Summary: We have found that there was fault as the care home failed to properly plan Mrs B’s father’s care, it failed to carry out the necessary risk assessments after her father suffered falls and it failed to respond to complaints relating to the matters. The Home has agreed to apologise, pay a financial remedy and has carried out service improvements.

The complaint

1. Mrs B complains on behalf of her father, Mr C, who has died. She complains about the care provided by Croft House Care Home (the Home) in Eastburn, Keighley.
2. Mrs B complains about the Home’s care for Mr C, the falls Mr C suffered while he was at the Home, the Home’s communication with her and its failure to call an ambulance when Mr C was unresponsive. She also says the Home never responded to her complaints.

Back to top

The Ombudsman’s role and powers

3. 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. If they have caused a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

5. 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)

Back to top

How I considered this complaint

6. I have discussed the complaint with Mrs B. I have considered the evidence that she and the Home have sent, the relevant law, policies and guidance and both sides’ comments on the draft decision.

Back to top

What I found

Care Quality Commission

7. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards.
9. This says that:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. (regulation 12).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

What happened

10. Mr C was an older man who lived at home with his wife, Mrs C, who was terminally ill. Mr C had a fall at home and was taken to hospital. As Mrs C was in hospital at the time and, as it was not safe for Mr C to return home on his own, it was decided that Mr C would move to the Home when he was discharged from hospital. This was intended to be for a short period only.
11. Mr C moved to the Home on 26 July and was taken to hospital on 29 July 2024. He died a few days later.
12. Mrs B complained verbally to the Home on 2 August 2024 and complained in writing on 24 September 2024.
13. Mrs B complained that:
• The Home failed to provide safe care to Mr C.
• Mr C suffered four falls during his first night at the Home, causing him injuries to his arm and head. The Home failed to take appropriate measures to reduce the risk of falls and failed to inform the family of the falls. Mrs B says she rang the Home on the following day and was then informed of the falls.
• Mr C’s health deteriorated in the three nights that he stayed at the Home. Mrs B visited Mr C on 29 July 2024 and found him unresponsive in a wheelchair. The staff had taken no action in relation to this and Mrs B said she had to demand an ambulance was called for Mr C.
14. Mrs B did not receive a response to her complaint so she chased the Home for a response on and 2 and 15 October 2024 but did not receive any response.
15. Mrs B took her complaint to the Ombudsman on 22 November 2024.
16. The Ombudsman contacted the Home in November and December 2024 and in March 2025 but also did not receive a response. The Ombudsman started its investigation in April 2025 and asked for a response to its enquiries and chased the Home in May 2025 (by email and by post). I then spoke to the manager at the Home in June 2025 who informed me the Home did not check its general email address so the letter of enquiries was re-sent to different addresses. The Ombudsman finally received the response to the enquiries in August 2025.

The evidence

17. I asked the Home to send me the following documents:
• Assessments of Mr C’s needs including any risk assessments, for example relating to mobility and falls.
• Mr C’s care plans, including mobility and falls care plans.
• The daily records of care provided to Mr C.
• Records relating to the four falls, including incident reports, risk assessments, notifications of the falls to outside agencies such as the CQC or local authority, if appropriate.
18. The Home sent me a pre-admission needs assessment which was only partially filled in. The Home did not have a care plan for Mr C. The Home sent me 1 falls risk assessment but, although the name of Mr C was at the top of the assessment, the assessment related to a person with a different female name.
19. There was one body map which showed 5 bruises that Mr C suffered during one of the falls. There were no incident reports, risk assessments or care plans relating to the falls.
20. There were no records of notifications to the CQC about the falls. There was no record that the family was contacted after the falls occurred.
21. Mr C’s daily records said:
• 26 July 2024 (pm). ‘Carer stay with [Mr C] as he (sic) very unsteady on feet and very confused.’
• 27 July (am). ‘Had a fall in the room in the morning’
• 29 July (14:45). ‘[Mr C] has been noticed to be unwell following several falls including were (sic) his injuries including brain bleed x 2. He has been noticed to have deteriorated from how he is responding.’
• 29 July. ‘I have called 999 requesting for ambulance following [Mr C] being noticed by staff to have deteriorated from injuries sustained on different falls. Today [Mr C] could not use his left hand, also could not respond as he normally does. Paramedics arrived at 14:38 and went at 15:20 with [Mr C]. They advised he is going to hospital with his daughter [Mrs B].’
22. The Home provided the following comments to the Ombudsman. The Home admitted multiple faults in its actions. It said a lot of the problems related to a particular member of staff who no longer works at the Home. The Home said that, since the complaint, there had been a complete change in leadership and governance.
23. The Home said it had made the following changes to ensure a similar problem did not occur again:
• Strengthened documentation and care evidence.
• Pre-admission and ongoing assessments now conducted in person, not via telephone.
• Transition to electronic care plans for transparent real-time record-keeping.
• Revised admission times. No admissions after 16:00 on weekdays. No admissions after 14:00 on Fridays.
• Regular audits by the new manager to ensure documentation accuracy and completion.
• Strengthened induction and accountability for agency staff.
• Falls risk assessments fully completed on admission.
• Audit system established to monitor assessment quality.
• Incident reporting had been standardised: All falls/significant events must be documented with body map, incident form, and daily notes.
• Weekly visits by a GP.

Analysis

24. There was fault in the way the Home provided care to Mr C. The Home should have carried out a full assessment of Mr C’s needs before he moved in or at the time he moved in and this should have included a falls risk assessment. The Home failed to do this and this was fault.
25. Mr C was at high risk of falls and therefore the Home should have taken preventative action in relation to falls which should have been detailed in the care plan. However, the Home failed to provide a detailed care plan for Mr C which should have included a mobility plan and falls prevention plan. Failure to provide these documents was fault and meant that Mr C was at increased risk of falls.
26. The Home then failed to take any of the appropriate steps every time Mr C had a fall. The Home should have filled in an incident report and body map and it should have updated the falls risk assessment and/or the mobility/falls risk plan to reduce the risk of a further fall. I could not see any evidence that the Home took the necessary steps or kept the appropriate records. That fault compounded the Home’s initial error and meant Mr C continued to be at high risk of falls.
27. The Home also failed to contact Mr C’s family once Mr C had suffered the falls. Mrs B only found out about the falls when she rang the Home. The Home should have contacted the family and its failure to do so was fault.
28. The Home should also have informed the CQC and did not do so.
29. Mrs B said that she found Mr C on 29 July in his wheelchair, unresponsive and the Home had not taken any action in response to this. She said she had to insist that an ambulance was called. I accept Mrs B’s evidence in this respect.
30. The Home then failed to respond to Mrs B’s complaint despite repeated chasing from Mrs B. That was further fault.

Injustice

31. I have considered the injustice resulting from the fault. Sadly, the person who has suffered the most injustice, Mr C, has died so any injustice he has suffered cannot be remedied.
32. However I do not underestimate the level of distress Mrs B suffered. Mrs B has explained to me that her mother, Mrs C, was in hospital, dying, when Mr C was ready for discharge from hospital. The family made the difficult decision to place Mr C at the Home as they thought he would be safe there while the family spent time with Mrs C during her final days. Mrs B said she would always carry the immense distress that Mr C suffered so much in his last days at the Home. This added to the pain of losing both parents within days of each other.
33. The aim of the Ombudsman’s remedy is to put the complainant in the position they would have been if the fault had not happened. Sadly, that is not possible in this complaint.
34. I note that the Home has not charged the family for the stay. I asked Mrs B what she wanted to achieve from coming to the Ombudsman. She said that she wanted to ensure that no family ever had to go through what she and her family went through.
35. I note that the Home has upheld a lot of Mrs B’s complaints in its response to the Ombudsman which is a positive factor. The Home has also made a number of improvements since Mrs B’s complaint which should address the failings that I have found. Nevertheless, I will forward this decision statement to the CQC as the CQC is best placed to consider whether any further service improvements are required.
36. I will also ask the Home to share this decision statement with all the relevant staff so that the decision can assist in the staff’s training and reduce the risk of similar incidents occurring.
37. In a case such as this one, where there is no financial injustice resulting from the fault, the Ombudsman sometimes recommends a small symbolic financial remedy of a few hundred pounds. The Ombudsman is not a court and we do not recommend compensation. I know that Mrs B has not asked for a financial remedy but, as we normally recommend this, I recommend the Home pays Mrs B £300.

Back to top

Action

38. The Home has agreed to take the following actions within one month of the final decision. It will:
• Apologise to Mrs B in writing for the fault that I have found.
• Pay Mrs B £300.
• Share this decision with relevant staff.
39. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

Decision

40. I have completed my investigation and have found that the Home’s actions have caused an injustice. The Home has agreed the remedy to address the injustice.

Back to top

Investigator's decision on behalf of the Ombudsman