longer being taken; and,
• make a payment of £300 (£150 each) to Mrs X and Mr Z for the distress and uncertainty caused by the Care Provider’s handling and complaint responses,

53. Within three months of my final decision, the Care Provider agrees to remind all Care Home staff about:

• the importance of full record keeping, highlighting the guidance provided in our Good record keeping: guide for care providers - February 2023;
• ensuring they adhere to the guidance within the Care Provider’s falls policy around when risk assessments should be reviewed;
• ensuring families are notified of key events affecting a resident in a timely manner
• the importance of obtaining statements from all witnesses to incidents involving Care Home residents in a timely manner to help preserve the accuracy of the information obtained

54. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

55. I have completed my investigation and found fault with the Care Provider, which it has already partially remedied. It has agreed to take further actions to fully address the injustice caused to Mrs X, her brother and father.

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Investigator's decision on behalf of the Ombudsman