Summary: Mr Y complained about the way Acton Care Centre, commissioned by the Council, provided care to his late mother-in-law (Mrs X) and acted following her fall. Mr Y also said the care provider Gold Care Homes failed to respond to his complaint. We found fault with the Council for its failure to ensure its commissioned care home met all the fundamental standards of care. The Council’s fault caused injustice to Mr and Mrs Y. The Council has agreed to apologise and make symbolic payments to Mr and Mrs Y to acknowledge their distress. The Council has also agreed to work with the care provider to ensure service improvements.

The complaint

1. Mr Y, on behalf of his wife Mrs Y, complains that the Council’s commissioned care home Acton Care Centre (the Care Home) provided poor care to his mother-in-law Mrs X, which caused her to fall and later die in hospital. Mr Y says the Care Home failed to:
• manage environmental risks to Mrs X (sharp objects in the room and unsuitable sensor mats as well as sensor mats not working);
• provide sufficient clinical oversight (refer Mrs X to hospital in a timely manner);
• hold accurate records about Mrs X’s fall (disparity between the care records and findings of the inquest);
• provide accurate information to Mrs Y after her mother’s fall.
2. Mr Y also complains about Gold Care Homes’ (the Care Provider):
• breach of the data protection legislation;
• choice of a witness and the Care Provider’s representatives for the Coroner’s Inquest as well as late submission and the quality of the documents;
• failure to address concerns raised at the meeting in February 2025.
3. Mr Y says the Council’s failings led to Mrs X’s death. They also caused significant distress to him and Mrs Y.

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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 a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2) and 34C(2), as amended)

6. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), 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. We normally expect someone to notify the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
9. We have no jurisdiction to investigate most complaints about coroners. And for the limited areas we could investigate, we would usually exercise our discretion not to investigate as we cannot look at the decision making by the coroner.
10. 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.
11. 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)
12. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

13. I have not investigated anything about the Coroner’s Inquest, including a choice of witnesses and the Care Provider’s representatives as well as late submission and the quality of the documents. This is because a coroner is an independent judicial office holder and not a local authority employee. Although they are appointed and funded by councils0 when undertaking tasks as part of the coroner’s statutory functions relating to coronial investigations, coroner’s officers are exercising the coroner’s functions, not those of the council. We cannot therefore consider complaints about those actions.

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How I considered this complaint

14. I considered evidence provided by Mr Y and the Council as well as relevant law, policy and guidance.
15. Mr Y and the Council as well as Gold Care Homes 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

Law and guidance

Fundamental Standards

16. 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.
17. The fundamental standards are the standards below which the care must never fall. Everybody has the right to expect the following standards:
1. person-centered care – you must have care or treatment that is tailored to you and meets your needs and preferences;
2. dignity and respect – you must always be treated with dignity and respect while you are receiving care and treatment. This includes making sure you have privacy when you need and want it;
3. safety – you must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Providers must assess the risks to your health and safety during any care or treatment and make sure their staff have the qualifications, competence, skills and experience to keep you safe;
4. safeguarding from abuse – you must not suffer any form of abuse or improper treatment while receiving care. This includes neglect and degrading treatment;
5. food and drink – you must have enough to eat and drink to keep you in good health while you receive care and treatment;
6. premises and equipment – the places where you receive care and treatment and the equipment used in it must be clean, suitable and looked after properly;
7. good governance – the provider of your care must have plans that ensure they can meet fundamental standards. They must have effective governance and systems to check on the quality and safety of care. These must help the service improve and reduce any risks to your health, safety and welfare. The records kept for you should be accurate, complete and contemporaneous;
8. staffing - The provider of your care must have enough suitably qualified, competent and experienced staff to make sure they can meet these standards. Their staff must be given the support, training and supervision they need to help them do their job.
18. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

Record keeping

19. Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided. (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17)

Safeguarding

20. 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)
21. It is important that all partners are clear where responsibility lies where abuse or neglect is carried out by employees or in a regulated setting, such as a care home, hospital, or college. The first responsibility to act must be with the employing organisation as provider of the service. However, social workers or counsellors may need to be involved in order to support the adult to recover. (Care and Support Statutory Guidance, paragraph 14.68)
22. The employer should investigate any concern (and provide any additional support that the adult may need) unless there is compelling reason why it is inappropriate or unsafe to do this. For example, this could be a serious conflict of interest on the part of the employer, concerns having been raised about non-effective past enquiries or serious, multiple concerns, or a matter that requires investigation by the police. (Care and Support Statutory Guidance, paragraph 14.70)

Confidentiality

23. Systems and processes must support the confidentiality of people using the service and not contravene the Data Protection Act 2018. (CQC guidance on Health and Social Care Act 2008 (Regulated Activities) Regulations, Regulation 17(2)(c))

What happened

Mrs X’s care at the Care Home

24. In September 2024 Mrs X was over 90 years old. She had dementia and a medical condition which causes visual hallucinations in people with significant vision loss. She also had other complex medical conditions.
25. Before her hospitalisation in June 2024, Mrs X lived with Mr and Mrs Y. She had multiple falls. She bruised easily as was on blood thinning medication.
26. In the second week of September Mrs X moved to the Care Home. On admission the Care Home carried out some risk assessments for Mrs X, including a falls risk assessment. She scored highly on a clinical frailty scale. Although the Care Home considered the use of a call bell for Mrs X appropriate, she was assessed not to be able to use it. She did not have mental capacity to make specific decisions about admission to the Care Home and provision of care.
27. On the day of admission the Care Home also recorded a result of early observations. Mrs X was admitted with some ulcers and bruises.
28. Mrs X’s care plan stated she could communicate verbally. She required assistance with all her care needs. She could walk for a short distance and used wheelchair for long distances. Mrs X needed a call bell, a sensor mat and a cushion sensor. The Care Home explained to us that although technically the use of a call bell was appropriate, Mrs X could not use it independently because of her visual impairment. References to the call back checks in her care records, they said, applied to the sensor mat checks.
29. The Care Home put in place hourly checks for Mrs X. She had a sensor mat in place to alert staff when she would try to stand up without help. She had a low profiling bed. The care notes state that she was encouraged to sit in the lounge for discreet supervision but she would wander at times. Mr Y queried this statement as Mrs X was too weak, he said, to walk unaided.
30. The next day after admission Mrs X was moved to a different room. The following day a General Practice (GP) nurse (Nurse 1) recorded the Care Home’s concerns about Mrs X’s drowsiness.
31. On 25 September 2024 Mrs X had an unwitnessed fall. She was found on the floor by night staff during one of the regular checks. The staff did not note any injury. The Care Home’s nurse carried out regular checks for Mrs X. Mrs X was awake and alert and did not report any pain. Nurse 1 reviewed the situation and recorded that Mrs X should be referred to a dementia service.
32. The next day the Care Home carried out some further assessments for Mrs X, such as bed rails assessment and nutritional assessment. It marked her history of falls and confusion.
33. A day later the care staff, alerted by an activated sensor, found Mrs X sitting on the floor next to her chair. There was no obvious injury and Mrs X managed to get up with the help of two members of staff. The Care Home carried out post-fall observations. Mrs X spent the afternoon with her family with no concerns raised.
34. On the same day the Care Home carried out another falls risk assessment for Mrs X. It recorded Mrs X was at the high risk of falls. The Care Home found it needed to ensure:
• Mrs X’s room was free from any harmful objects;
• her bed was in its lowest position;
• she was safe when transferring to or sitting in the chair;
• a sensor mat and a sensor cushion were in place;
35. The Care Home also found it needed to supervise Mrs X and provide her with guidance while walking and to help her with transfers to the wheelchair.
36. At the beginning of October the Care Home referred Mrs X to the Council’s Falls Service.
37. Two days later in the evening Mrs X had another fall. There are two versions of this incident:
• the care notes state that during the regular hourly check a care assistant on duty (Carer 1) found Mrs X looking for something in the plastic bag on the chair. She suddenly fell down on the floor. Carer 1 recorded the fall as a witnessed incident;
• during the Coroner’s Inquest and in the response to our enquiries the Care Home said the fall happened when Carer 1 was leaving the room at the end of the regular check. Carer 1 immediately turned back to find Mrs X on the floor. The Coroner decided the fall was unwitnessed.
38. Carer 1 called a nurse who carried out a physical examination. Carer 1 with the help from her colleague (Carer 2) helped Mrs X to get up.
39. The following day in the morning Nurse 1 did not record any bruising. At mid-day the care staff helped Mrs X with personal hygiene and helped her to get up. The staff noted bruises on Mrs X’s right thumb and on the left-hand side of her face. She looked drowsy and did not eat or drink. An hour later the care staff called Mrs Y and left the voicemail. Nurse on duty (Nurse 2) referred Mrs X to a GP and advised the care staff to tell the Council’s safeguarding team of Mrs X’s head injury. At the review around 4:00pm Nurse 1 told Nurse 2 to call the emergency service. When helping with personal hygiene the care staff noticed a bruise on Mrs X’s right hip. The emergency service arrived around 7:00pm. The staff contacted Mrs Y with an update.
40. The following day Mrs X lost consciousness and did not regain it. When the family visited she remained unconscious.
41. Eight days after the last fall Mrs X died in hospital.
42. In mid-October 2024 the Care Provider sent condolences to Mrs Y. The correspondence referred to a different person who died in the Care Home.

Complaint

43. In mid-January 2025 the Coroner carried out an Inquest into Mrs X’s death.
44. In the third week of January 2025 Mr Y sent a complaint to the Care Provider. Because of technical issues the Care Provider did not receive this complaint. Mr Y held a telephone call with the Care Provider’s staff and exchanged correspondence. Mr Y pointed out:
• false recording in the care records about whether Mrs X’s fall was witnessed or not;
• late submissions at the Coroner’s Inquest;
• concerns about the documents filed on the day of the Inquest;
• non-activation of Mrs X’s sensory mat;
• delay in contacting the ambulance;
• no information given on Mrs X’s head injury;
• concerns about risk assessments;
• delay in Mrs X’s referral to the falls clinic.
45. Mr Y stated he would like his concerns to be fully investigated. He raised the risk of the Care Home’s failings to other residents and asked what steps the Care Provider took following Mrs X’s death.
46. After chasing up contact from Mr Y at the beginning of February 2025 the Care Provider said the case would be dealt with through its complaint procedure.
47. In mid-February 2025 an online meeting with the Care Home Regional Manager (the Manager) and the Care Provider Senior Compliance Officer (the Officer) requested by Mr Y took place. At the beginning the Manager confirmed the meeting would be recorded. During this meeting Mr Y raised the issue of disparities between the care notes and the witness statements at the Coroner’s Inquest. The Manager explained how people with dementia and the eye-sight problems, such as Mrs X, would perceive dark sensor mats laid on the lighter floor. They would see it as a black hole in the flooring and try to avoid it. This, the Manager said, could explain why the mat was not activated when Mrs X fell. Mrs Y stated her mother was too frail to step over the mat and was seen to step on it. She said it was unlikely that it would take nearly 24 hours for Mrs X’s bruises to appear as her mother was taking blood-thinning medication which caused her to bruise immediately.
48. At the meeting the Manager and the Officer reassured Mr and Mrs Y that they would treat their concerns as a formal complaint. It was agreed Mr and Mrs Y would put in writing details of all the issues they wanted the Care Provider to investigate.
49. Immediately after the meeting Mr Y asked the Care Provider for the recording of this meeting. The Care Provider failed to respond to this request.
50. At the beginning of July 2025 Mr Y came to us. The Care Provider told us that it did not have any records of Mrs X’s family complaining following her death. The Care Provider stated that at the meeting in February 2025 it had been agreed that Mr Y would send a written submission which the Care Provider would investigate following its complaint process. This had not happened, the Care Provider said, and instead Mr Y had submitted a legal claim in March 2025. The claim did not progress and the Care Provider did not receive any correspondence from Mr and Mrs Y’s solicitors after June 2025.
51. The Care Provider clarified that at the time Mrs X was admitted to hospital following her fall the only identified injury was bruising. As there was no evidence of significant harm, the fall was not at first reported as a serious injury. No safeguarding alert was raised.
52. During my investigation I asked the Care Provider for a recording of the meeting in February 2025. The Care Provider responded: “no recording or transcript of the meeting is available”.

The Care Providers policy on slips, trips and falls

53. The policy states the Care Provider will ensure the residents’ risk of falls is minimised. Care homes will carry out a risk assessment for residents who have a history of falls and will add results to their service user’s plan. As part of the falls prevention programme care homes will access falls-prevention advice from care professionals, including physiotherapist and occupational therapist support if needed to implement treatment and prevention strategies.

The Care Provider’s Safeguarding Adults policy

54. The policy states that non-urgent concerns should be raised with the Council within 24 hours.

Analysis

55. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, any fault in the care Mrs X received at the Care Home is fault by the Council. The Care Provider acted on the Council’s behalf when providing services to Mrs X.

Management of the environmental risks to Mrs X

56. When offering a place to Mrs X the Care Home was aware of her history of falls. It should have assessed Mrs X’s risk of falls without delay and should have done all that was reasonably practicable to mitigate these risks.
57. The Care Home failed to take all steps necessary to manage the risk of Mrs X’s falls as it:
• delayed referring Mrs X to the Falls Service; this only happened at the beginning of October 2024, so five days after the last fall. The Care Provider explained that it would normally refer residents to the Falls Service after three falls. This, however, still does not explain why it took the Care Home five days from the last fall to send a referral;
• failed to explore suitability of a standard sensor mat; at the meeting in February 2025 the Manager explained the difficulties people with visual impairments have when using dark sensor mats. If the Care Home staff had known that Mrs X might try to avoid her sensor mat as she would perceive it as a black hole in the flooring, it is not clear why the Care Home did not try to find an alternative way to mitigate the risk of falls for her. If the Care Home had no alternative solutions, it should have at least consulted professionals to explore this issue.
58. The Care Home’s failings described above are a breach of the fundamental standard of providing safe care. It is not possible to decide whether this breach caused injustice to Mrs X as we could not say whether Mrs X’s falls could have been avoided if not for the Care Home’s failings. This is because the risk of falls was very high for Mrs X and any protective measures had to be balanced with respecting her independence. The Care Home’s failure to complete all reasonable actions to mitigate risks for Mrs X caused, however, uncertainty to Mr and Mrs Y whether Mrs X could have been better protected.
59. There is no evidence the sensor mats were not working properly. The care notes recorded regular checks of Mrs X’s equipment and after one of Mrs X’s falls the staff was alerted by an activated sensor mat.
60. Mr Y said Mrs X fell in the area where there was a cabinet with sharp edges. If Mrs X’s room had inappropriate furniture we would expect the visiting family to have raised this with the Care Home at the time.

Clinical oversight following Mrs X’s fall in October 2024

61. The Care Home has a Slips, Trips and Falls policy which explains what should happen after a fall. The procedure depends on the severity of the fall and varies for falls with no injury, minor injury and major injury.
62. Early examination after Mrs X’s fall in October did not reveal any injuries, therefore led to implementation of the non-injury procedure. The procedure involved regular observations and assessments by medical staff.
63. It is unclear why, despite regular checks, the bruising on Mrs X’s face and thumb was only observed the following day after 1:00pm and the bruising on her hip even later. Considering Mrs X’s blood-thinning medication and previous experience of falls resulting in bruising within a short period of time it is unlikely that after the fall it would take more than 17 hours for bruises to appear.
64. I cannot say, even on the balance of probabilities, why the Care Home staff carrying out post-fall observations failed to notice bruising on Mrs X’s face, thumb and hip earlier. This should have been explored through the safeguarding proceedings.
65. When bruising on Mrs X’s face and thumb were observed, Nurse 2 advised the care staff to tell the Council’s safeguarding team of Mrs X’s head injury. This did not happen and was a breach of the fundamental standard of good governance. This breach caused injustice to Mr and Mrs Y as they did not get an external review of the circumstances around Mrs X’s fall and remained in doubt whether the Care Home staff acted with due diligence following Mrs X’s fall. The Council’s safeguarding process would have brought some resolution and closure to Mr and Mrs Y’s concerns.

Records about Mrs X’s fall

66. As explained in paragraph 13 I cannot evaluate any records prepared as part of the Coroner’s Inquest.
67. In our ‘Good record keeping: guide for care providers’ published in February 2023 we explain how care providers should keep their records to ensure good governance. We refer care providers to the CQC guidance. To be fit for purpose care records should be complete, legible, indelible, accurate and up to date.
68. The Care Home failed to keep accurate records for Mrs X’s care. There were disparities between the incident report, the post-fall observation log and Mrs X’s care records, such as:
• contradictory reports about the circumstances of Mrs X’s fall; care records state it happened at the beginning of the hourly check when the carer was entering Mrs X’s room whereas later reports state it happened at the end of the hourly check, when the carer was leaving the room;
• contradictory statements in Mrs X’s care notes and the post-fall observation log about whether Mrs X was in pain following her fall and whether she was asleep.
69. These inaccuracies of records and statements are another breach of good governance. They meant that Mr and Mrs Y could not get a clear picture of the circumstances around Mrs X’s fall in October 2024. Because of the contradictory and confusing records they could not find out whether the care and medical staff followed correct procedures. This was particularly distressing as on the second day after the fall Mrs X became unconscious and died a few days later.
70. Mrs X’s care notes contain regular references to checking Mrs X’s call bell. During the investigation of this complaint the Care Provider stated Mrs X could not use a call bell because of her visual impairment and any references in the care records to a call bell applied to a sensor mat. This lack of rigour when recording information in the care notes is fault, which meant that Mr and Mrs Y could not rely on the accuracy of the notes.

Information provided to Mrs Y after her mother’s fall

71. The Care Home staff left a message on Mrs Y’s voicemail after her mother’s fall in early October. It left another message about Mrs X’s bruising once it was found and told her about Mrs X’s hospitalisation. Because of the frequency of Mrs X’s falls the Care Home staff was not alarmed by the fall especially since Nurse 1 did not find any injuries or bruising when she first examined Mrs X.
72. I cannot determine details of the Care Home staff’s messages to Mrs Y but their timing shows that the Care Home told Mrs Y about the fall and kept her updated on any changes.

Breach of the data protection legislation

73. Information about a deceased person is not personal data for the purpose of the General Data Protection legislation. As indicated in paragraph 23, however, good governance requires observing confidentiality for people using care providers’ services.
74. The Care Provider should not have shared personal data of a deceased resident with Mrs Y. It is likely to be a human error, rather than the evidence of a wider failure.

Failure to respond to Mr Y’s complaint

75. At the meeting in February 2025 Mr Y agreed to provide a detailed list of his concerns in writing, which the Care Provider would investigate applying its complaint procedure. This did not happen. We would, therefore, not criticise the Care Provider for not considering Mr Y’s complaint.
76. In January and February 2025 Mr Y expressed various concerns about the Care Home. Immediately after the meeting in February 2025 he asked for its recording. The Care Provider failed to respond to this request. Mr Y challenged the Coroner’s Inquest and took some action to file a court claim against the Care Provider. In July 2025 Mr Y raised his complaint with us. In such circumstances to be transparent the Care Provider should have kept the recording of the meeting. Not keeping this recording is an administrative failure. It did not cause injustice to Mr and Mrs Y as they had their own recording.

Service improvements

77. The Care Provider confirmed that since Mrs X’s death the Care Home:
• had introduced an enhanced governance structure by a member of the quality team reviewing incidents on a weekly basis;
• had undertaken internal learning to improve the accuracy of incident recording; and
• had reviewed and revised the post-fall protocol.
78. The Care Provider’s actions address some of the failings identified in this investigation but not all of them.

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Action

79. 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/service of the Care Provider and make the following recommendations to the Council.
80. To remedy the injustice caused by the faults identified, we recommend the Council complete within four weeks of the final decision the following:
• apologise to Mr and Mrs Y for the injustice caused to them by the faults identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology I have recommended;
• make a symbolic payment to Mr and Mrs Y of £250 each to recognise their distress.
81. We also recommend the Council within three months of the final decision:
1. ensure the Care Provider sets up an action plan to address:
• evaluation of the equipment used for new residents to mitigate the risk of falls;
• safeguarding reporting following falls; and
2. provide us with evidence of the action undertaken by the Care Provider to improve accuracy of the incident record-keeping and care notes.

The Council should provide us with evidence it has complied with the above actions.

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Decision

82. I find fault causing injustice. The Council has accepted my recommendations, so this investigation is at an end.

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Investigator's decision on behalf of the Ombudsman