Summary: There was fault in the quality of care provided to Mr X’s late grandfather Mr Y by the care home. It failed to carry out a thorough pre-assessment, delayed taking action when Mr Y’s food and fluid intake reduced and failed to properly assess and respond to Mr Y’s risk of falls. It also delayed billing Mr X. The care provider has agreed to apologise to Mr X for the distress and uncertainty this caused and confirm it has cancelled the bill. It has already taken action to prevent recurrence of the faults.

The complaint

1. Mr X complained about the quality of care provided to his late grandfather Mr Y at Blenheim House Care Home (the care home). In particular, he complained it:
• carried out an inadequate pre-admission assessment so it was not fully aware of Mr Y’s physical and mental health conditions.
• failed to appropriately risk assess, manage and respond to falls which left Mr Y at risk.
• failed to ensure Mr Y received adequate nutrition and hydration and to make timely and appropriate referrals to address his poor intake.
2. Mr X says the care home’s actions contributed to the deterioration in Mr Y’s health and caused the family significant distress and frustration.
3. Mr X also complained the care provider inappropriately billed the family for a two-week period after Mr Y had died, nearly 11 months later and which was not in line with the contract, which added to their distress.

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The Ombudsman’s role and powers

4. 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)
5. 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.
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).

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How I considered this complaint

8. I considered evidence provided by Mr X and the care provider as well as relevant law, policy and guidance.
9. I gave Mr X and the care provider an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

10. 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. The standards include:
• providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences (regulation 9).
• providers must make sure that people who use their services have adequate nutrition and hydration to aid good health. People must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition (regulation 14); and

What happened

11. The following is a summary of the main events relevant to this complaint.
12. In Summer 2024 the care provider visited Mr Y and completed a pre-assessment. This noted Mr Y had dementia, he had been hospitalised after a fall and was at high risk of falls. He was self-neglecting and had a poor appetite. Mr Y moved into the care home.
13. During his second week at the care home Mr Y had two unwitnessed falls. An ambulance attended but Mr Y did not need a hospital admission. The care home placed a crash mat by his bed. He had a further fall the following week and was found on the crash mat on his bedroom floor. Miss Z raised concerns about the repeated falls and whether staff were leaving his bed too low so he could not get out of it easily. She also requested a thin crash mat and sensor mat be placed by his bed.
14. In early September Mr Y had a further unwitnessed fall but had no injuries. Throughout this time staff noted what Mr Y was eating and drinking but he often refused food or ate very little. Mr Y was also resisting personal care and was aggressive to staff when they tried to assist. The care home made a referral to the care home liaison team. The referral said Mr Y would not allow the team to support him with personal care and was not eating and drinking and was at risk of further deterioration.
15. In mid-September the care home liaison team visited Mr Y. It suggested the GP review Mr Y’s bloods and rule out an infection. The notes also said Mr Y might require a dietician referral to monitor his weight loss. A Doctor from the team also visited and made changes to Mr Y’s medication.
16. Mr Y had further falls later that month. Following one fall he was bleeding from a cut to his head and the care home called an ambulance. A nurse from the care home dressed Mr Y’s head. Mr Y remained lying on the crash mat on the floor for 14 hours until the ambulance arrived. A paramedic later visited and closed the wound.
17. Mr Y fell again in late September. He was found lying on the floor and had a cut on the back of his head. He was assisted to bed. The following day the care home asked the GP for an urgent review due to Mr Y’s fall and overall concerns around his eating and drinking. It also spoke with Miss Z who advised the care home of an old injury Mr Y had which may be causing him pain. The care home also spoke with the care home liaison team which agreed to a further review regarding the possibility of covert medication. Around this time the care home placed a motion sensor in Mr Y’s room.
18. The next day staff again found Mr Y on his crash mat. He was assisted to his chair. Miss Z visited Mr Y around an hour later and found him slumped and unresponsive in his chair. Staff assisted Mr Y to bed. He passed away later that day.

