Summary: Ms X complained about her late relative Mrs Y’s care in a council-funded care home placement. We found fault by the care home which acted for the Council. It failed to involve Ms X or the family with Mrs Y’s care planning and failed to tell them about one of two falls. This was poor communication causing avoidable distress for which this Council will apologise.

The complaint

1. Ms X complained about her late relative Mrs Y’s care at Bromford Lane Care Centre (the Care Home) which the Council arranged and funded. Ms X said the Care Home:
1. Failed to provide personalized care or involve them in care planning
2. Did not provide safe care which led to two falls and failed to notify them about the first fall
3. Failed to promote good hydration
4. Failed to ensure Mrs Y was wearing her own clothes
5. Failed to ensure Mrs Y was getting all the medication prescribed
6. Assaulted her (Ms X) while she was visiting Mrs Y
7. Deprived Mrs Y of her liberty
8. Lost some items of clothing
9. Allowed her to enter the building unchallenged
10. Left soiled continence products and a pillow in Mrs Y’s bathroom.
2. Ms X said this caused avoidable distress.

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The Ombudsman’s role and powers

3. The law says we cannot normally investigate a complaint unless we are satisfied the organisation knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the organisation so it can investigate and reply. We call matters which have not been through an organisation’s complaint procedure ‘premature complaints’ (Local Government Act 1974, section 26(5))
4. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service and use public money carefully. We do not start or continue an investigation if we decide any injustice is not significant enough to justify our involvement. (Local Government Act 1974, section 24A(6), as amended, section 34(B))
5. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
6. Mrs Y’s care was funded by the Council under powers and duties in the Care Act 2014. The Care Home acts on the Council’s behalf and we can investigate Ms X’s complaints about the standard of care.
7. 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)
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

9. I investigated complaints (a), (b) and (c). I did not investigate the other complaints because:
• Complaints (d) (e) (f) and (g) are premature. Ms X needs to use the Council’s complaint procedure about these matters and if unhappy with the response, she can ask us to investigate.
• There is no significant personal injustice in complaints (h) (i) and (j).

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How I considered this complaint

10. I considered evidence provided by Ms X, the Council and the Care Home as well as relevant law, policy and guidance.
11. Ms X, the Council and the Care Home had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision.
13. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences. Guidance on regulation 9 says each person and/or their representative must be involved in an assessment of needs and preferences as much or as little as they wish.
14. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.
15. Regulation 12 of the 2014 Regulations says care must be provided in a safe way including assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks.

What happened

16. Mrs Y had dementia and other long-term health conditions. She was admitted to the Care Home from hospital under local arrangements designed to free up acute hospital beds. Mrs Y stayed in the Care Home in September 2024. She had two falls there and returned to hospital after the second fall.
17. Mrs Y’s care plans said:
• She had a normal diet and fluids and was a little overweight. She had no difficulties eating and drinking. Food and fluid intake were to be documented. The target daily fluid intake was 8-9 glasses of fluid a day
• She was continent and needed one person to help her in the toilet. She wore pads as a precaution. She asked to use the toilet
• She needed support of one person with personal care, washing, dressing and oral care
• She used a frame when walking and changing position, under supervision. She had a tendency to wander unsupervised. The physiotherapist saw Mrs Y and observed her walking. The care plan was changed to say she needed assistance from two staff when walking and a wheelchair for distances over 5-6 meters.
• She was to have 15-minute checks due to her history of falls. Staff were to make sure she wore suitable footwear (slipper socks or slippers)
18. The Care Home recorded the drinks it offered Mrs Y and noted how much she had taken and when. The records indicate she was offered different drinks regularly throughout the day and her intake was not noted to be of any concern.
19. The daily records noted Mrs Y had an observed ‘controlled fall’ as she became unstable while walking in the corridor on 23 September. This was witnessed by carers and the nurse. She was helped to get up and did not appear to have any injuries.
20. The Care Home has provided an accident report for a fall on 25 September and the falls log only records one fall. The accident report said:
• A carer found Mrs Y on the floor during a half hourly check.
• The nurse checked her over and did observations.
• Mrs Y appeared uninjured and said she did not hit her head.
• Staff supported her to turn over and get up.
• A different family member was called and informed.
21. The Care Home’s daily record said staff called 111 for advice on 28 September as Ms Y had strong-smelling urine and was complaining of pain when passing urine. The nurse then called an ambulance as they thought Ms Y needed to have IV antibiotics. She also had a swollen right leg and a bruise. Staff informed Ms X.
22. Ms X provided us with two letters to the Care Home dated 26 and 28 September 2024 about the matters she has raised in her complaint to us. The Care Home responded to the second letter saying:
• A comprehensive care plan was in place. It was sorry for not involving the family with this.
• An incident report was completed after a fall and family should have been told immediately
• Mrs Y’s fluid charts showed she had been drinking enough
• The manager and Ms X met to speak about Ms X’s concerns. Mrs Y had been admitted to hospital and her bed was now unavailable
• They were sorry for the distress caused.

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Findings

Failed to provide personalized care or involve them in care planning

23. There is no evidence the Care Provider involved Mrs Y or Ms X who was her representative in its assessments or care plans. The Care Provider accepted this in its complaint response. Care was not in line with Regulation 9 which was fault causing avoidable distress.

Did not provide safe care which led to two falls and failed to notify them about the first fall

24. We expect a care provider to have in place a care plan which promotes and encourages safe mobility, but it cannot prevent a mobile adult from walking, even where they are at risk of falls. The records indicate the Care Provider had mobility care plans in place for Mrs Y that promoted safe mobility, and these were reviewed and updated with the involvement of the physiotherapist. Care was in line with Regulations 9 and 12 and there is no fault in this aspect of care.
25. The accident record of the fall on 25 September noted a member of staff informed Mrs Y’s family shortly after the fall. The other recorded fall was the ‘controlled fall’ on 23 September, which was not reported to a family member. This was poor communication and was fault causing avoidable distress.

Failed to promote good hydration

26. Regulation 14 requires a care provider to promote good hydration. The records indicate staff monitored Mrs Y’s fluid intake regularly including when she was offered and refused a drink. There were no concerns about intake for Mrs Y’s stay. Care was in line with expected standards and there is no fault.

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Agreed Action

27. When a council commissions or arranges for another organisation to provide services, we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with care provider and make the following recommendations to the Council.
28. Within one month of my final decision, the Council will apologise for the distress caused by the failure to inform Mrs X’s family about a fall and for the failure to involve them in care planning. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology I have recommended in my findings.
29. The Council should provide us with evidence it has complied with the above actions.

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Decision

30. I find fault causing injustice. The Council has agreed actions to remedy the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman