Summary: Mrs Y complained that her late father, Mr W, experienced avoidable injuries during his short time at a Council commissioned residential care home. She also says that staff did not communicate with her properly about the incident and did not properly investigate. We find the home failed to properly assess Mr W’s risks and at the frequency agreed in his care plan. Although we cannot say that Mr W’s fall was preventable, the fault has caused uncertainty for which the Council should apologise and make a symbolic payment for. The home has already implemented some service improvements following Mrs Y's complaint.

The complaint

1. Mrs Y complains about the care her late father, Mr W, received during a period of Council funded rehabilitation at the home ‘Beckfield’. She says staff wrongly left Mr W in the garden unsupervised and he suffered preventable injuries which left him bed bound.
2. Mrs Y says that staff lacked compassion when talking to family members about the incident, were slow to seek medical help and failed to properly investigate and provide an adequate complaint response.
3. Mrs Y wants the Council to ensure that improvements are made to the service to safeguard other service-users.

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The Ombudsman’s role and powers

4. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
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)

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How I considered this complaint

7. I considered evidence provided by Mrs Y and the Council as well as relevant law, policy and guidance.
8. Mrs Y and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Fundamental standards of care

10. 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. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
11. Regulation 12 sets out how providers should properly manage risks. It says risk assessments relating to the health, safety and welfare of people using services must be completed and reviewed regularly by people with the qualifications, skills, competence and experience to do so. Risk assessments should include plans for managing risks.

What happened

12. At the time of the matters complained about, Mr W lived with dementia and vascular trauma from a brain injury he sustained many years prior. He lived at home and received daily visits from carers to help him with personal care.
13. In October 2023 Mr W went into hospital after falling at home. After a short period in hospital, Mr W moved into a Council owned residential care home on 28 October 2023 to help improve his mobility in readiness for a return home.
14. Mr W was a cigarette smoker. At around 10pm of 20 November Mr W went outside in a wheelchair for a cigarette. A member of staff initially assisted him. The worker recorded that they left Mr W with a ‘care call’ buzzer to call for help if needed. They then returned into the home while Mr W remained outside alone.
15. Mr W needed to use the toilet and tried to mobilise. Notes made after the event suggest Mr W fell onto the ground where he lay for over 20 minutes. Mr W was unable to use his buzzer to call for help. When a staff member found Mr W, they assisted him back inside to his room.
16. The daily record sheet completed by the staff member at 1am said, “When staff went outside to check on him, he was on the floor at the side of the smoking shelter. He said he had gone round there to urinate. He was checked over and asked if he felt he had injured himself and he said he was OK. He was assisted up by staff and assisted back into his wheelchair. He was then taken back up to his bedroom for a thorough check… he has bruising to his left hand side below the rib area”
17. The home arranged a virtual medical appointment at 3am due to Mr W reporting pain. The Nurse advised staff to monitor Mr W and any worsening symptoms and to call back if needed.
18. The next note says, “Staff have been told under no circumstances that [Mr W] must not [sic] be left unaccompanied in the garden”. Mr W’s care plan was also updated on 20 November to reiterate that Mr W must not be left outside alone.
19. Mrs Y received a call early the next morning to inform her about Mr W’s fall. She went to visit and reported that he cried out in pain and held his side. A staff member checked the bruising which was, “very purple and slightly swollen”. Mr W reported a pain level of four out of ten. Mrs Y spoke to a manager and said in her view residents should not be left outside unattended.
20. The home arranged another virtual appointment. The Nurse said Mr W had likely experienced muscular bruising and advised staff to use a cold compress. They advised the home to call back if Mr W’s symptoms changed.
21. The next day Mrs Y took Mr W to hospital for a pre-arranged appointment. Mr W was still experiencing significant pain and said it hurt to walk and breathe. Mrs Y took Mr W back to the home and reported her concerns. The home arranged another virtual appointment with a Nurse who observed Mr W to be in pain whilst breathing in and out. The Nurse agreed to organise a GP appointment.
22. Later that day a GP called to assess Mr W in a telephone appointment. The GP discussed the possibility of prescribing codeine but decided it would not be appropriate due to Mr W’s low blood pressure. Instead, the GP prescribed anti-inflammatory pain relief gel and told the home to continue using cold compresses. The home called Mrs Y, and she thanked the staff member for the update.
23. Early the next morning Mrs Y received a phone call to say that Mr W had fallen late the previous night. The notes say, “[Mr W] declined to go to bed and so I left him in his wheelchair. When I left the room a few minutes later [Mr W] fell out of his chair. Body checked for injuries, none apparent”.
24. The home arranged for another virtual medical appointment and the Nurse checked Mr W’s bruising. The Nurse said there would be no treatment for broken or cracked ribs unless Mr W was vomiting or urinating blood. The Nurse arranged an out of hours GP appointment.
25. The GP called later that evening and said they would arrange for an ambulance to take Mr W to hospital. The home informed Mrs Y and she went with Mr W to hospital.
26. Mr W received a CT scan at hospital which showed he had broken ribs in three places, destabilising his chest and placing Mr W at increased risk of Pneumonia.
27. Mrs Y complained about the injuries sustained by Mr W. In summary, the complaint response said:
• The home has a “safely reduced” staff team at night.
• Mr W wanted to smoke, and staff provided him with a buzzer and supported him outside. The home said the staff member could not stay with him due to other responsibilities inside the home.
• When a staff member checked Mr W’s room, he was not there. When they checked outside they found Mr W on the ground.
• Mr W was not assessed as needing 1:1 support and at times enjoyed spending up to 45 minutes outside smoking. Staff would sit with him when possible and undertake visual checks.
• Management have shared lessons across the team and are looking to improve processes to try and reduce further instances.
• The home apologised for any suffering incurred.
28. Mr W remained in hospital for just over three weeks. During his time there, professionals initially decided he needed an interim care bed for further assessment. However, ten days later, the hospital requested a package of care for Mr W to return to his home and receive four care visits each day.
29. The Council considered a safeguarding referral in November 2023. This concluded that – based on the evidence available – there was no reasonable cause to suspect that Mr W has, or is, experiencing or at risk of abuse and neglect.
30. Mr W returned home on 18 December 2023 and received a substantial package of home care to help meet his needs.
31. Mr W sadly died in early 2025.

Was there fault in the Council’s actions causing injustice to Mrs Y and Mr W?

32. We find fault with the actions of Beckfield for the following reasons:
• The ‘enablement plan’ completed the month before Mr W’s fall said he was weak, quite shaky and needed 1:1 close supervision when mobilising. The risk assessment said Mr W was at high risk of falling. It goes on to say that Mr W sometimes tries to walk unsupervised when staff are not around. There are no records to show how staff appropriately monitored Mr W on the evening of 20 November despite knowing his frailty and the high risk of him falling.
• Mr W’s smoking care plan does not correspond with the general care plan which says that he needed close 1:1 supervision when mobilising. Staff updated the smoking plan after Mr W’s fall on 20 November to say he must always be accompanied when going outside to smoke. Given that Mr W had already fallen on two occasions before this date, there was a lost opportunity to review the smoking plan to ensure it appropriately met Mr W’s needs.
• Mr W’s care plan says the home should: “review falls assistance score at least weekly or more frequently if further fall(s)”. The records show Mr W’s score was reviewed only twice during his four weeks at the home despite falling on four documented occasions.
• Mr W’s care plan also says that staff should gently prompt Mr W to use the toilet before meals or going outside for cigarettes. There is no record to show that staff prompted Mr W before he went outside on 20 November. The cause of Mr W mobilising and subsequently falling was due to his need to urinate.
33. The failure to proactively assess and manage Mr W’s risks is a potential breach of the CQC fundamental standards of care and is fault. I consider the fault caused injustice to Mrs Y and Mr W. Although we cannot say that Mr W’s fall on 20 November was preventable, the fault has caused uncertainty. If Beckfield had managed Mr W’s risks as it should have done – and in line with the assessment tool and care plan – the chances of Mr W falling and sustaining significant injuries may have reduced. This leaves Mrs Y with avoidable uncertainty which the Council should acknowledge with a symbolic payment.
34. I have also considered Mrs Y’s complaint about how staff spoke with her in the days after the incident. Having reviewed the available information, I am satisfied the home maintained an appropriate level of contact with Mrs Y and in line with the family’s preferences as outlined in Mr W’s care plan.
35. I have also considered the medical intervention arranged by the home. The records show that Mr W received assessments by a Nurse on four occasions and a GP on two occasions in the days between 20 November and 23 November. Staff at the home also monitored Mr W’s clinical observations and provided pain relief as advised by medical professionals. In my view, there is no evidence of fault in how the home assessed and treated Mr W in the days after his fall. I cannot consider decisions made by the Nurses and GPs who assessed Mr W as these are health decisions and therefore fall outside of our jurisdiction.

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Action

36. In response to Mrs Y’s complaint, Beckfield confirmed it has made several service improvements:
• reviewed and updated the smoking policy.
• updated the telemedicine procedure to state when a fall has occurred telemedicine will be called to allow the clinician to assess for injuries.
• care plans transferred on a new system to allow all staff to see real time updates regarding each service user.
• increased night staff staffing levels.
37. Within four weeks of our final decision, the Council will share with us a copy of the updated smoking policy and telemedicine procedure.
38. To remedy the personal injustice experienced by Mrs Y, within four weeks the Council will also:
• Apologise to Mrs Y for the failures we have identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology recommended in my findings.
• Make a symbolic payment of £300 in recognition of the avoidable uncertainty Mrs Y experienced from the fault we have identified.
39. The Council will provide us with evidence it has complied with the above actions.

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Decision

40. There is fault causing injustice for the reasons explained in this statement. We have recommended actions to remedy that injustice, and the Council has agreed to implement those actions.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman