Summary: We will not investigate Ms X’s complaint about night time care provided to Ms Y at her care home. This is because it is unlikely an investigation would add to the response Ms X has already received.

The complaint

1. Ms X complains about night time care provided to her sister, Ms Y, at her care home. The Royal Borough of Kensington & Chelsea (the Council) and NHS North West London Integrated Care Board (the ICB) jointly funded Ms Y’s care home placement. Specifically, Ms X says Ms Y fell one night and was left alone on the floor for a long time before anybody helped her. Ms X complains about a further incident when Ms Y injured herself after falling from a damaged chair at the care home.
2. Ms X said Ms Y was traumatised by these events and felt anxious and scared. She said Ms Y was admitted to hospital and diagnosed with dementia and delirium as a result. Ms X said she felt Ms Y’s complaint had been dismissed because of her mental health diagnosis.
3. As an outcome of her complaint, Ms X wants the care home to improve its policies and provide staff training so other people are not similarly affected. She wants staff to be placed under review. Ms X also seeks financial remedy for Ms Y.

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The Ombudsmen’s role and powers

4. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
5. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
6. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe:

• it is unlikely they would find fault, or
• it is unlikely they could add to any previous investigation by the bodies.

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

7. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)

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How I considered this complaint

8. I spoke to Ms X and read the information she sent us. I also considered information from the Council.
9. Ms X had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Section 117 aftercare

10. Anyone who may have a need for community care services is entitled to a social care assessment when they are discharged from hospital to establish what services they might need. Section 117 of the Mental Health Act imposes a duty on health and social services to meet the health/social care needs arising from or related to the person’s mental disorder for patients who have been detained under specific sections of the Mental Health Act (e.g. Section 3). Aftercare services provided in relation to the person’s mental disorder under S117 cannot be charged for. This is known as Section 117 aftercare.

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My assessment

11. Ms Y’s care home placement was jointly funded by the Council and ICB under Section 117 aftercare. On 10 March 2022, Ms Y fell, and a member of care home staff found her on the floor. The daily records show staff had checked Ms Y at 11.55pm on 9 March, and then at 02.03am and 04.25am on 10 March. For each of these checks, the records say Ms Y was asleep. An entry in the records at 05.51am says that a staff member had found Ms Y on the floor at 5.20am, after she had tried to sit in an arm chair. The records say: “checks carried out appears ok, please observe”.
12. I recognise Ms X said Ms Y recalls being on the floor for a long time and was very cold. The response to the complaint reflects the information in the records, which say Ms Y was sleeping when checked at 04.25, and was found on the floor at 05.20. The records also say Ms Y was checked and did not appear injured. My view is it is unlikely an investigation could add any further explanation for Ms X about what happened.
13. Ms X also complains about a further incident on 19 March when she said another resident tried to get into bed with Ms Y. She said Ms Y was very distressed by this. She said the next morning, Ms Y was rocking in a reclining chair which was faulty, and she fell out of the chair and hit her head. The records say that a staff member was in the kitchen and heard a noise in Ms Y’s room. The records say the staff member found Ms Y with a bump on her head, and the chair broken at the back. An ambulance was called and Ms Y went into hospital later that day.
14. Ms Y’s room was on the ground floor of the care home. Ms X said if there had been a staff member permanently on the ground floor overnight, they could have better managed these incidents. In response to her complaint, the care home apologised for any distress caused. It said there was a senior member of staff permanently on the ground floor. It said they might be required to attend other floors if there was an emergency, but other than that they would be on the ground floor. Ms X disagreed with this. She said this was not the case when she had previously visited Ms Y, and that she had raised this issue with the care home then. I recognise Ms X’s view on this. However, my view is that an investigation would be unlikely to add anything further to the response Ms X has already received about whether a member of staff was present on the ground floor at the time Ms Y fell on 10 March.
15. Ms X also said the reclining chair was faulty and had not had the proper maintenance checks, causing Ms Y to fall. The care home’s response did not say whether the chair was faulty, as it said maintenance and repairs for the chair were done by an external organisation. As the records say the staff member was in the kitchen at the time, the fall does not appear to have been witnessed. Therefore my view is that an investigation would be unlikely to add any further explanation for Ms X about what happened.

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Final decision

16. We will not investigate Ms X’s complaint about night time care provided to Ms Y, as an investigation would be unlikely to add to the response Ms X has already received.

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Investigator's decision on behalf of the Ombudsman