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West Berkshire Council issue apology following elderly man falling at care home

WEST Berkshire Council (WBC) has apologised after a care home failed to adequately put in place measures to prevent an elderly man from falling repeatedly, writes Local democracy Reporter Tevye Markson.

A report from the Local Government and Social Care Ombudsman (LGSCO) found fault with the actions of the care provider, which is commissioned by the council.

When a council commissions another organisation to provide services on its behalf, it remains responsible for those services and for the actions of the organisation providing them.

West Berkshire Council
West Berkshire Council

Council spokeswoman Peta Stoddart-Compton said: “Following the complaint made to the care home, a full investigation was made by the Local Government and Social Care Ombudsman (LGSCO).

“The majority of the complaint was not upheld by the LGSCO.

“The council accepts the LGSCO’s finding that there were two measures the care home could have considered to potentially reduce risk further in addition to actions taken.

“The council has apologised to the family member.

“The LGSCO confirmed that they were satisfied and the complaint was subsequently closed.”

The man, anonymised as Mr F in the report from LGSCO, who has since passed away, went into hospital in January 2017, following an unwitnessed fall at his home and then went into a care home in May 2017.

The care home reviewed Mr F’s risk of falling every month and noted in April 2019 that he had become unsteady on his feet and had issues with balance.

It said he had a high risk of falling due to his medication, visual impairment and cognitive issues that could impact his perception of risk.

His daughter, known in the report as Mrs C, said his risk of falls was mainly due to the type of dementia he had.

In May 2019, Mr F has several suspected unwitnessed falls and was referred to a physiotherapist for a mobility assessment, leading to the council ordering a walking frame that he could use in the evening when he was less steady on his feet, as well as a chair raiser.

Four unobserved falls in June 2019 culminated in a broken hip and hospital admission from the fourth fall.

When the care home noticed that Mr F’s risk of falls had increased, it organised two reviews by his GP, a physiotherapy assessment, provided a walking frame and chair raiser, and told staff to regularly check up on him.

The LGO inspector said it is clear the care home responded to Mr F’s increased risk and pursued various options to reduce this.

However, the inspector said, as Mr F’s falls were unwitnessed, the home should have encouraged him to be more in communal areas where staff would be present.

The care home acknowledged at the time that staff should try and observe Mr F as much as possible but the inspector said it could have considered regularly encouraging Mr F to spend more time in a communal area as a possible strategy to try and reduce the risk.

Although the council said staff had regularly tried to ensure Mr F would spend time in communal areas during the day, the inspector said it provided insufficient evidence to support this.

Additionally, while Mr F had a sensor mat next to his bed to alert staff when he would try to get out of his bed, there was no evidence the care home considered putting a sensor mat in front of Mr F’s chair to alert staff when he would try to get up and mobilise.

The inspector said the care home should have considered this.

But the inspector admitted these measures would not necessarily have reduced the number of falls Mr F experienced.

The inspector asked the council to provide an apology for the care home failing to put in place, or at least consider, the two measures that could have reduced Mr F’s risk of falling.

West Berkshire Council accepted the recommendations and has apologised to Mrs C.

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