Summary: Mrs X complains Somerleigh Court failed to protect her father from harm, resulting in him incurring an injury to his thumb. Based on the evidence seen so far, Somerleigh Court was at fault over the fact her father had a glass in his room, which he injured himself on. It needs to apologise and pay financial redress for the distress caused to him.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains Somerleigh Court failed to protect her father from harm, resulting in him incurring an injury to his thumb

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The Ombudsman’s role and powers

2. 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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)

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How I considered this complaint

3. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents Somerleigh Court has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Mrs X and the care provider, and taken account of the comments received.

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What I found

Key facts

4. Mrs X’s father, Mr Y, went to live at Somerleigh Court in September 2021. He lived on the top-floor, which is for people with dementia.
5. On 28 January 2022 Mr Y got up around 08.22 and accepted help with personal care. He spent the day in the lounge and conversed with another resident. Staff helped him to bed around 18.26. Staff had further contact with him at 19.33, 20.15, 20.59 and 21.04, when they made him comfortable in bed after his buzzer went off. He appears to have remained awake, as during this time staff helped him to the toilet and provided him with drinks and a snack.
6. Around 23.20 a member of staff found Mr Y standing by his bedroom door with a 2 ½ centimetre cut in his left thumb, which was bleeding profusely. A nurse contacted a local triage service, which passed the call on to NHS 111. NHS 111 said it would inform a clinician as soon as possible. The nurse dressed the wound.
7. Staff took Mr Y to the lounge where they checked on him regularly and gave him drinks and a snack.
8. The nurse called NHS 111 around 02.26 on 29 January, having changed the dressing three times as it continued to bleed. A doctor called around 03.14. As no one was available to visit to treat the wound, the doctor arranged for an ambulance to take Mr Y to hospital. This happened around 05.50.
9. Staff searched Mr Y’s room and found a “glass with water” behind a coffee table. The glass had sharp edges. Staff disposed of it without taking a photograph.
10. A doctor from the hospital called and asked how Mr Y had sustained the injury. Somerleigh Court said no one witnessed the incident and Mr Y could not say because of his dementia. It told the hospital about the broken glass when one a hospital nurse called about 30 minutes later.
11. Mrs X told Somerleigh Court the glass should not have been in Mr Y’s room.
12. The hospital kept Mr Y in overnight so he could have surgery the next morning to make sure there was no glass left in the wound. After having the wound stitched, Mr Y returned to Somerleigh Court around 17.45 on 30 January.
13. Mrs X says a member of staff told her sister her father was taken to the ground floor for drinks on the evening he injured himself and a broken glass had been found in his room which looked like a sherry glass. However, there is no other evidence to suggest Mr Y spent time on the ground floor where he may have been given or picked up a glass.
14. On 31 January Somerleigh Court reported the injury to the Care Quality Commission. It says it also reported it to Dorset Council’s Safeguarding Team, but has no formal record of this.
15. Mrs X complained to Somerleigh Court about the incident.
16. Mr Y moved to a care home closer to where Mrs X lives
17. When Somerleigh Court replied to Mrs X’s complaint in March, it said:
• it assumed someone had given Mr X a glass with his jug of water;
• it did not know how this happened or who gave him the glass;
• its policy was for residents on the top floor to have non-breakable glasses;
• it had reminded staff not to take glassware to the top-floor;
• it would raise this at staff meetings;
• it was planning to develop posters to remind staff of its policy of only taking non-breakable glassware and crockery to the top-floor;
• any non-plastic items found on the top-floor would be returned to the kitchen, an incident form would be completed and an investigation completed within 24 hours.
18. Mrs X was not happy with its response, so she complained to the Care Provider which runs Somerleigh Court.
19. When Care Provider replied, it said:
• it was unclear how a glass came to be on the top floor and whether a visitor or a member of staff brought it on to the floor;
• it was unclear how Mr Y came to be in possession of the glass or how it came to be broken;
• the housekeeper did not see the glass in Mr Y’s room when cleaning it on the morning of the incident;
• the day after the incident the housekeeper checked the room for small pieces of glass and found none;
• the room was deep cleaned before Mr Y returned from hospital;
• without conclusive evidence, it could only assume Mr Y injured his thumb on the broken glass; and
• having reviewed the photographs of the injury, it was possible Mr Y injured himself in another way as in its view the injury was “not necessarily consistent with being cut by glass”.

Did the care provider’s actions cause injustice?

20. There is no dispute over the fact there should not have been a glass in Mr Y’s room. It appears he had been drinking out of the glass, as it still had water in it when found. It is not clear how long it had been there. However, it appears to have been there for over five hours, as Mr Y had been in bed for that length of time when he injured himself. The housekeeper had not noticed it in the morning of the incident. However, staff will have provided him with a fresh drinking vessel for water each day. During the time it was in his room, someone should have noticed Mr Y was using a glass, rather than a plastic cup, and removed it. He did not have any visitors on 28 January, although there were other visitors to his floor that day. On the balance of probabilities, it seems likely there was fault by Somerleigh Court over the fact Mr Y had a glass in his room which staff either gave to him or at least failed to remove. While this was no doubt an oversight, it still reflects fault by Somerleigh Court.
21. When Somerleigh Court first replied to Mrs X’s complaint, it accepted someone must have given him the glass with his jug of water. The most likely person to have done this was a member of staff.
22. After staff found the broken glass in his room, Somerleigh Court accepted that was what Mr Y must have cut his thumb on. This resulted in the hospital operating on his thumb to ensure there was no glass left in the wound before stitching it. When it responded to Mrs X’s complaint, the Care Provider suggested there may have been another cause for the injury as it was not consistent with being cut by glass. But that was not a medical opinion and no alternative explanation for the injury has been provided.
23. If Somerleigh Court had ensured Mr Y did not have a glass in his room, in line with its policy, he would not have injured himself. This was a distressing experience for Mr Y, which is an injustice which requires a remedy.

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Recommended action

24. I recommend Somerleigh Court within four weeks, writes to Mrs X apologising for the avoidable distress caused to Mr Y and pays him £500. Somerleigh Court has agreed to do this.
25. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of my final decision statement.

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Final decision

26. I have completed my investigation on the basis Somerleigh Court’s actions have caused injustice which requires a remedy.

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Investigator's decision on behalf of the Ombudsman