Summary: There is insufficient evidence that fault has caused injustice to Mr X. The falls protocol has been enacted when appropriate. There were some concerns about hospital transport but the care provider has worked to resolve those. The Council and care provider have provided evidence that staff are appropriately trained.

The complaint

1. Mrs A (the complainant) complains about the standard of care and treatment for her disabled brother Mr X in a care home. She says he has fallen frequently because of staff failure. She says hospital appointments have been missed or aborted because of poor arrangements. She says the care home staff do not have the right expertise to manage her brother and fail to observe his traditions.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

4. I considered evidence provided by Mrs A and the Council as well as relevant law, policy and guidance. I spoke to Mrs A.
5. Mrs A and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

6. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has.
7. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months.

What happened

8. Mr X is an elderly man with autism and cerebral palsy: he has been supported in his current tenancy with other adults since 2010. His mobility has decreased over recent years. Mr X can make his own decisions about his care and accommodation. He has other siblings and friends with whom he socialises.
9. Mrs A says since 2018 when the care agency took over caring for Mr X from local authority staff, she has noticed more problems arising. She says the staff are not sufficiently well trained in cerebral palsy in particular, and Mr X started having a lot of minor injuries and mishaps because they were not accustomed to meeting his needs. She said staff could not support him properly at medical appointments, which he feared, and he had a meltdown which staff could not manage, so he missed the appointment. She said there were mix-ups over transport to dental appointments. She also complained that she could not always understand the staff, and that they did not celebrate traditional cultural occasions like Easter in the preferred way.
10. In February 2025 Mrs A complained to the Council about the lack of specialist training and its impact on Mr X.
11. The team leader responded at the end of March. She said the agency team had all had the autism training required. She said as Mr X also had a nurse and social worker involved from the learning disability team, any other specific required training would have been recommended by them. She said while it was true that Mr X had fallen more often, the evidence showed the staff had followed the correct protocols. She said neither his nurse nor his social worker had identified that he needed any different level of care.
12. The team leader also said that she would ask the Learning Disability nurse to support staff with ways to manage difficult behaviours displayed by Mr X (such as the ‘meltdown’ which had prevented him receiving treatment at appointments). In respect of preventing further falls, she described the sensor mats and other assistive technology which was already in place but said she would ask for a further review.
13. The Council did not uphold the complaint.
14. Mrs A also complained to the agency, whose manager spoke to Mrs A by telephone and then wrote to her in April. She said all staff at Mr X’s tenancy had received refresher training on autism and specifically on cerebral palsy in addition to the required level of training for all staff. She said there was a comprehensive falls protocol in place for Mr X. In terms of missed appointments, she said this had been raised at a meeting previously and the provision of wheelchair accessible taxis discussed. Finally she acknowledged that Mr X’s room and possessions had not always been maintained in good order. She said staff had given Mr X (who had capacity to make his own choices in this respect) autonomy to choose what he kept and threw away.
15. Mrs A remained unhappy and contacted the Council again. The Council reviewed the complaint and responded to it but did not uphold it. Mrs A complained to the Ombudsman.
16. The Council has provided details of the staff training and logs of the falls Mr X has had, together with his falls risk assessment and the protocols which apply, and an environmental risk assessment for the property where he lives It says “the Falls risk Assessment was reviewed as part of the complaint investigation and was deemed to be appropriate. The night support element at the provision was changed from a sleep into a waking night in July 2025 to help to reduce falls. This has remained in place and at the last review in October 2025 (Mr X) had had no additional falls.”
17. The Council also says that Mr X is still receiving physiotherapy and his therapist does not consider a referral to the falls team is needed at the moment.

Analysis

18. There is no evidence the Council and care provider have failed to consider Mr X’s needs and put in place measures to meet them. There is a falls protocol in place which has been adhered to, his falls risk assessment has been reviewed and no further measures recommended at the moment. That has been confirmed by his physiotherapist.
19. Mrs A has had concerns about the staff training specifically in relation to Mr X’s cerebral palsy but again there is no evidence to suggest that has been lacking (staff have had refresher training in both autism and cerebral palsy) or that staff could have acted differently. The Council has undertaken to review whether different strategies might be adopted but I see no evidence of fault in the training which has been undertaken.
20. The Council and the care provider investigated and responded to Mrs A’s other concerns about some items (of sentimental value) which had gone missing from Mr X’s room. They pointed out there was a balance to be struck between allowing Mr X the autonomy to choose what he kept, and having oversight of the state of his room. I do not see evidence of fault there.
21. There were also some concerns about the arrangements for Mr X’s dental hospital appointments. However, those were now some time ago and since then the support staff have looked at different options (wheelchair accessible taxis, hospital transport and so on) which should prevent a recurrence.

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Decision

22. I have completed this investigation as I find no fault on the part of the Council which has caused injustice to Mr X.

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Investigator's decision on behalf of the Ombudsman