Faults identified in care planning by nursing home

What happened

Mr T had a history of falls and needed support to help him to and from the toilet. He used a call buzzer to request assistance.

Ms V was worried by the number of falls her father had and the length of time it took for staff to help him after his falls; that staff did not minimise the risk of falls; that the nurse in charge did not investigate his concerns appropriately, and that staff did not administer medication consistently.

Ms V said that her father felt suicidal because of the lack of support from staff at the care home, which caused her distress and upset. On one occasion Mr T was found on the floor in his room. Mr T's family later noticed a large bruise to his head that had not been identified.

On another occasion, staff did not answer Mr T's call buzzer when he wanted to use the toilet. Mr T then telephoned his daughter using his mobile phone. Ms V says that she stayed on the telephone with her father for around twenty minutes, but the call buzzer was not answered. Subsequently, the nursing home arranged for a pressure sensor to be used to identify when Mr T climbed out of bed.

Ms V first complained to the home about the care given to her father in winter 2013.

What we found

Although there was evidence of some care planning, there was fault in the nursing home's falls prevention. The individualised care plan was not in line with national guidance. This meant that Mr T's risk of falling was not minimised. However, the faults we identified did not result in harm to Mr T.

Staff did not respond to call buzzers in a timely manner. However, the nursing home had already made changes that went some way to putting this right. The nursing home responded appropriately following Mr T's fall and there was clear documented evidence that showed an appropriate examination had taken place and there was no sign of bruising at that stage.

There was fault in the nursing home's complaint handling, which did not help resolve the complaint and made Ms V's distress worse. A request for access to records was also ignored.

Putting it right

The nursing home accepted our recommendations and acknowledged the failings identified in our report and apologised for them. It paid £500 to Ms V to recognise the distress caused as a result of the faults we found. It responded to her information request, and produced an action plan to address the faults identified.