Summary: Mr X complained about the quality of care provided to his mother Mrs Y at the care home. On the evidence considered, there were some faults with the care provided. The Care Provider has already taken appropriate actions to address the faults with the quality of Mrs Y’s care. It will also apologise and make a payment to acknowledge the frustration they were caused.

The complaint

1. Mr X complained about the quality of care the Care Provider gave to his mother, Mrs Y, which included an incident where Mrs Y got injured. Mr X also complained that the Care Provider did not properly investigate their concerns or take any proactive steps to ensure the quality-of-care Mrs Y received was consistently of a good standard. He complained that the Care Provider’s communication was poor.
2. Mr X said as a result they were caused distress, worry and frustration.

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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 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. 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)
5. Under our information sharing agreement, we will share the final decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I spoke to Mr X and considered the evidence he provided.
7. I considered evidence provided by the Care Provider and a third party (the Council) in response to our enquiries as well as relevant law, policy and guidance.
8. Mr X and the Care Provider had an opportunity to comment on the draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

The fundamental standards of care

9. 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 that the equipment that is used to deliver care and treatment is clean, suitable for the intended purpose, maintained, stored securely and used properly. (regulation 15)
• providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints (regulation 16).

Safeguarding

10. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

Bupa care homes complaints procedure

11. The Care Provider publishes its two stage complaints procedure online:

• Stage one – local resolution. In most cases complaints will be managed locally within the care home. However, in the case of complaints that do not relate specifically to the care home (such as a complaint about Bupa advertising for example), the complainants may receive correspondence from the head office.
• Stage two – escalation. If the complainant is not satisfied with the response they receive at stage one, they can request an internal review by a member of the senior management team.

What happened

12. This section sets out the key events in this case and is not intended to be a detailed chronology.
13. Mr X’s mother Mrs Y has lived in the care home since November 2024. She has vascular dementia. Records about Mrs Y’s capacity show that she is able to make simple decisions with support from her family and relevant professionals.
14. Mr X raised various concerns related to Mrs Y’s care following her admission to the care home. I have focussed on the main concerns which had the potential to cause the most significant injustice to Mrs Y.

Safeguarding incident

What happened

15. Mrs Y sustained an injury in the shower - the health care assistant (HCA) supporting her closed the shower screen doors together and one door fell on Mrs Y’s leg. Paramedics attended and dressed her wound. Mrs Y remained in the care home and received follow-up care from the care home staff.
16. The Care Provider investigated what happened. It found:

• Mrs Y’s moving and handling care plan was followed at the time of transfer. She required two members of staff to transfer her to a shower chair and once there, one member to provide support with washing.
• The HCA who was present at the time of the incident said they carried out checks (while waiting for the water to heat up) from inside the shower cubicle and when the shower was about to start, they pushed both shower doors together with the palm of their hand and that at this point, the left door fell and landed on Mrs Y’s leg. They said that the top of the shower door was attached via the hinge and that they had not noticed if the bottom hinge was detached. They said they had not applied undue force while closing the door.
• Mrs Y was interviewed and said the HCA was leaning over the shower door to adjust the shower fixtures to get the water to the right temperature when the door fell. The Care Provider noted that while this did not match the HCA’s statement that the water temperature was checked from inside the shower cubicle before the door was closed, it could not be ruled out as a possible reason for the door falling.
• Housekeeping staff responsible for cleaning the shower confirmed they had not observed any fault or repair issues with the door.
• Management inspected the incident area and looked at the possible ways the door could have fallen. It concluded that if the HCA had used the handles on the shower door rather than their palm to close the doors, they may have been able to stop the door from falling. However “this was not something that is trained or competency assessed” and therefore there was no evidence of poor training. It added that if the HCA’s account of how the door fell was correct then the bottom hinge was already broken prior to the incident. This showed that staff either failed to report this or they were unaware it was broken.
• The Health & Safety team had confirmed that the screen doors did not require regular maintenance or servicing, only visual checks at the time of use and proper reporting of any defects (and removal from use if necessary).
• Mrs Y’s injury (shape of wound and direction of skin movement) and bruising was suggestive of impact from a moving item with a large surface area. Mrs Y’s medication put her at an increased risk of bleeding and bruising. It also added that Mrs Y was provided with first aid care in line with ISTAP (International Skin Tear Advisory Panel) guidance.
• It put the shower out of use until the door was replaced and checked for safety. It reminded staff of their responsibility to check shower doors prior to use and of their duty to report any defects or hazards.

17. Mr X raised a number of issues related to this incident. He said the Care Provider’s investigation of the incident was flawed and that it issued different versions/reports of its investigation of this incident. He felt the door must have been closed with some force to enable it to come out of its socket and fall on Mrs Y. Mr X also said the care home did not have the appropriate mechanisms (paper accident book) to report and record incidents properly.
18. Regarding its accident reporting system, the Care Provider said its web-based system met the Health and Safety requirements and provided a functional way by which incidents could be recorded, reviewed and investigated both at home and regional levels.

Findings

19. The Care Provider’s investigation was detailed – it recorded accounts from relevant staff, investigated the incident, explained its findings and apologised for the distress caused. It said that its fixtures and fittings needed to be safe and fit for purpose, and in this instance the shower screen was not. The care home’s use of an unsafe fixture and its lack of prior checks was fault. This was not in line with the fundamental standards of care. This fault caused Mrs Y an injury and her family distress and that was a significant injustice.
20. The Care Provider took appropriate actions following the incident. It put the shower out of use before replacing it, reminded staff to conduct checks before use and to promptly report any fault/repair issues to ensure immediate safety of its residents and to prevent recurrence. The Care Provider’s investigation of this incident was without fault.
21. The Care Provider said after re-evaluating the incident it reported the matter to the Council. Mr X also referred his safeguarding concerns to the Council separately. The Council undertook a section 42 safeguarding enquiry as Mrs Y had experienced harm. It investigated and closed the safeguarding alerts. Records of its investigation concluded that there was no evidence of abuse or acts of omission of care, rather the shower door came off its hinges and injured Mrs Y’s leg. It was satisfied that the Care Provider had taken appropriate actions and had also treated Mrs Y’s injury appropriately following the incident.

Other complaints

22. Mr X raised other complaints with the Care Provider about the care it provided to Mrs Y. It investigated and responded to Mr X in May 2025. These included:

Nighttime checks

23. Mr X complained that Mrs Y’s nighttime checks were not completely properly – the care home records said that Mrs Y had been checked properly through the night, but this did not match Mr X’s records of the camera footage from Mrs Y’s room. Mr X said the care home staff had falsified the records of Mrs Y’s nighttime checks.
24. The Care Provider accepted fault - it acknowledged that the checks completed (by looking through the door) were not thorough and of its expected standard, for which it apologised. It said it did not consider that there was any intent to deceive or deliberate attempt to distort the records. It reminded the relevant staff of the importance of completing robust checks and the consequences of not doing these properly. It has provided us with evidence that shows it had since completed these checks robustly.

Findings

25. The Care Provider has already accepted fault in that the checks were not thorough and has taken action to prevent recurrence of the faults. It has already apologised and there is no evidence the fault caused Mrs Y a significant injustice.

Testing of electrical appliances

26. Mr X complained about portable appliance testing (PAT) of electrical appliances in Mrs Y’s room. He said items including a lamp was not included in the check and there were many older PAT labels still attached to another appliance.
27. The Care Provider said it had not included the items in the previous inspection; an oversight on its part for which it apologised. It arranged for the items to be tested and said it would remind staff to promptly inform the relevant officer of any new electrical items in the home to ensure they were added to the PAT schedule before being used. It also sent us a recent record of the testing completed for the entire care home.

Findings

28. The Care Provider was at fault for not testing all the electrical items in Mrs Y’s room. It took prompt action to correct this error and prevent recurrence. Although there is no evidence this caused Mrs Y an injustice, it is likely to have caused Mr X some concern.

Sling hoist

29. Mr X said the sling used to hoist Mrs Y was overdue for safety checks – the tags displayed the date of inspection which the care home staff disagreed with.
30. In response to Mr X’s concern the care home provided an alternative sling the same day and arranged for the external contractors responsible for the checks to visit the next day. The contractor serviced and appropriately tagged the sling which had not been looked at during their previous visit. In addition to arranging an immediate check, the care home issued a policy reminder to all staff to check the safety tags prior to every use. It also apologised to Mr X.

Findings

31. The Care Provider should have ensured that any equipment in its care home was up to date with its safety checks. It failed to do this which was fault and was not in line with the fundamental standards of care. The Care Provider took actions outlined above which were an appropriate remedy for any injustice caused by its fault.

Staff handling of Mrs Y

32. Mr X complained that Mrs Y had sustained a skin tear to her arm due to not being handled carefully by the care home staff. He later complained that Mrs Y had also sustained an unexplained bruise to her neck at a later date and added that Mrs Y had told him that certain staff were rough when moving and handling her. Mr X said that the Care Provider’s response was not satisfactory.
33. The Care Provider said it spoke to Mrs Y about both incidents. Regarding the skin tear incident it said records showed that Mrs Y sustained this tear while staff helped her get changed – Mrs Y felt “her top had pinched her skin” and the staff discovered a stain of blood when they checked Mrs Y. They immediately reported the incident to the nurse who cleaned and dressed the wound and informed Mrs Y’s family. The Care Provided noted that Mrs Y made no allegations of abuse or rough handling and there were no grounds to raise a safeguarding alert. It issued a reminder to all staff to take extra care due to Mrs Y’s fragile skin.
34. Regarding the unexplained bruise, the Care Provider said Mrs Y was unaware of the bruise and could not say how it was sustained. The staff responsible for Mrs Y’s care also could not explain a probable cause for the bruise. It noted that Mrs Y was on medication that put her at an increased risk of bruising. The Care Provided said because Mrs Y did not raise concerns about how the bruise was sustained, it was unable to investigate the matter further.
35. The care home management spoke to Mrs Y about her comment that certain staff were rough when moving and handling her. It asked Mrs Y if she felt that staff were being intentionally heavy-handy or abusive and if she wanted to report any issues. It noted that Mrs Y denied any abuse and said that that staff could sometimes rush and be unaware of their own strength. Records showed that the home manager addressed this concern straightaway. It apologised to Mr X and Mrs Y in its complaint response for any distress caused as a result.

Findings

36. The Care Provider responded appropriately to Mr X’s concerns and to Mrs Y’s comment. It looked at records and spoke to Mrs Y and the relevant staff involved in her care to ascertain what had happened and how/why. It apologised for any distress caused and reminded all staff to be extra careful when handling and moving Mrs Y. It is not denied that Mrs Y sustained a skin tear and an unexplained bruise but there was no fault in how the Care Provider responded to and addressed these issues when it became aware.

Communication and complaint handling

37. Mr X complained about the Care Provider’s communication and complaint handling; their care concerns and queries were not followed up or responded to appropriately and in a timely manner, and that their stage one complaint was closed without a written response to their complaint.
38. In response to Mr X’s concern the Care Provider acknowledged that there were “deficiencies in communication from the care and nursing team”. It advised Mr X to direct queries to the nurse and senior management as care staff may not have the answers to their concerns or queries.
39. Regarding its complaint handling, the Care Provider said “it was not uncommon for complaints to be resolved via local resolution meetings” and that it had held a meeting to discuss concerns, which was the resolution and response to Mr X’s complaint. It added that Mr X’s complaint was escalated to stage two of the complaints process when he complained of his dissatisfaction and of further issues. The Care Provider apologised that Mr X was expecting a written stage one response and that its process (of the meeting being the response and resolution) was not adequately explained.

Findings

40. The Care Provider accepted that it did not communicate effectively which was fault that caused Mr X avoidable frustration. The Care Provider’s lack of written stage one complaint response was in line with its published policy and not fault, however the Care Provider accepted that the process was not explained properly. This was fault in the Care Provider’s communication which added to Mr X’s frustration.

Remedy

41. In response to our enquiries, the Care Provider offered to provide a credit of £1000 to Mrs Y’s account to recognise the distress and upset caused by the faults identified. It also offered Mr X £200 to acknowledge the frustration and distress he was caused in pursuing his concerns.
42. The Care Provider’s offer of a financial personal remedy is in line with our guidance on remedies and acknowledges the injustice caused by the faults identified. The Care Provider has also taken appropriate action to address the concerns identified through Mr X’s complaints and its investigations and no further recommendations for service improvements to address these concerns are required.

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Agreed action

43. Within one month of this decision the Care Provider will:
1. Apologise to Mrs Y and Mr X for the avoidable frustration and distress caused by its faults. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Care Provider will consider this guidance in making the apology.
2. Add £1000 in credit to Mrs Y’s account to acknowledge the avoidable distress and upset she was caused by the faults in the quality of care she received.
3. Pay Mr X £200 to acknowledge the avoidable frustration and distress he was caused by the Care Provider’s faults.
44. The Care Provider will provide us with evidence it has complied with the above actions.

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Decision

45. I found fault causing injustice and the Care Provider agreed actions to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman