HC-One Oval Limited (20 003 652)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 16 Mar 2021

The Ombudsman's final decision:

Summary: The Ombudsman finds the care provider caused Mrs X an injustice in failing to provide satisfactory care to her. This includes poor hygiene and nutrition levels, and for failing to adhere to its own risk assessments. The care provider has agreed to apologise to Mrs X and pay a financial remedy.

The complaint

  1. The complainant, whom I refer to as Mrs X, complains that Willowbrook House care home did not provide satisfactory care to her while she lived there.
  2. Mrs X complains that poor care resulted in her having multiple falls, causing long term mobility problems.
  3. Mrs X also complains the care home did not treat her with dignity and respect regarding her personal hygiene and continence, and that the care home failed to provide appropriate support for eating and nutrition

Back to top

The Ombudsman’s role and powers

  1. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
  2. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

Back to top

How I considered this complaint

  1. I have considered the information provided by Mrs X’s representative, Mrs A. I have also considered information and care records provided to me by the care provider. I considered comments from Mrs A and the care provider on my draft decision.

Back to top

What I found

Fundamental standard for Care Providers

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
  2. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
  3. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

What happened

  1. Mrs X lived in a care home for approximately nine weeks between December 2019 and February 2020. The cost of the care home was £900 per week.
  2. Mrs X was removed from the care home in February 2020 by her family. Her family say they grew concerned about the level of care she was receiving and the impact of the falls on her long term health.
  3. Mrs X’s family complained to the care home in July 2020. Mrs X’s family were particularly concerned about the lack of nutrition she had received throughout her stay, the lack of personal care, and the falls that she had suffered while living at the home.
  4. In its complaint response, the care home agreed it would review provision of drinks and snacks to residents. It also said that decisions about Mrs X’s mobility were made by NHS physiotherapists, but that it would review Mrs X’s last fall to see if any learning could be achieved. The home said it hoped it would continue to work with residents and families to provide person centred care.
  5. The care home also offered Mrs X’s family a refund of £2400. The family did not accept the refund, and chose to bring their complaint to the Ombudsman as they remained unsatisfied by the care given to Mrs X.

Mrs X falling in the care home

  1. During Mrs X’s pre-admission assessment for the care home, she was identified to have a history of falls, with two members of staff needed to help her mobilise.
  2. Four days after moving into the home, Mrs X had a fall. The home said that Mrs X tried to mobilise herself out of bed without calling for help and fell. This fall resulted in injuries to Mrs X, and the home called for an ambulance. Mrs X was treated at the hospital and returned to the home the same day.
  3. After her fall, the care home put a sensor mat in Mrs X’s room to alert staff to any attempts to mobilise herself without support.
  4. Five weeks after moving into the home, Mrs X had a second fall. The home say the second fall took place was a controlled fall, where a member of staff was helping Mrs X when she fell. The staff member supported Mrs X to the floor and she suffered no injury.
  5. Although the care home said it would review the falls to Mrs X, it accepted that Mrs X’s second fall happened when she was being supported to mobilise by one member of staff. The care provider said that Mrs X was working with a physiotherapist and her mobility was improving, but her care plan remained unchanged and she should have been supported by two members of staff. The care provider has said that falls training for staff was reviewed and all staff attended a refresher of the training because of this.
  6. Mrs X’s family complain that she has suffered long term impact on her health because of the two falls she experienced while living in the care home. They say that she now cannot walk without a walking aid.


  1. The care home records show the care home sought out medical attention and completed the necessary paperwork for Mrs X’s first fall. As a result, a sensory mat was placed in Mrs X’s room and a referral was completed to the occupational therapist. This would have minimised the risk of falls and potential harm.
  2. However, Mrs X’s pre-assessment clearly identified that she had a history of falls. It is my current view the sensory mat should have been placed in Mrs X’s room from the start of her stay there. This would have alerted staff to her movements and could have prevented the first fall and the injuries she sustained.
  3. During the second fall, the care home has said that Mrs X was only being supported by one member of staff instead of two when she fell, however it was a “managed fall” and she did not suffer injuries.
  4. The home has reviewed its falls training and all staff have attended a refresher. In its response to the Ombudsman’s enquiries, it accepted that when the second fall happened, it had not followed its own risk assessment. However, it had not acknowledged this to Mrs X or her representative previously.
  5. Therefore, it is my current view that there is fault by the care home regarding Mrs X’s safety. The care home did not adequately address the initial risk of Mrs X falling and failed to adhere to its own risk assessment. This was fault causing Mrs X significant injustice.
  6. Mrs X’s representative says that Mrs X was able to walk unaided when she entered the care home, and since leaving can only walk with an aid. I cannot decide on health-related matters. In the case of this complaint, I have not seen evidence to suggest that Mrs X requires walking aids because of her falls at the care home.

Mrs X’s personal care and dignity

  1. Mrs X complains the care home did not provide satisfactory support for her personal care and dignity.
  2. I have reviewed Mrs X’s records from the care home about her personal care. I observed that during Mrs X’s stay at the home, she had a bath or a shower on nine occasions. On the other days, she received a body wash. The regularity of the baths or showers is inconsistent, and there were occasions where Mrs X did not have a bath or shower for up to 11 days.
  3. I also observed the care home did not regularly wash Mrs X’s hair. Mrs X’s care plan recorded that Mrs X took pride in her hair and presentation. The records show that Mrs X’s hair was washed most of the time during hairdressing appointments and there were periods of up to 10 days where Mrs X’s hair was not washed.
  4. Additionally, Mrs X’s family have said they observed that on multiple occasions, Mrs X soiled herself because staff took too long to take her to the toilet. This meant that she restricted the amount she ate and drunk because she was worried about soiling herself. This would have contributed to the poor personal hygiene that she was experiencing.


  1. This is an unacceptable level of personal hygiene that Mrs X had to endure during her stay at the care home. Mrs X’s care plan documented that she could shower with support, and that her hair was important to her personal identity.
  2. I uphold Mrs X’s complaint the care home did not provide satisfactory care towards her personal hygiene.
  3. Mrs X’s nutrition intake
  4. Mrs X’s representative complains about the nutrition that Mrs X received throughout her stay at the care home.
  5. I have reviewed the care home records from Mrs X’s stay. Her records show that on multiple occasions, Mrs X ate minimal levels of food, and sometimes did not eat at all after lunch time. It also showed that on Christmas Day 2019, Mrs X had no food at all. The records show that Mrs X was offered food on these occasions, but refused it.
  6. Mrs X’s fluid records show that she did not meet her fluid goal for approximately a third of the days that she lived in the care home. Again, the records show that this was down to Mrs X refusing fluids.
  7. Additionally, care home records show that when she first moved into the care home, Mrs X weighed 56.3 kilos, and when she left the care home nine weeks later, she weighed 53.6 kilos. This shows she lost just under three kilos of weight during her stay, despite having reduced mobility.
  8. The care home said that it would review what snacks and drinks it has available for residents.


  1. The CQC guidance for care homes says “Providers must follow people's consent wishes if they refuse nutrition and hydration unless a best interest’s decision has been made under the Mental Capacity Act 2005. Other forms of authority such as advance decisions should also be taken into account.”. Mrs X had not had a decision made about her nutrition and hydration needs under the Mental Capacity Act 2005, and could give consent about the food and fluids she wished to have.
  2. However, the CQC guidance also says, “Nutrition and hydration needs should be regularly reviewed during the course of care and treatment and any changes in people's needs should be responded to in good time.” Mrs X’s records show that staff made the same comment sometimes daily that she needed to be encouraged to eat more, therefore recognising that she was often not eating enough. It is my current view that the care home should have acted on this repeated observation and worked with Mrs X and her family to identify ways to encourage her to eat more food.
  3. It is also my current view that it is not acceptable for Mrs X to have had no food on Christmas Day. There appears to be no reason given for this except that she refused, and it is my view that Mrs X suffered an injustice. Mrs X experienced a significant fall on the night of Christmas Eve/Boxing Day and did not have any food until arriving back at the care home, therefore her records show she did not have any food for approximately 40 hours.
  4. Having also reviewed Mrs X’s fluid charts, I can see that throughout her stay she regularly did not meet her fluid input goals. The care home again cited her refusal being the reason for her not meeting her goals. It is my current view that if staff were repeatedly identifying that she was not meeting her goals because of her refusal, that this should have been addressed and strategies identified to better encourage Mrs X.
  5. Mrs X’s family say her refusal of food and fluids to her being worried about soiling herself because staff did not always take her to the toilet in time. It is my view that further discussions could have been had with Mrs X and her family which would have addressed these issues when they started to arise.
  6. The care home has said that the records for Christmas Day were a “recording omission”. However, I have reviewed all of the daily records from the care provider and find that the rest of its record keeping is detailed and consistent. The record from Christmas Day does contain recordings from staff, therefore I am of the view it is not a recording omission, but that the notes on the records are accurate and Mrs X did not eat any food.
  7. The care home also said that the fluid target for Mrs X was a guide for her fluid intake, and that she regularly consumed an appropriate amount of “cups of fluid”. I have reviewed the fluid intake charts do not find this to be a suitable unit of measure as all the records and guides are completed in millilitres.
  8. I have reviewed how the care home calculates a guide amount, and this was not the target set for Mrs X. She was given a target lower than the one used as a guide, which was acceptable as she did not require a fluid restriction. However, she still did not meet the lower target set for a third of her stay in the home.
  9. It is my current view the care home did not act on the repeated observations of Mrs X’s fluid and nutrition, and Mrs X continued to lose weight. This was fault by the care home causing Mrs X significant injustice.

Back to top

Agreed action

  1. The care provider has offered Mrs X’s family a refund of £2400, which Mrs X’s family have refused.
  2. It is my view the care provider failed to manage almost all of Mrs X’s care needs. It has agreed to apologise to Mrs X and refund the fees in full within four weeks of the issue of my final decision.
  3. In addition, it has also agreed that within eight weeks of my final decision it will
    • Explain what action the care provider will take to ensure residents receive appropriate personal hygiene care, and how supervisors will review care records and ensure care plans are followed.
    • Explain what action the care home will take to ensure it provides nutritional and fluid care that is in keeping with the Care Regulations. This should include action to ensure care staff are appropriately trained to identify when further action needs to be taken.
    • Explain what action the care provider will take to ensure residents risk assessments appropriately address risks when they are first identified and are adhered to throughout the residents stay.
  4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

Final decision

  1. I have found the care provider caused an injustice by not providing satisfactory care and support for Mrs X’s personal care, safety and nutrition.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

Privacy settings