The Local Government & Social Care Ombudsman has found fault with HC-One’s Winters Park care home in Penrith following a complaint about the way it responded to a resident’s falls.
The complainant, referred to as Mrs C, complained Winters Park Care Home had failed to do enough to prevent her mother, referred to as Mrs X, from suffering falls, failed to inform the council’s safeguarding team and should not have moved her mother from the floor onto a bed when she had broken her hip following a fall.
In his findings, the Ombudsman noted the home was in a difficult situation as Mrs X had refused to use her walking frame, which had significantly increased her risk of falls.
While finding no fault with the home’s risk assessments risks and review, the Ombudsman found staff had failed to: update the falls diary on two occasions; consider installing a door sensor, as Mrs X would try to avoid triggering the floor mat sensor; refer Mrs X to the Falls Team via the GP; and discuss Mrs X with the council’s safeguarding team.
The Ombudsman also found staff failed to carry out a sufficiently comprehensive check of Mrs X before moving her after she suffered a fall on 6 May 2020 which resulted in a broken hip fracture.
In his final decision, the Ombudsman recommended HC-One apologised to Mrs C and Mrs X for faults in care and any distress caused, pay each £200 for distress experienced and share lessons learned with relevant staff about falls response and escalation to external stakeholders.
A spokesperson for the home said: “The health, safety and wellbeing of our residents is our number one priority, and we take all feedback from the Ombudsman very seriously.
“We were therefore disappointed in these findings and we acknowledge we fell short of the high standards our residents rightfully expect and deserve. We are deeply apologetic to this resident and their family for the shortcomings in the care provided.
“We immediately addressed the concerns raised as well as the Ombudsman’s actions and we have taken steps to strengthen our oversight process to prevent anything like this happening again.”