3. Mr O complains about several falls his mother had while she lived at the care home in 2021. Mr O says staff at the care home were not monitoring his mother properly when she was moving around the care home, and this led to her having several unwitnessed falls.
4. Mr O says his mother got several cuts and bruises to her head because of the impact of the falls. He was worried, concerned and distressed.
5. Mr O wants an apology from the care home and a financial payment.
6. Mrs O lived at the care home in 2021 and had continuing healthcare (CHC) funded care during this time (when the NHS pays for your care).
10. The care home stated that on 16 September 2021, the falls prevention team came out and recommended that Mrs O should continue to use walking aids, wear hip protectors and a head guard. But, Mrs O did not comply with this.
11. The falls prevention team also recommended to use a wheelchair when Mrs O was walking and to keep the wheelchair behind her. Mrs O would not do this at times and would say she did not want to use a wheelchair. The care home documented that Mrs O was at a high risk of falls due to poor mobility caused by Huntington’s disease (a condition that affects the brain) and challenging behaviour. The team also documented that they had discussed regular chiropodist (foot care) appointments, and they were told that Mrs O refused to see the chiropodist when they visited on 29 July 2021.
12. Mr O says the care home was not taking enough measures to prevent his mother from having falls.
13. A fall is defined by the World Health Organisation as an event that results in a person coming to rest by accident on the ground, floor or other lower level.
14. Section seven of the NMC standards for nurses guidance states:
• ‘use evidence-based, best practice approaches for meeting needs for care and support with mobility and safety, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
• observe and use evidence-based risk assessment tools to determine need for support and intervention to optimise mobility and safety, and to identify and manage risk of falls using best practice risk assessment approaches
• use a range of contemporary moving and handling techniques and mobility aids
• use appropriate moving and handling equipment to support people with impaired mobility
• use appropriate safety techniques and devices’.
15. Section one of the NICE guidance for falls in older people states:
• ‘following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function.
• multifactorial interventions with an exercise component are recommended for older people in extended care settings who are at risk of falling.’
16. Section six of the care home’s falls and risk management policy states:
• ‘staff will use the normal risk assessment process to identify and assess the risk of falling which will include assessing the person to identify risk factors that may lead to falls. Assessing the environmental and other risk factors from within the home that might lead to falls.
• Staff will decide what interventions they need to implement to prevent falls from occurring and put these systems in place.
• Staff will record the interventions on the care/service plan so that staff know what they should do for each service user.
• Staff will record falls using the Data Recording Sheet and evaluate falls regularly to monitor success.’
17. Mrs O’s risk of falls was fully assessed and reviewed by the care home during her admission from May 2021. The care home records show that Mrs O was assessed as being at a very high risk of falls.
18. Mrs O’s pre-admission care plan, dated 12 May 2021, says she was able to mobilise for short distances, she holds onto furniture and equipment and she is at risk of falls. On 16 September 2021 the falls prevention team stated that she should use her wheelchair when wanting to walk long distances and her wheelchair should be kept behind her, so if she did have a fall the chair would be there to support her. It was also stated that the falls risk assessment should be completed and updated regularly. It was noted that the falls prevention team were told Mrs O usually falls forward, not backwards, so it may not be appropriate for staff to walk behind Mrs O with a wheelchair.
19. The care home noted that Mrs O was encouraged by staff to sit in the wheelchair, but she refused to do this on several occasions. It was stated that Mrs O had been told why a wheelchair was needed and it was explained that she was at a high risk of falls, but she said she did not want to use a wheelchair.
20. Staff noted that Mr O had told them that they should use a wheelchair for all Mrs O’s transfers. Mr O was advised that staff could not force Mrs O to sit in a wheelchair if she did not want to. The falls prevention team also advised for Mrs O to use a sensor mat by her bed but the care home explained this was not needed because Mrs O did not get out of bed during the night and once she is up in the morning she sits in the lounge or in a chair in her room. A sensory mat is designed to alert a carer when a person gets up in case they need help.
21. The falls, trips, and slips assessment stated Mrs O was observed by staff every 15 minutes. The general-purpose risk assessment dated 5 November 2021 stated Mrs O could move independently, she held onto furniture when walking and staff were to offer her a wheelchair for long distances.
22. The falls log dated 24 July 2021 stated all Mrs O’s falls happened when she was either trying to move or showing challenging behaviour. Mrs O was monitored closely and a behaviour monitoring chart was completed by the care home. Mrs O was referred to the falls and fracture prevention service in July 2021.
23. The records show that care home staff were to make sure the environment was free from any potential hazards that could cause a trip, slip, or fall.
24. Mrs O did not cooperate with the fall’s interventions suggested by the falls prevention team and she refused to wear her helmet, hip protectors and to have a wheelchair behind her while she walked. Mrs O was referred to the mental health team in August 2021 due to her increasingly challenging behaviour and reluctance to accept support, which increased her falls risk. A clinic letter from Mrs O’s consultant to her GP dated 1 September 2021 stated Mrs O sometimes bangs her head against the wall and has caused many injuries to her scalp.
25. After careful consideration, we think the records show that staff at the care home were taking appropriate action to reduce the chances of Mrs O falling. The records support that staff acted in line with national guidance, NMC standards and the care home’s own policy. This is because Mrs O falls risk was assessed before she went to the care home and regularly while she was there. The records show that staff were aware of the situations that would be most likely to lead to Mrs O falling. Interventions (support) were in place, including 15-minute observations through the day and behaviour charts. She was referred to the mental health team because she was refusing support that was suggested by the falls prevention team. We have not seen any signs of failings.
26. We know the care home’s falls prevention policy that we have referred to is dated after the events we have investigated. This is because the version from 2021 is no longer available, due to it being outdated. We have referred to it here for context, but we are also satisfied the care home’s actions were in line with the national guidance that was available at the time.
The falls and whether they were avoidable
27. Mr O says the falls his mother had could have been avoided and care home staff should have done more to stop her falling.
28. As we have explained above, we think the care home took appropriate actions to reduce the risk of Mrs O falling. To consider whether the care home should have done any more we looked at her care home records and got clinical advice from our adviser.
29. Our adviser stated that falls cannot be completely prevented because to do so would involve the use of restraint to stop a person from moving. The National Patient Safety Agency’s guidelines define restraint as, ‘the intentional restriction of a person’s voluntary movement or behaviour…’.
30. The Ministry of Justice state ‘restraint may only be used when it is necessary to protect the person from harm and is proportionate to the risk of harm’.
31. Our adviser said it is not proportionate (fair) to restrict a person’s movement to stop them from having a fall. Preventing people from falling is a particular challenge in care settings because patient safety must be balanced against their right to make their own decisions about the risks they are prepared to take and their dignity and privacy. As we have explained above, the care home took different steps to reduce the risk of Mrs O falling.
32. Our adviser said that the care home could not and should not restrain Mrs O to stop her from moving. They also cannot force interventions on a patient. The care home referred Mrs O to the falls prevention team and the mental health team to try to address the challenging behaviours that affected Mrs O’s falls risk. This was the appropriate action for it to take and in line with national guidance.
The unwitnessed falls
33. We have carefully considered whether the care home should have been doing more to monitor Mrs O to try and stop her from falling. Mrs O was on increased observations every 15 minutes. The care home records show she was a private person and liked to spend time alone in her bedroom. It was stated in her records that Mrs O preferred her own company in her bedroom in a quiet environment. Our adviser stated that falls interventions should be balanced against the person’s desire for privacy.
34. Based on the clinical advice and the actions we have referred to, we think the care home took appropriate and proportionate steps to try and stop Mrs O from falling. Although Mrs O did have falls at times, it does not mean the care home should have been doing more to try and stop Mrs O from having a fall.
35. We have not found any signs of failings with the actions the care home took to try and reduce the chances of Mrs O falling.
36. We understand the issues raised have caused a lot of upset and distress to Mr O and we appreciate it was upsetting for him to learn his mother had fallen and been injured. We hope the explanations we have provided show Mr O that we have thoroughly investigated his complaint.
1. We have carefully considered Mr O’s complaint about a care home in the Birmingham area (the care home), and we have not found any signs of failings.
2. We understand Mr O has been through a difficult and distressing time and we are sorry to learn about the issues he has raised. We are particularly sorry to hear about the injuries his mother, Mrs O, sadly got when she was living at the care home in 2021.