The Ombudsman's final decision
Summary: We will not investigate this complaint about negligent respite care in a care home. This is because we are unlikely to be able to add to the investigation already carried out or achieve the outcomes requested.
The complaint
Mrs Y complains that her mother, Mrs X, received negligent respite care in a care home. She says Mrs X suffered 19 separate incidents with the final fall resulting in her suffering serious injuries to her face, head, wrist and brain.
Mrs Y would like an apology from the care home, service improvements and care home fees to be waived.
The Ombudsman’s role and powers
The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide we cannot achieve the outcome someone wants. (Local Government Act 1974, section 24A(6))
How I considered this complaint
I considered information provided by the complainant which includes the Council’s responses.
I considered the Ombudsman’s Assessment Code.
My assessment
Part 3 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.
A council must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. 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) In this case the Council has responded to Mrs Y’s concerns on two occasions in conjunction with carrying out a safeguarding investigation.
Overall, the Council found the Care Home acted appropriately with both risk and mitigations measures in place.
Firstly, Mrs X was identified to be at high risk of falls and fell once or twice a week. It noted risk assessments of Mrs X’s risk of falling were up to date. It saw information showing the Care Home worked with and took advice from various professionals involved in Mrs X’s care such as the Occupational Therapist and the District Nurses. It said Mrs X’s hospital consultant had explained that due to Mrs’s medical conditions Mrs X did not understand her risk of falling and would try to get up independently.
Secondly, all measures to mitigate against the risk of falls were in place including equipment such as a falls sensor. It did not agree with Mrs Y that bed rails should have been arranged saying they were not suitable for people who can be mobile. It also said the covid measures forcing Mrs X to isolate in her room following discharge from hospital ‘compounded’ her risk of falls albeit she was checked on regularly.
Final decision
I will not investigate as we are unlikely to be able to add to the investigation already carried out or achieve the outcomes requested. As the Council’s response says the number of falls does not amount to neglect as Mrs Y alleges. We are also unlikely to be able to achieve the outcomes requested albeit the Council has apologised for the lack of empathy shown to Mrs Y in its first complaints response.
Investigator's decision on behalf of the Ombudsman