Sheffield Council ordered to apologise as its care provider 'failed to look after elderly woman'

The case of Mrs Y – who had dementia – was raised with the Local Government and Social Care Ombudsman by her daughter, Mrs X.

A report concluded that it was “no longer possible to remedy the injustice to Mrs Y as she has died” after a fall at a care home, but the council should apologise to her daughter, make a symbolic payment of £250 and work with the care home to improve its practices.

According to a report, Mrs Y had lived at home with her husband. Sheffield Council first gave her “reablement support” in December 2022 when she went home from hospital to help her independence and then it agreed to long-term support (in the form of four calls a day – this included help with washing, dressing, medication, continence, meal preparation).

In February 2023, the report said, the council agreed Mrs Y should access day services to prevent social isolation and it then agreed to respite care because “Mr Y was struggling to cope because Mrs Y was wandering around at night”.

The same assessment said Mrs Y needed help maintaining her nutrition and hydration as she needed prompting to take three prescribed fortified drinks a day and had a dietician monitoring her.

Following this, the council made a care and support plan and sent a copy of it to its care provider Valley Wood.

The plan said she needed help with stoma care, personal care, administering medication, ensuring she had her fortified drinks, as prescribed and making meals and drinks.

The report said Mrs Y had gone to stay at Valley Wood on March 21.

The respite care plan included, among other things, that she was not a falls risk, she would wander around the unit at night and she needed hourly checking.

While the care home had not formally recorded her food and fluid intake, the report said they had recorded some of what she had eaten and drank and it suggested “Mrs Y ate and drank most of what she was given”.

On March 26 she had an “unwitnessed fall” at 6.45am where she cut her head and broke her collarbone.

The staff, who called for an ambulance after 7am, said they had been helping another patient when they had heard a bang.

Following an investigation by the company that runs the care home, a staff member had been suspended. It also admitted that “it had been distressing for Mrs Y to be on the floor for an hour after her fall”.

However, this was put down to the time taken for the ambulance to arrive and following advice not to move her until it arrived.

The care provider had accepted that “a lack of care and compassion had been shown to Mrs Y and her family, and apologised”.

The ambulance service said that Mrs Y had been covered in bruises and they were told she had been up all night banging her head and shoulders on doors.

Also, they added “there was a strong smell of cannabis in the entrance to the care home” – but it was suggested this could have come from outside the home.

The council had also made safeguarding enquiries into a number of concerns raised.

It found that Mrs Y had been covered in bruises due to her fall but she had not been banging her head on door frames.

It found: “Mrs Y had been walking around the unit and was unsettled, but had not been banging her head on door frames. If this had happened staff would have sought assistance.”

The report said Mrs Y had left the hospital on April 28 and relocated to another care home where she died on May 7.

The ombudsman found that a number of faults had been made.

This included the fact that neither the council nor the care home had assessed Mrs Y as being at risk of falls.

Another one is while the care home assessed Mrs Y as needing hourly checks at night, records showed that it did not provide hourly checks.

“That was further fault, which put Mrs Y at risk of harm”, the report said.

In conclusion, the ombudsman said: “It is no longer possible to remedy the injustice to Mrs Y as she has died.

“However, the council should apologise to Mrs X, make a symbolic payment (£250) to her for the distress she has been caused and work with the care home to improve its practices.

“The faults identified raise the possibility that there have been breaches of the fundamental standards.”