Mr X’s complaint

19. In November 2024 Mr X complained to the care provider about issues including the effectiveness of its care planning and risk assessments, Mr Y’s nutrition and hydration and falls and the lack of/way it used equipment to mitigate risks. Mr X also raised his concerns with the CQC.
20. The care provider responded to Mr X’s complaint in December 2024. It said it was conducting a thorough investigation and had shared his concerns with the Council’s safeguarding team and the CQC.
21. It noted Mr Y’s behaviour differed significantly from the pre-admission assessment. It said the assessment primarily focused on physical and clinical needs rather than Mr Y’s emotional well-being. It said referrals to the care home liaison team were not normally accepted until a resident had been there six weeks. In this case, the manager requested earlier support (after 24 days) due to the ongoing challenges caused by Mr Y’s resistance and aggression.
22. It said the care home closely monitored Mr Y’s nutritional intake during his stay and kept daily records of meals offered and when they were declined. It said during the MUST (malnutrition universal screening tool) assessment it noted Mr Y was refusing food as he believed care staff were trying to harm him. It said the care home took this concern seriously and recognised this would make it even more challenging to encourage him to eat and drink. It said the care plan did not specify Mr Y’s dislikes. Having spoken to Miss X it created a poster for staff of Mr Y’s preferred foods and staff made efforts to offer these. It said the care home made a referral to the care home liaison team in early September detailing Mr Y’s minimal nutrition and hydration intake.
23. The care provider said the care home had noted Mr Y may require a dietitian referral but there was no record of this being actioned.
24. In relation to Mr Y’s falls, it said his falls risk was clearly identified during the pre-admission assessment. It said the care home followed the falls risk protocol and sought appropriate medical assistance.
25. It said there were areas where processes could have been improved to better support Mr Y’s needs. This included:
• It should have conducted a better pre-admission assessment focusing on Mr Y’s emotional and mental health needs as well as his physical requirements.
• The care home sought to secure appropriate multi-disciplinary team support. There were delays in some areas but these were often outside the care home’s control. However, it acknowledged it should have communicated these challenges with the family.
• It should have conducted a more detailed investigation and developed a comprehensive plan to reduce Mr Y’s risk of falls. It noted a crash mat may not have been the most appropriate intervention for Mr Y as this could create instability underfoot.
• An earlier meeting with the care home manager to address how Mr Y was settling in could have provided reassurance of the care provided.
26. It concluded it would be beneficial for the manager to attend weekly clinical meetings so they could identify areas where their support may be needed earlier. Open and transparent communication with families was also an area highlighted for improvement. It noted Mr Y’s condition was already deteriorating when he entered the care home and it did not consider any actions taken by the care home could have completely prevented his further deterioration. However, the actions identified could have made his stay more comfortable and reduced the family’s distress.
27. Mr X remained unhappy and asked that his complaint be considered at the next stage of the care provider’s complaints procedure. The care provider sent Mr X a final response in March 2025. It acknowledged that:
• the pre-assessment did not address every aspect of Mr Y’s health and that further input from Mr Y’s GP and additional family insights could have provided a more comprehensive evaluation.
• The care home’s interventions did not sufficiently address Mr Y’s dietary preferences or the decline in his eating. It acknowledged that delays in escalating these issues and the lack of an individualised dietary plan contributed to the family’s distress.
• The care home identified Mr Y’s high falls risk at admission but it delayed the initial risk assessment, and interventions were not implemented with the required urgency. The measures it did put in place did not fully mitigate the risk and communication with family could have been more proactive.
28. As a result it said it would:
• Implement a more comprehensive evaluation process for pre-admission assessments with management oversight.
• Revise its nutrition protocols for recording and acting upon dietary intake and preferences with quicker referrals for specialist support
• Strengthen its falls risk assessment procedures, ensuring quicker implementation of safety measures and proactive communication with families.
• implement weekly clinical risk assessment meetings to ensure concerns were addressed promptly and so families receive direct comprehensive updates.
29. The Care Quality Commission inspected the care home in December 2024. It rated the care home as requiring improvement.
30. In September 2025 Mr X received a bill for 14 days of care for the period two days before Mr Y’s death and 12 days afterwards. Mr X said there was nothing in the contract regarding this.

Response to my enquiries

31. In response to my enquiries the care provider said it developed a comprehensive action plan following the CQC inspection which included an immediate review of governance systems, reinforcement of audit processes and enhanced oversight by the general manager and Quality Director.
32. It explained, and provided evidence of, the action it was taking to prevent a recurrence of the issues identified including:
• Strengthening of the pre-admission documentation to ensure a complete health profile was obtained for new residents and all pre-admission assessments to be signed off by the general manager prior to accepting a new admission.
• All new residents being placed on a three-day nutrition and hydration monitoring chart to establish baseline intake and identify any early risks, and a meeting with the Chef within 24 hours of admission to discuss dietary preferences, allergies and cultural or medical requirements.
• Any decline in nutritional intake to be escalated immediately. If a resident had not eaten or drank in 24 hours this would be reported to the GP the same day. If concerns persist, a dietitian or speech and language therapy referral would be made without delay.
• Falls risk protocols to be completed within two hours of admission and reviewed weekly or after any fall with appropriate safety equipment deployed immediately after an assessment.
• Weekly clinical meetings were already now embedded to review incidents and address concerns.
33. In relation to the late bill, the care provider said it was due under the contract. However, due to an administrative oversight, the final invoice was issued late. It acknowledged this delay was below acceptable standards and in view of the distress it said it would not pursue the invoice.

Findings

34. There were faults in the care provided to Mr Y by the care provider. In particular:
• The pre-assessment was not sufficient to fully capture Mr Y’s emotional and physical health needs.
• The care provider failed to take appropriate action to review Mr Y’s risk of falls and to properly assess what equipment would be most appropriate to mitigate the risks.
• Although it monitored Mr Y’s food and fluid intake the care provider delayed taking action and making appropriate referrals to address the decline in his intake.
35. These faults were not in line with the CQC fundamental standards.
36. The care provider has provided evidence to show it has taken appropriate action to address the faults it identified through its complaint investigation and so no further recommendations for service improvements to address these concerns are required.
37. I could not say, even on balance, that the faults identified contributed to the deterioration in Mr Y’s condition. In addition, Mr Y has died so I cannot remedy any injustice to him caused by the care provider’s actions. However, the faults have caused Mr X distress and uncertainty about whether they may have been a better outcome for Mr Y.
38. The care provider also delayed billing Mr X for Mr Y’s last weeks at the care home. This delay was fault. Mr X says this charge was not in line with the contract. I have not investigated this further. This is because the care provider has agreed not to pursue the invoice which is an appropriate remedy for any injustice caused.

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Agreed Action

39. Within one month of the final decision the care provider has agreed to:
1. Apologise to Mr X for the distress and uncertainty caused by the faults identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
2. Confirm in writing to Mr X that it will not pursue the outstanding invoice.
40. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

41. I found fault causing injustice which the care provider has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman