Summary: Ms X complained about the standard of care Mr Y received during a period of respite care. The Council was at fault because the care provider failed to carry out some of Mr Y’s care in line with the pre-admission agreement, failed to notify the family about its decision-making, failed to keep records of its decision-making, failed to clarify the position on Mr Y’s medication administration, failed to tell the family about redness to Mr Y’s skin, and failed to seek out of hours medical help. This caused Mr Y’s family uncertainty, frustration and distress which the Council agreed to provide a financial remedy for.

The complaint

1. Ms X complained about the standard of care a care provider, HC One Ltd, gave to Mr Y during a period of respite care at Berry Hill Park Care Home.
2. Ms X said Mr Y was injured falling out of bed, and developed sores, because of HC One Ltd’s neglect and lack of personal care. She said HC One Ltd would not give her a copy of the accident report, failed to give Mr Y correct medication, and lost items of Mr Y’s clothing.
3. Ms X said this caused distress to Mr Y and stress and upset to the family.

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The Ombudsman’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
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. 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)
8. 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

9. As part of the investigation, I considered the complaint and the information Ms X provided.
10. I made written enquiries of the Council and considered its response along with relevant law and guidance.
11. Ms X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has issued guidance on how to meet the fundamental standards.
13. Regulation 9 says care and treatment must be appropriate and meet service users’ needs.
14. Regulation 10 says service users must be treated with dignity and respect.
15. Regulation 12 says care and treatment must be provided in a safe way for service users, preventing avoidable harm, managing risks, and managing medicine properly.
16. Regulation 13 says care providers must protect users from abuse, neglect, and improper treatment.
17. Regulation 17 says care providers should maintain accurate, complete, and contemporaneous records in respect of each service user.
18. Regulation 20 says care providers should be open and transparent with users about care.

What happened

19. I have summarised below some key events leading to Ms X’s complaint. This is not intended to be a detailed account of what took place.
20. Mr Y suffers from dementia. He was at Berry Hill Park Care Home for a weeks’ respite care during April 2025. This was commissioned by the Council.
21. Ms X received a call from the care home during Mr Y’s stay, saying Mr Y reported he fell from his bed. A carer told Ms X that Mr Y had a small cut to one arm. Ms X questioned how this could happen with bedrails and crashmats in place.
22. When Ms X collected Mr Y and brought him home at the end of his respite stay his regular carers cuts to both Mr Y’s arms and bruising, as well as cuts and bruising to one leg and redness around his groin and forehead.
23. Ms X contacted the Council to report Mr Y returned home with bruises and skin issues around his groin and back. She wanted to make a complaint but said the care home was avoiding her. The care home told her Mr Y had a fall but there was no paperwork. The Council suggested Ms X complete the complaint procedure on the care home's website.
24. Ms X complained to the care home on 14 April 2025 about a lack of care and neglect.
25. Ms X said a carer from the home visited Mr Y before his admission to find out his needs and medication. Ms X told the carer Mr Y needed bedrails and crashmats. She also gave details of his medication with doses and frequency. This was all written down. Ms X then gave a list of Mr Y’s medication on entry and double checked he would have bedrails. A carer also told Ms X that Mr Y would always have a sensor pad under his seat.
26. Ms X said when she collected Mr Y, he was sat in the lounge looking sad. He was not on a sensor pad and no carer was present. He was also in someone else’s clothing. Items of clothing were missing and there was medication left untaken when Ms X had provided the exact amount needed for Mr Y’s stay. She said the care home had not given Mr Y any of one of his prescriptions. Carers told Ms X this was because of the wording on the label. Ms Y questioned why carers had not telephoned her to check or telephoned Mr Y’s doctor. Ms X also said she asked for a copy of the accident report, but the care home would not give it to her. Ms X said she asked Mr Y about his injuries and he said, “no bedrail”.
27. Ms X said Mr Y sustained cuts to his other arm with bruising, and bruising and cuts to one leg. His skin was red around his groin, and he had rashes on his bottom and forehead. She said he had no cuts or marks before going into the care home. The care home also did not put Mr Y in his own pull-up pads, but a smaller, inadequate pad.
28. The Council commenced safeguarding enquiries on 17 April following Ms X’s complaints about unexplained bruising, a skin tear, groin redness, missed medication, and an unwitnessed fall.
29. HC One Ltd responded to Ms X’s complaint on 12 May 2025. It said Mr Y self-reported a fall during his stay after a carer noted a skin tear and bruising to his arm. The injuries were on the side where the bed rail and bumpers were in place, and it appeared the injuries were caused by the bed rail.
30. Staff undertook post fall observations, and a nurse conducted a full head to toe assessment. The nurse dressed Mr Y’s wounds and made a referral to the district nursing team. Staff completed body maps and found Mr Y had a sore groin. There was no bruising to Mr Y’s legs at this time. HC One said although staff told Ms X about this at Mr Y’s discharge, they should have communicated this to her sooner so she could get barrier cream. It apologised for any distress this caused and said it raised it as learning with staff.
31. HC One said it could not ascertain whether Mr Y fell or rolled from bed, but it placed him on 30-minute observations after finding his injuries. It said his injuries were on the right side, which was the side of the bed rail. As part of its assessment, due to Mr Y’s mobility status and potential confusion of a new environment, the care home put a low profiling bed in place with sensor equipment for a period of assessment as the least restrictive measure whilst balancing the risk. After the self-reported fall, the care home put bed rails and a crash mat in place. HC One considered the home appropriately managed the risk. However, it said the home should have better communicated this to Ms X.
32. HC One said the care home had to wash Mr Y’s clothing and gave him clothing from the home in the meantime. It also said Mr Y’s own supply of continence pads ran out quicker than expected, so the home supplied him with some of its own stock. It said this was not an act of neglect and Mr Y had a continence change 2.5 hours before his return home.
33. HC One said some of Mr Y’s medication was not used because it was Mr Y’s evening dose and he was discharged before needing it. It said Mr Y did not need his laxative medication as he experienced lose bowels. Last, it said it did not administer one of Mr Y’s medications because the label said to take it “when needed”. It said Mr Y showed no signs of anxiety, depression, or insomnia and to administer the medication could have had a mood altering or sedating effect. It also said it telephoned Mr Y’s doctor the day he returned home and the surgery understood why the home did not give Mr Y the medication.
34. The Council closed its safeguarding enquiry on 24 September 2025. It noted the care home’s manager gave a detailed account of the incident, including clinical observations, decision-making around bed rails, and post-incident actions. The care home acknowledged areas for improvement and held a comprehensive lessons-learned meeting with staff. It also implemented measures to prevent recurrence, including revised protocols for clinical escalation and equipment use. The Council considered the risk had been removed as Mr Y had returned home.

My investigation

35. As part of my investigation, the Council provided me with records of its safeguarding enquiries with the Berry Hill Park Care Home.
36. The care home told the Council Mr Y had bed rails and a crash mat at home which his family requested during respite. However, staff delayed putting the bed rails up for 48 hours to assess Mr Y’s mobility and the risks. Staff were concerned about tripping hazards and depriving Mr Y of his liberty. The care home put the bed rails up and used bumper mats after finding Mr Y’s arm injury.
37. The care home suspected Mr Y caught his arm on the bed rail. It could not rule out a fall, but said the sensor mat on the floor did not activate and it did not believe Mr Y could have returned to bed unaided. It confirmed the bed rail was not up.
38. The care home carried out observations for 48 hours and contacted Mr Y’s family in the morning.
39. The care home confirmed it found the redness to Mr Y’s groin on the day of his reported fall. It said he is prescribed barrier cream to be applied during pad changes, but the family did not send it with him. The home did not contact Mr Y’s doctor as it was bank holiday. It recognised it should have contacted 111, the National Health Service non-emergency number, instead.
40. The care home said it did not administer Mr Y’s anti-depressant medication as he was settled, calm, and eating and drinking well.
41. The care home manager held a clinical meeting with staff to review the incident, bed rail decision making, groin redness and failure to contact 111.
42. The Council’s enquiries highlighted concerns regarding delays in communication, lack of documentation, failure to act promptly on health concerns, and inconsistent medication management. It found the care home exposed Mr Y to potential neglect and abuse. The care home acknowledged these shortcomings in communication and clinical response.
43. The Council considered the care home’s internal review was positive in mitigating similar incidents happening in future. It considered there was no ongoing risk and took no further action.
44. The Council was to follow up with the care home to assess its improvement plan.
45. The Council also provided me with records from Berry Hill Park Care Home, including a pre-admission assessment, the incident report, body maps, daily notes, night check records, and food and fluid intake records.
46. Mr Y’s pre-admission assessment states trained staff with administer his prescribed medications. It also states he can mobilise a short distance and bed rails will be in place due to previously falling from bed.
47. The daily notes show a carer found Mr Y in bed with a skin tear to his inner elbow. Mr Y said he had a fall. The carer checked for further injuries but found none. The notes also show a carer found redness to Mr Y’s groin during a pad check two days after the reported fall. They applied cream.
48. The care home contacted Mr Y’s doctor’s surgery on the day he returned home about his anti-depressant medication. The home told the surgery the medication label stated, “to be taken twice daily as required”. The home therefore entered on its system that the medication should be given to Mr Y ‘as needed’. The doctor’s surgery reviewed their system and described the prescription label as ‘ominous’.
49. The incident report states a senior carer found Mr Y in bed with a bruising to his arm. Mr Y said he fell to floor and then got back into bed. The fall was not witnessed. The carer called for a nurse to assess Mr Y and check for further injuries. They dressed Mr Y’s skin tear and put 30-minute observations in place. The senior carer contacted the district nursing team to advise them about the injury. They arranged to visit Mr Y at home the following week.
50. The deputy manager of the care home then completed a falls investigation. They considered Mr Y could not have fallen from bed and got back in. They considered it was likely he caught his arm on the bed rail, due to the position of the injury.

Analysis

51. Ms X told the care home Mr Y slept with bed rails and bumper mats in case he fell out of bed. She thought the care home was going to implement the same, and I found it recorded this in its pre-admission assessment. However, the home decided it wanted to assess whether this was necessary. It considered there was a risk of injury if Mr Y got trapped by the rails or tripped. It also considered it may be a deprivation of Mr Y’s liberty.
52. While the care home explained this reasoning to the Council as part of the safeguarding enquiry, there is no record of this decision making in the contemporaneous records I have seen. This is fault. The home should also have discussed its decision with Ms X, since it was a deviation from the discussed pre-admission plan.
53. It is not possible to say for certain whether Mr Y fell out of bed. The home does not consider this is likely. On the evidence seen, the care home responded appropriately by putting observation in place and by putting bed rails and bumper mats in place to reduce any ongoing risk. A nurse from the home also assessed and treated Mr Y’s injury.
54. The home later found Mr Y had redness to his groin, which it gave him cream for. It appears Mr Y normally had cream applied each time his pads were changed. I found Mr Y’s family did not supply the home with this cream, and I have not seen evidence from the notes that this was discussed before admission. However, I am satisfied the home acted by giving Mr Y cream as soon as it identified the redness. The Council criticised the home for not contacting 111 when Mr Y’s doctor’s surgery was closed. That was fault. The home should also have notified Ms X.
55. The home did not administer some of Mr Y’s medication because it did not consider he needed it. It is clear Ms X expected the home to give the medication to Mr Y each day. While the home spoke with Mr Y’s doctor’s surgery around the lack of clarity on the label for his anti-depressant medication, this came when Mr Y was discharged home, so was too late. The home should have spoken to Ms X or the doctor’s surgery for clarification earlier. I appreciate the home said Mr Y appeared settled, and it was concerned about giving him medication when it was not needed, but it should also have considered the implications of stopping a medication Mr Y was regularly taking. That was fault. Again, I saw no contemporaneous records for this decision-making, which is also fault.
56. The records I have seen showed no changes in Mr Y following the suspected fall. He was eating and mobilising as normal and seemed settled in the lounge.
57. The Council was satisfied the home had appropriately mitigated future risks, and there was no ongoing risk to Mr Y after he returned home. The home also reviewed the incident and gave advice to staff. I found the Council suitably investigated and addressed the matter with the care home.
58. The Council found the care home exposed Mr Y to potential neglect and abuse. By not using bed rails from the outset as agreed, the care home exposed Mr Y to the risk of harm. However, I cannot say this led to Mr Y’s injuries, but it will have caused Mr Y’s family uncertainty and distress.
59. In addition, the care home’s failure to administer all Mr Y’s medication or discuss this with the family will have also caused additional uncertainty and distress. And the care home’s failure to tell Ms X about the redness it found on Mr Y’s skin, or to call 111, caused her frustration. It left her with a sense of outrage about the standard of care Mr Y received.

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Agreed Action

60. 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 the actions of the care provider and make the following recommendations to the Council.
61. Within four weeks of my final decision, the Council will:
• Apologise to Ms X for the distress, frustration and uncertainty caused by the standard of care Mr Y received.
• Pay Ms X a symbolic payment of £300 to recognise the distress, frustration and uncertainty the family suffered.
• The Council was due to follow up with the care home to check on future compliance. The Council will do so now.
62. The Council should provide us with evidence it has complied with the above actions.

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Final Decision

63. I found the Council at fault because the care provider failed to carry out some of Mr Y’s care in line with the pre-admission agreement, failed to notify the family about its decision-making when changing the agreement, failed to keep records of its decision-making, failed to tell the family about redness to Mr Y’s skin, and failed to seek out of hours medical help.

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Investigator's decision on behalf of the Ombudsman