Summary: Mr X complained about the care provided to his late mother, Mrs Y, at one of the Care Provider’s care homes. The Care Provider was at fault for leaving Mrs Y with food while she was lying down, failing to check her commode and for not telling her family about some incidents. This caused Mr X distress and uncertainty over whether she was being properly supported. The Provider has already acted to remedy the injustice. The Provider was not at fault for the way it responded to Mrs Y’s resistance to care, the number of falls Mrs Y had or for the delay in diagnosing her fractured wrist.

The complaint

1. Mr X complained about the care the Care Provider gave his late mother, Mrs Y, in one of its care homes. Mr X said his mother had repeated falls, staff delayed diagnosing her fractured wrist, did not always tell family members about incidents and left her lying down while eating and drinking without support. Mr X said he also had concerns about the Care Home’s handling of Mrs Y’s personal care issues and resistance to care.
2. Mr X said this caused him distress and meant his mother did not receive the care she paid for.

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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 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. 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.
5. 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).
6. 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).

7. 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

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

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What I found

The Law

Adult social care providers

10. 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. These include:
• Regulation 9: Person-centred care: This regulation describes the action that providers must take to make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences.
• Regulation 12: Safe care and treatment: people must not be given unsafe care or treatment or be put at risk of harm that could be avoided.
• Regulation 14: providers must make sure that people who use their services have adequate nutrition and hydration to aid good health. People must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition.

Care Provider’s residency agreement

11. The Care Provider’s residency agreement states it will tell relatives or representatives about any accidents, injuries or illnesses a resident experiences as soon as practically possible. It also states it will make a record of all incidents.

Background

12. Mrs Y had dementia and was a resident in one of the Provider’s care homes. Mrs Y moved into the Care Home in November 2023.
13. In late December 2023, the Care Home completed a falls risk assessment for Mrs Y which set out what the Care Home could do to reduce the risk of falls.

What happened

14. Mr X and his relative Ms Z complained to the Care Provider about Mrs Y’s care in June 2025. The Provider responded in late July 2025.
15. Mr X and Ms Z complained to the Care Provider about further incidents in early August 2025. The Provider responded in mid-August 2025.
16. Mr X and Ms Z remained unhappy, and Mr X complained to the Ombudsman in early September 2025.

Mrs Y’s falls and fractured wrist incident

What happened

17. The Care Home’s records showed Mrs Y had 21 falls over 12 months. In November 2024, it referred her to a falls clinic. An assessment found Mrs Y’s falls were mainly due to cognitive factors.
18. The Care Provider said Mrs Y had no falls in December 2024 or January 2025 and two falls in February 2025. The Care Home’s records showed that for one fall, staff found no injuries. For the other fall, Mrs Y complained about back pain, so the Care Home called paramedics.
19. In March 2025, the Care Home recorded that Mrs Y had a further fall, after which the staff called Mrs Y’s GP.
20. The Care Home recorded that Mrs Y had three falls during April 2025. For two of the falls, staff recorded Mrs Y had no injuries. For the other fall, which happened on 13 April 2025, the Care Home called Ms Z and paramedics, who visited the Care Home and found Mrs Y had some pain, but no obvious injuries. The Care Provider said Ms Z and the paramedics decided that as it was late at night, it would cause Mrs Y distress to go to hospital at night so the Care Home would arrange for Mrs Y to have an x-ray the next day. A medical professional visited Mrs Y the following day and arranged for her to have an x-ray in hospital on 16 April 2025. Around this time, the Care Home discussed an increase in Mrs Y’s falls with Ms Z, and it made a falls referral to Mrs Y’s GP.
21. The Care Provider said it was told during Mrs Y’s x-ray appointment the results would be sent to her GP, and the hospital did not raise any immediate concerns about Mrs Y. On 30 April 2025, a doctor told the Care Home that Mrs Y’s x-ray showed she had fractured her wrist during the fall on 13 April 2025.
22. In May 2025, Mrs Y had four falls with no injuries recorded. The Care Home recorded a further three falls in June 2025, in which staff also found no injuries.
23. Mrs Y had four falls during July 2025. Staff found no injuries after two of the falls, but Mrs Y had a facial injury after one fall and shoulder pain after the other fall. The records stated Mrs Y did not want an x-ray for her shoulder pain.

Findings

24. The Care Provider’s records showed that Mrs Y had several falls, some causing injury. The evidence showed the Care Provider completed falls risk assessments, recorded falls and injuries, made falls referrals and asked for medical assistance when needed. The falls assessment in late 2024 also found most falls were linked to cognitive issues. On balance, the Care Provider was not at fault for the number of falls Mrs Y had and it took reasonable steps to prevent and respond to them.
25. After Mrs Y’s fall on 13 April 2025, the Care Provider called paramedics who found no injuries. Ms Z and the paramedics agreed to wait for Mrs Y to have an x-ray to avoid causing her distress. The Care Home were not aware of Mrs Y’s fractured wrist until it received the x-ray results on 30 April 2025. The evidence showed the Care Provider took reasonable steps to get medical treatment and advice for Mrs Y’s injury. The Care Provider is not at fault.

Care Home telling family about falls and incidents

What happened

26. The Care Home recorded 30 incidents, including the falls and incidents related to Mrs Y’s behaviour, between February 2025 and July 2025.
27. In March 2025, the Care Home recorded that Mrs Y was involved in an incident with another resident. The record showed the staff did not contact Mr X or Ms Z about this.
28. In April 2025, the Care Home records showed staff told Mrs Y’s family about two of the falls and said it would tell the family the next morning about the other fall. There is no record of whether staff told the family the next morning. The Care Home also recorded an incident where Mrs Y acted aggressively. The record stated staff de-escalated the situation, so it did not tell her family.
29. The Care Home recorded that it had not informed Mrs Y’s family about one of her falls in May 2025, but it would tell them in the morning. There is no record of whether staff did so.
30. In June 2025, the Care Provider said it did not tell the family about one of Mrs Y’s falls, but it would do so in the morning. There is no record of whether staff contacted the family. The records also showed the Care Home did not contact Mrs Y’s family about a small finger injury she received.
31. The Care Provider said there were two incidents in July 2025 where Mrs Y declined personal care or became agitated during personal care. The Care Home’s records stated it did not tell the family about these incidents at the time, as it had agreed to provide weekly updates to the family about personal care matters.

Findings

32. The Care Provider’s guidance says it will tell families about any accidents, injuries or illnesses. The Care Provider’s records showed it informed Mrs Y’s family about most incidents that happened between February and July 2025. However, it accepted it failed to do so on some occasions. This was fault and caused Mr X distress and uncertainty about whether other incidents had occurred that he was unaware of. Most of the incidents did not involve any injuries to Mrs Y and were managed by staff. There is no evidence the Care Provider caused Mrs Y harm by not telling the family of these incidents at the time. The Care Provider has apologised to Mr X and I consider this to be a suitable remedy for the distress and uncertainty this caused.

Care Home’s handling of Mrs Y’s resistance to care and personal care, including eating and drinking incident

What happened

33. The Care Home recorded nine incidents between February 2025 and July 2025 in which Mrs Y was resistant to care, distressed or refused personal care.
34. The Care Provider accepted in its complaint response that on one occasion, Care Home staff had left Mrs Y lying down and trying to eat and drink without support. The Provider said Mrs Y had declined to get out of bed and staff had left her meal in the room in case she wanted it later. The Provider accepted the staff should not have left food with Mrs Y while she was lying down and said it had updated her care plan to prevent it happening again.
35. The Care Provider also said in its complaint response it accepted that there was one occasion where Care Home staff had not properly checked Mrs Y’s commode, leaving it full, and there were times when Mrs Y was distressed when using it.
36. The Care Provider’s complaint response said it accepted there had been challenges with Mrs Y resisting personal care. It started using charts to better understand the causes and how staff could best respond to meet her needs. The Provider said this had improved Mrs Y’s care and her response to it.
37. In August 2025, the Care Provider responded to a second complaint from Mr X and Ms Z about a recent incident involving Mrs Y’s personal care. The Provider said it had checked on Mrs Y overnight at the times it had previously agreed with the family and this incident happened outside of those times. The Provider said it was aware that Mrs Y found personal care distressing and said it was being supported by other professionals. This included the GP, the mental health team and positive behaviour support team.
38. Around this time, the Care Provider met with the Care Home and the Council to discuss Mrs Y’s needs. The professionals at the meeting agreed the Care Home could no longer meet Mrs Y’s needs and she should be moved to a different care home. Ms Z agreed and Mrs Y moved to another care home in early October 2025. Mrs Y has since died.
39. In response to my enquiries, the Care Provider provided three months of care records. These showed staff regularly checked on Mrs Y overnight, gave her personal care when she agreed to it and recorded when she declined.

Findings

40. The Care Provider accepted it left Mrs Y with food within reach while she was lying down without staff support. This was fault. The Care Provider accepted the distress this caused Mrs Y’s family and said it had changed Mrs Y’s care plan to make sure it did not happen again. The evidence suggested this was an isolated incident and it did not cause Mrs Y harm. However, this care was not in line with the CQC fundamental standards and added to Mr X’s uncertainty over whether Mrs Y was receiving appropriate care. The Care Provider took steps to prevent recurrence of the fault, which was appropriate.
41. The Care Provider recognised Mrs Y often resisted care and found personal care distressing. The evidence showed the Care Provider discussed concerns with Mrs Y’s family and tried different approaches to her care as her dementia progressed. The Provider also sought help from other professionals where needed and regularly updated Mrs Y’s care plan with her needs and risks, including falls risk. The care shown in the Care Provider’s records was mostly in line with the CQC fundamental standards. On balance, the Care Provider took reasonable steps to meet Mrs Y’s needs around care and personal care. The evidence showed there were challenges to this, but on balance, the Care Provider is not at fault.
42. The Care Provider accepted it failed on one occasion to check Mrs Y’s commode properly and she found it distressing to use. The Care Provider was at fault for not checking the commode. This caused Mrs Y and Mr X distress. The evidence suggested this was an isolated incident. The Care Provider has already apologised to Mr X and said it had reminded staff of the need to check commodes. I consider this to be a suitable remedy for the frustration and uncertainty caused to Mr X.

Injustice

43. Mrs Y has since died so any injustice to her cannot now be remedied. The care provider, through its complaints procedure, has already taken action to address the faults identified so I am satisfied no further service improvement recommendations are required. It also apologised to Mr X which was an appropriate remedy to acknowledge the frustration and distress he was caused.

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Decision

44. I find fault causing injustice. The Care Provider has already taken actions to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman