Summary: There was some fault in the way the Council investigated safeguarding concerns into Mrs C’s care at the care home. The Council has agreed to apologise to Mr B.

The complaint

1. Mr B complains on behalf of his mother, Mrs C, who has sadly passed away. He complains about the Council’s safeguarding enquiry into the actions of the care home where Mrs C was living.
2. Mrs C suffered two falls while at the Home and Mr B said that the staff sometimes unplugged Mrs C’s call bell so that she was unable to call for help. He said the Council did not properly investigate these concerns.

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What I have investigated

3. The Home was funded by a different council, Council 2. I have investigated the Home’s actions and Council 2’s actions in a separate report.
4. This current investigation relates to the safeguarding enquiry by Essex County Council only.

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The Ombudsman’s role and powers

5. 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)
6. If we are satisfied with a council’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 referred to the conclusions in my other investigation regarding the Home’s and Council 2’s actions insofar as it is necessary to draw conclusions on the Council’s actions.
8. I have discussed the case with Mr B. I have considered the documents that he, the Council and Council 2 have sent and any relevant law, guidance and policies.
9. I have considered the comments the Council and Mr B have made on the draft decision.

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What I found

Law, guidance and policies

Care Act 2014

10. The Care Act 2014 and the Care and Support Statutory (CASS) Guidance set out the council’s safeguarding duties.
11. Section 42 of the Care Act 2014 says councils have a statutory duty to safeguard adults.
12. The safeguarding duties apply to an adult who:
• has needs for care and support (whether or not the local authority is meeting any of those needs);
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
13. If a local authority decides that the section 42 threshold is met, it must:
• ‘Make or cause to be made whatever enquiries it thinks necessary to enable it to decide whether any action should be taken in the adult’s case and, if so, what and by whom.’

The Home’s Policies

14. The Home also has its own policies which are relevant to the complaint.

Call Bell Policy

15. The Home’s call bell policy says:
• An emergency call must be responded to within one minute and all other calls, within four minutes.
• Under no circumstances should support mechanisms such as call bells and sensor mats be removed from residents or unplugged. Staff who do this may face disciplinary action.
• The care home has a duty to regularly monitor call bell response time. This can be done by analysing a printout of all call bells and/or doing daily checks to see how long it takes for call bells to be answered on the various units.

What happened

16. Mrs C was an elderly woman who had restricted mobility. She moved into the Home on 26 August 2020.
17. The Home assessed her needs and provided a care plan which said:
• Mrs C was able to mobilise with her wheeled rollator frame for short distances but needed assistance from one care worker for longer distances.
• Mrs C was at high risk of falls, especially at night as she used the toilet a few times at night.
• Mrs could express her need to use the toilet by using the call bell.
• Mrs C had a floor sensor mat to address the risk of falls. The mat was positioned to the right side of the bed when Mrs C was in bed and in front of her chair when she was in the chair.
18. The following is a chronology of what happened based on the care records.

Fall - 10 September 2020

• Mrs C’s call bell was ringing at 16:18. The care worker went to Mrs C’s room and found her sitting on the floor, near the bathroom. She was not in any pain and had been able to move enough to reach the call bell. She had a minor tear on her right shin.
• The fall was added to the care plan and the care plan made reference to an ‘accident form’.

23 September 2020 (Wednesday)

19. Mr B rang the Home at 10:38. He said staff continued to remove Mrs C’s call bell at night and ignored her. The manager said it was unacceptable to take the call bell away and she would check the call bell herself in case there was a loose connection.
20. The daily record showed that that a care worker recorded, at 13:50 (on 23 September 2020):
• ‘Went into [Mrs C’] bedroom this morning to find her call bell and sensor mat was unplugged from the wall.’

24 September 2020

21. Mrs C’s social worker contacted the Home. She said Mr B had told her that Mrs C’s call bell was pulled out of the wall Tuesday night. The manager said:
• She went to Mrs C’s room with the night staff, but Mrs C could not remember the nights the call bell was pulled out from the wall.
• The manager had never observed the call bell being pulled out of the wall.
22. Mrs C’s social worker made a safeguarding referral to the Council. The Council requested further information from the Home to try to establish whether the referral met the threshold for a safeguarding enquiry, but the Home did not respond.

Fall - 30 September 2020

23. The daily record said:
• ‘At 17:30, [Mrs C’s] call bell was going and [Mrs C] sitting on the floor in her ensuite between her toilet and the wall. I asked [Mrs C] how did she fall she said she was trying to get up from the toilet.’
24. The call bell monitoring system said the response time for the call was 1 minute and 28 seconds.
25. Mrs C was taken to hospital where it was discovered that she had a fracture at the bottom of her spine.

1 October 2020

26. Mr B called the Council on 1 October 2020 and informed them of the fall. Mr B said that Mrs C had gone to the toilet by herself as nobody had come to help her. She fell when she was trying to get off the toilet.

13 October 2020 – start of the safeguarding enquiry

27. The Council officer spoke to Mr B on 13 October 2020. Mr B was very concerned about Mrs C who was in a lot of pain. He said Mrs C did not want to go back to the Home when she was discharged from hospital.
28. The officer tried to speak to Mrs C but it was not possible because she was in a lot of pain.
29. The Council decided that the two referrals met the threshold for a section 42 enquiry and started the enquiry.
30. Sadly, Mrs C passed away on 17 October 2020.

Complaint - 4 December 2020

31. Mr B made a complaint to the Home about the falls Mrs C suffered and said they were caused by lack of supervision and the fact that the staff, in particular the night-time staff, did not answer Mrs C’s calls when she pressed the call bell to go to the toilet. Mr B said he had alerted the Home on two occasions that the night staff had unplugged the call bell so Mrs C could not call.

The Home’s complaint response to Mr B

32. The Home responded (undated letter) and said:
• On 10 September 2020 Mrs C was trying to go to the toilet. She walked over her sensor mat which activated the alarm. When the care staff attended her care bell, they found Mrs C sitting near her ensuite.
• On 30 September 2020, Mrs C was found in the ensuite when the staff attended her call bell.
• Mrs C would frequently say to care staff that her call bell was unplugged.
• ‘There was not one occasion when the call bell was unplugged.’

The Home’s response to the CQC – 7 December 2020

33. The CQC became involved and the Home responded to the CQC on 7 December 2020 and said the following about the 30 September 2020 fall:
• ‘The service user’s call bell was activated which prompted staff to check them in the bedroom and it was then that the service user was found in the ensuite on the floor.’

The safeguarding enquiry

34. The Council completed its safeguarding enquiry on 18 February 2021. The report said:
• The Home said Mrs C’s call bell was working on the nights of 21 and 22 September 2020 but its call bell monitoring system was not working, so the Home could not provide evidence of the response times to the call bell.
• The Council checked Mrs C’s daily records from 21 September 2020 at 20:08 until 22 September 2020 at 08:20 and from 22 September 2020 at 20:18 until 23 September 2020 at 07:45.
• These records showed that Mrs C had had regular checks and toilet access during those two nights.
• The call bell monitoring system was not working but the Home had taken measures to undertake hourly observations. Steps were taken to ensure residents were safe in the absence of the call monitoring system.
• There could have been better manual recording of the call bell being pressed.
35. The Council made these observations about the 30 September 2020 fall in the safeguarding enquiry report:
• At 17:30 Mrs C’s call bell was going off and the staff came to check her. Mrs C was found sitting on the floor in her ensuite. She said she was going to the toilet but fell.
• The Home said: ‘During the 17:31 call, the staff member answered the call bell and assisted [Mrs C] to go to the toilet. [Mrs C] said that once she was finished she would press the buzzer again. The carer who assisted [Mrs C] to go to the toilet was on her way back to check on [Mrs C] and this was the time that the emergency alarm got activated and she found [Mrs C] with the call bell around her wrist and already on the floor.’ Following this response from staff, the call bell was activated a further six times but the Home said the later calls were caused by staff dealing with the emergency walking over the alert mat.
36. The Council completed its enquiry and said the allegation of neglect was ‘unsubstantiated’.
37. I found fault in the actions of the Home in the other investigation. The faults were:
• The records showed that Mrs C’s call bell and alert mat were unplugged on 23 September 2020. This put Mrs C at risk of harm as she could not call for help when she needed help. It also put Mrs C at greater risk of falls as she could not walk safely without assistance.
• The Home failed to monitor the call bell. The Home own’s policy says the call bell system should be monitored to ensure that the staff respond within the required times. The Home said it provided hourly monitoring of residents, but that would not have fully addressed the issue. The correct response, in line with the Home’s own policy, would have been to keep a manual record of the call bell response time and the Home failed to do this.
• The Home provided two different versions of what happened during the second fall on 30 September 2020. In its initial complaint response to Mr B, the Home said that the call bell was ‘going’ and the care worker went to Mrs C’s room and found Mrs C on the floor near the toilet. This is also what the Home told the CQC.
• The Home then changed its story and told the Council, in response to the safeguarding enquiry, that the care worker had assisted Mrs C in going to the toilet and then left her there. The care worker was on her way back and triggered the alert and then found Mrs C.
• This was concerning as it suggested that there was no proper record of the incident or a proper investigation at the time of the incident.

Analysis

38. Firstly, I should clarity that the aim of a safeguarding enquiry is different than an Ombudsman’s investigation.
39. The Ombudsman tries to find out whether there was fault in the Council’s (and the Home’s) actions. The Ombudsman can say there is fault, even if the matter does not meet the threshold for a safeguarding issue. Also, an Ombudsman’s investigation is wider as it does not limit itself to preventing risk of harm.
40. The aim of a safeguarding enquiry is to decide whether a person has suffered harm or is at risk of harm and, if so, to take action to ensure that they do not suffer further harm.
41. The Council investigated two safeguarding allegations:
• Staff were not responding to Mrs C’s call bell and sometimes even unplugged the bell. Mrs C said this happened during the nights of 21 and 22 September 2020, but had happened on other occasions.
• Mrs C’s fall on 30 September 2020 happened because staff failed to attend her call bell.
42. I appreciate that, at the time of the Council’s investigation, any risk to Mrs C had been addressed as she was in hospital and it had been decided that she would not return to the Home.

Call-bell monitoring

43. In terms of the first allegation, the main document that could have provided the answers was the bell recording system, but the Home said the recording system was not working. I asked the Home how long the recording system was out of order, but it did not answer the question.
44. I note the Council checked the care records for the two time periods (21 and 22 September 2020) which were the night-time periods that Mrs C complained about. That was good practice as the Council did not simply accept the Home’s assurances that nothing was wrong, but checked the source documents.
45. The Council noted that Mrs C was checked and received care on multiple occasions during those nights, but said there was no evidence to say how many times the call bell was pressed or how long it took staff to respond.
46. The Council came to a different conclusion than the Ombudsman but that was partly because the Council did not request all the records, but only the records for the two nights.
47. It would have been good practice, in my view, for the Council to ask the Home for the call bell monitoring records and the daily general records for other nights because Mrs C was saying that there had been other occasions when her call bell had not been answered or had been unplugged.
48. The Council made the same observation as I did, about the failure of the electronic call bell monitoring, which was that the Home could have had better manual recording of the call bell response times.

Fall on 30 September 2020

49. There was fault in the way the Council investigated the fall on 30 September 2020.
50. The Home provided two different versions of how the fall occurred. This suggested that the Home was either not keeping proper records or had not properly investigated the matter. The Council should have questioned the Home’s responses further and its failure to do so was fault.

Injustice and remedy

51. Mr B has suffered an injustice as a result of the fault. Mr B had concerns about the Home and wanted answers to the safeguarding concerns he had raised. The Council could have provided some of the answers Mr B was seeking earlier. Mr B had to pursue his complaint via the Ombudsman to obtain the information he wanted which caused him delay and stress.

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Agreed action

52. The Council has agreed to apologise in writing to Mr B within one month of the final decision.

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Final decision

53. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman