Summary: Mrs X complained about failings in the care her mother, Mrs Y received while a resident at Newbury Manor Nursing Home. We found there is no evidence of fault in the actions of the Care Home.

The complaint

1. Mrs X complained about failings in the care her mother, Mrs Y received while a resident at Newbury Manor Nursing Home. In particular Mrs X complained:
• Mrs Y had a number of falls causing injuries including fractures to her femur and bruises to her head and hands. Mrs X complained the home did not do enough to prevent these falls. She also complains the home did not inform her of Mrs Y’s falls or explain how they had happened. Mrs X is particularly concerned about an unwitnessed and unexplained fall on 15 June 2024 in which Mrs Y sustained a fracture to her femur.
• Mrs Y lost a significant amount of weight in 2024 but the home did not inform Mrs X or take appropriate action to address this;
• Mrs Y was constantly wearing clothes belonging to other residents. Mrs X complained that when she brought this to staff’s attention the home failed to take action to address it; and
• Mrs Y’s toenails were not looked after appropriately, despite Mrs X paying for a chiropodist.
2. Mrs X has asked Mr Z to assist her in pursuing this complaint.

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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. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, 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)

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What I have and have not investigated

7. Mrs X complains about failings in Mrs Y’s care at Newbury Manor since she moved there in 2020. However we will not investigate this full period. As set out above, we expect people to come to us within 12 months of them thinking the Care Provider has done something wrong. As Mr Z contacted us in July 2025 we would generally only consider events since July 2024.
8. I have exercised discretion to look at events since January 2024 but will not consider events prior to that. The more time passes between the events and a complaint, the more unlikely it is we can investigate them effectively, gather reliable evidence and reach a sound decision. I do not consider we would be able to we would be able to achieve a worthwhile outcome by investigating events from so long ago.

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How I considered this complaint

9. I considered evidence provided by Mr Z and the Care Home as well as relevant law, policy and guidance.
10. Mr Z and the Care Home had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

11. The following is a summary of the key events relevant to our consideration of the complaint. It does not include everything that happened.
12. Mrs Y has a number of medical conditions, including a diagnosis of dementia. When Mrs Y moved to the Care Home she was identified as being at high risk of falls due to reduced mobility. The Care Home carried out risk assessments and developed care plans. Mrs Y was nursed in a height adjustable bed with a sensor mat in place to minimise her risk of falls while in her bedroom. Two carers hoisted Mrs Y for transfers from her bed to her chair and used a wheelchair for transportation.
13. As part of the care plan for Mrs Y’s nutritional needs staff monitored Mrs Y’s daily intake to reduce weight loss and checked her weight regularly. The Care Home’s records of Mrs Y’s weight show she weighed 68.8 kg in January 2024 and this had reduced to 64.4 by June 2024.
14. Mrs Y’s foot care plan noted she needed professional assistance to maintain a good standard of foot health. As Mrs Y did not meet the criteria for NHS referrals her family would meet the cost for professional foot care.
15. The Care Home’s records show a carer found Mrs Y sat on the sensor mat in her room in January 2024. The records say staff checked Mrs Y for injuries and signs of pain or distress but did not observe any and Mrs Y appeared comfortable. The Care Home informed Mrs X of the incident the following day. The records show it also informed Mrs X of a haematoma on Mrs Y’s left hand which had been seen by the doctor. The doctor had advised the Care Home to monitor this.
16. Following this incident, with Mrs X’s agreement the Care Home arranged for Mrs Y to have bed rails with bumpers to prevent her from rolling out of bed.
17. In May 2024 care home staff notices a bruise and swelling on Mrs Y’s finger. The Care Home informed Mrs X.
18. Mrs X says Mrs Y had an unwitnessed fall at the care home in June 2024. Mrs X is concerned that carers may have dropped Mrs Y while hoisting her. She says Mrs Y could not have fallen out of bed, as the bed had bumpers on both sides and she was too weak to mobilise and get out of bed by herself. Mrs X complains the Care Home failed to prevent the fall or to explain what had been put in place to prevent it. And that care home staff failed to properly respond to Mrs Y’s fall.
19. The records show staff carried out two hourly checks and repositioned Mrs Y throughout the night of 14 June 2024 into the morning of 15 June 2024. An entry at 04:19 states that staff repositioned Mrs Y and noted the right side of her hip was swollen and painful when touched. The staff informed the nurse. A subsequent entry notes Mrs Y had vomited and appeared tired and frail but alert, and her vital signs were within normal range.
20. Staff monitored Mrs Y then called an ambulance and informed Mrs X. The ambulance took Mrs Y to hospital where she had surgery to repair a fractured femur.
21. The Care Home made a safeguarding referral to the local council, as did the ambulance service and the hospital.
22. Mrs Y did not return to the Care Home when she was discharged from hospital. Mrs X says she felt she had no choice but to move Mrs Y to another care home to safeguard her.
23. In February 2025 Mr Z made a formal complaint to the Care Home on Mrs X’s behalf about the care Mrs Y had received. He complained:
• Mrs Y had a fall in 2022 as a result of which she broke her femur
• Mrs Y had experienced many falls resulting in several bruises to her head and hands. And none of these falls were reported or explained to Mrs X.
• Mrs Y had lost a significant amount of weight since 2022 and the Care Home had failed to tell Mrs X that Mrs Y had stopped eating or taken steps to address this;
• Mrs Y was constantly wearing clothes belonging to other residents. Mrs X had raised this several times but the Care Home failed to address this;
• Mrs Y’s toenails were not looked after appropriately despite Mrs X paying for a chiropodist;
• Mrs Y had an unwitnessed fall in June 2024 which the Care Home had failed to prevent and had not explained what had happened.
24. The Care Home investigated Mrs X’s concerns and responded in early April 2025. It said it had no record of Mrs Y fracturing her femur in 2022 but there was a record of Mrs Y falling in 2021 and being admitted to hospital with a fractured hip. Its records also showed two unwitnessed falls in 2022 which were reported to the local council. The Care Home said Mrs X was fully informed of all falls and incidents in line with its policy.
25. In relation to Mrs Y’s weight, the Care Home noted she had not lost weight, but rather Mrs Y’s weight had increased by around 6kg over the course of 2022. The Care Home also said Mrs X had not raised concerns about Mrs Y wearing other residents clothes. Had she done so, it would have investigated. It noted Mrs Y had the fix on system in place so all of her clothing was labelled to avoid mix up.
26. The Care Home also said Mrs Y received chiropodist care from 2021 to 2024, with gaps in treatment being due to funding. It said care resumed once the financial issues were resolved.
27. In relation to Mrs Y’s fall in June 2024 the Care Home said it had implemented risk assessments, care plans and interventions to prevent falls. It also provided prompt medical attention and followed safeguarding procedures for each incident. And maintained regular communication with Mrs X about Mrs Y’s health and wellbeing.
28. As Mrs X was not satisfied by the Care Home’s response, Mr Z has asked the Ombudsman to investigate her concerns. Mrs X said the paramedics who attended to Mrs Y in June 2024 had said the Care Home’s nurse in charge was not aware Mrs Y’s leg was very deformed. And that the ambulance crew had said the doctor at the hospital had said the fracture was unlikely to have just happened overnight.
29. Mrs X also noted a member of staff from the hospital had called the Care Home to enquire whether Mrs Y had had a fall and had stated it did not look like a spontaneous fracture but an injury. Mrs X is concerned that the fracture occurred more than 24 hours before it was discovered on 15 June 2024.
30. In response to our enquiries the Care Home says the nurse on shift denies saying they were unaware Mrs Y’s leg appeared deformed. They also suggested the paramedic’s comments about the doctor’s view were hearsay as there was no written evidence to support this. The Care Home also noted there was no formal medical statement to support the view that it did not look like a spontaneous fracture, but an injury.
31. The Care Home says that on 14 June 2024 Mrs Y received personal care during the day and no concerns were noted. Mrs Y ate breakfast and lunch well and ate half her evening meal. It says staff completed positional turns in accordance with Mrs Y’s care plan and carried out regular checks during the night. It says there were no recorded expressions or signs of pain prior to 4:19 in the morning of 15 June 2024 when staff noticed swelling and deformity of Mrs Y’s hip.
32. Mrs Y’s weight monitoring confirmed consistent recording between January and June 2024 and Mrs Y’s Body Mass Index (BMI) remained within normal parameters. The Care Home also says there are no records of any chiropody appointments for Mrs Y in 2024.
33. The Care home says its investigation found there was no evidence to substantiate the allegation of abuse. Nor was there evidence Mrs X had previously raised concerns about Mrs Y’s care during her residency at the home.

Analysis

34. Mrs X complained Mrs Y experienced many unexplained falls and bruises to her head and hands and that the Care Home has failed to take appropriate action. The Care Home disputes this. As set out above, our investigations are evidence based and we are unable to accept one person’s word against another’s.
35. The documentation shows the Care Home developed individual care plans for each aspect of Mrs Y’s care, including falls, nutritional care, personal hygiene, and foot care. The records also show that these plans were regularly reviewed and updated.
36. There is no evidence the care home staff failed to follow these care plans or that Mrs Y’s did not receive appropriate care. The documentation records four incident between January and June 2024: a haematoma on Mrs Y’s hand; a bruise on her finger; an unwitnessed fall from bed which did not cause any injuries; and the broken femur in June 2024. The Care Home informed Mrs X about each of these incidents. There is no evidence Mrs X raised any concerns about Mrs Y's care or safety following these incidents until June 2024.
37. It is unclear how Mrs Y sustained a fractured femur in June 2024. The Care Home’s daily records do not include any reference to Mrs Y sustaining an injury or falling from bed on 14 or 15 June 2024. Nor is there any reference to Mrs Y reporting any discomfort prior to the early hours of 15 June 2024.
38. It is unfortunate that Mrs Y’s medical conditions meant she was unable to offer any insight into how she sustained the fracture. And I note the council’s safeguarding investigation was unable to establish the cause. The ambulance crew felt the fracture was likely to be from an injury and was unlikely to have happened over night. And the hospital’s safeguarding referral refers to a mid-shaft fracture of unknown mechanism. Neither offer any view on how or when Mrs Y sustained the fracture.
39. While I recognise Mrs X is distressed and frustrated by the unexplained injury, I do not consider I can achieve any more by further investigation. I am unable to speculate on the cause. And in the absence of any documentary evidence I am unable to conclude it was caused by the acts or omissions of the Care Home.
40. Mrs X has also raised concerns about Mrs Y’s weight loss, wearing other residents’ clothes and poor care for her toenails. There is no evidence Mrs X raised these concerns with the care home prior to her formal complaint of February 2025.
41. The documentation shows the Care Home was monitoring Mrs Y’s food and drink intake and recording her weight on a monthly basis, in line with her care plan. Mrs Y did lose weight between January and June 2024. But not to the extent Mrs X suggests. Mrs X says Mrs Y’s weight fell from 70kg in April 2024 to 60 kg, while the Care Home records show Mrs Y lost just over 4kg, from a weight of 68.8kg in January 2024 to 64.4kg in May 2024.
42. In the absence of any evidence I am unable to say, even on the balance of probabilities whether, or to what extent, Mrs Y wore clothes belonging to other residents.

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Decision

43. I have completed my investigation and do not uphold Mrs X’s complaint.

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Investigator's decision on behalf of the Ombudsman