Summary: Mrs X complained about the care her late father received at Harewood Court when he fell and injured himself. Mr Y did not recover fully from his injuries and died soon after. Mrs X says this caused her and the family distress and she feels guilt for placing him there. We found fault in some aspects of Mrs X’s complaint, some of which has already been adequately addressed by a safeguarding enquiry. We recommended the Council apologise to Mrs X, pay her £300 for the distress it caused, and take action to prevent similar faults in future. It has agreed to do this.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complained on behalf of her late father, Mr Y. She says the care provider commissioned by the Council did not seek medical assistance when Mr Y fell causing him serious injury.
2. Mrs X says this led to Mr Y’s death and caused her and the family distress. She would like the Care Provider to accept responsibility.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), 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. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

7. (Local Government Act 1974, section 26A(2), as amended). We consider Mrs X to be suitable to complain on Mr Y’s behalf.
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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How I considered this complaint

9. I considered information from the Complainant and from the Council.
10. I sent both parties a copy of my draft decision for comment and took account of the comments I received in response.

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What I found

What should happen

Fundamental Standards of Care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.

The Care Quality Commission

12. The Care Quality Commission (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.
13. Regulation 9 is about person centred care. The guidance says “Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be.”.
14. Regulation 12 is about safe care and treatment. The guidance says:
• “Incidents that affect the health, safety and welfare of people using services must be reported internally and to relevant external authorities/bodies. They must be reviewed and thoroughly investigated by competent staff, and monitored to make sure that action is taken to remedy the situation, prevent further occurrences and make sure that improvements are made as a result. Staff who were involved in incidents should receive information about them and this should be shared with others to promote learning. Incidents include those that have potential for harm”.
• “The provider must actively work with others, both internally and externally, to make sure that care and treatment remains safe for people using services.”.
15. Regulation 13 is about person centred care. The guidance says “Providers must make sure they implement, robust procedures and processes that make sure people are protected.”.
16. Regulation 17 is about good governance. 17(2)(c) says care providers should “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.

Safeguarding

17. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse (section 42, Care Act 2014).

What happened

18. Mr Y was discharged from hospital to Harewood Court in late August 2021 with a life limiting health condition. Harewood Court (the Care Provider) was commissioned by the Council. Mr Y had various health conditions and limited mobility and communication. The discharge advice note referred to longstanding confusion and a referral to the memory clinic. The note also mentioned that Mr Y needed follow up appointments for treatment of another condition.
19. The Care Provider assessed Mr Y’s risk of falls as high and set his bed at its lowest point. It also provided a sensor mat and crash mat to reduce the impact should he fall. It noted that he was “very unsteady” and could walk with a frame and help from two care workers. This was likely to be an appropriate way to manage the risk of falls to Mr Y. Four days later the Care Provider decided his presentation suggested he could have dementia and moved him to its dementia unit.
20. Nine days after arriving at the home, Mr Y fell. Staff, alerted by the sensor, found him on the crash mat. The records state that the senior nurse on duty checked Mr Y and found no apparent injury or indication of pain. He was still able to move his limbs and to communicate that he was not in pain. The Care Provider’s records note that Mr Y continued to behave as normal during the day, including mobilising with his frame. He showed no sign of injury. There is no record that staff monitored Mr Y more frequently following his fall or completed a fresh risk assessment or reviewed his care plan, which was required. This was fault.
21. The following day, during personal care, staff noticed that Mr Y’s knee and thigh was swollen and at 09:48hrs called 999. The operator asked the address of the “emergency” and how the fall had happened. The member of staff gave the address and said “he was just trying to get up. This gentleman thinks he can still mobilise. He can’t”. The operator said: “can’t just strap them in can’t you?”. The member of staff said “no” and continued answering the operator’s questions. They said Mr Y was complaining of pain in his knee and had contractures in his legs so couldn’t completely straighten them when they assessed him after the fall. They also said Mr Y had knobbly knees anyway so they didn’t know whether something was protruding more than usual. The operative noted this and said they were “incredibly busy” and that a paramedic or nurse would call back in about two hours.
22. The Care Provider monitored Mr Y and said he remained stable. The ambulance service did not call back and later confirmed it had raised the priority so Mr Y would be seen sooner, so it had not felt it needed a call back. It says it sent an ambulance at the earliest opportunity. However, due to heavy demand it took longer than expected and arrived at 13:34hrs. This was just over four hours after the 999 call.
23. Mrs X later listened to a recording of the Care Provider’s call to the ambulance service. She complained about it because she believed staff had not made it clear this was an emergency and was upset that they did not phone again to chase. She was also upset by the comment “can’t just strap them in”. The delay was not the Care Provider’s fault. The call was to 999 which is for emergency services only. There was no reason for the Care Provider to state this was an emergency. The operator asked what the address of the emergency was at the start of the call so it was clear they knew this. It was the operator who made the comment “can’t just strap them in” and this was not the responsibility of the Care Provider. I found no problem with the call to 999. The Care Provider said the ambulance service would usually call back just to check whether anything had changed. Since nothing had changed the Care Provider did not feel the need to chase for a call.
24. The ambulance crew spoke to staff at the home about what had happened. Staff gave the crew Mr Y’s ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) form which said he should be resuscitated if needed. However, staff also gave the crew Mr Y’s MAR (medication administration record) sheet which noted that Mr Y should not be resuscitated. Later, the crew raised a safeguarding concern because of the conflicting records and because of the delay in seeking medical assistance after the fall. The concern raised said Mr Y could not weight bear after the fall and had been hoisted back to bed. The Council began a safeguarding enquiry into the concerns.
25. The day after Mr Y went to hospital, the Council called the Care Provider about the safeguarding concerns that the ambulance service had raised. The Care Provider explained the details were wrong and the ambulance crew had misunderstood. Mr Y had been behaving as usual following his fall and had walked several times using his frame.
26. Mrs X also complained that the home had not followed up on Mr Y’s health appointments and this had contributed to an increased impact on Mr Y. This was because he had not received the treatments which he needed. The safeguarding enquiry found the Care Provider should have followed up on this.
27. Two days after he was admitted to hospital, Mr Y had surgery. The surgeon advised that this was to relieve his pain and that it was unlikely Mr Y would walk again. Mr Y sadly died just over two months later. Mrs X says he could have lived longer without the fall and the Care Provider’s delayed response.
28. The Care Provider’s records of a discussion with Mrs X, after Mr Y was admitted to hospital, note it said Mr Y’s confusion could have been related to dementia. The note continues “as there was a definite capacity issue as well as a language barrier and that with Dementia pain receptors can be blocked.”. This was by way of explanation around how Mr Y’s injury was not apparent on the day of the fall.
29. The Care Provider’s records that I saw were not all dated or complete. This was fault and a potential breach of regulation 17. This increased the risk of harm to Mr Y.
30. There is no evidence to suggest staff should have called the emergency services sooner. If Mr Y’s injury were apparent at the time of the fall, this would mean several staff including a qualified nurse, being complicit in hiding this and deciding not to act. In addition, they would then have each given false evidence. On the balance of probability, this is highly unlikely. There is also no reason to question the professional judgement of the nurse when they assessed the injury. The nurse was senior and experienced and checking for injury would be something done regularly in a care home. Mrs X is concerned that the consultant who dealt with Mr Y at the hospital said Mr Y would not have been able to walk with the injury. However, the consultant was not present at the time of the fall or while he was in the home after that. They cannot know what injury he sustained at that time. It may be that walking when injured caused a more severe injury, but we cannot be sure the injury existed at the time of the fall, or that the outcome for Mr Y would have been different had he been taken to hospital sooner. This was not the fault of the Care Provider. However, we can say that if Mr Y had been monitored frequently following his fall, action could have been taken at the earliest possible opportunity. This was fault and was addressed by the safeguarding enquiry. It caused Mrs X uncertainty about what might have happened. Sadly, we cannot now put right any injustice to Mr Y.
31. Both the Care Provider and the Council could have dealt with the complaint better. This was also fault and caused Mrs Y undue anxiety. The safeguarding enquiry found that the home should not have completed the investigation report on itself. Additionally, the report was not adequate and the Care Provider’s response to Mrs X was not helpful and inflamed matters. There was also delay by the Council during the safeguarding process. The enquiry made several recommendations which included:
• Clinical risk assessments to be completed for residents at high risk of falls and residents to be continuously assessed following admission. Risk assessments to be updated with any changes.
• Falls checklist to be completed following a fall and 24 hour observations completed.
• ReSPECT forms to be checked on admission and information sent to GP for updating.
• Information on MAR sheets to be accurate and clear.
• Learning from this to be shared with staff team via team meetings.
• Care Provider to follow up with residents’ health appointments.
32. The Council completed contract monitoring visits in January and June 2022. Its findings included shortfalls in the documentation. It put in place a further action plan which was suitable action to take.
33. The safeguarding enquiry, though delayed in places, considered the matters adequately and I have therefore not reinvestigated those issues and have not recommended actions where actions have already been put in place.

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Recommended action

34. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Care Provider, I have made recommendations to the Council.
35. To remedy the injustice identified above, I recommend the Council, within two months of my final decision:
• Apologise to Mrs X, acknowledging the faults identified above and the actions it has taken or will take to prevent similar faults occurring in future.
• Pay Mrs X £300 in recognition of the distress caused to her by these events.
• Review the safeguarding process to ensure that delays such as in this case are avoided in future.
• Ensure the Care Quality Commission has been alerted to the Care Provider’s failings in this case.
• Confirm that the actions identified by the safeguarding enquiry and monitoring have been completed.
36. The Council should provide us with evidence it has complied with the above actions.

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Final decision

37. I have completed my investigation. When the Council completes the recommended actions, it will remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman