14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
Failure to properly assess and manage falls risk
15. Mrs H says the Care Home failed to properly assess and manage her uncle’s known falls risk between 23 October and 21 December 2024. She says this resulted in her uncle experiencing avoidable harm. She says 1:1 was not put in place until 21 December, which she feels should have been put in place earlier.
16. We are very sorry to hear Mr C suffered harm as a result of his falls. It must have been scary for him at the time, as we understand he was vulnerable and terminally ill. It must have been difficult and frustrating for Mrs H to witness this during the last weeks of her uncle’s life. To address her concerns, we reviewed Mr C’s relevant records and sought clinical advice from a nurse.
17. Our adviser told us the following guidelines are applicable to this complaint: the NMC Code, NICE CG161 and Safeguarding Adults.
18. The Safeguarding Adults guidelines says ‘the prevention of falls is the most important aspect of the safeguarding process. It is the care provider’s responsibility to ensure they protect the people in their care from harm through having robust policies and procedures to prevent falls. It is recommended all new individuals are assessed for their potential to fall within 24 hours of admittance. Where there is a risk of falling, an Individualised Care Plan should be created to identify risks and mitigate where possible.’
19. The Safeguarding Adults guidelines lists examples of situations when a safeguarding concern should be raised after a fall. This includes significant injury, repeated falls despite preventative advice, and fall as a result of poor monitoring or low staffing.
20. Section 1.1 of NICE CG161 says older people who report recurrent falls in the past year should be offered a multifactorial falls risk assessment. This assessment should be part of an individualised care plan. The assessment may include identification of falls history, assessment of gait, balance and mobility, and muscle weakness, and assessment of the older person’s perceived functional ability and fear relating to falling.
21. Section 13 of the NMC Code says nursing staff should recognise and work within the limits of their competence. They must accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care. They should make a timely referral to another practitioner when any action, care or treatment is required.
22. Mr C’s pre-admission assessment document dated 21 October 2024 identified him as at risk of falling. Specifically, it states he had a history of two falls due to slipping on urine and had sustained falls when at home. The document also notes Mr C required the assistance of one person for activities of daily living. He got up to go to the toilet and a sensor mat was required to alert staff to him getting out of bed on his own. Mr C’s transfer document notes he walked ‘with stick or frame’ and ‘wanders off frequently’.
23. We consider this pre-admission assessment is in line with NICE CG161. The Care Home documented a sensor mat should be in place to alert staff of movement.
24. On 23 October, the Care Home completed Mr C’s falls risk assessment. This is within 24 hours of his admission and therefore is in line with the Safeguarding Adults guidelines. The risk assessment notes Mr C was at risk of falls.
25. The records indicate Mr C’s risk assessment was evaluated every two weeks. This is in line with NICE CG161. Whilst he remained at high risk of falls, he did not experience any. The Care Home reassessed Mr C’s falls risks on 20 November and 9 December.
26. Mr C’s resident care summary documents he ‘will often walk very quickly and become unsteady’. Staff were expected to observe when Mr C mobilised and use a sensor mat when he was in bed. We consider these measures are individualised to Mr C’s care needs. This is in line with the Safeguarding Adults guidelines and NICE CG161.
27. On review of the wellbeing observation records dated between 23 October and 17 November, we note Mr C had hourly checks by staff and a sensor mat in place. This is also documented on wellbeing observation records dated between 21 November and 22 December. These records indicate Mr C’s individualised care plan for falls was being adhered to by staff. The wellbeing observation records were updated hourly.
28. The Care Home kept a falls diary, which recorded the following:
• on 20 November, Mr C told staff he had fallen in his ensuite and bumped his elbow. A bruised elbow is noted on the body map. Staff completed an incident report and updated Mr C’s risk assessments • on 23 November, Mr C told his brother he had fallen earlier in the day, who reported the incident to staff. Staff checked him for injuries, but none were found • overnight on 19 and 20 December, staff found Mr C crawling on his floor to his ensuite and was distressed and agitated. Staff gave oxycodone and midazolam after putting him back to bed. They noted he settled well. A body check was completed, but no injuries were sustained.
29. Our adviser told us the Care Home’s actions following the self-reported falls on 20 and 23 November were appropriate. The Care Home completed a full body check and an accident form. Staff observed and monitored Mr C after both falls.
30. On 20 December, Mr C’s hospice team visited Mr C. They increased the dosage of his medication and suggested 1:1 care. They also noted they would consider admission to the hospice as part of his symptom management.
31. The Care Home completed a safeguarding log sheet and referral on 21 December. This notes Mr C had a sensor mat in place and had ‘been found on the floor a couple of times now’. The referral recommended he be transferred as an inpatient to his hospice team, as the Care Home did not have the skills required to continue to care for him.
32. We consider this safeguarding alert is in line with the NMC Code, which says staff should recognise the limits of their competence and refer elsewhere if this meets patient need. The alert is also in line with the Safeguarding Adults guidelines. This is because this incident was a repeated fall despite the preventative measures in place.
33. On discussion with Mrs H, the Care Home noted she did not feel a transfer would be in Mr C’s best interests. Mr C remained at the Care Home until his death on 29 December.
34. Between 21 and 29 December, the Care Home put Mr C on 1:1 care. It updated his wellbeing observation record accordingly. Our adviser told us this was appropriate. By this time, Mr C’s high risk of falls had become compounded by his terminal agitation. It put him at severe or extreme risk of falls. Our adviser told us 1:1 care would have also provided great support to both Mr C and his family in a psychological and physical manner.
35. Our adviser told us individuals in care settings are not placed on 1:1 care purely due to falls. The need for close 1:1 supervision must be identified and considered thoroughly, as it is seen as a restriction on a person’s liberties.
36. Mr C’s reassessed moving and handling risk assessment from 24 December notes he was ‘very high risk of falls’. It notes he would ‘become distressed and will get up and walk unaided’. Mr C’s falls risk assessment was also reassessed on 24 December.
37. Based on what we have reviewed, we consider Mr C’s records show a structured falls risk assessment was completed within 24 hours of admittance. This is in line with the Safeguarding Adults guidelines. The records also show his risk assessments were evaluated every two weeks. We can see from the use of a sensor mat and hourly checks that Mr C had an individualised care plan in place, which is in line with NICE CG161.
38. We note Mrs H felt the 1:1 care should have been put in place earlier than 21 December. We asked our adviser about this.
39. Our adviser noted no injuries were found following Mr C’s self-reported falls on 20 and 23 November. They noted Mr C started to show signs of rapid deterioration and was experiencing terminal agitation from 13 December. Specifically, the records document he was in and out of bed frequently, had very varied days, and was having anticipatory medication for agitation (midazolam) to good effect.
40. Our adviser also noted the records from 21 December indicate Mr C was restless and agitated. He is noted as continuing to try to get out of bed. His records document the family had assisted him to the toilet nine times during their visit. By 25 December, Mr C had a syringe driver in place with continuous symptom relief.
41. Our adviser stated there were opportunities to have a 1:1 in place earlier. However, it was not clinically required. Until 19 December, Mr C had only experienced two falls both of which were self-reported and unwitnessed. Our adviser told us there was no indication he required close 1:1 supervision. Had it been in place, the falls may still have happened. Close supervision would also have been restrictive and an infringement of Mr C’s liberties.
42. We note our adviser’s concerns about an earlier 1:1 being restrictive, and to do so was not clinically indicated in Mr C’s case. We consider the Care Home’s safeguarding alert of 21 December was in line with the NMC Code and the Safeguarding Adults guidelines.
43. In this case, we have not seen sufficient evidence of any indications the Care Home should have put earlier 1:1 care in place. According to our adviser, it was not clinically required. We also consider the Care Home completed regular risk assessments in line with relevant guidelines.
44. Based on this, we do not consider there are any indications the Care Home failed to properly assess and manage Mr C’s falls risk. We therefore do not intend to do any further work on this complaint.
45. We realise this is unlikely to be the outcome Mrs H was hoping for when she approached us. We hope she is reassured by our explanations and thank her for bringing her concerns to our attention.