Summary: We partially upheld a complaint from Mrs B about care provided to her mother, Mrs C, by the Care Provider. We found fault in the Care Provider’s record keeping around cuts and other wounds Mrs C sustained while living in one its care homes. We also raised concerns about the procedure followed by the Care Provider when it gave Mrs C notice to leave the care home. While Mrs C subsequently died, we considered these faults caused injustice to Mrs B as distress. So, we recommended action we wanted the Care Provider to take to remedy that injustice and improve its service for others. The Care Provider said it agreed our recommendations.

The complaint

1. Mrs B complained about the care her late mother, Mrs C, received while resident at the Haywood Lodge Care Home (‘the Care Home’). Ideal Carehomes (Number One) Limited, which is part of the HC-One Group (‘the Care Provider’) operates the Care Home. In particular, Mrs B complained the Care Provider:

• gave inaccurate accounts of falls Mrs C had at the Care Home in April and November 2024;
• over-medicated Mrs C between September 2024 and November 2024;
• could not properly explain cuts Mrs C received to her arms at the end of October 2024;
• did not properly manage Mrs C’s needs associated with her having dementia. Wrongly it served notice on Mrs C in January 2025, requiring her to move to another care home despite saying it could meet the needs of residents with dementia;
• temporarily moved Mrs C into another room within the Care Home during December 2024 for longer than needed. That temporary room was in poor condition.

2. Mrs B said because of the above she experienced avoidable distress, worried for her mother’s care. In particular, she worried about the cause of falls she sustained and the cuts to her arms. She also had concern about the impact of moving her to another care home. Mrs B said because she complained her relations with senior staff at the Care Home declined and thinks this also influenced the Care Provider’s decision to serve notice on Mrs C.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. 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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC). This will be before any publication of the decision on our website.

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How I considered this complaint

8. I considered the following evidence:

• Mrs B’s written complaint and enclosures sent to the Care Provider and to this office:
• the Care Provider’s replies to Mrs B’s complaints and comments and documents it sent to us in reply to our written enquiries;
• records from the local authority area in the vicinity of the Care Home which considered undertaking a safeguarding investigation into Mrs C’s care in Autumn 2024 and made some preliminary enquiries;
• records from the CQC which received an allegation about the circumstances of a fall Mrs C experienced in April 2024 and investigated that;
• records obtained by Mrs B from Mrs C’s GP, a hospital and ambulance service;
• relevant law, policy and guidance.

9. I also gave Mrs B and the Care Provider chance to comment on a draft version of this decision statement and provide any further evidence they consider relevant to the content. I considered their responses to the draft decision before putting this statement in its final format.

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What I found

Relevant Legal Considerations

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. We take account of the standards and accompanying guidance when deciding if a Care Provider has acted with fault.
11. I consider the following fundamental standards relevant to this complaint:

• Regulation 12, which covers ‘safe care and treatment’. Providers must assess the risks to health and safety of those in their care. They must ensure their staff have the qualifications, competence, skills and experience to keep people safe. This includes ensuring their premises and equipment are safe. There must also be suitable systems in place for administering medications accurately as prescribed.
• Regulation 16, which requires care providers to receive and act on complaints. This includes making information available to those who complain on what to do if dissatisfied with the provider’s reply. It also says providers must not discriminate against anyone who complains, including where someone complains on their behalf.
• Regulation 17, which covers ‘good governance’. This requires providers to keep accurate, complete and detailed records about each person using their service.

12. The CQC provides advice to care providers on ‘service user bands’, which refer to how they describe the services they provide. It says that where a provider gives residential care specialising in dementia, it must show that it can meet the need “throughout the time that a person requires your service”. It gives as an example, that “a person living with dementia will experience a decline in their cognitive abilities. This may cause them to experience anxiety or distress and can lead to behaviour changes. You must have the skills and experience to understand and respond to each person's experience of dementia and its progression”.
13. Some care providers offer nursing care, not residential care. Nursing homes too can specialise in dementia. To help decide if someone needs one or the other, the NHS produces a continuing healthcare (CHC) checklist. This tool helps NHS and care staff assess who needs nursing care and if so, at what level.
14. The Competition and Markets Authority (CMA) publish guidance to care providers on applying consumer law to those entering care homes. It includes sections on providing information to residents and relatives including prospective residents. It says this should include advice on the care needs the care home caters for (paragraph 3.18). Also, when setting out notice periods, it says care providers should give explain why they might end an agreement (see paragraph 4.103).
15. Local authorities which are social service authorities sometimes receive reports that adults are at risk of, or suffering, abuse or neglect in care settings. If they do so, the council must make enquiries if:

• it thinks a person may be at risk of abuse or neglect; and
• they have care and support needs which mean they cannot protect themselves.

16. An enquiry is any action taken by a council in response to a concern about abuse or neglect. A council can decide whether it, or another person or agency, should take any action to protect a person from abuse or neglect. (section 42, Care Act 2014)

My approach to investigation

17. I considered each part of Mrs B’s complaint in turn. In the sections below I briefly summarise her complaint and the Care Provider’s response. I then summarise my investigation, which includes setting out the key facts on which I based my findings, which follow. Where I have upheld parts of the complaint I have gone on at the end of the statement to set out recommended actions I want the Care Provider to take to remedy the injustice caused as a result, and to improve its service to try and prevent a repeat.

The complaint about Mrs C’s falls

Summary of the complaint and response

18. In April 2024 Mrs C experienced a fall that resulted in a fracture to her hip. She was in hospital for around a week. In August 2024 the Care Provider gave Mrs B an account of how the fall occurred. In her complaint to the Care Provider, Mrs B complained at the delay in it providing its account, something the Care Provider acknowledged and apologised for.
19. During this investigation, Mrs B said she also believed the Care Provider at fault for the circumstances giving rise to the fall. She said the Care Provider had given Mrs C medication earlier in the evening than previously. She believed this had contributed to her becoming unsteady leading to her fall. She had information leading her to believe the decision to give medication earlier in the evening was because the Care Home did not have staff on duty qualified to give it later in the evening. This also led her to believe the account of the fall provided by the Care Provider contained inaccuracies.
20. In November 2024 Mrs C had another fall at the Care Home which resulted in a hospital admission. The Care Provider told Mrs B of the fall and said it happened as Mrs C walked in the lounge. Mrs B did not think this a credible account as her understanding was that at the time Mrs C could not stand or walk unaided. Mrs B also learnt the Care Provider had recorded Mrs C would walk into other resident’s rooms. This too Mrs B considered could not happen because Mrs C could not walk or stand unaided.
21. In its reply, made in December 2024, the Care Provider said that Mrs C could walk and transfer when she fell. It said one of its staff witnessed the fall and it provided an account of this.

My investigation

22. I noted Mrs C moved to the Care Home in April 2023. When she moved in the Care Provider recorded that Mrs C walked with the aid of a stick.
23. I found Mrs C took various medications, for different health conditions. In April 2024 a review of her medication took place with her GP surgery. Both the Care Home and the GP surgery kept notes of the review. Mrs C had recently begun taking a new medication. The review recommended the Care Home try giving this medication to Mrs C earlier in the evening than first prescribed. The Care Home recorded doing this. The majority of the notes record the review took place on a specific day in April. However, in one place on a medical administration record a later date appears, of some three days difference.
24. On the first night after giving Mrs C medication earlier than previously, she experienced a fall. The Care Provider recorded this witnessed by Care Home staff whom it said had attended Mrs C’s room just after 2:00am. The Care Home called an ambulance at 2:25am. The ambulance service notes recorded an account of the fall, consistent with the Care Home’s notes, although notes recorded later by a hospital said Mrs C had an “unwitnessed” fall. Mrs C sustained a hip fracture and was in hospital around a week.
25. In September 2024 the Care Provider noted in a review that Mrs C was “not standing” and it used a hoist to help her transfer. Although, a note made in October 2024 said that Mrs C varied in her capacity to stand or walk. While in November 2024 the Provider recorded Mrs C “rarely walked”.
26. At the beginning of November 2024, the Care Provider also completed a ‘mobility and function assessment’, and a risk assessment, of Mrs C. This referred to Mrs C having a ‘decreased’ number of falls at the Care Home. But said she tried to mobilise with her walking frame.
27. When Mrs C experienced her fall a member of staff at the Care Home recorded the incident as later explained to Mrs B.
28. During this investigation Mrs B received an account of the fall that took place in April 2024, from a third party. This differed from that given by the Care Provider. The CQC also received this alternative account. The CQC made enquiries and after reviewing the Care Provider’s records resolved to take no further action.

My findings

29. I accepted that Mrs B’s experience from her regular visits to the Care Home was that around the time Mrs C fell in November 2024, she no longer tried to stand or walk.
30. However, the Care Provider’s contemporaneous notes said something different. They showed a marked decline in Mrs C’s ability to stand or walk unaided during her time in the Care Home. But they did not show by mid-November that Mrs C had lost all ability to do so, or that she did not try to stand and walk sometimes.
31. That said, I thought the Care Provider may have confused Mrs B through the content of a ‘Behaviour Management Plan’. I found it wrote that document in February 2024. It described Mrs C having wandering behaviours. The Care Provider did not update that description, even though I considered by November 2024 it was inaccurate given what it said elsewhere about her mobility. I explore this document in more detail below and the extent to which the Care Provider was at fault for how it maintained it.
32. But on balance I could not uphold this part of Mrs B’s complaint. This was because I find nothing inconsistent in the account recorded by the Care Provider of the fall and what is elsewhere in its notes.
33. I had initially decided not to investigate Mrs C’s fall in April 2024. The Care Provider had acknowledged delay in sending Mrs B an account of the fall. But with it having apologised for that, I could not see that there was anything more we could add. However, when during the investigation Mrs B received information questioning the account she received from the Care Home, I thought it reasonable to explore what happened.
34. I came to the view the Care Provider was not at fault in April 2024 either. I understood Mrs B’s concern about the timing of the medication given to Mrs C the evening before she fell. I also understood she had concern about the medications given to Mrs C. But there was a clear evidence trail kept by both the Care Provider and in NHS notes, that both the medication given to Mrs C and the timing of its administration were in line with the advice of Mrs C’s GP surgery. So, the Provider was not at fault, even if it could be shown these factors led Mrs C to fall.
35. Further while there were some discrepancies in the records surrounding Mrs C’s medication and fall, I did not consider these significant. I could not account for why one record appeared to date her medication review differently to the others. But I considered nothing turned on this, as Mrs C was in hospital at the time of the wrongly dated record and all other records on this point aligned.
36. I also noted a hospital had recorded Mrs C’s fall as unwitnessed. But this was not in line with all other accounts, including those in the Care Home notes and made by the ambulance service. So, there was no reason to find the Care Provider at fault for this inaccuracy.

The complaint about medication between September and November 2024

Summary of the complaint and response

37. Mrs B’s complaint focused on Mrs C having a prescription for three medications, two for pain relief and one for anxiety that had a sedative effect. Following a conversation with a member of staff in early November 2024, Mrs B understood the Care Provider had stopped giving one of the pain medications. Also, that it only gave the anxiety medication at night. But she later found Mrs C continued to have both medications, including the anxiety medication during the day. Mrs B considered Mrs C over-medicated, being too heavily sedated. She said Mrs C would lie in her own urine and miss meals as a result.
38. In its reply, the Care Provider said it had stopped giving Mrs C one of the pain relief medications during October and the other at the beginning of November 2024. It apologised that its member of staff gave Mrs B wrong information, as they mistakenly said which of the pain medications it had stopped giving in October. The Care Provider also said it stopped giving Mrs C the anxiety medication in mid-November.
39. The Care Provider said it had only given medication to Mrs C as prescribed. On only two days from mid-September had it given Mrs C the maximum prescribed dose of one of the pain relief medications. It had never given her the maximum prescribed dose of the anxiety medication.

My investigation

40. The Care Provider gave us medical administration records which enabled me to check when and how often it gave Mrs C the medications central to this part of her complaint.
41. I also noted that in mid-November 2024, Mrs B contacted Mrs C’s GP to discuss her medication. He then contacted the Care Home and asked it to stop giving Mrs C the anxiety medication. He said it was “not a long term solution for her behaviour concerns”.

My findings

42. I could understand Mrs B’s concerns about the medications Mrs C had prescribed concurrently for a time between September and November 2024. She explained how she worried these impacted on Mrs C’s presentation. That they made her excessively tired and caused her not to recognise when she was wet or needed to eat. I considered that in its reply to this part of the complaint the Care Provider could have focused on this consideration more. It could have offered reassurance to Mrs B about what it did to meet Mrs C’s need for continence care and food.
43. However, I could find no fault in the Provider’s response in addressing Mrs B’s specific concern about how it gave medication to Mrs C. It recognised giving Mrs B wrong information about which medication it stopped at the beginning of October 2024. It apologised and I considered this a proportionate remedy for the injustice caused, which was some avoidable confusion for Mrs B.
44. Crucially, I found the Provider’s administration of medication to Mrs C in line with her prescriptions. I also found its records in order. As the Care Provider explained in its complaint response to Mrs B, it gave Mrs C less of the pain relief and anxiety medication than prescribed. This suggested it took a cautious approach to try and ensure it did not over-medicate Mrs C.
45. So, while understanding of Mrs B’s concern, I could not find the Care Provider at fault for its medication management.

The complaint about wounds

Summary of complaint and response

46. At the end of October, and beginning of November, Mrs B and her sister noted Mrs C had two distinctive wounds on her arm, she described as ‘gouges’. Mrs B said not until a week later was she told the wounds arose from a tray table. Mrs B said on visiting the home she noted laminate lifting from many of these tray tables and asked why the Care Home still used them.
47. In its reply, the Care Provider said that at the end of October 2024 Mrs C had ‘brushed’ against a hoist when transferring. This had caused a skin wound on her arm. It said the Care Home staff should have better recorded this and it apologised to Mrs B that they did not do so.

My investigation

48. I noted that at the end of October 2024, a member of staff completing a handover to a colleague recorded Mrs C had ‘brushed’ her arm on a hoist during a transfer. They said this caused a skin tear and that Mrs C had received first aid.
49. Two days later the Care Home made another record saying Mrs C had a cut near her wrist as she tried to “push away” a wheeled table and caught her arm. The Care Provider made a record of the wound location and took a photograph. These both depicted a single cut on Mrs C’s arm.
50. A few days later Mrs B visited the care home and took her own photograph. This showed two cuts on Mrs C’s arm.
51. During a meeting with a manager from the Care Provider in November 2024 Mrs B said she thought the wounds to Mrs C’s arm looked like fingernail marks. This was because they had a crescent shape. Mrs B said when she had put this to a member of staff in the Care Home, they had agreed.
52. I noted that after Mrs B complained, Mrs C also suffered further skin wounds while at the Care Home. These included wounds to her legs in October 2024. She also fell and cut her head at the end of November 2024. Mrs B mentioned these incidents in ongoing correspondence with the Care Provider, during its investigation of her complaint. During this investigation Mrs B also made me aware of earlier concerns she had expressed for the Care Home’s wound care in November 2023, after Mrs C underwent a biopsy.
53. In November 2024 Mrs B contacted the CQC concerned for her mother’s care. Her contact with the CQC mirrored her complaint. The CQC referred her contact to the local Council in turn and invited it to consider undertaking a safeguarding investigation. The Council made preliminary enquiries, but decided not to begin a detailed investigation, as the Care Provider was already investigating Mrs B’s complaint.
54. The Council asked the Care Provider about the cuts to Mrs C’s arms and when Mrs B alerted it to Mrs C’s later wounds. The Care Provider recognised it had not properly recorded how Mrs C sustained the cuts to her arm. It also recognised that after Mrs C cut her head it took too long (12 hours) to call an ambulance, saying staff on duty should have done that straight away.
55. The Provider kept some record of how it treated wounds over time. This included a record of a skin tear on Mrs C’s arm. It first recorded treating this at the end of October 2024, and recorded it had not healed by February 2025, when Mrs C moved out of the Care Home. I presumed this referred to at least one of the cuts noted by Mrs B. I noted Mrs C also had an infection to the leg wounds sustained in October. The Care Provider reported this had cleared by mid-December following a course of antibiotics.
56. In early January 2025 a nurse visiting Mrs C recommended the Care Provider contact her GP to see if Mrs C had a condition which caused her skin to tear and bruise more easily. The Care Provider has no record it did this subsequently.
57. The Care Provider told me that it expected care staff to record all cuts and bruises that residents received, in line with its Event Management and Response Procedure. This described an event as encompassing “any unexpected or avoidable harm to a resident”.

My findings

58. I considered the Care Provider caused confusion in its reply to this part of Mrs B’s complaint. It did not make clear that it had a record of two separate incidents at the end of October 2024, which potentially explained the skin wounds Mrs B and her sister saw.
59. I cannot say exactly what caused the cuts to Mrs C’s arms that Mrs B had most concern about. I understood why Mrs B thought fingernails could have caused the cuts, given the shape and depth of the wounds. However, I could not find that as fact. I considered when Mrs B put this suggestion to a member of staff at the Care Home they likely agreed for the same reason; i.e., because the cuts looked as if they could have arisen that way. But that was different from saying fingernails had caused the cuts, something for which there was no record.
60. I found it more likely that at least one of the cuts resulted from Mrs C catching her arm on a wheeled tray table. The Care Provider recorded such an incident on the day it happened. They also kept a ‘body map’ drawing and a photograph which showed the distinctive crescent-shaped cut on Mrs C’s arm. It was unfortunate that in its complaint reply, the Care Provider focused instead on the other incident where Mrs C ‘brushed’ against a hoist.
61. The Care Provider recognised in its communications with the Council that it did not keep a clear record of this latter incident. So, there was no detailed description of what happened and no body map or photograph that showed how serious the skin tear was. I considered the Provider should have kept such records given Mrs C needed first aid. I therefore recorded a finding of fault on this point, considering the Care Provider may not have met the relevant fundamental standard to always keep adequate and accurate records.
62. But I also had further concerns about related matters. I recognised it was impossible for care providers to ever provide an environment where there could be no risks to residents in care homes. But I considered when accidents happened, they needed to ensure residents received prompt and effective care and take action to avoid a repeat of preventable accidents.
63. I did not consider the Care Provider’s records showed that Mrs C always received safe and effective care after she received skin injuries. First, I had concerns about the records showing how long it took to treat the skin tears on her arm and legs, which suggested these incidents were not minor. But there was little detail about the Provider reviewing how such incidents occurred nor how to avoid a repeat. Where there was evidence of cause, from a wheeled tray table, I consider the Care Provider should have taken more seriously Mrs B’s helpful suggestion that it check the condition of these. It offered her no reassurance that it had considered if any rough or exposed edges on the table caused the cut or could cause such cuts in the future. It did not comment on her suggestion some tables needed repair or replacement.
64. Second, the Provider had a record showing it was advised to check with Mrs C’s GP if she suffered with a condition causing her skin to cut and bruise more easily. While I considered it unlikely such a diagnosis would have altered how the Provider gave care, it might have provided some more explanation for Mrs B about the appearance of Mrs C’s wounds. So, following the advice given would have had value in Mrs C’s care.
65. Third, there was the long delay in calling an ambulance when Mrs C cut her head in November 2024, something the Provider recognised as unacceptable.
66. These concerns led me to make a further finding of fault. They called into question if the Care Provider had always met the relevant fundamental standard to provide safe and effective care to Mrs C.
67. I considered the faults identified had also caused some avoidable distress both to Mrs C as resident, and Mrs B as her concerned next of kin. With Mrs C having sadly died we could not remedy any injustice caused to her but we could ask the Care Provider to remedy the injustice caused to Mrs B. I set out my proposed remedy later in this statement.
68. I noted also the evidence Mrs B provided me about the wound care Mrs C received in November 2023, which did not form part of her original complaint. However, I did not consider it appropriate to investigate this matter given the findings I had already reached, set out above.

The complaint the Care Provider could not meet Mrs C’s needs

Summary of complaint and response

69. In her complaint Mrs B said she understood in mid-November 2024 that a nurse employed by the Care Provider would assess Mrs C’s care, to see if she needed nursing care. But she said the Provider had not told her the outcome of this assessment. Later, Mrs B expressed concern when the Care Provider told her that it considered the Care Home could no longer meet Mrs C’s needs.
70. In its reply, the Care Provider apologised if Mrs B felt it had not shared enough detail about this assessment. It said that it had arranged a second assessment in early December 2024, to which it invited Mrs B, but she declined. It said it understood that by this time Mrs B had taken a decision to seek a different care home for Mrs C. It said that it had “always been clear” with Mrs B that the Care Home could only provide “low level dementia care”. It considered Mrs C’s needs were now greater than that.

My investigation

71. When Mrs C entered the Care Home in April 2023 the Care Provider issued her with its standard set of terms and conditions, which Mrs B signed on Mrs C’s behalf. This included a term saying the Care Provider could give four weeks’ notice, asking a resident leave. It said it would do this if fees went unpaid. It also contained another clause saying in exceptional circumstances it might give one week’s notice for a resident to leave, if it could not meet their needs.
72. In its initial assessment of Mrs C’s needs, made in April 2023 the Care Provider reported Mrs B did not show any aggression. By February 2024 however, the Care Provider had concerns about Mrs C’s behaviours associated with her condition. It drew up a 'Challenging Behaviour Plan'. This recorded Mrs C becoming more agitated towards staff, that she would bang doors, go into other resident’s rooms and become aggressive towards staff when they tried to encourage her to leave. The plan said the Provider aimed to reassure Mrs C and if this did not work to let her calm in her own time.
73. The Care Provider updated this plan monthly up to November 2024. However, the changes in content were minimal. There was never any change to how it described Mrs C’s behaviour. However, the Plan did note changes to her medication.
74. I noted that between August 2024 and late January 2025 the Care Provider recorded dozens of incidents of challenging behaviour by Mrs C in daily care logs. These included episodes where she had struck out at employees, shouted or screamed, and became highly distressed.
75. In mid-September 2024, during a review of Mrs C’s care needs, the Care Provider recorded that it should consider if she needed nursing care. It said that it had “person centred, planned interventions” in place which helped minimise risk caused from Mrs C’s behaviours but that it could not eliminate that risk. At no piint did the Care Provider undertake a CHC checklist, nor ask any other professional to do so.
76. In mid-November 2024 Mrs B met with a senior manager from the Care Provider. During this meeting the Care Provider recorded saying to Mrs B that the Care Home could only meet low level dementia needs, as it went on to restate in its reply to the complaint.
77. At the start of December 2024, a manager for the Care Provider with specialism in dementia care, visited the Care Home to review Mrs C’s case. She reported offering to meet with Mrs B, who did not attend. The manager recorded that she considered the Care Provider had “exhausted all attempts to continue to care” for Mrs C.
78. In December 2024 an NHS service reviewed Mrs C’s mental health needs. They recommended and prescribed a new medication for her, which she began at the start of January 2025.
79. In mid-January 2025 Mrs B met again with the manager. During the meeting the Care Provider checked with Mrs B on her search for alternative accommodation for Mrs C. It said that it intended giving Mrs C notice to leave the Care Home the following week, which it went on to do. Its letter said it could no longer meet Mrs C’s “challenging behaviours” and had not taken its decision lightly.
80. During my investigation I received contact from the manager of a care home Mrs C later moved to. He told me the care home, registered to provide residential care only, had experienced no difficulties in meeting Mrs C’s needs. And that her behaviour did not present any problems for the care home staff.
81. Mrs B asked me to note that before Mrs C moved to that care home, she had spent a few weeks in another care home not well suited to her needs. Mrs B considered the Care Provider could have prevented Mrs C having to make this intermediate move if it had not served notice on her stay.
82. In response to the draft version of this decision statement the Care Provider asked me to note that it had recently introduced new “Moving On” guidance. This provides advice for staff in circumstances where they consider a care home can no longer meet someone’s needs. The guidance provides staff with a checklist of matters to consider before serving notice. For example, considering if a physical health condition might cause changes in behaviour. Or making checks with health professionals to explore the resident’s needs. It says care homes should take “all efforts” to meet needs before serving notice and take time to reflect before doing so.

My findings

83. I considered the ‘Challenging Behaviour Plan’ produced by the Care Provider a largely unhelpful document. It described some of Mrs C’s behaviour from around February 2024. But at no point did the plan update that description, despite Mrs C’s changing mobility recorded elsewhere. I therefore had to rely on the daily care logs to get more idea of Mrs C’s needs from Autumn 2024 onward.
84. The plan also contained limited advice to staff on how to respond to Mrs C’s challenging behaviour. It offered no commentary on how they found working with the plan. And while the plan recorded changes in Mrs C’s medication, it offered no commentary on any changes to her mood or behaviour as a result. I therefore questioned what useful or practical purpose the plan served.
85. That said, I did not dispute all the information provided by the Care Provider detailing Mrs C’s distress and anxiety. Nor the resulting challenges this posed for her care. So I understood why the Care Provider questioned if the Care Home remained the right setting for Mrs C’s care. While I disliked the use of the phrase “low level” dementia needs, it was fair for the Care Provider to try and draw a distinction between needs it could meet and those it could not. No residential care home can ever offer an unqualified promise of a ‘home for life’ given people’s needs can change beyond its capacity to respond. Some people with dementia require more care than that commonly available in a residential care home and will need nursing care.
86. So, I could not say the Care Provider was at fault for reconsidering if it could meet Mrs C’s needs. And I did not find its actions motivated by any revenge for Mrs B’s complaints. But I considered any decision to serve notice should have been considered a last resort and taken only when the Care Provider had thoroughly satisfied itself it has no alternative.
87. I was disappointed therefore to note therefore Care Provider did not arrange for completion of the CHC checklist before saying it believed Mrs C needed nursing care. This is because the checklist provides a screening tool with a high degree of objectivity to assess when someone needs nursing care. I could not say if the Care Provider had used this tool whether the outcome would necessarily have been the same as its own assessment, although I accepted it might have been.
88. I was also disappointed to note the Care Provider did not reconsider its position in January 2025. Following a change in medication, the Care Provider recorded a significant fall in the number of incidents of challenging behaviour by Mrs C. Between the start and third week of January 2025 the Provider recorded eight relevant entries on its daily log of events, on four separate days. The same numbers for the same period in December 2024 were 34 entries over 13 separate days.
89. So, I found the Care Provider at fault for not doing more before it reached the point where it served notice. It may have avoided this with:

• better planning for how to respond to the challenges caused by Mrs C’s needs;
• an assessment of her possible need for nursing care using the CHC checklist; and
• a review of the effectiveness of the change in her medication from January 2025.

90. In considering the consequences of this fault, I accepted the Care Provider may still have decided it could not continue to meet Mrs C’s needs even after taking these steps. I also considered Mrs B may still have chosen to look for another care home given her trust in the Care Provider had clearly declined by January 2025. I could not say that Mrs C having to move care homes twice in quick succession was avoidable, although it may have been. For the Care Provider’s actions still forced Mrs B’s hand. Its actions caused Mrs B avoidable distress, which was an injustice to her.
91. I also had some concern the current terms and conditions given to residents of the Care Home were not sufficiently clear about when the Care Provider may give notice. This view took account of the CMA guidance I referred to earlier. For giving seven day notice, the Care Provider explained the exceptional circumstances where this might apply. But it did not say that changes in needs might also trigger the longer four week notice period. I considered this would be useful information for residents and their relatives.
92. I noted that since the events covered by this complaint the Care Provider had introduced new guidance for staff applicable to circumstances such as these. I considered the Care Provider’s actions had largely mirrored that guidance. For example, it only gave notice after discussing Mrs C’s case with professionally qualified nursing staff and meeting with Mrs B. So, I did not think that had the guidance been in place sooner and followed, it would have significantly impacted on the events that took place. While I felt the guidance useful therefore, I considered there was scope for its improvement as I set out in my recommended actions below.

The complaint about Mrs C moving rooms

Summary of complaint and response

93. During December 2024, while Mrs B’s complaint remained under consideration Mrs C had to change rooms in the Care Home because of an electrical fault. Mrs B contacted the Care Provider when after nine days Mrs C remained in the temporary room. Mrs B said she had understood Mrs C would be in the temporary room for one night only. She said the room was unsuitable because it was “filthy”.
94. In early January 2025 the Care Provider recognised that Mrs C should have returned to her own room after one night. It said that it would not charge Mrs C for the time she spent in the alternative room. It also later apologised as the alternative room was “not kept to the standards we would expect”.

My investigation

95. The Care Provider told me that following this correspondence it credited to Mrs C’s account an amount equivalent to its charge for 13 days’ care.

My findings

96. There was no dispute that in December 2024 Mrs C had to move out of her own room for a time, because of an electrical issue. The Care Provider recognised this temporary move should only have been for a night, something Mrs B had no complaint about. But Mrs C spent nearly a fortnight in a room that was not her own.
97. The Provider recognised being at fault here. First, for not arranging for Mrs C to move back when her own room became ready. Second, for the temporary room not being of a good standard.
98. I was concerned the Provider did not offer explanation for how either of these faults occurred. While not unavoidable, I considered it must be unusual, that residents of the Care Home have to move temporarily in this way. I could not understand why therefore, as part of the daily business of running the Care Home, its management were not more vigilant to ensure Mrs C moved back to her own room sooner. Nor why the temporary room was not of an acceptable standard. This suggested a serious inattention.
99. However, I found the Care Provider had provided a generous remedy for this part of the complaint, by writing off all of Mrs C’s care costs for 13 days. Had it not done so, I did not think I would have recommended this. Because while I considered it right the Care Provider should not have charged Mrs C for her accommodation, I did not think it needed to waive all other elements of her charges. For example, the cost of her personal care.
100. I did not therefore recommend the Provider take further action to remedy this part of the complaint.

The Care Provider’s complaint handling

101. In the standard terms and conditions given to residents, the Care Provider tells them they have the right to complain. It says if dissatisfied with the reply, the complainant has the right to contact the CQC.
102. The Care Provider also has a separate complaint procedure. This says that it aims to reply to complaints within 21 days. And that when it replies, it will offer ‘additional guidance’ explaining that complainants can contact this office.
103. I noted that in this case the Care Provider was late in replying to Mrs B. But I noted the manager assigned the case took the time to meet with Mrs B. Even if this added delay I did not want to discourage this good practice. I also found the Care Provider offered signposting to Mrs B, advising her to complain to this office if she remained dissatisfied after it sent its final reply to her complaint.

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Recommended Action

104. In paragraphs 67 and 90 I identified where fault by the Care Provider resulted in an outstanding injustice caused to Mrs B. The Care Provider has indicated that it accepts this finding and is willing to complete the actions recommended below. Which are, that to remedy Mrs B’s injustice, it will, within 20 working days of this decision:
1. provide a written apology to Mrs B accepting the findings of this investigation. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Care Provider should consider this guidance when making its apology;
2. offer a symbolic payment of £500 to Mrs B in recognition of her injustice.
105. I also recommend that within three months of a final decision on this complaint the Care Provider undertake the following:
1. if it has not already done so, prioritise an inspection of the wheeled tray tables used in the Care Home to ensure their suitability and safety. It should repair or replace any found in a condition likely to cause injury to residents;
2. complete a light touch review of its ‘Moving On’ guidance. This should take account of the commentary at paragraphs 83 to 89 above. So, it will include looking at if, or when, care homes use ‘challenging behaviour plans’ and how they use and review these. It should also consider introducing reference to use of the CHC checklist if it considers a residential care home resident has potential nursing care needs. And if the guidance should also contain explicit advice on allowing time for medication reviews to impact behaviour. The Provider will write to us once it has completed the review and let us know what changes it has made or proposes to make to the guidance and how it will communicate that to relevant staff. If it decides that it does not need to make changes to the guidance it will still consider if it needs to brief or remind relevant staff on good practice in this area. It will tell us of any steps it has taken, or proposes to take, in that regard also;
3. revise the current terms and conditions given to residents of the Care Home (and any other care homes in its ownership that use the same standard terms) covering circumstances where it might give four weeks’ notice to a resident. The revisions should take account of the CMA guidance and my commentary above;
106. The Care Provider will provide us with evidence of compliance with these recommended actions.

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Final Decision

107. For reasons set out above I upheld this complaint finding fault by the Care Provider caused injustice to Mrs B. I have set out action I want the Care Provider to take that I consider will remedy that injustice. As the Care Provider has indicated its agreement to these proposals I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman