Summary: Mrs C says the care provider failed to provide appropriate care to her during two periods of respite during which she sustained injuries and some belongings went missing. There is no evidence fault by the care provider caused Mrs C to fall but there is no evidence the care provider updated the risk assessment following that fall. The care provider also lost some of Mrs C’s belongings, a photo frame was damaged and on one occasion the home provided Mrs C with dirty cutlery. An apology, payment and training for care staff is satisfactory remedy.

The complaint

1. The complainant, whom I shall refer to as Mrs C, is represented by her daughter whom I shall refer to as Mrs D. Mrs D complained the care provider failed to provide appropriate care to Mrs C during two periods of respite during which she sustained injuries and some of her personal belongings went missing.
2. Mrs D says difficulties with both respite stays meant neither she nor Mrs C received proper respite and both were caused distress.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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(i), as amended)

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How I considered this complaint

6. As part of the investigation, I have:
• considered the complaint and Mrs D's comments;
• made enquiries of the care provider and considered the comments and documents the care provider provided.
7. Mrs C, Mrs D and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
8. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

What should have happened

9. The care provider has a management of falls policy. This says the care plan and risk assessment must be reviewed following a fall. It goes on to say falls and associated themes should be discussed at weekly clinical risk meetings and actions completed where risk is identified. It says falls analysis must take place for all residents who have sustained a fall during the previous month using the falls analysis tool.
10. The residency agreement says the care provider will not be responsible for any damage or loss to resident’s personal belongings unless the provider has breached the terms of the agreement.

What happened

11. Mrs C stayed at the care home for two periods of respite. The first period of respite took place between 2 and 16 February 2022. Mrs C was at first placed in the residential suite but when it became clear her needs were greater than could be met in that suite the care provider moved her to the memory care community.
12. On admission for that first period of respite the care provider assessed Mrs C as not being at risk of falls. However, Mrs C had a fall on 11 February which resulted in a head injury. The care provider called the paramedics, who attended and sutured the wound. The care provider updated the care plan following that fall.
13. The second period of respite took place between 2 and 16 March 2022.
14. Mrs D put in a complaint in August 2022. Mrs D raised concerns about the care provided to Mrs C, damage to her belongings, missing belongings, treatment of Mrs C in the home and failure to provide Mrs C with socialisation or activities. When responding to the complaint the care provider offered to reimburse Mrs C for any lost items if she could provide a receipt.

Analysis

15. Mrs D says the care provider failed to provide appropriate care to Mrs C during two periods of respite. Mrs D notes particularly that Mrs C sustained injuries when she had a fall during the first period of respite in February 2022.
16. Having considered the preadmission documentary records and the care plan completed by the care provider I note before Mrs C went into the care home for the first period of respite she did not have a history of falls. That is also information confirmed by Mrs D. I appreciate Mrs C nevertheless had a fall during her first stay at the care home. As that was an unwitnessed fall I cannot say this was due to any fault on the part of the care provider particularly as, at that point, there had been no assessment Mrs C was a risk of falls.
17. I am satisfied the care provider followed the right procedure when dealing with Mrs C’s fall in February 2022 by making prompt contact with the paramedics who attended later that day. I am also satisfied the care provider updated Mrs D about was happening, albeit the information the care provider could give Mrs D was limited until the paramedics completed their assessment and treatment.
18. I am concerned though with what happened after the fall. I refer in paragraph 9 to the procedure the care provider should follow after a fall. I would expect the care provider to have updated Mrs C’s care plan and carried out a formal risk assessment, particularly as Mrs C had not previously had a history of fall. I am satisfied the care provider updated the care plan. However, although the care provider says it completed a risk assessment I have not seen a copy of one. As the care provider’s policy requires a risk assessment to be completed following a fall failure to do that is fault.
19. I am also concerned with what happened following a further fall on 16 March, which was the day Mrs C was due to go home. On that occasion care staff found Mrs C on the floor in her room but she did not have any injuries. Under the care provider’s management of falls policy it should have begun hourly observations for the next six hours and completed the falls observation record. There is no evidence the care provider followed the procedure in this case. That is fault. That is again unlikely to have satisfied Mrs D the care provider was properly looking after Mrs C.
20. Mrs D also has other concerns about the care provided by the care provider. One of those concerns relates to the care provider not being available to provide a daily update to Mrs D. Mrs D says before Mrs C entered the care home the care provider said it could provide daily telephone contact. Having considered the documentary records I have found no evidence of any commitment by the care provider to provide Mrs D with daily updates. As there is nothing recorded in the documentary records for that point I cannot reach a safe conclusion about whether the care provider misled Mrs D about what it could provide in terms of telephone contact.
21. Mrs D also raises concerns about damage to Mrs C’s belongings during her respite stays. Mrs D says the home deliberately broke Mrs C’s hearing aids as they could not have been damaged in the fall in February 2022 but when she returned home the hearing aids were twisted. The Ombudsman cannot take evidence on oath and therefore has to rely on the documentary records. The documentary records show the home provided regular hearing aid care including taking the hearing aids out and putting them safely away in the cupboard and then putting the hearing aids back in Mrs C’s ears. There is nothing in the documentary records to suggest the hearing aids were damaged. While I understand why Mrs D would believe the damage was intentional I cannot reach a safe conclusion about that given I do not know how the hearing aids became damaged.
22. Mrs D says Mrs C sustained an injury to her ear canal while resident in the home. The audiologist identified the injury to the ear canal in April 2022. The last respite stay for Mrs C at the home ended on 16 March 2022. There was therefore a gap between the second respite stay and the injury to the ear being identified. Given there is no reference in any of the care provider’s documentary records to suggest Mrs C injured her ear during her stay at the care home I cannot say fault by the care provider resulted in the injury to Mrs C’s ear.
23. Mrs D says poor care by the home resulted in Mrs C developing a cyst on her eye. Mrs D links the cyst on the eye to the possibility of the care provider not properly cleaning Mrs C. I understand why Mrs D would make that link. However, there is nothing in the documentary records to suggest the care home identified an injury to Mrs C’s eye and there is evidence of regular washing. In the absence of any documentary records about an injury I cannot reach a safe conclusion about whether the injury occurred in the home. Nor can I reach a safe conclusion about whether poor care provided by the home resulted in the injury.
24. Mrs D has raised concerns about the home not providing Mrs C with access to soap and toothpaste. I am satisfied this relates to Mrs C being placed in the memory unit. Due to risks associated with some of the residents of that unit the care provider placed toiletries in cabinets with magnetic locks and therefore they were not accessible to Mrs C without a member of the care staff being present. I note though Mrs C’s care plan made clear she required assistance with all her daily care needs which included washing. I am therefore satisfied, on the balance of probability, Mrs C would not have needed to access toiletries without a member of care staff being present. So, I do not consider it likely Mrs C suffered any injustice from the toiletries being placed in a cabinet.
25. Mrs D is concerned the care provider did not provide Mrs C with companionship and stimulation. Mrs D says despite promising activities would be available for Mrs C to access this was not the case and she only went on one trip from the home during the four weeks she stayed there. I have found nothing in the documentary records to suggest the care provider gave any commitment about the number of trips Mrs C would go on during her respite stay. However, the care plan completed for Mrs C is clear she feared being alone and enjoyed company. I would therefore have expected the care provider to ensure Mrs C had sufficient stimulation and an opportunity to engage with other residents. I have to rely here on the daily care records completed by the care provider. That shows Mrs C was involved in activities when they took place, or was given the opportunity to take part in those activities. The records also show Mrs C was able to engage with other residents. This was not on a daily basis necessarily but it does indicate some level of stimulation and engagement with Mrs C was available. On balance I therefore do not consider the care provider at fault here.
26. The care provider accepts one of Mrs C’s photographs was damaged, some of her belongings were lost and have not been recovered and on one occasion she was provided with dirty cutlery. That is fault and the care provider has apologised for those matters.
27. So, I have found fault as the care provider has not provided any evidence it completed a risk assessment following Mrs C’s fall in February 2022. I have also found fault as some of Mrs C’s belongings were lost or damaged and on one occasion she was provided with dirty cutlery. I consider a reasonable outcome for the complaint would be for the care provider to apologise to Mrs C and Mrs D and pay Mrs D £100. That is to reflect her uncertainty about whether Mrs C’s experience at the care home would have been improved had the fault I have identified not occurred as well as to recognise the loss of some of Mrs C’s belongings and the time and trouble Mrs D had to go to pursuing the complaint. I also recommended the care provider carry out a training session for care staff to remind them of the steps they need to follow when a resident has had a fall, particularly around the need for a formal risk assessment. The care provider has agreed to my recommendations.

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Agreed action

28. Within one month of my decision the care provider should:
• apologise to Mrs C and Mrs D;
• pay Mrs D £100; and
• carry out a training session for care staff to ensure they are aware of the actions they need to take under the care provider’s management of falls policy when a resident suffers a fall.

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Final decision

29. I have ended my investigation and uphold Mrs C’s complaint. I have made recommendations the organisation has agreed to carry out.

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Investigator's decision on behalf of the Ombudsman