Summary: Mr U complains that despite his warnings, the care provider left his wife unsupervised near to another resident. This led to his wife falling and breaking her leg. He says the care provider should pay for the cost of adaptations to their home. We uphold the complaint. But we do not agree the fault led to the direct need for the home adaptations. The care provider has agreed to our recommendations to remedy the uncertainty caused by the fault.

The complaint

1. The complainant, whom I shall refer to as Mr U, complains on behalf of his wife (Mrs U) who was a resident in a care home that at the time was run by the provider. Mr U complains:
• he had had a long meeting with a member of staff about problems with Mrs U mistaking another resident for a relative. At that meeting he warned that Mrs U needed close supervision when she was with the other resident; but
• shortly after the meeting, the care provider did not properly supervise Mrs U and the other resident. This resulted in the other resident pushing Mrs U, resulting in a fall that broke a bone in her leg. Mrs U had to go to hospital;
• there has been a permanent decline in Mrs U’s mobility.
2. As a remedy, Mr U wants the care provider to pay the £10,000 costs of a ground floor bathroom he has had to have built. This was after he decided he wanted Mrs U to return to live with him.

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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 injustice, could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused 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 made by Mr U;
• made enquiries of the care provider and considered its response;
• asked the local council for records of its safeguarding investigation;
• spoken to Mr U;
• sent my draft decision to Mr U and the care provider and considered the responses I received.

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What I found

7. Mrs U had been resident at the care home since the autumn of 2020. She is in her 80s and has a diagnosis of dementia and osteoarthritis.
8. Around a couple of months after moving to the care home, Mrs U began to mistake another resident (whom I shall refer to as Mr B) for a relative. This led to some concern about the safety of both of them (and also that of another resident). The care home referred the issue to a team at the local council.
9. The council says its team’s involvement was ‘light touch’, as the care home was managing the situation. This care provider changed Mrs U’s support plan to include instructions:
• that Mrs U and Mr B did not have meals at the same table;
• to engage Mrs U in other activities where possible;
• care staff to monitor Mrs U’s whereabouts to ensure she was not close to Mr B;

• that at least one carer needed to be present in communal areas to “monitor, identify risk, de-escalate concerns and offer support to the residents when required”.

10. Mr U and a co-ordinator at the care home had a conversation in the spring of 2021. Mr U insisted Mrs U should be kept away from Mr B. The care provider says it told Mr U that Mrs U did not need one-to-one care or supervision.
11. At the end of the spring of 2021, Mrs U was involved in an accident at the care home. This happened after breakfast. The care home’s accident report notes Mrs U was sitting in the dining area. Mr B was also there, around two metres from Mrs U. A carer was in the dining room washing dishes, with her back to the room. She said she heard a noise “which sounded like slapping”. The carer found Mrs U lying on the floor. She at first presumed Mr B had pushed Mrs U. But she later clarified that she did not see this. Mrs U was taken to hospital in an ambulance. An x-ray confirmed Mrs U had broken her hip.
12. The care home reported the incident to the council’s safeguarding team. It opened a file but asked the care provider to lead the investigation. Its conclusions were that a finding of neglect was unsubstantiated. The council agreed and closed its investigation.
13. As an outcome of the investigation, the then care provider produced a ‘lessons learned’ document. This appears to be an internal document. It noted its analysis had found:

“The carer who was in the dining area had to monitor, identify risk, de-escalate concerns and offer support to the residents when required. In addition, the carer was responsible for serving breakfast to the residents; washing up; cleaning the coffee machine; cleaning and stocking up the hydration station; preparing the nutritional supplements by manually shaking them; cleaning the bain marie, microwave and toaster; taking and documenting fridge and dishwasher temperatures; cleaning the dining area after breakfast; sweeping the floor; cleaning the tables and the chairs; serving snacks and milkshakes at 10:30 and preparing the dining room for lunch (laying the tables and placing the menu into the separate menu folders).

[Mrs U] was independently mobile and managed to find her way towards [Mr B] while the carer working in the dining area was busy.”

14. After Mrs U’s stay in hospital, Mr U moved her to a new care home. He also decided that he would like Mrs U to return to live with him. He says the fall has permanently affected her mobility. He says this has meant he has had to spend £10,000 on a ground floor bathroom.

Analysis

15. The care home had identified the risk to both Mrs U and Mr B of them being left unsupervised together. Mrs U’s revised support plan reflects this; introduced well before the incident that Mr U complains about. I am unclear of the layout of the care home’s dining room and whether the area where the carer was washing up was in the same space as the dining room. But that detail is not decisive. That is because the carer did not witness the incident until she heard a sound, by which time Mrs U had fallen. That means the carer cannot have been checking Mrs U and identifying risk. That put Mrs U at risk. So I uphold the complaint.
16. Turning to the injustice: Mr U reports the fall has affected Mrs U’s mobility. He draws a conclusion that this is the care home’s fault. Also, he says he has had to spend a considerable amount of money on a bathroom because of what happened.
17. I am sorry to hear of Mrs U’s reduced mobility. I accept, more likely than not, that the fall had an effect. But a remedy for personal injury is a matter for the courts, not the Ombudsman.
18. I cannot decide what would have happened if the carer had not been washing up. The monitoring would always have been carried out by a carer performing more tasks than just watching over Mrs U – her needs were not for one-to-one supervision. And we do not know how and why Mrs U fell (although more likely than not it was the result of an interaction between Mrs U and Mr B). But there remains a possibility, even without fault, that a carer might not have been able to reach Mrs U before she went to Mr B.
19. But the uncertainty about whether things might have been different if the care provider had not put Mrs U at risk of harm is an injustice that demands a remedy.
20. Mr U says the care provider should pay for the costs of the bathroom he has installed at the family home. I do not agree this cost directly flows from the fault I have identified. Other care choices were available to Mr U.

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Recommended action

21. I recommended, that within a month of my final decision, the care provider pay Mr and Mrs U £1000 as a recognition that its inadequate monitoring put Mrs U at risk of harm, leading to an uncertainty about whether things might have been different, but for the fault.
22. The care provider has agreed to this recommendation.

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Final decision

23. I uphold this complaint. The care provider has agreed to my recommendations. So I have ended my investigation.

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Investigator's decision on behalf of the Ombudsman