‘Poor practice’ found at care home where frail woman was found slumped in wheelchair ‘crying in pain’

A woman in Rochdale was admitted to hospital with a broken hip after her care home failed to "properly record falls," leaving her family in doubt as to when the injury occurred.

The woman, known as Mrs Y, was staying at Stamford House Residential Home, a Rochdale Council commissioned care home, when the incident happened, leading to a complaint to the Local Government and Social Care Ombudsman.

Mrs Y was struggling with mobility issues after a fall at home in September 2021 which led to a fracture. After being taken to hospital due to the fall, she was discharged to the care home while her long-term care options were assessed. An occupational therapist in the hospital recommended that she remain in bed, but she continued to try and get up.

Her notes from the care home found that after this she continued to regularly get up out of bed despite the risk of another fall. She was receiving all her care in bed, due to concerns that she might fall again while getting up. The care home reported Mrs Y was often trying to get up in the night and it had put a crash mat in place in case she fell.

Her daughter, known as Mrs X, received a call on 4 November 2021 that her mother had fallen, bumping her head and cutting her lip – but the care home had no record of this according to the Ombudsman’s findings.

Care notes on 7 November stated that Mrs Y “scraped her shoulder” after coming out of bed, but that everything “seems fine.” The care home completed an incident report at 1.15am on 10 November which noted Mrs Y had fallen, bruised her head and cut her lip. The care home records include a second accident report at 6.30pm also dated 10 November. This stated "found [Mrs Y] on the floor behind the bedroom door."

On 12 November, a physiotherapist visited and stated that Mrs Y was “unsafe to stand or move independently due to general weakness and lack of balance”. When her daughter visited on 18 November, she said she found her mother “slumped in her wheelchair, grey in colour and in pain.”

Her care notes the following day noted that she was “crying and complaining of back pain” while getting dressed.

She was later taken to see a GP about the pain and this led to referral for an x-ray in December, revealing that one hip was broken and the other dislocated. Her daughter spoke to a council officer to try to find out about any other reported falls and how the injuries were sustained.

However, the care home manager said there had only been one fall recorded on 10 November, where the rapid response team reported that Mrs Y was fine. At this point, Mrs Y’s daughter said she wanted to raise a safeguarding concern about how the injury occurred and why it was not discovered sooner. She claimed that she was concerned the care home had “neglected” her mother and that she did not want her returning there.

After looking into the record-keeping at the care home, the council found that it was not possible to pinpoint the fall that caused the injuries, and there were discrepancies in the records about the times and nature of Mrs Y’s falls. The council did not find any evidence of abuse or neglect, but it noted “poor recording of incidents, poor practice and communication.”

A complaint to the Ombudsman followed in September 2022, which stated that it could not be said that the care home’s actions led to Mrs Y’s fall, but that poor record keeping created a sense of “uncertainty and distress” for her daughter over how long Mrs Y had the injuries.

The Ombudsman also found that the council “failed to keep Mrs X updated with the actions it was taking to investigate.” Following the outcome, the council agreed to apologise and pay Mrs Y and her daughter £500 each. It also agreed to provide safeguarding refresher training to relevant staff.

Hayley Ashall, the council’s adult care assistant director for commissioning, said: “We have accepted the Ombudsman’s findings and ensured the report’s recommendations have been actioned.

“An apology has been provided to the complainant and, through ongoing action, we have ensured the care provider’s policies and procedures have been fully updated. The safety and wellbeing of our older and vulnerable residents is always a priority.”

A report by the Care Quality Commission in late 2021 rated the care home as “inadequate.” In the latest report in January this year, it was rated “good.”

Stamford House Residential Home was contacted for comment.

Declan Carey, Local Democracy Reporter