Summary: There was fault on the part of the care provider which caused injustice to Mrs P. There were gaps in its compliance and recording of the post-falls protocol. There were also failings in personal care and meeting hydration needs. The care provider has already taken staps to improve aspects of care and record-keeping but in addition it should offer a refund of the fees paid in recognition that its failings caused distress for Mrs P and a payment to her family in acknowledgement of the distress caused to them.

The complaint

1. Ms X (the complainant) says the care provider failed to seek medical attention quickly enough for her mother Mrs P when she fell in the care home, and was later discovered to have a broken hip. She complains about the haphazard use of slip mats and crash mats in the home. She says Mrs P was often cold with inadequate covering when they visited and did not have a drink available to her. On one occasion a male resident who was partly clothed was found in Mrs P’s room.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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)

Back to top

How I considered this complaint

5. I considered evidence provided by Ms X and the care provider as well as relevant law, policy and guidance.
6. Ms X and the care provider had an opportunity to comment on my draft decision. I considered comments before making a final decision.

Back to top

What I found

Relevant law and guidance

7. 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.
8. Regulation 10 says service users must be treated with respect.
9. Regulation 13 says that care providers must not act in such a way that significantly disregards service users’ need for treatment.
10. Regulation 14 says service users’ nutritional and hydration needs must be met.
11. 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)
12. The care provider has a post-falls protocol which requires observations over a 24-hour period: every 15 minutes during the first hour, every 30 minutes for the next hour and a half, then hourly, followed by a two-hourly observation and finally four-hourly intervals until completion of the 24 hours. For unwitnessed falls the policy does not currently require a call to 111.

What happened

13. Mrs P was resident at the care home between 12 March and 19 March 2025. She was receiving nursing care in the home’s dementia unit. She was assessed as being a high falls risk on admission and had a sensor mat in her room. Ms X says there was never any evidence of a crash mat.
14. Ms X says despite her mother being assessed as a high falls risk, the only safety measure in the room appeared to be a sensor mat which was light and easily moved (by Mrs P herself as well as staff). She says she raised this concern from the start of her mother’s stay, along with concerns that Mrs P was thirsty and didn’t have drinks readily available and was sometimes cold. She also says on 14 March when family visited there was a male resident in her mother’s room who was only wearing an incontinence pad, and her mother was undressed from the waist down. She called for staff who attended and escorted the man away but “made light” of the intrusion.

The fall

15. On 18 March Mrs P had an unwitnessed fall. In her room. Her sensor mat did not activate but staff found her at 20.40 on the floor. The nurse on duty carried out a post-falls assessment and found no evidence of injury. The care provider says “a top-to-toe assessment was completed by the Registered General Nurse. No visible injuries were identified and neurological observations were undertaken. (Mrs P) did not report pain at that time, and there were no documented soft signs of fracture or clinical deterioration”. Mrs P was assisted back to bed and the home’s post-falls protocol commenced.
16. The nurse recorded that Mrs P would not tolerate any clinical observations at the checks which were carried out. The records show that one of the 30-minute checks was missed altogether, and two of the later nighttime checks were delayed by one and two hours respectively. At 13.10 on 19 March (a four-hour check which was two hours late) Mrs P was found to be in pain with her left leg rotated. 111 was called and advised an ambulance. The ambulance arrived and took Mrs P to hospital at 21.10 where she was discovered to have a fractured hip.
17. The home’s notes show that during the day Mrs P had also been seen by carers who had assisted her to the toilet using her walking frame. The home’s notes also show that Mrs P had been seen by carers at 17.10 on 19 March and said to be in pain and awaiting an ambulance. Ms X says family were at the home with Mrs P at that time and there was no observation carried out by staff at that time.
18. The care provider says, “Whilst we acknowledge that some observations were missed or completed later than required, the records also demonstrate that (Mrs P) continued to receive regular welfare checks and personal care interventions throughout the night. Care records show multiple interactions with staff, including continence care, repositioning, wellbeing checks and monitoring of her condition.” The care provider also notes that some post-fall monitoring records were completed on separate paper documentation in accordance with the recording systems in use at the time. So while the observations did not always comply with the schedule, there is evidence that Mrs P was being monitored regularly.
19. Mrs P did not return to the care home on discharge from hospital. A safeguarding alert was raised by the hospital about the fall.

The complaint

20. Ms X complained to the home about inadequate safety measures in her mother’s room, delay in calling an ambulance, failure to care for Mrs P properly after the fall including leaving her in bed covered only with a quilt cover and not realising she was cold. She also complained again about earlier incidents of poor care and finding the male resident in Mrs P’s room.
21. The care provider’s resolution director wrote to Ms X in May with a response. In response to Ms X’s request for a written report of what had happened between the fall and the hospital admission, she said the manager had been required to send a report to the safeguarding team and she copied that to Ms X. The director said the manager noted in her report that “Following investigation, I feel that the RGN who reported (Mrs P)’s fall did not follow the full protocol around un-witnessed falls. An ambulance should have been called straight away”. She also found the nurse was at fault for not completing all the checks. She said however that the safeguarding team had closed the referral.
22. The director said the sensor mat in Mrs P’s room was moved when there were visitors as otherwise it would be set off repeatedly. She said the use of bed rails was not appropriate as Mrs P was independently mobile. She apologised that Mrs P had been covered only with a quilt cover next day.
23. The director also said that the manager had instructed staff to offer fluids more often to Mrs P following the complaints of thirst. She said the records showed times when Mrs P declined offers of personal care and hygiene which may have led to her being inappropriately dressed. She also said that the records did not note the incident with the male resident.
24. Ms X was unhappy with the response and complained again. She said the care provider had not responded to her request for a fee refund although the family had paid £5814 for the period from 12 March to the month’s end. It had not explained properly the circumstances around the use of the crash mat and sensor mat. It claimed the safeguarding enquiry was closed which was not true. It had not properly responded to the other points of complaints on the days before the fall.
25. The regional director responded with more detail. She said a refund of £3488 would be issued. She apologised where there were errors in the first response. She said in terms of the sensor mat and crash mat, these would only be used at night as Mrs P was fully mobile. She apologised that staff had not been accurate in some of their records of what happened on the night of the fall and said a new system was being introduced which would include photographs of accident sites. She also said the nurse had called 111 instead of 999 as that was often the faster route to obtaining an ambulance.
26. Ms X remained unhappy. She complained to the care provider’s Chief Executive and then to us. She said the poor care and delay had meant Mrs P was now immobile and had moved to another care home. She said the care provider’s contradictory responses had been unhelpful and that it had also introduced, at the second stage, the mention of paper records as well as the electronic records. The welfare checks the director said had been carried out while Ms X’s brother was present had not happened. Her complaints that the skin condition on Mrs P’s legs had not been managed were not properly answered. Finally she said the refund offered was inadequate.
27. The safeguarding enquiry concluded that there had been neglect by omission. It said this was “ evidenced by the inconsistencies and lack of detail in care documentation, inadequate record keeping, lack of response to requests for pain management and failures in the implementation of safety equipment protocols. The absence of clear guidance in care plans, particularly concerning the frequency and location of cream application, further contributed to the inability to confirm whether appropriate care was delivered. These omissions indicate that residents’ needs were not fully met during the period in question”.
28. The safeguarding report noted that “Fluid intake records indicate that (Mrs P) was provided with fluids consistently throughout the day but only consumed minimal amounts”.
29. The care provider says that as a result of the complaint, it has reviewed practice in the home and

“- Staff have been reminded of the importance of regular equipment checks (including sensor mats and crash mats)

- The positioning and use of safety equipment has been reviewed to ensure it remains effective and appropriate

- Documentation standards have been reinforced, particularly where different recording methods are used

- Hydration practices have been reviewed to ensure residents have appropriate access to fluids

- Reflective discussions have taken place with staff regarding falls management and escalation”.

30. The care provider also notes that “ under the existing protocol and based on (Mrs P)’s clinical presentation at the time, contacting emergency services was not deemed necessary at that stage. The later view expressed by management that medical services should have been contacted following an unwitnessed fall formed part of the learning identified from the incident and informed subsequent review of procedures”.
31. The care provider notes that there was an extensive review following this incident and as a result it has taken significant steps.

Analysis

32. The care provider did not always ensure that there was sufficient fluid available for Mrs P to drink. That was a failing on its part and a potential breach of the regulations, which caused injustice.
33. There were legitimate concerns raised over the use of the safety mats and crash mats as it was not possible to confirm their usage from the documentation. Anecdotally the family had concerns about their usage which they reported to the care provider.
34. There was also evidence of a lack of respect for Mrs P’s dignity. She should not have been left thirsty or covered only with a quilt cover. There was inadequate documentation of personal hygiene care.
35. There was a failure to complete the falls protocol properly (although there is some evidence that monitoring continued but was not always documented appropriately). That was fault which caused injustice to Mrs P.
36. At the time of these events the protocol did not include a requirement to contact emergency services

Back to top

Action

37. The care provider has already reviewed its practices as a response to the complaint and the safeguarding enquiries. Within one month of our final decision, it should provide documentary evidence of this. It should also provide evidence that it has reviewed its protocol in respect of unwitnessed falls.
38. Within one month of my final decision the care provider will refund the remainder of the fees paid as the care provided was not of an acceptable standard and failed to meet Mrs P’s needs.
39. Within one month of my final decision the care provider will also offer £500 to Mrs P’s family for the distress and uncertainty caused to them by the events here and their concerns that an opportunity to treat Mrs P more quickly after her fall was lost.
40. The Care Provider should provide us with evidence it has complied with the above actions.

Back to top

Decision

41. I have completed this investigation on the grounds that I find fault causing injustice. That can be remedied by completion of the recommendations at paragraphs 37 - 39 above.

Back to top

Investigator's decision on behalf of the Ombudsman