Summary: Ms X complains on behalf of her mother, Mrs Y, the Council failed to provide adequate care for her mother in her Council funded care home placement at The Lodge Care Home from January 2025 to February 2025. Ms X says this caused her and her family distress. We have found fault in the actions of the Council funded care provider for failing to complete hourly checks on Mrs Y in accordance with her care plan. The Council has agreed to write to Ms X to issue an apology, pay a symbolic payment and complete a service improvement.

The complaint

1. Ms X complains on behalf of her mother, Mrs Y, the Council failed to provide adequate care for her mother in her Council funded care home placement at The Lodge Care Home (the Care Home) from January 2025 to February 2025.
2. Ms X says this caused her and her family distress.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this report, we 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. We refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. We normally name care homes and other care providers in our reports. 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)
6. 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.
7. 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)
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. I considered evidence provided by Ms X and the Council as well as relevant law, policy and guidance.
10. Miss X and the Council were invited to comment on my draft decision. I have considered any comments before making a final decision.

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What I found

Relevant law and guidance

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets 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.
12. Regulation 9 says the care and treatment of service users must be appropriate, meet their needs and reflect their preferences.
13. Regulation 10 says care providers must treat all service users with dignity and respect.
14. Regulation 17 says care providers should “maintain secure” records and should have “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.

Care Providers Procedures Manual

The care homes procedures manual states that staff should respond to call bell notifications within 4/5 minutes.

What happened

15. Mrs Y moved into the care home towards the end of January 2025. The care home created a care plan the following day. The care plan notes that staff should ensure they complete hourly checks and note Mrs Y’s location.
16. Mrs Y suffered an unwitnessed fall in late January 2025 but did not sustain an injury. The care home told Mrs Y’s family about the fall.
17. Mrs Y’s family met with the care home in early February 2025 and raised that staff had been slow to react to the care bell. The notes from the meeting said the care home advised staff should be responding to the call bell within 4-5 minutes as per its policy. The notes also said the care home installed a sensor mat in Mrs Y’s room as she had not always been able to remember that she could use the call bell.
18. The care home confirmed it had installed a sensor mat in an email the following day.
19. Mrs Y suffered another fall in mid-February 2025 which resulted in her being admitted to hospital. Mrs Y did not return to the care home.
20. Ms X raised a complaint with the care home in late May 2025. Ms X said she was unhappy with the time it had taken staff to respond to the call bell. She also said the care home had a high turnover of staff and the same person did not deal with Mrs Y twice. Ms X also said the care home completed Mrs Y’s care plan with an incorrect name on it twice and the care home did not install a sensor mat when she had asked for it. Ms X also said the care home did not check on Mrs Y regularly and she had fallen twice.
21. The care provider responded to Ms X’s complaint in late June 2025 and said it had taken action regarding the staffs’ response time to call bells. It said only one member of staff had left in the time Mrs y was in their home. The care home acknowledged and apologised for the incorrect name being in the care plan. The care home also said sensor mats were seen as restrictive and as a setting it would always look to use less restrictive methods initially.
22. Ms X said she was unhappy with the care home’s response in early July 2025 and the home responded to say it was sorry she remained unhappy.

Review of daily care notes

23. The care provider has provided a copy of its daily care note log. I have reviewed this for the period Mrs Y was staying in the care home.

Analysis

24. Ms X complained that the care home did not respond to the call bell for long periods when Mrs Y used it. I can see that Ms X raised this with the care home at the time and it took action to remind staff to respond within the timescales in its policy. It also increased the volume on the call bell notifications to try to improve response rates. I am unable to say whether staff responded to call bells in line with the care homes policy. However, the action the care home took following Ms X raising an issue addressed the matter and I cannot see Ms X raised this again with the home until the complaint several months later.
25. Ms X says the care home did not install a sensor mat when she asked for it. The care home has said it initially used less restrictive methods than a sensor mat but after it became apparent Mrs Y was not always using the call bell a sensor mat was installed. It is noted this was installed in early February 2025 shortly after Mrs Y moved in. I have not found fault in the actions of the Council in respect to this element.
26. Ms X says the care home recorded the incorrect name on Mrs Y’s care plan. The care home acknowledged and apologised for this. This is fault but I am satisfied the care home has already provided a suitable remedy in its apology for this element.
27. Ms X says the care home did not always check on Mrs Y. I have reviewed the care homes daily care notes. While I have been able to see hourly checks were completed most of the time. There are several examples where Mrs Y was not checked on, or it was not recorded she was checked on, for several hours. This is fault and would have caused Ms X distress and uncertainty.

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Action

28. Within four weeks of a final decision, the Council should:

• Write to Ms X to apologise for the distress and uncertainty caused by the fault identified.
• Pay Ms X £150 to recognise the distress and uncertainty caused by the fault identified.
• Advise the Ombudsman of what action it will take to ensure care providers are acting in accordance with care plans.

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

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Decision

30. I find fault causing injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman