Summary: A care home, owned by the Council, failed to take appropriate action to manage the falls risk for Mrs Y, despite her vulnerability.

The complaint

1. Mrs X complains about the quality of care provided to her late mother, Mrs Y, at Meadowrythe Residential Home. She says the care home failed to take seriously Mrs Y’s falls risk and this resulted in her mother falling from her bed. Mrs X also complains she was not informed that her mother had been sent to hospital unaccompanied.
2. The care home is owned and operated by Nexxus Trading Services Limited, which is wholly owned by Staffordshire County Council.

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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. We investigate complaints about councils and certain other bodies. Where a care provider is providing services on behalf of a council, we can investigate complaints about the actions of the provider. (Local Government Act 1974, section 25(7), as amended)
5. We normally name care homes and other care 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. 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

7. I have:

• considered the complaint and discussed it with Mrs X;
• considered the correspondence between Mrs X and the care home, and between Mrs X and the Council;
• considered the Council’s response to the complaint;
• considered relevant legislation;
• offered Mrs X and the Council an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

8. 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 following standards are relevant to how the care home managed Mrs Y’s care.
9. Regulation 9 Person Centred Care says the Care Provider must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate and meets their needs. Each person, and/or person lawfully acting on their behalf, must have all the necessary information about their care and treatment.
10. Regulation 12 Safe Care & Treatment says people must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Care Providers must assess the risks to a person’s health and safety during any care or treatment and make sure care staff have the qualifications, competence, skills and experience to keep people safe.
11. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.
12. Regulation 18 - providers must tell the CQC of all incidents that affect the health, safety and welfare of people who use their services;
13. Regulation 20 - providers must be open and transparent with people using their services and their families and must notify them and apologise if something has gone wrong with the person’s care or treatment. Providers must tell the person or their representative if there has been a ‘notifiable safety incident’.

Care Quality Commission Inspection Report

14. The care home was inspected by QCQ in October 2022. This found the care home ‘required improvement’ in the areas:

• Safe
• Effective
• Well led.

Background

What Mrs X says

15. At the time of the events Mrs Y was in her nineties and had a diagnosis of dementia. For many years she lived with Mrs X, who was her primary carer.
16. Due to Mrs Y’s declining health, Mrs X sought support from social services. A social care assessor visited Mrs Y at home on 13 December 2023 to commence a needs assessment. Mrs Y’s family and an Occupational Therapist (OT) were involved in the completion of the assessment. Initially, a care package and regular respite were agreed. A few days later, Mrs Y was reported to have deteriorated further, she needed the support of two people to stand and was unable to walk. She was repeatedly trying to stand unaided and at high risk of falls. An emergency respite placement was agreed.
17. Mrs Y went into the care home for respite care on 20 December 2023 at 7pm, accompanied by Mrs X. Mrs X says she explained the reasons Mrs Y needed 24-hour care, and that she was at high risk of falls. She asked about the use of cot sides on Mrs Y’s bed. She was told by the care home that cot sides could not be used as it would be classed as abuse. Mrs X says the care home offered to put a crash mat on the floor. Mrs X left the care home around 8pm.
18. Three hours later, at 11.30pm, Mrs X received a telephone call from the care home to say Mrs Y had fallen and would be going to hospital. Mrs X says she was unaware that Mrs Y went to hospital unaccompanied. She says she would have met Mrs Y at the hospital had she known she was alone.
19. The following day, Mrs X telephoned the care home numerous times for an update, but the calls went unanswered until 2pm, it was then she discovered Mrs Y had gone to hospital unaccompanied. Mrs X immediately contacted the hospital and found Mrs Y had been in the patient discharge lounge since 02.50am awaiting discharge but the staff had no information about where she should be discharged to. Mrs X says the ward sister said nursing staff had been telephoning the care home since Mrs Y’s arrival in the patient discharge lounge, but the calls were unanswered. She said the hospital had no information about Mrs Y or her medication and that she had not received any medication during her stay, she said Mrs Y had been agitated and had only recently settled.
20. Mrs X says she lost confidence in the care home and decided Mrs Y should not return. She collected Mrs Y and took her back to their shared home. She says the family provided Mrs Y with 24-hour care, but she did not fully recover from the fall, and she passed away on 28 December 2023.
21. Following Mrs Y’s return home, the Council’s social care assessor updated Mrs Y’s needs assessment, that “…two care staff are required to transfer using a standing hoist, a profiling bed and a chair have been supplied”. The OT recorded Mrs Y needed a floor bed, standing hoist and an armchair.
22. The following day Mrs X received a telephone call from the care home asking for updates on Mrs Y. Mrs X was too distressed to take the call, so her daughter spoke the staff member and explained, that due to the poor care Mrs Y had received she would not be returning to the care home.
23. Mrs X and her daughter went to the care home to collect Mrs Y’s belongings. Whilst there she requested copies of:

• the incident report of the fall;
• the initial care plan for Mrs Y;
• the risk assessment carried out on Mrs Y’s arrival at the care home.

24. Mrs X says at first staff refused saying she did not hold power of attorney for health and welfare, then said, the paperwork was not available as it had been sent to the Care Quality Commission.
25. Mrs X submitted a complaint to the care home on 23 December 2024.

The care home’s response

26. The care home responded to Mrs X’s complaint in writing on 5 January 2024. The author of the letter, the care home manager, said the use of cot sides required a ‘robust risk assessment’, and involvement of a multi-disciplinary team to decide if this would be in Mrs Y’s best interests. She (author) acknowledged the assessment documents provided by the Council, and the discussion with Mrs X highlighted Mrs Y to be a at high risk of falls. However, cot sides had not been mentioned. Mrs X refutes this and says she specifically asked about cot sides. The author acknowledged cot sides had been used whilst Mrs Y was in hospital but said a hospital’s policy differed from that of a care home.
27. The author acknowledged a falls risk assessment should have been completed sooner, and that Mrs X should have been made aware that the use of cot sides was “…something that needed to carefully considered before admission”. On that basis, the author partially upheld the complaint. She went on to say even if a risk assessment had been completed, it would not have recommended the use of cot sides.
28. The author confirmed the timeline of events after Mrs Y’s fall, and that she had not been left alone whilst the care home awaited the arrival of an ambulance. She explained that night-time staffing levels did not allow for a carer to accompany Mrs Y to hospital, but said, it was ‘unclear’ if care staff had informed Mrs X that Mrs Y was unaccompanied. On that basis, the author partially upheld the complaint and said Mrs X “…should have been made aware at that time that we were unable to send a staff member”. She said care staff had provided the ambulance crew with a list of Mrs Y’s medication and said the care home was not responsible if this information had not been passed to the hospital. She said hospitals usually contact it for information about a person’s medication, but on this occasion that did not happen.
29. The author refused to provide Mrs Y with information she requested because Mrs X only had power of attorney for Mrs Y’s finances.

Analysis

30. 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. In this case the care home is owned by the Council.
31. People have a right to expect safe, effective, and appropriate care that meets their needs. This is not what happened here.
32. Mrs Y’s needs and risks around falling were well documented and reiterated by Mrs X on Mrs Y’s admission. I have seen no evidence that a falls risk assessment was completed, or that any consideration was given to mitigate the risks, and keep Mrs Y safe, for example, a low bed or that a safety mat was in situ. Care was not in line with the assessment of Mrs Y’s needs in this area, as required by Regulation 9.
33. The care home’s comment said any completed risk assessment would not have recommended cot sides contradicts current Government Guidance which says, “When medical devices (bed rails, mattresses and others) are prescribed, issued or used, it is essential that any risks are balanced against the anticipated benefits to the user””. As a risk assessment was not completed, the care home cannot predict what the outcome would have been.
34. In respect of Mrs Y’s admission to hospital, the care home should have informed Mrs X that Mrs Y had been sent to hospital unaccompanied. This was poor practice which likely added to Mrs Y’s distress.
35. It is not possible for me to come to a definitive finding on the issue of the care home providing ambulance staff with information about Mrs Y’s medication/history.
36. Both Mrs X and the hospital attempted to contact the care home numerous times over many hours, calls were unanswered. This led to Mrs Y remaining in the hospital discharge lounge for longer than necessary. This is poor practice by the care home and likely contributed to Mrs Y’s recorded agitation.
37. In respect of Mrs X’s request for documents pertaining to Mrs Y’s care. Mrs X was involved in the assessment and support planning process and accepted by the care home as a suitable representative on Mrs Y’s admission to the care home. There is no good reason for the care home’s refusal to provide Mrs X with copies of documents to which she was involved in completing.
38. Mrs Y has now sadly passed away and therefore it is not possible for the Ombudsman to remedy any injustice caused to her. We can remedy the distress and uncertainty caused to Mrs X including the time and trouble taken pursuing her complaint.

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Agreed action

39. The Council should, within four weeks of the final decision:

• apologise to Mrs X for the failures highlighted above and offer the sum of £250 in recognition of the distress caused and a further £250 in recognition of the time and trouble taken in pursuing this complaint;
• arrange a meeting with the care home to discuss the lessons learnt from this complaint.

40. The Council should provide this office with evidence it has complied with the above actions.

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Final decision

41. A care home, owned by the Council, failed to take appropriate action to manage the falls risk for Mrs Y, despite her vulnerability.
42. The above recommendations are a suitable way to settle the complaint.
43. It is on this basis; the complaint will be closed.
44. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman