Summary: Mrs B complained about the standards of care her mother Mrs X, received at a care home. The Council was at fault. The care provider failed to carry out some of Mrs X’s care in line with her care plan and kept poor and inaccurate records. This caused distress, frustration and uncertainty about the care Mrs X received. The Council will apologise and make a symbolic payment to Mrs B to remedy the injustice caused. It agreed to carry out service improvements with the care provider.

The complaint

1. Mrs B complained about poor standards of care provided to her late mother, Mrs X, by the Council commissioned care provider, Prime Life Ltd, which runs Lyndon Croft Care home (the Home). She said a lack of supervision led to Mrs X having an unwitnessed fall which she says contributed to her death.
2. She said the Home has provided misinformation about the incident causing the family distress, frustration and uncertainty.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service and use public money carefully. We do not start or continue an investigation if we decide any injustice is not significant enough to justify our involvement. (Local Government Act 1974, section 24A(6), as amended, section 34(B))
4. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions.
5. 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).
6. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
7. 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(i), as amended)
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

9. I considered evidence provided by Mrs B, the Council and the Care Home as well as relevant law, policy and guidance.
10. Mrs B, the Council and the Care Home had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

Back to top

What I found

Relevant law and guidance

Fundamental Standards of Care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision.
12. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences..
13. Regulation 12 of the 2014 Regulations says care must be provided in a safe way including assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks.
14. Regulation 17 of the 2014 Regulations says providers must securely maintain accurate, complete, and detailed records in respect of each person using the service.
15. Regulation 20 of the 2014 Regulations requires providers to act in an open and transparent way with persons receiving treatment from them. Duty of candour must be applied for ‘notifiable safety incidents’.
16. In 2023 we issued Good record keeping: guide for care providers . We said care providers should ensure:
• all care records are accurate honest and comprehensive; and
• we are likely to find a care provider at fault where records are illegible, have clearly been changed after the event, where they are inadequate or purpose, or where they omit essential information or include misleading information.

CQC (role)

17. 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.

Call bells in care homes

18. Care homes are required to have a suitable Nurse Call system to ensure the safety and well-being of residents. They provide residents with a means to request help and facilitate timely and targeted interventions for care. The care providers call bell policy, May 2024 said:
• call bells should be responded to at the earliest opportunity and within no more than five minutes;
• if unable to respond immediately to a request, it is important to still establish the client is not vulnerable to risk or injury; and
• where response times exceed the expectations, the manager will instigate an investigation into the reasons for the delay.

What happened

19. Mrs X was an older woman who lacked capacity, needed additional care and support who had lived at Lyndon Croft care home (the Home) from late 2022 until her death in 2024.
20. Mrs X’s care plan and fall prevention plan dated May 2024 outlined the following:
• to be observed every half an hour during the day and hourly at night;
• at high risk of falls with associated fall prevention plan.
• Falls saving equipment in place on a night, including a sensor mat by her bed.
21. At the end of May 2024 staff conducted a nighttime check of Mrs X at 03:02am and reported her to be asleep. At 05.02am Mrs X’s room call bell was recorded as sounding and was recorded as being turned off at 05.36am.
22. Care staff on duty gave an account of what happened. They said during hourly checks at 5:00am, Mrs X’s call bell sounded. They entered her room at approximately 05.15am and found Mrs X had fallen out of bed and had blood near her eye and on her nose and leg. They said a senior member of staff was alerted, an ambulance called and then they informed Mrs X’s family. Mrs X was taken to hospital by the ambulance.
23. An incident report was completed by the Home that day, it said:
• Mrs X’s fall was reported to a senior member of staff at 5:15am;
• a safeguarding referral and CQC notification had been made;
• the Council and family had been informed; and
• it had updated Mrs X’s risk assessments, care plan and fall log.
24. At the start of June 2024, a debrief report of Mrs X’s fall was produced for staff and her care plan updated, they said:
• Mrs X had been diagnosed with a bleed to the brain because of the fall;
• she was at high risk of age-related frailty and falls causing injury due to a history of falls and anticoagulant medication;
• she was unable to use a call bell and a call bell risk assessment was in place. A bed, chair and floor sensor mat were all in place;
• care staff were to ensure Mrs X always had access to her call bell, with it being in reach and in good working condition;
• a fall prevention plan was in place, with observations remaining half hourly throughout the day and hourly during the night;
• Mrs X required a lot of encouragement to get into bed and tended to sleep in her day clothes. She would often sleep in her chair;
• she was not at risk of choking; and
• if she refused prescribed medicines for three consecutive days, her GP should be informed.
25. A CQC referral was also made at the start of June 2024.
26. Mrs X passed away in late June 2024.
27. Mrs B complained to care provider, she said:
• the family had been phoned by the care provider and told Mrs X had experienced an accident and had ‘slight’ wounds to her head and leg. On arriving at hospital, they found Mrs X to have a bleed on the brain, a broken nose and bloodied feet. She had also been sent to hospital with no underwear and had another resident’s prescription;
• the family had asked for the incident report but had been told this was not ready;
• Mrs X’s sensor mat was under the bed and had clearly not been used. It was dusty and given the amount of blood from the incident Mrs B would have expected it to be ‘ruined’;
• Mrs B had been supporting her mother’s care for 22 months, going into the Home three to four times a week. Mrs X very rarely slept in her bed, preferring to sleep in her clothes in her ‘big’ chair;
• after returning to the Home from hospital, Mrs X had a further scan on her brain and it was found the bleed was continuing, she was prescribed pain relief and antibiotics, but these were never given to her; and
• after recognising Mrs X was declining in health the family stayed at the home for four nights. They were told by a member of senior staff that the home did not know what had happened to Mrs X. Staff seemed evasive and they overheard a member of staff talking about Mrs X’s end of life treatment which the family were unaware she was receiving.
28. After meeting with Mrs B to discuss her concerns, the care provider provided a response in late November 2024. It said:
• statements from staff said Mrs X had fallen in her room and nowhere else in the home. It said Mrs B could confirm this through ambulance records;
• Mrs X’s body map of the incident recorded a cut above the eye as a head injury. An ambulance was called due to Mrs X being on anticoagulant medication and significant bruising could occur because of this;
• prescribed medicines were not given because they had been unable to be administered orally and staff had noted a risk of choking;
• the open discussion of Mrs X’s end of life medicine was not what was expected of staff; and
• the family had spent long periods with Mrs X in the final days and had requested staff not to keep entering the room.
29. At the end of December 2024, Mrs B escalated her complaint, she said:
• the response had not answered all her questions;
• there had not been a request made for staff to not enter Mrs X’s room;
• she was aware that information was not recorded and that accidents do happen;
• she wished to have a further meeting in the new year; and
• Mrs X had been receiving 24-hour care, receiving no answers was distressing to the family.
30. In its response the care provider said it had reviewed all the available documents, spoken with the staff and was unable to provide further answers to what had happened to Mrs X. It reiterated that Mrs B could contact the ambulance service and to contact the Council if she felt it had not provided a full enough response to her concerns.
31. Mrs B remained unhappy with the actions and responses she had received and asked the Ombudsman to investigate.

The care provider’s response to the Ombudsman

32. The care provider said
• Mrs X’s care plan did state, at the time of the incident, she should have been receiving hourly observations on a night, however this was not required as she had an alarm mat in situ and so these should have been conducted every two hours. This should have been amended on the care plan and was an oversight by the care home. Staff carried a priority list giving the ‘headlines’ for each client’s care which showed Mrs X to be on two hourly observations at night.
• After Mrs X’s fall in May 2024, observations were increased as per policy and updated on her care plan.
• Correct staffing of four carers and one senior were on duty on the night of the incident.
• No documentation was left by the attending ambulance and the time the call to the ambulance was made had not been logged by staff.
• Staff contacted the family after the incident but failed to record the time this was completed. Electronic care planning was now in place to avoid such omissions in the future.
• Staff attended to Mrs X at 5:15am but there is no evidence to support why there was a delay getting to the room. Deactivation was not completed until 5:36am but it would be reasonable to assume that the priority would have been Mrs X’s care and support.
33. The care home said it completes call bell checks every six months. The care provider provided call bell audits for:
• February 2024, reporting one line of information advising all nurse call bells and all residual current devices (RCD’s) had been tested with no defects; and
• May 2024 reporting one line of information advising not all nurse call bells had been tested however all RCD’s had been tested. No defect information recorded

The Council’s response to the Ombudsman

34. The Council received a safeguarding report from the Home regarding Mrs X’s unwitnessed fall. It said:
• The Home told a social worker she had left her bed and was encouraged by staff to return to bed at 5:00am. At 5:15am Mrs X’s sensor alarm sounded and staff attended to Mrs X who was found on the floor;
• It was decided a full safeguarding investigation was not required as the incident appeared to be accidental. The social worker was advised by the ambulance, Mrs X had said she had tried to turn over in bed and her injuries looked consistent with making contact with bedroom furniture;
35. It said it maintained oversight of the Home by conducting audits and visits, with the frequency of these determined by the level of risk identified through safeguarding alerts, stakeholder feedback and care reviews. The Home had been subject to a high number of visits from the start of 2024 and through 2025 due to the level of risk identified as well as significant drop in its CQC rating in December 2024. The Council had suspended all new placements in December 2024 as a result of the issues raised in the CQC inspection report and implemented an action plan for improvement.
36. The Council made 18 visits both announced and unannounced to the Home between the start of January 2025 and November 2025 to monitor the actions against the issues identified and offer support where it was required. It removed the new placement suspension in May 2025 as a result of progress.
37. It said despite previous sanctions, the care provider had failed to adhere to policy and notify it of the complaint from Mrs B. It only became aware of her concerns via a CQC safeguarding referral.
38. During its monitoring after the December 2024 CQC inspection report, it had identified delays updating and inconsistencies in care plans, issues with quality and consistency of record keeping. This was identified as a risk to residents and the Home had been required to make improvements as part of the action plan, which remained an area of ongoing oversight. The care provider had implemented an electronic care record system at the end of 2024.
39. It said the care provider had not previously shared call bell response time with it and these had been found to be below expectations. It had identified that call bell responses times were not part of its standard audit process and these were now included.

Analysis

40. At the time of the incident in May 2024, Mrs X’s care plan required her to receive half hourly checks during the day and hourly checks at night. The care provider only checked her every two hours because a sensor mat was in place. These checks did not align with the care plan which was fault.
41. The care provider said Mrs X had not been given medication prescribed after her fall due to a risk of choking. However, Mrs X’s care plan at the time said she was not at risk of choking and her GP should be contacted if medicines are refused for more than three days. This response does not align with Mrs X’s care plan and further there is no evidence her GP was contacted. This was fault.
42. Records were not accurate regarding Mrs X’s care and her fall in May 2024. This is because
• The Council said a social worker was told by the Home, Mrs X was found out of bed a 5:00am on the day of the incident and encouraged to get back into bed. Her call bell is recorded as sounding at 5:02am. Had staff found Mrs X at 5:00am as was reported, it would be reasonable to assume they would be still with her at 5:02am, therefore Mrs X would not have needed to use the call bell. Further, staff statements say they attended Mrs X at approximately 5:15am, with the reason for the delay outside of the care providers ‘within five minutes’ policy not recorded.
• There is contradictory information regarding Mrs X’s type of call bell sensor in her care plan. It is recorded that she is unable to use a call bell however her plan also states it should always be easily accessible and within reach of her.
43. The inaccurate case records are fault. It leaves uncertainty around whether Mrs X’s care needs were properly met at all times during her time at the Home.
44. Poor record keeping and inaccuracies in testimony and documentary evidence indicate the care that Mrs X received fell below that which she was entitled to expect. She was put at an increased risk of harm. However, I cannot say these caused Mrs X’s deterioration and ultimately her death, but it would have caused avoidable uncertainty and distress to Mrs B and the rest of her family.
45. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. Mrs X has now passed away and therefore it is not possible for the Ombudsman to remedy any injustice caused to her.
46. However, if we consider the person who has complained to us has been adversely affected by the impact of that poor care on their relative, we may make a recommendation to remedy their own distress.
47. The faults identified caused Mrs B significant distress and uncertainty.
48. The Council is already carrying out significant work to improve the care provided by the Home. However, it is evident that the care provider is not following policy in notifying the Council when residents and their families raise concerns about the care being provided. This is fault. Therefore, it is appropriate to make recommendations relating to this.

Back to top

Action

49. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with care provided on behalf of the Council.
50. Within one month of the final decision, the Council will:
1. Apologise to Mrs B for the distress, frustration and uncertainty caused by the standard of care Mrs X received. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology.
2. Pay Mrs B a symbolic payment of £300 to recognise the uncertainty and distress caused to her.
3. Provide an update on the care providers compliance with the care providers improvement/action plan from November 2025 to date. If the Council has carried out any visits/inspections since then it will provide a copy of the report.
4. Ensure the provider has procedures in place to refer all complaints about care which the Council has commissioned to the Council for it to investigate under its own complaint procedures.
51. The Council will provide us with evidence it has complied with the above actions.

Back to top

Decision

52. I find fault causing injustice.

Back to top

Investigator's decision on behalf of the Ombudsman