Summary: There was fault in the care provided to Mrs D, particularly in relation to falls prevention, record keeping and keeping Mrs D safe from other residents. This has caused an injustice and the Council has agreed to apologise, reduce the invoice and carry out a service improvement.

The complaint

1. Ms B complains on behalf of her mother, Mrs D, who lacks the mental capacity to make the complaint.
2. Ms B complains about the care provided at Clipstone Hall and Lodge care home (Home 1) in Clipstone, Mansfield. She said Home 1 did not take appropriate action to prevent a fall in February 2024, the continence care provided to Mrs D was poor and the Home lost Mrs D’s walker.
3. Ms B also complains about Maun View care home in Mansfield (Home 2). She said there was an incident in August 2024 where the staff abused Mrs D and the Home took no action when Mrs D said she was frightened of a male resident who would enter her bedroom.

Back to top

The Ombudsman’s role and powers

4. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. 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(1), as amended)

Back to top

How I considered this complaint

6. I have discussed the complaint with Ms B. I have considered the information provided by Ms B and the Council, the relevant law, policy and guidance and both sides’ comments on the draft decision.

Back to top

What I found

7. The Care Act 2014, the Care and Support Statutory Guidance 2014 set out the Council’s duties towards adults who require care and support.

Safeguarding

8. Section 42 of the Care Act 2014 says that, if a local authority has reasonable cause to suspect that an adult in its area:
• has needs for care and support;
• 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.
9. The local authority must make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken.
10. The Care and Support Statutory Guidance emphasises the importance of putting the adult at risk of abuse at the centre of the enquiry. ‘Making safeguarding personal’ means safeguarding should be person-led and outcome-focused.

Care Quality Commission

11. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards. The guidance says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. (regulation 12).
• The Home must, as far as is reasonably practicable, ensure that service users are able to make decisions about their care or treatment (regulation 11).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

