Decision : Closed after initial enquiries
Decision date : 18 Oct 2023
The Ombudsman's final decision:
Summary: We will not investigate this complaint about adult social care in a residential care home. The Care Provider has investigated, accepted where it went wrong, and acted to prevent future problems. It is unlikely the Ombudsman could achieve anything further.
- Mr B’s father, Mr C, had a serious injury while living at Mayflower Care Home. Mr B feels the Care Provider lied and did not follow its own policies, and it should ensure not to do this in future.
The Ombudsman’s role and powers
- We investigate complaints about adult social 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. (Local Government Act 1974, sections 34B and 34C)
- We investigate complaints about adult social care providers. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe:
- it is unlikely we could add to any previous investigation by the care provider, or
- it is unlikely further investigation will lead to a different outcome.
(Local Government Act 1974, sections 34B(8) and (9))
- 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. The Care Quality Commission (CQC) is the statutory regulator of care services.
How I considered this complaint
- I considered information provided by the complainant.
- I considered the Ombudsman’s Assessment Code.
- It is unclear how Mr C’s injury happened, but it may have occurred when another resident pushed him over. This incident was unwitnessed but later seen on CCTV. Care workers found Mr C on the floor, but failed to report this and there is no evidence they checked Mr C for injuries. The Care Provider accepts this was fault. An agency provided these care workers. The Care Provider made the agency aware of this fault and will not use those care workers again.
- The Care Provider also accepts it missed opportunities to check Mr C for injuries in the days that followed, though a nurse from the GP practice saw Mr C. The Care Provider followed the medical advice received, which was Mr C did not need to go to hospital. It was therefore several days before Mr C’s injury was established when a family member took him to hospital. It is unlikely we would find that delay was caused by any fault of the Care Provider, or the outcome would be any different had Mr C gone to hospital sooner.
- The Care Provider has put in place procedure changes to prevent future issues, and reminded its staff they must report and record incidents, accidents, and injuries.
- The relevant safeguarding authority was informed and investigated. There is no ongoing risk to Mr C because he has moved to another care home.
- It was undoubtedly distressing for Mr C’s family to find out he had suffered a significant injury. The Care Provider has thoroughly investigated, accepted where things have gone wrong, apologised, and taken action to prevent future problems. It is unlikely the Ombudsman could add to that investigation or reach a different outcome.
- We will not investigate Mr B’s complaint because it is unlikely we could add to the Care Provider’s investigation or reach a different outcome.
- The Care Provider’s actions may be a breach of the fundamental standards for care. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
Investigator's decision on behalf of the Ombudsman