Summary: Miss X complained about the care the Council arranged for her brother, Mr Y and how the Council investigated safeguarding concerns about the Care Home. There was no fault in how the Care Home cared for Mr Y. There was some fault in how the Council carried out its safeguarding enquiries, but this did not affect the outcome. The Council has already taken steps to improve how it investigates safeguarding concerns.

The complaint

1. Miss X complains, of behalf of her brother Mr Y, about the care Mr Y received while in a care home arranged by the Council in early 2023. She says the Care Home failed to:
• prevent Mr Y falling;
• provide adequate care following the fall;
• inform her that Mr Y had fallen; and
• provide proper care for Mr Y, including helping him move around.
2. She also says the Council failed to properly investigate and hold the Care Home accountable for its failures.
3. As a result, Miss X says Mr Y suffered injury and pain, and she was caused avoidable upset and distress. She wants the Council to hold the Care Home properly accountable for the injustice caused to Mr Y.

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The Ombudsman’s role and powers

4. 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)
5. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
6. 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, sections 24A(1)(A) and 25(7), as amended).
7. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
8. We may investigate a complaint on behalf of someone 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)
9. When considering complaints 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.
10. 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

11. I considered evidence provided by Miss X, the Council and the Care Home, as well as relevant law, policy and guidance.
12. Miss X, the Council and the Care Home had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Standards of care

13. 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.
14. Regulation 9 says that care must be appropriate, meet peoples’ needs and reflect their preferences. Care providers should properly assess and plan someone’s care to ensure their needs are met.
15. Regulation 12 says care must be provided in a safe way. The includes assessing risks to the health and safety of people receiving care, doing what is reasonable to mitigate those risks and ensuring equipment is used safely.
16. Regulation 20 says care providers must be open and transparent. This includes informing people where something unexpected happens which did, or might, have caused harm to someone they are caring for.
17. There is no guidance which says care homes should assess whether everyone they care for should have bed rails. Government guidance about bed rails say there are risks in using these, particularly for certain groups of people, including people who have:
• dementia;
• learning disabilities; or
• reparative or involuntary movements, such as with epilepsy.
18. The Government guidance also says that before using bed rails there must be a robust assessment of whether the use of a bed rail will prevent the person from moving freely or make the person feel restricted from moving freely. In all cases the least restrictive options should be explored.

Safeguarding adults

19. 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)
20. The aims of adult safeguarding are to:
• prevent harm and reduce the risk of abuse or neglect to adults with care and support needs;
• safeguard individuals in a way that supports them in making choices and having control in how they choose to live their lives;
• promote an outcomes-led approach in safeguarding that works for people resulting in the best experience possible; and
• raise public awareness so professionals, other staff and communities as a whole play their part in preventing, identifying & responding to abuse and neglect.
21. When making enquiries, councils should focus on:
• establishing facts;
• finding out the person’s views and wishes and seeking consent;
• assessing the needs of the adult for protection, support and redress; and
• make decisions about what follow-up action should be taken regarding the person or organisation responsible for any abuse.

What happened

22. Miss X’s brother, Mr Y, has several health conditions, including epilepsy, learning disabilities and Alzheimer’s disease. He went into hospital in early 2023, as he was struggling in his accommodation at the time.

Mr Y’s stay in the Care Home

23. Mr Y left hospital in late April 2023 and moved into the Care Home. This was arranged by the Council.
24. Mr Y arrived at the Care Home in the late afternoon, so the Care Home carried out various risk assessments and completed planning his care the following day. In the meantime, care staff checked on Mr Y around every 15 minutes overnight.
25. The Care Home assessed various aspect of Mr Y’s care, including his risk of falling, what help he needed with moving around and his usual levels of pain. The Care Home did not, at that time, assess whether Mr Y needed bed rails.
26. During that night, Mr Y fell from bed. Staff found Mr Y during a routine check and described him as having half fallen out of bed, with his head on the floor. A nurse checked Mr Y and found no injuries. The Care Home placed a crash mattress in place and monitored Mr Y closely. Mr Y returned to sleep shortly after his fall and slept until the following morning.
27. The following day the Care Home told Miss X about Mr Y’s fall. Miss X suggested the Care Home use bed rails for Mr Y, as he had these in hospital. The Care Home carried out a bed rails assessment for Mr Y and began using bed rails for the rest of his stay.
28. Over the next week, Mr Y displayed no signs of pain or discomfort, either to care staff or the several visitors Mr Y had during that time.
29. One morning in early May 2023, Mr Y had a seizure which lasted for a few seconds. A nurse checked Mr Y, including his blood pressure, heart rate and breathing. Carers noted that, after his seizure, Mr Y was quite sleepy.
30. Nurses from outside the Care Home visited Mr Y later that afternoon. They were concerned about Mr Y’s condition and that carer’s mentioned Mr Y had also been sleepy the previous day. They arranged for Mr Y to go to hospital for checks. Mr Y did not return to the Care Home.
31. While in hospital, Mr Y fell from bed again. The hospital scanned Mr Y’s head and neck, but noticed no injuries.

The Council’s safeguarding enquiries

32. Shortly after Mr Y went back into hospital, nursing staff raised two safeguarding concerns with the Council, about:
• the fall Mr Y had in early April; and
• that the Care Home had not acted sooner when Mr Y possibly showed signs of being unwell before his seizure.
33. The Council assessed these concerns a few days later. It decided to start a safeguarding enquiry because Mr Y was a vulnerable adult and there was conflicting information about whether Mr Y had suffered any harm as a result.
34. The Council asked the Care Home to review its processes to identify any learning from what had happened.
35. There is no evidence the Council took further action on these safeguarding concerns until September 2023, after the hospital chased it for an update.
36. The Care Home told the Council it had made some changes to how its care staff and nurses worked together, including more frequent nurse checks and better reviews of care records to identify health concerns earlier. The Care Home had also held meetings with its staff about raising health concerns and involving health professionals sooner.
37. The Council ended its safeguarding investigation in November 2023 as it was clear, at that time, that Mr Y would not be returning to the Care Home.

My findings

38. I am satisfied that, because of his learning disability and other health conditions, Mr Y cannot consent to Miss X complaining on his behalf. I am also satisfied that Miss X is a suitable person to complain on Mr X’s behalf.

Care in the Care Home

39. I am satisfied there was no fault in how the Care Home cared for Mr X.
40. I do not consider it was fault for the Care Home to not have considered using bed rails for Mr Y as soon as he moved there. The care plan which the Council prepared when Mr Y was ready to leave hospital, and shared with the Care Home, did not mention any concerns about Mr Y falling from bed or that he needed bed rails.
41. Mr Y’s health conditions were included on the list of those which can make bed rails riskier. Therefore, without any other suggestion that Mr Y was at risk of falling from bed at night, I would not have expected the Care Home to consider bed rails.
42. Once Mr Y did show signs he might fall from bed, and after Miss X suggested it, the Care Home assessed Mr Y for bed rails and used these for the remainder of his stay.
43. In any case, I do not consider Mr Y’s fall from bed while at the Care Home caused him any significant harm. The records show there were no signs of pain or discomfort after Mr Y’s fall and the scan the hospital carried out after Mr Y later fell in hospital showed no signs of injury. While Mr Y does have some “wedge fractures” in his spine, these are in his mid-back and are suspected to be a result of osteoporosis, rather than a physical injury.
44. The records show staff responded appropriately after Mr Y had a seizure at the end of his stay. He was checked and monitored by a nurse and care staff at the time of the seizure, including a check of his vital signs. While Mr Y had been sleepy the day before, there is no evidence to suggest that the Care Home should have realised he was unwell or needed to go to hospital sooner.
45. In any case, I do not consider Mr Y suffered any avoidable harm. He was admitted to hospital shortly after his seizure and there is no evidence any delay in him going into hospital caused any harm or risk of harm to Mr Y.
46. The care home’s records show that care staff helped Mr Y move around in line with his care plan, including helping Mr Y change position in bed.

Safeguarding

47. I consider there was fault in how the Council carried out its safeguarding investigation.
48. The Council took too long to carry out the section 42 safeguarding enquiries. There is no evidence it took any action on these concerns between mid-May and September 2023. While Mr Y was no longer at the care home, the Council has provided no explanation for the delay or how it decided it did not need to take any action during that time.
49. The Council also failed to properly investigate whether Mr Y came to any harm. The Council itself identified there was conflicting information when it assessed the safeguarding concerns. However, there is no evidence it resolved that conflict, such as seeking information from the hospital.
50. However, I do not consider this fault caused an injustice. There is no evidence Mr Y experienced any abuse or neglect while at the care home, or that the Care Home caused Mr Y any harm. Mr Y did not return to the Care Home, so the Council did not need to take any action to protect him. The Council also agreed actions with the Care Home for improving its processes to help reduce possible risks to others in future.
51. I also do not consider the delay caused Miss X an injustice. Even if the Council had completed its review earlier, I think it is unlikely Miss X would have acted differently.
52. Since the events I have investigated took place, the Council has made various improvements to how it investigates and manages safeguarding concerns. This included provided training for its staff. Because of the improvements the Council has made, I do not consider I need to make recommendations for further improvements.

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Decision

53. There was no fault in how the Care Home cared for Mr Y. There was some fault in how the Council carried out its safeguarding enquiries, but this did not affect the outcome. The Council has already taken steps to improve how it investigates safeguarding concerns.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman