Summary: Mr Y says the care provider failed to ensure a sensor mat was in place, failed to explain why the mat had been removed, failed to provide adequate care to Mrs X and failed to manage her medication properly. There is no evidence the care provider removed the sensor mat but it delayed considering whether to put one in place. The care provider failed to supervise provision of medication to Mrs X properly on occasion and failed to consistently apply eardrops. An apology, payment to Mr Y and training for care staff is satisfactory remedy.

The complaint

1. The complainant, whom I shall refer to as Mrs X, is represented by her grandson, whom I shall refer to as Mr Y. Mr Y complained the care provider:
• failed to ensure a sensor mat was in place when Mrs X had a high risk of falls;
• failed to explain why it had removed the sensor mat;
• failed to recognise Mrs X had advanced Alzheimer’s and therefore could not make her own decisions, which resulted in provision of poor care;
• failed to consistently apply eardrops;
• failed to refer Mrs X for a review of her medication when her behaviour altered; and
• delayed identifying the need to turn the bed sides round to provide padding to prevent Mrs X hurting her arms.
2. Mr Y says the care provider’s actions meant Mrs X had a terrible end to her life which was preventable.

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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. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
6. 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).
7. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

9. As part of the investigation, I have:
• considered the complaint and Mr Y's comments;
• made enquiries of the care provider and considered the comments and documents the care provider provided.
10. Mr Y and the organisation now have an opportunity to comment on my draft decision. I will consider their comments before making a final decision.
11. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

What should have happened

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. Regulation 9 requires person centred care. Regulation 10 requires care providers to treat people with dignity and respect. Regulation 12 requires the care provider to provide safe care and treatment. Regulation 17 requires care providers to maintain an accurate, complete and contemporaneous record of the care provided for each service user.

What happened

13. Mrs X had been living in one of the care provider’s homes for a number of years. Mrs X had advanced Alzheimer’s and had been assessed as at high risk of falls. Mrs X had experienced a number of falls in 2021 and 2022. Following those falls the care provider completed a risk assessment but there is no evidence of specific measures put in place until Mrs X fell and broke a bone in December 2022. At that point the care provider initially provided a sensor mat and later introduced bed rails with a bumper so Mrs X could not get out of bed.
14. Mrs X’s family raised concerns about some of the care provided to her and about the failure to provide a sensor mat given she had been assessed as being at high risk of falls. The care provider investigated the complaint but had not responded before Mrs X sadly died.
15. The care provider accepted there had been occasions when it had fallen short of its standards and apologised. The care provider agreed to reduce the increase in care fees planned for January 2023 from 15% to 7% to reflect the concerns raised. The care provider told Mr Y it had provided all staff trained to administer medication with a supervision session to remind them of the medication policy.

Analysis

16. Mr Y says the care provider failed to ensure a sensor mat was in place when it knew Mrs X was at high risk of falls. The documentary evidence I have seen satisfies me Mrs X had experienced a number of falls in 2021 and 2022 and was assessed as being at high risk of falls. I am satisfied following those falls the care provider followed the right procedure by carrying out risk assessments. However, given the number of falls and the fact several took place in Mrs X’s bedroom I would have expected the care provider to put in place something to manage the risk of falls, such as a sensor mat.
17. None of the documentary evidence I have seen satisfies me the care provider properly considered how to manage the risk of falls in Mrs X’s bedroom, particularly given the care provider says it had not put in place a sensor mat before the fall in December 2022. I find that surprising given Mrs X’s propensity to fall and the fact she was assessed as being at high risk of falls. In those circumstances I consider the care provider’s failure to consider putting in place a sensor mat at an earlier stage is fault.
18. I could not say though if the care provider had put in place the sensor mat it would have prevented the fall in December 2022. That would have been dependent on whether staff in the home responded quickly enough to the alarm to prevent Mrs X falling. I consider though Mr Y is left with some uncertainty about whether the fall in December 2022 could have been prevented if proper consideration had been given to falls management when Mrs X fell previously.
19. Mr Y believes a sensor mat was in place before the fall in December 2022 but had been removed. That is not supported by the documentary records. There is no evidence the care provider had a sensor mat in place before Mrs X’s fall in December 2022. I therefore could not say the care provider had removed the sensor mat when it should not have done.
20. As I have made clear though, it would be usual in cases where a resident has a high risk of falls for a falls management plan to be in place and this will usually involve provision of a sensor mat. I therefore consider the care provider at fault for failing to ensure that was in place in this case. As part of the remedy for that I recommended the care provider carry out a training session for care staff on falls management and, in particular, the measures which should be considered to manage the risk of falls when a resident is assessed as being at high risk of falls. The care provider has agreed to my recommendation.
21. Mr Y says the care provider failed to provide adequate care to Mrs X. Mr Y says the care provider regularly left Mrs X in the same clothes when it should have recognised as she had advanced Alzheimer’s she could not make her own decisions about that.
22. I have considered the documentary records in this case. Those show on occasion Mrs X refused when staff attended her to carry out personal care, including changing her clothes. I am satisfied though the records also show staff attempted to encourage Mrs X to wash or change her clothes and regularly returned to her later in the day to try and encourage her further. Other than by restraining Mrs X to force her to get dressed or washed, I do not consider the care provider could have done more. I say that particularly as I note Mrs X could become aggressive towards staff on occasion.
23. I understand Mr Y’s concern this could be left to go on for an indefinite period of time. I am satisfied though, based on the documentary records I have seen, that did not happen in Mrs X’s case. I have seen no evidence of Mrs X being left in the same clothes for multiple consecutive days. In those circumstances and as I am satisfied the records show staff attempted to encourage Mrs X to change her clothes when she refused I have no grounds to criticise it.
24. Mr Y says the care provider failed to supervise Mrs X taking her medication. Mr Y says this was important as the care provider knew Mrs X had suicidal ideation and she should not have been allowed to hoard her medication.
25. Having considered the documentary records there are some references to staff supervising Mrs X to take her medication. Most of the time though there is no recording about whether staff supervised the provision of medication to ensure Mrs X took it. Mr Y has also provided evidence of a tablet being found on Mrs X’s clothing/bedding on one occasion. It therefore seems likely, on the balance of probability, staff did not always properly supervise Mrs X taking her medication. That is fault. I am satisfied the care provider has taken action to address this by reminding care staff of the need to follow the medication policy, which I welcome.
26. Mr Y says on occasions Mrs X’s room was not properly cleaned, soiled sheets were on the bed and there was no toilet roll available. The care provider has provided a copy of the daily cleaning records which show cleaning of Mrs X’s room each day. On the other hand, Mr Y has provided photographs showing a dirty sheet on one occasion and Mrs X lying on a bed without any bedding on it on one further occasion. I cannot say how long the dirty sheets had been on the bed or whether the dirty floor had been in that state for an extended period. I therefore cannot reach a safe conclusion about whether those instances show systemic problems with cleaning which would warrant a finding of fault.
27. Mr Y says the care provider failed to consistently apply eardrops. Mr Y says that meant Mrs X had to have eardrops applied for more than a year. Having considered the documentary records I can see the audiologist recommended eardrops for Mrs X in March 2022. The GP also recommended them in September 2022. However, none of the medication charts I have seen record the requirement to apply eardrops.
28. The care provider says staff at home knew of the need to apply eardrops and although it tried to keep the same staff on Mrs X’s unit that was not always possible. I do not consider that should be an issue if Mrs X’s care plan and medication records showed the need for daily application of eardrops. However, they did not. I therefore consider it likely, on the balance of probability, the care provider failed to apply eardrops consistently.
29. I am satisfied that likely meant Mrs X had to have eardrops applied for longer than should have been necessary. Failure to ensure the requirement to apply eardrops was recorded on Mrs X’s paperwork is fault. As remedy for that I recommended the care provider carry out a training session for care staff in the home to ensure they know about the need to update medication charts when new medication is prescribed and to ensure this is recorded on the resident’s paperwork so it is not missed if different carers provide the care. The care provider has agreed to my recommendation.
30. Mr Y says the care provider failed to refer Mrs X for a review of her medication when her behaviour altered. Mr Y says instead Mrs X’s daughter did that in January 2023. Having considered the documentary records I note there was regular contact between the care provider and the GP as well as with the mental health team. I am also satisfied that resulted in the GP increasing Mrs X’s medication in September 2022 and undertaking another medication review in November 2022. I therefore could not say the care provider failed to refer Mrs X for a review of her medication.
31. Mr Y says the care provider delayed identifying the need to turn the bedsides round when Mrs X was confined to her bed. Mr Y says as a result Mrs X sustained injuries to her arms as the bedside was not properly padded.
32. Having considered the documentary records I note the care provider put in place the bed rails following Mrs X’s fall at the end of December 2022. The documentary records show this involved bed rails and bumpers. However, I do not have any evidence or photographs to show whether the care provider delayed making sure the bumpers protected Mrs X’s arms. Instead, the only evidence I have is that bumpers were in place. I therefore have no grounds to criticise the care provider.
33. So, I have found fault in how the care provider dealt with managing the risk of falls, in its supervision of providing medication to Mrs X and in its provision of ear drops. I cannot now remedy any injustice to Mrs X as she has sadly died, although I note the care provider has reduced the increased charge applicable in Mrs X’s case from January 2023 to reflect the concerns. I consider though Mr Y has suffered a significant injustice as he is left with some uncertainty about whether some of the issues could have been avoided. In addition to the training I have outlined in this statement I also recommended the care provider pay Mr Y £300 to reflect his uncertainty and distress. The care provider has agreed to my recommendation.

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Agreed action

34. Within one month of my decision the care provider should:
• apologise to Mr Y for the distress and uncertainty he and his family experienced due to the faults identified in this decision. The care provider may want to refer to the Ombudsman’s updated guidance on remedies, which sets out the standards we expect apologies to meet;
• pay Mr Y £300.
35. Within two months of my decision the care provider should:
• carry out a training session for care staff on falls management, including training on the types of measures which should be considered to manage risk when a resident is assessed as being at high risk of falls;
• carry out a training session for care staff on the need to update medication charts when new medication is prescribed and to ensure they know to record it on the resident’s paperwork so it is not missed if different carers provide care.

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Final decision

36. I have completed my investigation and found fault by the care provider in part of the complaint. I am satisfied the action the care provider will take is sufficient to remedy the injustice to Mr Y.

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Investigator's decision on behalf of the Ombudsman