Summary: There was fault in the way the care home made decisions to assist Mrs C after she had a fall. The Council and the ICB which funded the care have agreed to apologise to Mrs C, pay her a symbolic financial remedy and remind the care home of its duties.

The complaint

1. Mrs B complains about the care provided to her mother, Mrs C at Hadfield House care home in Oldham. The care was jointly funded by Oldham Metropolitan Borough Council and NHS Greater Manchester ICB.
2. Mrs B says that, after her mother had a fall in the care home’s garden, the staff pulled Mrs C up, removed her clothes and cleaned her outside. The staff did not ask Mrs C what she wanted to do.

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The Ombudsmen’s role and powers

3. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
4. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
5. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

6. I have discussed the complaint with Mrs B, I have considered information provided by the Council and the Home, the relevant law, guidance and policies and the comments on the draft decision from the agencies involved and from Mrs B.

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What I found

Law and guidance

CQC

7. 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.
8. 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. This says that:
• 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 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 care and treatment must be provided in a safe way for service users (regulation 12).

Home’s policy

9. The Home’s Falls Procedure sets out what should happen if a resident has had a fall.
• A senior member of staff must check the resident.
• If the fall was un-witnessed consider the possibility that the resident has hit their head, unless proven otherwise.
• If the resident is in pain or there appears to have been an injury a full assessment must be performed by a medically trained individual, for example a nurse, first aider, GP or Ambulance personnel.
• If a major or serious injury is suspected, do not move the resident and call 999 for an ambulance.
• If a minor injury is suspected, assist resident to a comfortable place (using hoist/handling aid as appropriate).

What happened

10. Mrs C is an older woman who has a mental health diagnosis and physical health needs. She was living at the Home at the time of the complaint but has since then moved to a different care home.
11. The complaint relates to an incident on 11 August 2022 and the Home’s response following the incident.

Mrs B’s complaint

12. On 18 August 2022, Mrs B complained to the Home about the way it responded after the fall. She also made a safeguarding referral to the Council.
13. Mrs B said she had spoken to Mrs C about what happened.
14. Mrs C said she had been in the Home’s back yard, getting a chair out for her to sit on. As she pulled the chair out, she had a fall. She was screaming for help and the Home’s cook was alerted. Staff came to her and put blankets on her. The manager then came outside, saw what happened and said: ‘Get her up from the floor and get her changed.’ Mrs C said she was too shocked to speak.
15. Mrs C said she was then lifted to her feet and the care workers took off her dress and her continence pad and changed her outside. Mrs B said Mrs C had not been able to defend herself. She said the care workers took off her mother’s dress and incontinence pad outside to change her. Mrs B said Mrs C was ‘nude outside, cold and shaking’.
16. She said Mrs C had been crying when she spoke to her, saying she was shocked and shaken by the Home’s actions. She said the Home had taken Mrs C’s dignity away and the Home’s actions could never be ‘acceptable or justified’.

The Home’s response – 15 September 2022

17. The Home’s manager responded to the complaint. She explained that, as Mrs C had been incontinent, she asked staff to clean her. The staff used a blanket to cover Mrs C.
18. She said: ‘Your mum seemed to be too upset to be moved inside the home at that point so we did what we felt was right at the time. Your mum never screamed and shouted out but I agree she seemed upset and shocked from the fall which is why we didn’t want to cause any more distress for her.’
19. The Home apologised if it had caused Mrs C distress.

The Home’s records.

20. The Home’s incident report said the following happened on 11 August 2022. At 06:50 staff heard Mrs C shouting outside and found her lying on the ground. One of the staff members rang an ambulance and provided Mrs C with some blankets to keep her warm.
21. The manager came out and noticed that Mrs C had urine and faeces on her legs. She said Mrs C’s bottom half needed to be cleaned. The staff members then assisted Mrs C to stand up and the staff then washed and changed Mrs C's bottom half. Mrs C then sat on a chair.
22. The staff member rang Mrs B to let her know what happened. Mrs B agreed that the staff had done the best for Mrs C. Mrs B then spoke to Mrs C. After the conversation, Mrs B told the staff member that Mrs C did not seem in any distress and the staff member agreed.
23. At 10:15, staff took Mrs C to a room. The ambulance arrived and the staff checked Mrs C but said she did not need to go to hospital. The staff member then rang Mrs B to let her know that Mrs C was fine.

The Council’s safeguarding enquiry

24. The Council carried out a safeguarding enquiry into the incident and the social worker interviewed the manager, the care workers and Mrs C.
25. The manager said she asked staff to wash and change Mrs C’s bottom half. She said she had ‘advised [Mrs C] of this and [Mrs C] did not disagree with these actions.’
26. The care worker said that ‘at no time did [Mrs C] appear uncomfortable or distressed.’ The care workers said no-one else accessed the garden and the area was private and protected by blankets/sheets to protect Mrs C’s dignity. The care worker said ‘at no time did [Mrs C] ask them to stop.’
27. The manager said that, throughout the process, Mrs C was never fully naked, but then later said she was ‘naked for a limited amount of time’.
28. The manager said that moving Mrs C to her bedroom was never an option ‘as they are advised that if a resident has an unwitnessed fall, then they should remain in situ until the emergency services arrive.’
29. The social worker also spoke to Mrs C. Mrs C said: ‘It was awful. I was just so shocked. I was speechless to be honest.’ Mrs C said: ‘I was stripped naked, outside in the garden. I am very upset...’
30. Mrs C said: ‘Next thing I know, I am being pulled up from the ground, and care staff are taking off my clothes, it was very upsetting, and I asked them to stop.’ Mrs C became tearful and told the social worker she could not talk about it anymore.
31. The Council carried out a risk assessment as part of the safeguarding enquiry. It recommended under the section ‘controls in place’ that, if Mrs C needed support ‘the care staff will approach her and discuss, they will also make sure [Mrs C] consents to the care.’

Care home’s further comments

32. The Home said:
• ‘As the fall was unwitnessed and onto hard ground, staff were cautious about moving Mrs C in case she sustained a potentially serious injury.’
• It was not appropriate to wait for the ambulance’s arrival to address Mrs C’s incontinence.
• Staff had to decide relatively quickly. Mrs C would have had to enter the Home via the dining area, other residents could have been alerted to Mrs C’s incontinence, compromising her dignity.
• ‘Staff did not wish for [Mrs C] to move too much prior to her being assessed by medical staff in case she had sustained an injury.’
• The area was not overlooked; it was covered by a canopy and surrounded by high walls/ fences; staff felt they could ensure Ms C’s privacy by using blankets/ sheets to further shield the area.
• Staff spoke to Mrs C throughout and at no time, did she say she wished for a different approach to be taken. Mrs C vocalised her wishes and feelings strongly during her time at the Home and staff had no reason to suspect she was not in agreement with how she was being supported. Had Mrs C asked staff to stop or take a different course of action, they would of course have discussed this with her.

Analysis

33. I have investigated whether there was any fault in the actions of the Home, considering the policy and procedures the Home should follow.
34. I appreciate that the Home was acting in an emergency and I accept the Home was of the view that it was acting in Mrs C’s best interests. It is not the Ombudsman’s role to decide whether the actions were or were not in Mrs C’s best interests. I have investigated whether there was any fault in the way the Home made its decisions and I have done so considering the relevant law, guidance and policies. I am of the view there was some fault in the Home’s actions.
35. Firstly, throughout the complaints correspondence the Home repeatedly said the main reason why it did not take Mrs C inside was because she should not be moved, in line with its falls policy. The Home said Mrs C had sustained a ‘potentially serious injury.’ The Home noted the fall was ‘unwitnessed and onto hard ground’ which presumably also raised the concern about a head injury. I note the Home had called an ambulance so a serious injury was suspected.
36. Therefore, I do not understand why the Home’s staff then lifted Mrs C to her feet to clean her up. It appears to me that the policy says a person should either be moved or not moved, depending on the seriousness of the injury. The Home assessed Mrs C as having a ‘potentially serious injury’, so this would suggest she should not be moved.
37. Or, if the Home was saying that Mrs C’s fall was not a serious concern, then I do not understand why it did not assist Mrs C to go back into the Home. There was a contradiction in the Home’s explanation of its actions.
38. I think the other fault was that the Home never asked Mrs C what she wanted to do. The Home had a duty to ensure that Mrs C’s wishes were at the centre of its decision making and to protect Mrs C’s dignity and respect. Mrs C had full mental capacity to make decisions.
39. Therefore, if it was the Home’s decision (rightly or wrongly) that Mrs C could be moved, it should have asked Mrs C whether she wanted to be cleaned up inside or outside. The Home made decisions on behalf of Mrs C without any consultation with Mrs C and without seeking her consent or even opinion.
40. I note that the Home described Mrs C as ‘upset and shocked’ after the fall so I do not agree that the fact that Mrs C did not actively object when she was pulled up and then cleaned, could be taken as consent.
41. I have considered the injustice Mrs C has suffered. I note that, thankfully, it transpired that Mrs C did not suffer a fracture or head injury so the decision to lift her did not cause her actual physical harm. However, the Home did not know that at time it moved her so the injustice was that Mrs C may have been at risk of aggravating an injury that had occurred.
42. However, I think the main injustice is that Mrs C was very distressed by the way the staff treated her and, in particular, by being changed outside. She felt shocked and powerless. But I have also considered the fact that the Home ensured that Mrs C’s body was mostly covered when they cleaned her and she was in a sheltered part of the garden. So hopefully, however distressing it was to Mrs C, nobody actually witnessed the events.

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Agreed actions

43. When a council or ICB commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the care provider, I have made recommendations to the Council and the ICB.
44. The Council and the ICB have agreed to take the following actions within one month of the final decision statement:
• Apologise to Mrs B and Mrs C in writing.
• Each pay Mrs C £100 for the distress caused.
• Remind the Home of the importance of person-centred care and adhering to the Falls Procedure.

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Final decision

45. I have completed my investigation and found fault. The Council and the ICB have agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman