Summary: Ms C complains the Care Provider failed to act properly after her mother, Mrs D had a fall which caused a decline in her health. The Care Provider is at fault for failing to properly record interventions, complete risk assessments, obtain medical help, and consider Mrs D’s communication needs. This delayed Mrs D receiving medical help and treatment. To remedy the complaint the Care Provider has agreed to apologise to Ms C, make her a symbolic payment, and remind care staff about the need to properly record and analyse interventions.

The complaint

1. Ms C complains about services provided to her late mother, who I call Mrs D. Ms C complains Richmond Villages Operations Limited, the Care Provider, failed to adequately support Mrs D after she had a fall.
2. Ms C says this resulted in a decline in Mrs D’s health and a prolonged period where she was in pain. Ms C also complains the Care Provider failed to respond to her complaint properly. Ms C says she has had the distress the Care Provider did not act as it should have, and left Mrs D in pain.

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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 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 a significant injustice or that could cause injustice to others in the future, we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
4. 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.

(Local Government Act 1974, section 26A(2), 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)

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How I considered this complaint

6. I spoke with Ms C and made enquiries of the Care Provider. This included asking for documents and specific questions about its actions. I considered:-
• Care Provider’s response,
• Care Provider’s falls, complaint, and incident policies and procedures;
• Mrs D’s care records;
• 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. I have used the fundamental standards as a benchmark for considering this complaint.
7. Ms C and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Background information

8. Mrs D lived at the residential care home for several years. Mrs D had dementia and could not use words to say how she was feeling. Mrs D was visited several times a week by her daughter, Ms C.

What should have happened

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
10. Regulation 9 “Person Centred Care” says care providers should enable and support relevant people to make or participate in making, decisions relating to the service user's care or treatment to the maximum extent possible…”.
11. Regulation 12 “Safe care and treatment” says care providers must assess risks to people's health and safety during any care and make sure that staff have the qualifications, competence, skills and experience to keep people safe.
12. Regulation 16 says care providers must make sure that people can make a complaint about their care and treatment. All complaints must be investigated thoroughly and any necessary action taken where failures have been identified.
13. Regulation 17 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.”

What happened

14. On 22 January 2023 around 9pm Mrs D had an unwitnessed fall in a corridor. A carer who heard Mrs D call out for help records she checked Mrs D straight away, “no injury, got up, and walking fine. Has a red mark top of her right shoulder. Will monitor overnight….had a fall requires monitoring for injury”.
15. Mrs D slept through the night and carers checked her at hourly intervals. The next morning staff noticed Mrs D had a skin tear on her right elbow and a swollen right wrist. Care staff contacted Ms C to tell her about the fall and Mrs D’s injuries.
16. Care staff described Mrs D as agitated and in pain. Care staff called 111 and later in the day at 8pm called both the GP and 111 explaining that although staff had given Mrs D paracetamol she was still in pain. Ms C says care staff made this call after her insistence.
17. It appears at this point Mrs D needed hospital attention. The Care Provider says there was an ambulance strike and they had both cars and drivers on standby for emergencies. In the Care Provider’s complaint responses to Ms C it provides two accounts about why it could not access transport. The first is care staff on duty did not know there were bank standby drivers as part of the contingency plan, and the second is while there were cars available there were no drivers.
18. The carer discussed potential difficulties in transporting Mrs D with Ms C. This included that Mrs D had not left the care home for over three years and whether Mrs D would get into a car. A decision was made to wait until the next day.
19. On 24 January Mrs D went to hospital and an x-ray found she had two broken bones in her forearm. The hospital put on a temporary plaster and made a follow up appointment for a full plaster. Over the next few days the records say Mrs D had difficulty walking even a few steps to the bathroom.
20. On 29 January Mrs D’s care records describe her as in pain when standing. The Care Provider called 999 and an ambulance crew visited but said there was nothing they could see of concern. Ms C says ambulance staff were unable to examine Mrs D because she was too distressed. The next day the Care Provider spoke with the GP. Ms C says she visited later in the day and was shocked to see her mother unable to walk and soiled. Ms C says she told the Care Provider to call an ambulance. Mrs D went into hospital and when x-rayed had a broken hip. Ms C says she told the Care Provider several times that her mother seemed in pain and could not walk and needed additional pain relief. Ms C says care staff were aware of Mrs D’s difficulties but thought she had lost her confidence in walking because of her fall, not a physical problem with walking.
21. Ms C complained to the Care Provider about several issues. The Care Provider sent a first response in February. It:
• apologised for failing to call Ms C as soon as the fall occurred and agreed to future contact arrangements. Appointed a new contact person following concerns about how a member of staff had spoken to Ms C;
• told Ms C that Mrs D walked back to her room without difficulty or distress;
• addressed issues about contractors in the care home, accessibility to the Head of Care, a resident going into Mrs D’s room and issues with sensor matt equipment;
• the Care Provider accepted it had not made the situation about the emergency drivers clear with Ms C and this may have affected her decision making;
• recognised that although carers gave Mrs D paracetamol following a GP prescription it could have given Mrs D extra pain relief medication over a three day period;
• accepted it failed to contact safeguarding because of the unwitnessed fall.
22. Ms C responded to the Care Provider and received a further response. It said:-
• on the day of the fall Mrs D’s notes confirm “that after being helped with walking, staff then transferred your mother to a wheelchair to escort her back to her room”;
• on 23 January there were no available drivers to take Mrs D to the hospital;
• there were no signs Mrs D was in pain or discomfort with her hip until 30 January. It acknowledged the concerns Ms C raised on 28 January about Mrs D’s discomfort but said she settled after receiving pain relief and there was no reason to take any further action at the time. The Care Provider said although it had acted properly it would arrange staff training in fall management.
23. Mrs D returned to the care home on discharge from hospital. Ms C says she never fully recovered and after a further hospital admission died a few weeks later in a different care home. Ms C complains the Care Provider’s omissions left Mrs D in needless pain and caused a decline in her health.

Was there fault/service failure which has caused injustice?

24. The Care Provider’s daily care records lack detail and are incomplete. There are few records of discussions with Ms C some of which the Care Provider later relies on. There are also conflicting accounts about what happened and incomplete records about changes in medication. The failure to properly record is fault and a potential breach of Regulation 17.
25. Because of these faults Ms C has the uncertainty the Care Provider did not properly record observations about Mrs D. She also has the uncertainty about not knowing what actions care staff took when Mrs D fell, did she walk to her room or was a wheelchair used for part of the return?
26. I also consider there was a potential breach of Regulation 12 “Safe Care and Treatment”. This is because the Care Provider failed to:
• complete an incident report and body map for the fall on 22 January which would have identified what happened, what steps the Care Provider was going to take and follow up actions;
• have an operable contingency plan, either by staff awareness of the plan or driver availability for the ambulance strike;
• update risk assessments and Mrs D’s care plan for her mobility;
• record and act on changes in medication for Mrs D’s pain relief.
27. Ms C says care staff should have noticed the skin tear on examination of Mrs D on 22 January. As explained above the Care Provider did not complete a body map and the record of the incident is minimal. While I cannot say the Care Provider should have noticed the skin tear Ms C has the uncertainty the Care Provider did not do a thorough examination of Mrs D.
28. I am unable to make a balance of probability decision about whether Mrs D would have gone to hospital on 23 January. This is because I do not know whether Ms C would have agreed to Mrs D going to hospital if a driver and wheelchair accessible transport was available; or whether Mrs D would have agreed to go. Ms C does however have the uncertainty that but for the faults identified Mrs D would have accessed medical care for her arm earlier.
29. I consider the Care Provider failed to act in a person centred way. Mrs D had dementia and could not tell care staff when and where she was in pain. Care staff therefore relied on Mrs D’s physical acts such as refusal or on occasion aggression to understand how Mrs D was feeling. I consider the Care Provider failed to explore other means to communicate with Mrs D after she fell and was reluctant to walk. Ms C raised concerns and while the Care Provider gave an explanation it did not follow up Ms C’s concerns.
30. There was a change in Mrs D’s behaviour which the Care Provider did not fully explore or monitor. It was not until Mrs D was no longer able to stand that the Care Provider acted. I consider this is a potential breach of Regulations 9 and 12.
31. I therefore consider had the Care Provider acted in a more person centred way and properly considered Mrs D’s reluctance to walk it is more likely than not Mrs D would have received medical attention earlier.
32. Similarly the Care Provider failed to follow up Ms C’s concerns that Mrs D needed additional pain relief. The Care Provider in its complaint response accepted this failure. The Care Provider should have taken this action without the need for Ms C’s intervention and again failed to properly recognise, assess, and take action, when it was aware Mrs D was in pain. This left Mrs D in pain for longer than necessary and caused distress to Ms C who could see her mother was suffering.
33. Mrs D was a vulnerable person and but for the faults I have identified I consider she would have received medication and medical help earlier. I cannot however say it caused a general decline in her health or contributed to her death. This would be a matter for a court.
34. The Care Provider’s response to Ms C’s complaint was comprehensive. It responded to concerns raised, provided remedial action, and considered other action it could take to improve practice. This is in line with Regulation 16 above. However, the Care Provider relied on a mixture of carer statements and records to respond to the complaint. This led to some inconsistent messages to Ms C and caused her frustration and left her questioning the Care Provider’s account.

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Agreed action

35. I have found fault in the actions of the Care Provider which has caused Mrs D and Ms C injustice. As Mrs D has now died, I cannot remedy her personal injustice. The recommendations below are therefore to remedy Ms C’s injustice and to improve future practice. The Care Provider has agreed the following actions.
36. Within one month of the final decision the Care Provider will:-
1. apologise to Ms C for failing to get medical attention and pain relief for Mrs D earlier; and for the uncertainty caused by the failure to complete proper records, monitor Mrs D properly after her fall and act on concerns;
2. pay Ms C £200 a symbolic payment for the time, trouble, uncertainty and distress the Care Provider’s actions caused her.
37. Within three months of the final decision the Care Provider will:-
1. remind, either through team meetings or a staff circular, and if necessary, provide staff training about:
1. the importance of recording clear contemporaneous records;
2. the need to complete incident/accident reporting forms and body maps;
3. updating risk assessments and care plans following falls;
4. when to make notifications to CQC and Safeguarding teams.
2. provide evidence of the falls training the Care Provider agreed to provide to all staff in the complaint response;
3. have a process which ensures that where necessary there are written contingency plans which are circulated and understood by staff members;
38. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

39. I consider there was service failure by the Care Provider which has caused Ms C and Mrs D injustice. I consider the agreed actions above are suitable to remedy the complaint. I have completed my investigation and closed the complaint on the basis of the agreed action.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman