Summary: There was fault in the Home’s recording of Mrs C’s medication requirements. There was poor record keeping in relation to the initial falls risk assessments and care plans and the Home failed to respond to Mrs B’s complaint. The Home has agreed to apologise and pay a financial remedy to reflect the distress caused by the fault.

The complaint

1. Mrs B complains on behalf of her mother, Mrs C. Her complaint relates to Bourne House residential home in Ashton Under Lyne, Lancashire.
2. Mrs B says Mrs C was at risk of falls, partly because of poor eyesight. She says the Home failed to properly record the medication requirements for Mrs C’s eyes and, as a result, administered the medication to the wrong eye.
3. Mrs C suffered four falls while she was at the Home and Mrs B says this was due to Mrs C’s deteriorating eyesight and the Home’s failure to properly address the risk of falls.

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The Ombudsman’s role and powers

4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

6. I have discussed the complaint with Mrs B. I have considered the information that Mrs B and the Home have sent, the relevant law, guidance and policies and Mrs B’s comments on the final decision.

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What I found

Regulations and policies

Care Quality Commission (CQC)

7. The CQC is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to 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 those registered to provide care services must achieve.
9. The CQC has provided guidance on the regulations. This says that:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• Care providers must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17).
• Care providers must report any incidents to the CQC which led to injury (listed in the regulations) which occurred while services where provided in carrying on a regulated activity or as a consequence of a regulated activity (regulation 18).

Home’s accident/incident policy

10. The policy says:
• The manager must carry out an analysis of the accident near miss report log and establish what caused the accident.
• The results of the analysis should be used to improve practice, reduce risk and prevent recurrence, to ensure that any non-compliance is resolved as quickly as possible.

Home’s complaints policy

11. The policy says:
• Service users should be made aware of the complaints process.
• The manager will send an acknowledgment within three days of receipt of the complaint.
• The response will be sent within 28 days of receipt of the complaint. If there will be a delay in the response time, then the complainant will be informed of the dealy.

What happened

12. I have made a chronology of events based on the documents the Home has sent me and the chronology provided by Mrs B.

Chronology

13. Mrs C moved into the care home on 20 March 2019. She had vascular dementia and glaucoma in the left eye.
14. My note: Glaucoma is a disease of the eye where the optic nerve becomes damaged because the pressure inside the eye is too high, often because of a build-up of fluid in the eye. Normal pressure is between 12-22 mm HG. Glaucoma is treated by lowering the eye pressure with medication such as eye drops or eye gel.
15. Mrs B said Mrs C had had falls at home and the risk of falls and the dementia were the main reasons why Mrs C moved to a care home. Mrs C had hip surgery in the past but was able to walk independently.
16. Mrs C moved into an upstairs room, but had been told she could move to a ground floor room as soon as one became available.

Assessment of Mrs C’s needs

17. The Home carried out an assessment of Mrs C’s needs. The document is undated and six pages long. Under the heading ‘personal safety and risk assessment’, it is stated that the assessor should provide, from a service user’s history, any concerns about their personal safety and risk including risk of falls. The assessment said Mrs C was ‘at risk of trips/falls due to eye-sight problems.’

30 March 2019 – first fall

18. On 30 March 2019, Mrs C had a fall. The incident report said that one of the workers heard a bang. They found Mrs C lying on the floor, holding her head. An ambulance was called and Mrs C was taken to hospital. She suffered a bump to her head and a cut which required gluing.
19. The Home carried out a moving and handling assessment and risk assessment and put in the following measures, among others, to reduce the risk of future falls:
• ‘Staff need to also be aware of [Mrs C’s] whereabouts at all times.’
• ‘Mrs C tries to go upstairs during her walks around her home. Staff need to ensure [Mrs C] does not go upstairs and must go with her. At night her bedroom door must be closed and call mat in place and plugged in.’
• Walkways and lounge floors should be clutter free with no trip hazards.
20. Mrs B was concerned as the fall had happened near the stairs. Mrs B said Mrs C previously lived in a bungalow and she struggled with stairs. Mrs B asked again whether Mrs C could move to a downstairs as she was worried Mrs C would fall down the stairs.

28 May 2019 – second fall

21. Mrs C had a second fall on 28 May 2019. Mrs C was in the hallway toilet and staff could hear her crying and trying to open the door. Staff were able to squeeze through the door and found Mrs C on the floor.
22. Mrs C had a lump and a small cut to her left eyebrow.
23. The risk assessment said Mrs C had slipped on the floor which was wet with urine and staff should:
• ‘When [Mrs C] needs the toilet, staff must take [Mrs C] into the toilet and remain with her and assist her to pull her underwear/trousers up after going to the toilet and then to walk with her to the lounge and ensure she is in their view. Even when she is walking around…’
24. The Home’s moving and handling assessment said:
• ‘Be aware of her whereabouts and ensure she is assisted upstairs or in the garden when she wishes to go.’
• ‘Please ensure you support [Mrs C] when she goes to the toilet, upstairs or into the garden…’
25. Mrs B said Mrs C was wearing another resident’s glasses at the time of the fall.
26. 23 June 2019 - Mrs B said Mrs C was wearing another resident’s glasses. Mrs B found Mrs C’s glasses in her bedroom and exchanged them.
27. 26 July 2019 - Mrs B said Mrs C was not wearing her glasses and she was unable to find them. She said Mrs C’s right eye looked slightly pink and the manager told her it was blepharitis and they would monitor it.
28. The care notes for 28 July 2019 said Mrs B was not opening her right eye as she said it was sore. She would not let staff bathe it.
29. 30 July 2019 - Mrs B said Mrs C’s right eye was partially closed. She took Mrs C into the office and enquired about Mrs C seeing the GP, but the assistant manager said the GP would not come out. Mrs B said the manager said they had been bathing it and putting the eye drops in.
30. 31 July 2019 – Mrs B said Mrs C’s right eye was closed. Mrs B took Mrs C to an orthopist who could find no infection, scratches or foreign objects in the eye but said that Mrs C’s pressure in the right eye was six and in the left eye was 16. So the pressure in the right eye was abnormally low.
31. Mrs B had brought a copy of Mrs C’s medication administration record (MAR) chart for the four-week period starting on 29 July 2019 to show to the orthotist. Mrs B has also sent me a copy of that chart.
32. The chart said:
• Medication 1 – eye drops: One drop to be used twice a day in the left eye.
• Medication 2 – eye drops: One drop to be used at night in the affected eye(s).
• Medication 3 – eye gel: One drop to be used in the affected eye(s).
33. Mrs B suspected that the staff may have misunderstood the prescription for medications 2 and 3 and may have put the drops/gel in both eyes, which would be the explanation for the unusual fall in the pressure of the right eye. She said the orthopist assured her that, when the drops in the right eye were stopped, the eye would begin to open as the pressure increased.
34. Mrs B said she took Mrs C back to the Home. She said she spoke to a senior carer. The senior carer looked at the chart and assured Mrs B that they would hand-write ‘left’ on the chart so that there was no risk of error in the future.
35. Mrs B said Mrs C’s eyesight was now quite poor as she was squinting from her left eye to keep her right eye for comfort. Mrs B said she observed Mrs C struggling to find the sink in the bathroom.
36. The daily record for 4 August 2019 said Mrs B had given Mrs C sunglasses to wear as Mrs C’s eyes were hurting. Mrs C did not want to have her eye bathed.

7 August 2019 – third fall

37. On 7 August 2019, the cleaner found Mrs C next to the toilet. Mrs C had attempted to use the toilet and tripped over her trousers. She had a small bruise to the left side of her chest. Staff also removed Mrs C’s dark glasses for her safety.
38. The risk assessment said:
• ‘Staff have been reminded of what it says in the plan about being with [Mrs C] when she goes to the toilet…’

10 August – fourth fall

39. Mrs C had a fall on 10 August 2019. The incident report said Mrs C was ‘walking around with one eye closed and tripped over chair leg. Checked over no shortening of leg and no pain around hip area. [Mrs C] is saying back of left leg is painful.’ Mrs C was taken to hospital later where it was discovered that she had sustained a hip fracture which needed surgery.
40. Mrs B said that Mrs C’s right eye improved greatly while she was in hospital. She suspected this was because she was no longer receiving eye drops in the right eye.
41. Mrs B and her brother decided to give notice to the Home and move Mrs C to a different care home. Mrs B’s brother wrote the notice letter on 14 August 2019. The letter did not mention poor care as a reason for the notice and I asked Mrs B why that was. Mrs B said they did not want to ‘rock the boat’ until they had found a new place for Mrs C to move to. It took longer than expected to find a new care home as Mrs C’s needs had increased because of the fall.
42. The Home updated the risk assessment for Mrs C and said Mrs C now walked with a Zimmer frame and was at high risk of falls. Mrs C now needed a member of staff with her when she was mobile and constant supervision from one member of staff when she was in the lounge.
43. Mrs C returned to live at the Home, but moved to a different care home on 9 October 2019.

Mrs B’s complaint

44. Ms B complained to the Ombudsman on 11 November 2019 and said the following:
• Mrs C was in an upstairs room, but had been told she could move to a ground floor room as soon as one became available. The Home did not move Mrs C to the ground floor and this put her at risk because of the stairs.
• Mrs C had poor vision and the Home failed to provide proper care in relation to this. Mrs C ’s glasses went missing and she was sometimes given another resident’s glasses.
• The staff put Mrs C’s eye drops (for the left eye) into both eyes causing the right eye to close. Mrs B says all these factors relating to Mrs C ’s eyesight increased the risk of her falling.
• Mrs C suffered four falls during her stay at the Home. The final fall on 10 August 2019 resulted in a broken hip. The Home did not carry out the proper risk assessments or provide the necessary support and supervision to prevent the falls.
• After Mrs C returned to the Home following her discharge from hospital, she told the Home she wanted to complain about the care it provided. The Home treated her and Mrs C differently and told her Mrs C would have to move out.

The Home’s complaint response

45. As Mrs B’s complaint had not gone through the Home’s complaints procedure yet, the Ombudsman asked Mrs B to make a complaint to the Home first so that the Home could respond.
46. Mrs B contacted the Ombudsman in February 2020 as the Home had not responded to her complaint yet. The Ombudsman contacted the Home on 11 February 2020 to chase its response to Mrs B. The Home responded on 17 February 2020 and said it would respond by the next day at the latest.
47. In the following months there were further requests by the Ombudsman for the Home to respond to Mrs B’s complaint. The Home never responded to Mrs B’s complaint and the Ombudsman agreed to investigate the complaint.

The Home’s response to the Ombudsman’s enquiries

48. Once I had sent my letter of enquiries to the Home, there were then repeated failures by the Home to provide the information I asked for. This went on for many months and it was only after the Assistant Ombudsman’s involvement and threats of a witness summons that the Home finally sent me most of the documents I asked for.
49. I have not received all the documents but decided to proceed with a draft decision and base the decision on the evidence I have received.

Further evidence

50. The Home has sent me statements from staff saying they never administered the eye drops to the right eye, only the left eye. The staff said they noticed Mrs C sometimes kept her right eye closed. The staff all said that Mrs C would often lose her glasses or swap them with other residents when she was walking around.
51. The Home has sent me seven MAR charts which cover a four-week period each.
• The first chart for 20 March 2019 was handwritten and said ‘left eye’ for the three different medications.
• From 8 April 2019, the charts were typed and printed and said ‘affected eye(s)’ for two of the medications. The word ‘left’ was hand-written next to ‘affected eye(s)’ for the charts of 8 April and 3 June 2019.
• However, on the 6 May 2019 the instruction for one of the medications was ‘affected eye(s)’ and did not specify which eye.
• The chart for 1 July 2019 was missing.
• The Home sent me the chart for 29 July 2019, which was the chart Mrs B previously sent me. In Mrs B’s version, the chart said the ‘affected eye(s)’ for two of the medications and there had been no hand-written amendments to the chart. However, the Home’s version of the 29 July 2019 chart had the letter ‘L’ hand-written next to ‘affected eye’ as did the chart for 26 August 2019.
• However, on the chart for 23 September 2019, two of the medications said ‘affected eye(s)’ and did not specify the eye.
52. The Home commented on Mrs B’s complaint about the room and said that unfortunately, no ground floor room became available during Mrs C’s stay at the Home.
53. The Home said that, in relation to the last fall, that ‘another resident moved her chair and [Mrs C] caught herself on it and fell.’
54. The Home commented on its failure to respond to the complaint. The director said she asked one of the staff to respond to the complaint. The first member of staff assured her she had provided the response and left the employment of the Home. The director then found out later that the response had not been sent and asked a different member of staff to provide the response, and this member of staff also told her the reply had been sent, when it had not.
55. Mrs B said the Home never provided her with its complaints procedure.

Analysis

Medication

56. In terms of the MAR chart, even though it is the pharmacy that normally provides the MAR chart, the Home has to ensure that the MAR chart is correct and, if there is any lack of clarity, that this is resolved.
57. Therefore, there was fault in the MAR charts as three out of the seven charts that the Home has provided me with did not have the required detail setting out which eye the medication related to.

Glasses

58. In terms of Mrs C’s glasses going missing, I understand Mrs B’s frustration at this as Mrs C needed her glasses and, without them, she was at a greater risk of falling. However, I do accept that Mrs B was mobile and may sometimes leave her glasses in different places and it may take time for staff to find them. Therefore, I cannot say there was fault.

Risk of falls

59. The Home should have carried out a falls risk assessment and should have written a care plan when Mrs C moved in.
60. The Home has been unable to send me those documents. Therefore, I cannot say whether the Home properly assessed Mrs C’s risk of falls and whether the care plan properly addressed the risk of falls.
61. The only assessment the Home has sent was only six pages long, did not give Mrs C’s history of falls and did not set out how her risk of falls would be minimised.
62. The regulations stress the importance of good record keeping in care homes and therefore was fault in the Home’s failure to keep the records relating to the risk assessment and care plan when Mrs C first moved in.
63. I note the Home provided an incident report and re-assessed the risk each time there was a fall which was in line with its policy. I note the Home put in measures to mitigate the risk of future falls. I accept that Mrs C was mobile and therefore it would be difficult for the Home to have a care plan that totally eliminated the risk of falls. One of the main risks related to Mrs C’s poor eyesight which meant she could not see obstacles.
64. However, I also note the following. Mrs C’s third fall occurred in the toilet when the risk assessment plan said Mrs C should be assisted at all times when she went to the toilet. The fourth fall occurred when Mrs C tripped over a chair leg, when the risk assessment said the communal areas should be kept free of all hazards and obstacles and Mrs C should be monitored at all times. I would have expected an analysis to determine how the falls happened and whether the plan was sufficient to manage the risk.
65. The incident reports and risk assessments did not provide that analysis so it was difficult to determine whether the Home was appropriately addressing the risk.
66. I am also concerned that the Home did not alert the CQC to the fourth fall as this was the type of incident which the CQC would normally be informed of.

Response to complaint

67. The Home failed to provide Mrs B with its complaints procedure and this was fault.
68. The Home failed to provide any response to Mrs B’s complaint despite repeated requests by Mrs B and the Ombudsman to provide a response. Its failure to provide a response was fault.

Other complaints

69. I cannot really comment on the fact that Mrs C wanted another room. The Home said that no other suitable room became available during Mrs C’s stay at the Home.
70. I have also investigated Mrs B’s complaint that the treatment of Mrs C changed once the family had given notice. It would be difficult to uphold that complaint as the main evidence I have is the written evidence by the staff of the care they provided and I appreciate that it would be unlikely that they would record any negative treatment. The records that I have seen do not show any change in the care that Mrs C received after the notice had been given.

Injustice and remedy

71. I cannot say, of course, whether the fault in the MAR charts meant that Mrs C received drops in the right eye. Therefore, the injustice Mrs C suffered is that she was at risk of receiving the incorrect medication and there will always be some uncertainty whether the correct medication was provided.
72. Similarly, the failure to provide the initial falls risk assessment or care plan documents or the lack of detail in some of the documents meant that there will always be uncertainty whether the risks were properly addressed when Mrs C moved into the Home.
73. The matter was made worse by the Home’s failure to provide a response to Mrs B’s complaint as soon as possible or at all as it would have been easier to investigate the complaints soon after the events, rather than months later.
74. For complaints such as this one, where there is no direct financial loss as a result of the fault, the Ombudsman can recommend a small amount (normally between £100 to £300) which is purely symbolic to reflect the distress caused by the fault. I recommend the Home pays Mrs C £200.
75. I will also share this decision with the CQC who will be better placed to address any service improvement issues.

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Agreed action

76. The Home has agreed to take the following actions within one month of the final decision. The Home will:
• Apologise in writing to Mrs B and Mrs C for the fault.
• Pay Mrs C £200.
77. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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Final decision

78. I have completed my investigation and have found that the Home’s actions have caused an injustice. The Home has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman