Summary: Miss X complained about the quality of care her grandmother, Ms Y, received at the care home, which she says caused avoidable distress. We have found the Care Provider was at fault. In part, it has already apologised to Miss X. It has now agreed to share its findings and its service improvements with her. It will also make a further apology for issues not covered in its initial response.

The complaint

1. Miss X’s complaints are as follows:
• A failure to recognise the deterioration in Ms Y’s condition, resulting in a delay in taking appropriate action.
• Ms Y was moved onto the floor following advice from NHS 111, despite the bed being equipped with a CPR function. There were also concerns regarding the appropriateness of the manual handling techniques used. In addition, it is reported that the nurse left the room while Ms Y had a reduced level of consciousness.
• Medication was not received and administered in a timely manner following the GP visit. When the family followed this up, the staff member on duty responded in a manner perceived as rude and unhelpful.
2. Miss X’s requested outcomes included adequate training for staff in line with relevant standards and confirmation measures have been put in place to prevent recurrence.

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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 this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I considered evidence provided by Miss X and Care Concern Limited (‘the Care Provider’).
7. Miss X and the Care Provider had the opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

What happened

8. Ms Y was a resident of White House Care Home (‘the Care Home’). In late June 2025, while a relative was visiting, they noticed a deterioration in her condition. This was not recognised by the nurse responsible for her care until the relative insisted that action be taken. A call was made to NHS 111 and, based on the information provided, the nurse was advised to move Ms Y onto the floor for monitoring. The nurse informed the call handler that Ms Y had a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order in place.
9. The Care Provider said that, during the move, the nurse, supported by four members of staff, used an appropriate moving and handling technique to lower Ms X safely to the floor, ensuring head support throughout.
10. The call was triaged and an emergency response dispatched. Following a clinical assessment, a decision was made by paramedics to not transport Ms Y to hospital, and her case was referred to a GP for further assessment.
11. The GP visited in the early evening, assessed Ms Y, and prescribed antibiotics electronically to a local pharmacy, with collection planned by the care home, on instruction from the GP, for the following morning. The GP planned to review
    Ms Y two days later. A few hours after, the relative present became concerned that the medication had not yet been received.
12. Ms Y’s relative raised this with a staff member but felt the response was rude and unhelpful.
13. As the GP visit took place on a Sunday evening, medication was not immediately available. Staff collected it the following morning, and the first dose was administered during the morning medication round.
14. A few days after the incident, Miss X made a complaint to the Care Provider which was acknowledged the same day.
15. A formal response was sent to Miss X in mid-July. The Care Provider acknowledged the events and identified that there was a delay in seeking medical attention and in adhering to internal policies. It said the matter would be addressed through its internal procedures.
16. The Care Provider apologised to Miss X and said all staff had received training on recognising early signs of deterioration. It also said it had held meetings to share learning, reinforce professional conduct, and encourage staff to engage with and respond appropriately to concerns. In addition, it said it would ensure nursing staff carry our prompt clinical assessments for residents with reduced levels of consciousness and seek immediate medical attention where required.
17. The Care Provider told Miss X that she could escalate her complaint to Stage 2 if she remained unhappy with the response.
18. Miss Y did not escalate her complaint but instead brought her concerns to the Ombudsman. She said this was because she did not believe further escalation would change the outcome and wanted the matter to be reviewed independently.
19. Following my enquiries, the Care Provider said it had carried out a number of actions in response to Miss X’s complaint including a ‘lessons learned exercise’.

My findings

20. The Care Provider acknowledged that the events of the day fell short of the standard that they would expect and took steps to prevent a recurrence. These included strengthened procedures for responding to clinically deteriorating patients and reinforcing expectations for timely and accurate record-keeping. I do not consider it necessary to recommend further action on this point.
21. In its complaint response, the Care Provider did not address Miss X’s concerns about moving and handling techniques used or the delay in administering medication, but it has shared its findings with me.
22. It is not for the Ombudsman to comment on how a medical practitioner has exercised their professional judgment, or to decide the adequacy or suitability of the medical care they have delivered. This is outside our remit and our expertise.
23. However, the Care Provider accepts that it was at fault for failing to properly explain its review of the incident to Miss X. It has agreed to write to her and share its findings and the service improvements it has made.
24. The Care Provider acknowledged and responded promptly to Miss X’s complaint and gave her the opportunity to escalate her complaint if she remained unhappy. She did not do so. Had she done so, this may have resulted in further investigation and a response addressing the outcomes she sought.
25. The Care Provider has provided evidence that it has taken steps to reflect and learn from the incident and has agreed to provide Miss X with further information about its findings. This will remedy the injustice caused.
26. The Ombudsman does not generally investigate staff conduct issues, or allegations that professional standards have been met. These are matters for HR procedures and for professional registration bodies, so I will not comment on these matters further.

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Action

27. Within four weeks, the Care Provider has agreed to:
• Apologise to Miss X for its failure to address all aspects of her complaint in its response. We publish guidance which sets out what we expect an effective apology to look like. The Care Provider will consider this guidance when writing to Miss X.
• Provide Miss X with the findings of its investigation into her concerns about the moving and handling of Ms Y and the delay in administering medication.
28. The Care Provider will provide us with evidence it has complied with the above actions.

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Decision

29. I find fault causing injustice. The Care Provider will now take steps to remedy Miss X’s injustice.

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Investigator's decision on behalf of the Ombudsman