What happened

13. Mrs D is an adult woman who has mobility issues and dementia.
14. Mrs D moved into Home 1 in February 2022 from another care home. Home 1 listed Mrs D’s belongings when she moved in and these included a 3-wheeled walker and a Zimmer frame.
15. Mrs D’s care plan for mobility, falls preventions and maintaining a safe environment at Home 1 said (updated on 29 January 2024):
• Mrs D was able to walk independently for short distances but needed a 3-wheeled walker to assist her. In other parts of the document, a 4-wheeled walker was referred to.
• She was at high risk of falls as she sometimes suffered from dizziness.
• Staff should check Mrs D regularly during the day and night to ensure she was safe.
• Mrs D had a profiling bed (bed that can be lowered) with a foam mattress.
• A sensor mat was in place at night by the side of her bed so that staff were alerted when Mrs D was awake and could assist her. Staff had to ensure that the sensor mat was activated when Mrs D was in bed.
• Staff had to make daily checks that Mrs D had access to her walking aid and that it was clean and in good order.
16. Mrs D’s continence plan said:
• Mrs D was mostly continent and able to use the toilet but, because of her slow mobility, she may arrive at the toilet late so she used continence pads for dignity.
• Staff had to assist Mrs D by encouraging her to go to the toilet and assisting her with continence wear.
17. Mrs D had an unwitnessed fall on 22 February 2024 and was taken to hospital later in the day.
18. The records said staff heard a bang from Mrs D’s room at 00:20 at night and found her on the floor. Mrs D told staff she ‘rolled over and fell straight out.’ Staff rang 111 and monitored Mrs D. As Mrs D developed bruising round the eye during the night, the clinician advising the Home said they would send an ambulance.
19. The Home filled in an incident form and notified the CQC (date not specified) and the Council (date of notification: 27 February 2024). The Hospital updated the Home and said Mrs D had fractured 3 ribs and had pneumonia.
20. The Council started a safeguarding enquiry into the fall.
21. Ms B raised further concerns during the safeguarding enquiry. She said:
• Mrs D had bed rails at home and the family had asked Home 1 to put bed rails in but Home 1 had failed to do so.
• Mrs D used a static Zimmer frame but this often went missing and the Home gave Mrs D a 3-wheeled walker to use instead of the Zimmer frame.
• The Home did not provide Mrs D with appropriate continence care and urine would run down her legs causing her legs to be sore and her Cellulitis to flare up.
22. On 19 March 2024 the social worker said they had completed their enquiries and the findings were:
• The Home said Mrs D arrived with a two-wheeled walker and a three-wheeled walker. She had access to both, but preferred to use the three-wheeled walker.
• The Home had carried out a falls risk assessment and had put in place a care plan to minimise the risk of falls. This included regular monitoring when Mrs D was in her bed and a sensor mat to notify staff when Mrs D was getting up. Mrs D’s profiling bed was set at the lowest setting when she was in bed at night.
• The records showed Mrs D was appropriately supported in her continence needs. She would sometimes use the toilet and also had continence pads in case she did not reach the toilet on time.
23. The social worker rang Ms B on the same day and informed her of her findings.
24. Ms B challenged the findings and raised further concerns. She said:
• Home 1 had never put in place a sensor mat.
• Mrs D had told her that she did not fall out of bed, but had got out of bed, was unable to find her walker and then fell.
• Mrs D only had the two-wheeled walker when she moved in and this walker often went missing.
25. The social worker carried out further investigations into those allegations. They called the hospital on the same day and asked the staff nurse to ask Mrs D whether she could remember whether she fell out of bed and whether there was a sensor mat by the bed.
26. The staff nurse said Mrs D’s mental capacity fluctuated but that Mrs D appeared lucid in her thinking on that day. The nurse rang back later and said Mrs D confirmed that she fell out of bed, the bed was at a low setting but she could not say whether there was a sensor mat by the bed. Mrs D told the nurse that Home 1’s staff arrived very quickly after the fall.
27. The social worker completed the enquiry in July 2024 and noted the following:
• Home 1 did not have a central data collection system which recorded when the sensor mat was activated and responded to.
• Home 1 did not use a bed rail as Mrs D had never fallen out of bed before. The social worker noted that Mrs D got in and out of bed independently so the use of a bed rail would require a specialist assessment as there was the risk of entrapment and increased risk of injury when a bed rail was used for a person who can get out of bed.
• Home 1’s manager said Mrs D had a Zimmer frame with a caddy but this had been stored away as Mrs D never used it. It may be that the wrong frame was given back to Mrs D as it had been stored away for such a long time.
• Home 1 took the correct actions after Mrs D had her fall in terms of seeking the appropriate health interventions and providing ongoing monitoring and support.
28. The social worker concluded that the safeguarding enquiry could be closed.
29. Mrs D moved to a different care home (Home 2) following her discharge from hospital on 23 April 2024.
30. Ms B complained about the care provided at Home 2 in November 2024. Ms B said:
• There was an incident in August 2024 where Mrs D was assaulted in the shower.
31. The Council responded to the complaint in November 2024 and said:
• Ms B visited Mrs D in August 2024 and Mrs D told her that she had been ‘punched and kicked.’ At the time Ms B said she did not believe this at all and thought Mrs D just needed time to settle in. However, Ms B then later raised concerns about the Home and said the staff were rude towards her. She then raised the alleged assault against Mrs D formally with the Police.
• The social worker visited the Home on 30 August 2024 to investigate the incident and had not found any evidence that an assault had taken place.
32. Ms B complained to the Home about the incident in August 2024. She added another complaint which was:
• Mrs D and Ms B witnessed a male resident throw his walker across the room and start punching staff. The resident’s room was opposite Mrs D’s room. Mrs D was very frightened of this resident as he would walk into her bedroom, without her consent and the Home did nothing to protect Mrs D.
33. The Home responded in December 2024 and said:
• There had been no evidence of abuse in August 2024 and the Council had confirmed this.
• The Home acknowledged that Mrs D was frightened of the man who lived opposite her but said: ‘The Home manager informed you there was little she could do around preventing him going into anyone else’s room as this is also his home.’
• The Home offered to move Mrs D to another room on another floor.

Further information

34. I have read Home 1’s daily records from 8 to 22 February 2024 and these showed:
• Mrs D’s pressure mat was checked on 12 February 2024. There was no other record that the sensor mat was checked. There was no record that the care worker switched on the sensor mat in the evening
• Mrs D was regularly checked, day and night.
• Mrs D’s incontinence pad was regularly changed each day, around 3 to 4 times, in addition to Mrs D using the toilet frequently.
• Mrs D walked almost every day, using her walker, although it was referred to as a Zimmer frame and as a four wheeled walker.
• During the evening of 21 February 2024, Mrs D used a 4-wheeled walker to walk to the bathroom and to the bedroom chair. The care worker ticked the task that the room was checked to ensure everything was ok.
35. I have read Home 2’s daily records from 14 to 31 August 2024 and on 21 August 2024 the record noted that Mrs D was ‘perfectly fine’ until Ms B came to visit her in the evening. Mrs D told Ms B that the care worker pushed her on the floor, rolled her over, gave her a shower with very hot water and stole her red shopping bag.’
36. The bag was found wrapped in a bedsheet in a box in the bedroom. Mrs D then said it was another member of staff and the incident happened yesterday but then said it was three days ago.
37. A senior staff was informed of the allegations and told Mrs D that they would refer it to the police. Mrs D then calmed down and said to ‘just let everything go down.’ Ms B was described as ‘upset’ but said Mrs D ‘had been playing her’ and she knew the allegations were not true. Ms B said Mrs D had made similar allegations when she was still at home. There was no evidence of any bruising on Mrs D, as far as I am aware.
38. There was then no further mention of this incident until 30 August 2024 after Ms B had reported the incident to the police and to the Council on 27 August 2024.
39. The Council’s social worker visited Home 2 on 30 August 2024 to investigate the incident.
40. Home 2’s manager said staff had contacted the GP on 27 August 2024 as Mrs D was displaying confusion and low mood and a urinary tract infection was suspected.
41. The social worker spoke to Mrs D and asked how staff were treating her. Mrs D replied: ‘good’ but said she was concerned about a male resident. The social worker asked Mrs D again whether any staff had hurt her and Mrs D said: ‘No. No. Not al all.’ The social worker said Mrs D appeared more concerned about the male resident.
42. The social worker read the daily record relating to the incident on 21 August 2024 and spoke to the manager about this. The manager said that they had not been informed of this incident, but one of the team leaders had been informed. The social worker said that the matter should have been recorded as an incident. The manager agreed and said it was a lesson learned and staff would fill in an incident report.
43. The social worker said that there was no evidence that Mrs D had been assaulted and closed the matter. The manager confirmed on 2 September that Mrs D had been treated for a urinary tract infection.

Analysis

44. Ms B’s main complaint relates to the fall Mrs D had at Home 1.
45. Ms B said the Home lied about how the fall happened. I note, firstly, that Mrs D has dementia and fluctuating mental capacity. I have considered the evidence and I note that Mrs D told the staff at the Home and the nurse in the hospital that she had fallen out of bed. I accept that Mrs D may also have told Ms B that she fell after she got out of bed and was trying to find her walker. Unfortunately, as this was an unwitnessed fall, it is impossible to say exactly what happened.
46. There was, however, fault in Home 1’s use of the sensor mat. Mrs D’s care plan said the care workers should check the sensor mat was in good working order every day and should ensure that it was switched on while Mrs D was in bed. There was a separate electronic task the care workers had to tick to show this had been done.
47. I have not find any evidence that this was done in the records of the two weeks that I read apart from one time on 12 February 2024 when the care worker checked that the sensor mat was working. Therefore, there is no evidence that the care workers were properly using the mat, as the care plan said, and this was fault.
48. I also note that there was no record that the sensor mat alarm went off when Mrs D fell on 22 February. The daily records and the incident report mentioned that the staff heard a bang, but nobody heard the sensor mat alarm. This again suggested that the staff had not switched on the sensor mat that night.
49. It is difficult to say whether Mrs D suffered any injustice because of this fault. If Mrs D fell out of bed, then she suffered no injustice as the staff were alerted by the sound of her fall and attended her immediately. However, if she fell after getting out of bed, then the alert mat may have prevented the fall as it would have meant that a care worker came to her assistance as soon as she stepped on the mat.
50. I also agree with the Council’s observation that it would be helpful to have a central record which notes when the sensor mat alarm goes off and how soon a care worker acts after the alarm goes off. Care homes often keep this record to monitor that staff are acting quickly in response to alerts.
51. In terms of the complaint that one of Mrs D’s walkers (walking aid/Zimmer frame) went missing, I note that Home 1’s list of belongings for Mrs D, when she first moved in from another care home, said she had a 3-wheeled walker and a Zimmer frame. The list of belongings did not specify whether the Zimmer frame was static or had wheels.
52. Mrs D’s care plan and the care records referred to Mrs D using a 2-wheeled, 3-wheeled and 4-wheeled walker, but most of the time the 3-wheeled walker was mentioned.
53. Walkers can be either static (no wheels), or have 2, 3 or 4 wheels. Different types of walkers are more suited to different people with different levels of mobility so Home 1 should have been set out clearly in its record keeping what type of walker Mrs D needed and could use. Its failure to do so was fault.
54. And I note that, in its response to the Council in July 2024, Home 1 admitted it may have given Mrs D the wrong walker as it had been in storage for so long so there was fault in that respect.
55. However, it is difficult to say whether Mrs D suffered injustice because of this. In the records I read, Mrs D used her walker every day so she was mobile and able to use the walker that was at her disposal. There was also no suggestion, from the evidence, that the fall in February 2024 was caused by Mrs D using a wrong type of walker.
56. Ms B said Mrs D was looking for her walker when she fell. As I have explained above, I cannot say whether Mrs D fell out of bed or fell while she was walking. I can also not say with certainty whether the walker was near Mrs D’s bed on the night of the fall. The records showed Mrs D used her walker in the evening and that the care worker checked the room and said everything was fine, but did not go into detail. So I agree that more detailed record keeping would have been helpful in this respect.
57. In terms of the complaint about Home 1 failing to meet Mrs D’s continence needs, I looked at the records and could not find evidence of fault. In the records I read, Mrs D used the toilet regularly and/or her continence pad was checked and changed regularly. I accept that Ms B may have observed incidents where Mrs D’s continence pad was wet, but I cannot say, from the records I have read, that there was a pattern of poor continence care.
58. I find no fault in Home 1’s decision not to use bed rails before the fall in February 2024. I accept the Council’s safeguarding enquiry response in this respect. There was no indication that Mrs D had fallen out of bed before and as Mrs D was mobile and able to get in and out of bed, a bed rail may have caused entrapment and increased the risk of a fall.
59. In terms of Home 2, I have investigated the complaint that Mrs D was assaulted or ‘manhandled’ by Home 2’s staff on 21 August 2024. I have read through Home 2’s records for 21 August 2024, the incident report and the Council’s investigation into the allegation and there is no evidence that Mrs D was assaulted or manhandled. In the absence of other evidence, I cannot conclude on the balance of probabilities that there was fault here.
60. I agree with the Council’s finding that Home 2 should have treated this an incident and filled in an incident report on the day that the incident happened so there was fault in terms of the record keeping.
61. I have also considered the complaint that Mrs D was frightened at Home 2 as a male resident would go into her room uninvited and without her consent.
62. I was surprised by Home 2’s complaint response that it could not take any action in this respect of the male resident as ‘it was his home too.’ I appreciate Home 2 was the male resident’s home but that did not mean that Home 2 did not have a duty to consider whether there was anything it could do to address this problem, for example by increased monitoring or management of the male resident’s behaviour if he was indeed violent towards staff.
63. Home 2 had a duty to ensure that Mrs D felt safe at Home 2 and should have at least considered whether there was any action it could take and not dismissed Ms B’s request to do so. I note that Home 2 offered Mrs D another room which was positive, but Home 2’s complaint response that nothing could be done to address the man’s behaviour was not adequate and was fault.
64. Ms B also complained that the Council has not properly investigated the safeguarding concerns she raised about the two care homes. I find no fault in that respect.
65. The Council carried out appropriate enquiries into the concerns that had been raised. The Council read the relevant records and visited the care homes. The social worker spoke to Ms B frequently and I note that the social worker discussed the conclusions of the enquiry on 19 March 2024 and the Council then agreed to continue to carry out further enquiries because Ms B had raised further issues. That was good practice and showed that the Council was taking Ms B’s concerns seriously and putting Mrs D, whose representative was Ms B, at the centre of the enquiries.

Remedy

66. I asked Ms B what she wanted to achieve by coming to the Ombudsman. Ms B said that she felt that Mrs D’s health had been permanently damaged by the fall at Home 1 and the pneumonia and she wanted the Council to pay compensation for this. She felt that Mrs D should not have to pay her contribution for her entire stay at Home 1 and Home 2 because of the concerns she had raised.
67. I explained to Ms B that if she wanted to make a personal injury claim and seek compensation, she would need to go to court as this was not something the Ombudsman could consider. I explained that the Ombudsman was not a court and did not provide compensation. Ms B said she understood.
68. Generally speaking, the main aim of the Ombudsman’s remedy is to place the person in the position they would have been if the fault had not happened.
69. In a case such as this one, were there has been no direct financial loss as a result of the fault, the Ombudsman can sometimes recommend a small symbolic financial remedy (a few hundred pounds) to represent the distress caused by the injustice. I recommend the Council reduces Mrs D’s outstanding invoice by £200.
70. Ms B also said that she wanted to ensure that similar problems did not occur again and I have made service improvement recommendations in that respect. I will also share this decision with the CQC under our information sharing agreement.

Back to top

Action

71. The Council has agreed to take the following actions within one month of the final decision. The Council should:
• Apologise to Ms B and Mrs D for the fault I have identified.
• Reduce Mrs D’s invoice by £200.
• Remind Home 1 to ensure that care plans are adhered to.
• Remind Home 1 and Home 2 of the importance of good record keeping.

Back to top

Decision

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

Back to top

Investigator's decision on behalf of the Ombudsman