Summary: Mrs X complained the Care Provider, Chimnies Residential Care home did not provide adequate care which led to her mother Mrs Y falling from her bed. Mrs X further complained the Care Provider did not act quickly enough after Mrs Y’s fall. She said this matter accelerated Mrs Y’s physical problems and caused her distress. There was no fault in the Care Provider’s management of Mrs Y’s care or in its response to her fall. There was fault in the Care Provider’s complaint management which caused Mrs X an injustice. To remedy this, the Care Provider should provide Mrs X with a written apology for the injustice caused by its complaint handling and provide evidence showing it has reminded its staff of the importance of responding to complaints in a fair and transparent manner.

The complaint

1. Mrs X complained the Care Provider failed to adequately safeguard her mother Mrs Y and this caused her to suffer a fall and fracture her hip whilst under its care.
2. Mrs X also complained the Care Provider did not act quickly enough to address Mrs Y’s fall.
3. She said the fall caused Mrs Y to deteriorate quickly and caused her and her family distress.

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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 an injustice, 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(i), as amended)
6. 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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How I considered this complaint

7. I spoke to Mrs X and discussed her view of the complaint.
8. I read the Care Quality Commissions 18 November 2021 inspection report.
9. I made enquiries of the Care Provider and considered the information it provided. This included, Mrs Y’s Care Plan, assessment of capability, accident record and day and night report.
10. I wrote to the Care Provider and Mrs X with the draft decision and considered the comments I received before I wrote the final decision.

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What I found

Law

The Care Quality Commission (CQC) is the statutory regulator of care services and has issued guidance on how to meet the fundamental standards below which care must never fall. 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.

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out the standards registered care providers must achieve when providing care services.
12. Regulation 9 requires care providers to make sure that each service user receives appropriate person-centred care and treatment that is based on an assessment of their needs and preferences. Care providers must work in partnership with the service user, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves.
13. Regulation 12 aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Care providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks.
14. Regulation 17 requires care providers to maintain accurate, complete, and detailed records in respect of each person using the service.
15. Regulation 20 states care providers must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying out a regulated activity.

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What happened

Background

16. Mrs X’s mother Mrs Y is elderly and suffers with dementia and hip problems.
17. Mrs Y went to live at the Care Provider’s care home in April 2021, after she fell over at home.
18. Mrs Y’s Care Plan stated that she:
• was a potential risk for falls;
• needed a zimmer frame to get around;
• could use the toilet at night independently but could press a nurse call button for assistance; and
• required day and night supervision.
19. On 13 October 2021, a GP examined Mrs Y and saw that her right hip was in poor condition. The GP told Mrs Y to consider having a hip replacement.

Mrs X’s complaint

20. On 6 December 2021, Mrs Y suffered an unwitnessed fall in her room. At the time Mrs Y had been assessed as a low fall risk. Carers found Mrs Y and recorded the following, “Mrs Y rolled out of bed and hit the floor...pain in right knee travelling to thigh on standing…couldn’t walk although she could stand when asked by nurse from 111…no bruising apparent or open wounds. ”
21. The Care Provider contacted Mrs X and explained what happened. Mrs X says she asked the carer how the fall happened, but the carer was evasive. The Care Provider says Mrs Y slept in a bed without rails because she needed to move around freely. The notes recorded at the time state the carer informed Mrs X there had been a low-level emergency and an ambulance was expected to arrive to take Mrs Y to hospital.
22. The Care Provider consulted 111, who assessed Mrs Y’s condition and found she was able to stand and walk several steps with a frame. 111 assessed Mrs Y as a low-level emergency and arranged an ambulance for her. A GP also called and spoke to Mrs Y. The GP agreed the situation with 111’s assessment and told the carers to give Mrs Y some paracetamol.
23. Paramedics arrived the following morning and after assessing her they called for an ambulance to take her to hospital. The paramedics told the Care Provider to call 999 if her condition worsened. Mrs Y was admitted to hospital later that afternoon.
24. Mrs X complained to the Care Provider on 8 December 2021. Mrs X said Mrs Y had broken her hip during the fall and needed an operation. She said several carers had contacted her about Mrs Y’s condition and were unclear and contradictory as to what was wrong with Mrs X and whether she was in pain. Mrs X questioned why the staff present did not call 999 immediately. She concluded the letter asking the Care Provider to send her written records of the incident.
25. The Care Provider responded the next day with its account of what had happened. The Care Provider denied giving Mrs X contradictory accounts of Mrs Y’s fall and said Mrs Y had asked for a bed without rails because she wanted to use the toilet freely. The Care Provider told Mrs X it would be inappropriate to place rails on the bed against Mrs Y’s wishes. The Care Provider told Mrs X it could not influence how quickly the ambulance arrived.
26. Mrs X brought the complaint to the Ombudsman as she was unhappy with the Care Provider’s response and actions.
27. In response to our enquiries the Care Provider confirmed it carried out monthly risk assessments for Mrs Y between May 2021 and January 2022 and she remained a low risk throughout this time. The Care Provider also provided a log of visits made to Mrs Y on the night of her fall, showing she had been supervised on an almost hourly basis.

Findings

28. The crux of this complaint is Mrs X’s belief the Care Provider did not do enough to prevent Mrs Y from falling. The Care Provider is required by law to provide person centred care which is appropriate to the service user. Mrs Y’s care plan states she required daily and nightly supervision. I have reviewed the records supplied by the Care Provider and the evidence shows the carers made regular visits to Mrs Y’s room on the day and night of her fall. There is no requirement in Mrs Y’s care plan to have rails affixed to her bed and it states Mrs Y was able to visit the toilet independently. I can appreciate Mrs X’s concern, but I there is no evidence of fault by the Care Provider regarding this part of the complaint.
29. Mrs X also complained the Care Provider failed to act quickly enough after Mrs Y’s fall. The Care Provider had a duty to seek suitable medical assistance for Mrs Y in a timely manner. I have reviewed the records and I see the Care Provider sought medical help for Mrs Y shortly after discovering her in her room. Both 111 and the GP that spoke to Mrs Y advised that the situation was a low-level emergency and the Care Provider acted on this advice. The paramedics who attended to Mrs Y the following morning decided an ambulance was necessary and instructed the Care Provider to contact 999 if Mrs Y’s condition deteriorated. I would expect the Care Provider to follow the advice given by medical professionals and the evidence shows it did this. There is no fault in the way it managed this situation.
30. When Mrs X complained to the Care Provider, she asked a series of specific questions and asked the Care Provider to send her the records taken at the time the incident occurred. The Care Provider is required to interact with service users and relevant persons in a transparent way. Whilst the evidence shows the Care Provider provided a full and thorough summary of the events which occurred on the night of the incident, I cannot see that the Care Provider supplied Mrs X with the records she requested or explained to her why it could not provide these records. This is fault. I can imagine this caused Mrs X to feel uncertainty about the way her mother had been treated and contributed to the breakdown in communication between Mrs X and the Care Provider. Had the Care Provider supplied this information, Mrs X may not have felt the need to refer the matter to the Ombudsman.

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Agreed Action

31. Within one month of the date of the final decision, the Care Provider should provide Mrs X with a written apology for the injustice caused by its complaint handling.
32. Within three months of the date of the final decision, the Care Provider should provide evidence showing it has reminded its staff of the importance of responding to complaints in a fair and transparent manner.

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Final decision

33. There was no fault in the Care Provider’s management of Mrs Y’s fall however there was fault in the Care Provider’s response to Mrs Y’s complaint. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman