Summary: The Care Provider was at fault for damaging and losing Mrs Y’s clothing. This caused Mrs X frustration and financial costs for replacing the clothing. It was also at fault for one occasion when it delayed washing and dressing Mrs Y and for a delayed complaint response to Mrs X. The Provider has already offered Mrs X a payment which is a suitable remedy for the frustration the faults caused. The Provider was not at fault for its actions after Mrs Y fell and for the hygiene and personal care it provided to Mrs Y.

The complaint

1. Mrs X complained the care her late mother Mrs Y received at the Care Provider’s care home Ridgewood Court, Wirral did not meet the expected standards and meant her mother did not receive adequate care. In addition, Mrs X complained the Provider lost Mrs Y’s shoes, damaged some clothing and failed to report a bruise on her leg to the family which caused her distress and frustration. Mrs X was also unhappy the Provider’s complaint response was delayed and included inaccurate information which added to her frustration.

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 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).
3. 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.
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. 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).

6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

7. I considered evidence provided by Mrs X and the Care Provider as well as relevant law, policy and guidance.
8. Mrs 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.

Back to top

What I found

The Law

Adult social care providers

9. 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.

The Provider’s falls policy

10. The Provider’s falls policy states that during and after an incident, nurses and team leaders are responsible for ensuring staff take proper action. This includes clinical assessment and observations, escalating to health professionals where appropriate and completing all relevant documentation.
11. The policy states the care home staff should encourage residents to be independent and safe. Staff should also supervise residents and provide support where needed, while following the resident’s care record.
12. The policy states there are three levels of guidance staff should follow if a resident has a fall:
• Green pathway – no injury
• Amber pathway – minor injury
• Red pathway – major injury
13. The amber pathway includes falls where a resident has not lost consciousness but has received an injury, such as minor bruising or swelling. For falls of this type, the guidance to staff includes helping the resident and giving first aid if needed, recording the incident and telling family as needed.

The Provider’s complaints policy

14. The Provider’s complaints policy says it has a three-stage complaint process. The Provider will aim to respond to the complainant at each stage of the complaints process within 20 working days.

Background

15. Mrs Y had advanced dementia and had stayed in the care home for respite care several times before.

What happened

16. Mrs Y moved into the Provider’s care home for four weeks of respite care in June 2025. The Provider completed a care plan for Mrs Y before she moved into the care home. The plan said staff needed to remind and supervise Mrs Y about going to the toilet. The plan also said Mrs Y had not recently had any falls and could use the bell for assistance when needed.
17. The Provider recorded in late June 2025 that Mrs Y had been removing her continence aid and putting it in the sink. The Provider said staff regularly monitored this, which helped reduce how often it happened.
18. In early July 2025, Mrs Y had an unwitnessed fall and staff found her sitting on the floor. The staff member used the emergency bell to alert team leaders. Four team leaders responded and checked her for injuries. The staff reported Mrs Y was jovial, wanted to stand up and had no visible injuries. The staff contacted one of Mrs Y’s relatives, Ms Z, who was listed as Mrs Y’s point of contact, to tell them about her fall. Ms Z said they did not want Ms Y to go to hospital unless necessary. Staff called the out of hours GP for advice and kept Ms Z updated with its actions.
19. After the fall, the Provider updated Mrs Y’s falls risk assessment and said she now had a room sensor to alert staff when she got out of bed, and they would check on her every hour during the night.
20. When Mrs Y’s care at the care home ended in late July 2025, Ms Z collected her and said she noticed a strong smell of urine when she was driving Mrs Y home.
21. In early August 2025, Mrs X complained to the Provider. Mrs X said she was concerned about the level of care the Provider gave Mrs Y, including staff allegedly not supporting her hygiene needs, not noticing a bruise on her leg and losing some clothing and shoes. Mrs X sent a copy of a photograph of Mrs Y’s bruise to the Provider.
22. The Provider responded around a month later that its records showed Mrs Y only declined help with personal and continence care on one day. It said there was another occasion she declined to clean her teeth, but she accepted help with personal and continence care. All other days, staff provided Mrs Y with help and support with her hygiene. Staff also recorded Mrs Y had some skincare issues, which it helped her with. The Provider said in its response that this showed staff were regularly checking and supporting Mrs Y with her personal care.
23. The Provider’s response said it had discussed the bruise to Mrs Y’s leg with Ms Z. Ms Z said Mrs Y had said the bruise occurred after she banged her leg on the bed when she was walking around her room. The Provider said bruising can show straight away but can also be delayed, so it could not say how or when the bruise occurred.
24. The Provider accepted there were creases in Mrs Y’s clothing and that it lost her shoes and socks and said it had apologised to Ms Z at the time. It said staff had followed the correct processes after Mrs Y’s fall and had correctly followed her care plan during her respite care.
25. Mrs X replied to the Provider and said she did not agree the bruising on Mrs Y’s leg was delayed and said the Provider’s apology for the damaged and lost property was not a sufficient remedy. Mrs X also said on one occasion, staff had left Mrs Y waiting for over 30 minutes while they were washing and dressing her. Around this time, Mrs X also complained to the Ombudsman.
26. Around eight weeks later, the Provider responded to Mrs X’s escalated complaint. The Provider apologised for the delay in responding, which it said was because it had originally allocated the complaint to a member of staff who then had an accident and was away from work. The Provider said it could not find any records of staff leaving Mrs Y for over 30 minutes but said if this happened then it should not have done. The Provider accepted staff should have noticed and reported the bruise on Mrs Y’s leg and said it should not have lost or damaged Mrs Y’s clothing and shoes. The Provider apologised to Mrs X and said it had discussed the issues with the care home staff. The Provider offered to pay Mrs X £500 so she could replace Mrs Y’s shoes and clothing.
27. Mrs X remained unhappy and escalated her complaint to stage three and said as well as the £500, she would like a week of free care for Mrs Y. The Provider responded and acknowledged there was a 30-minute delay when staff were washing and dressing Mrs Y and apologised for this. The Provider said it accepted Mrs Y had a small bruise on her leg, but it could not comment further. The Provider said it accepted it could have done some things better and apologised for this, but it felt the £500 offered was a reasonable remedy.
28. Mrs X continued complaining to the Provider. It responded to her in February 2026 and repeated its apology about losing or damaging Mrs Y’s clothing. The Provider also said based on the evidence it had, Mrs Y’s bruise in the photograph did not reflect how it looked when she left the care home. Mrs X responded that although she did not agree with some points of the Provider’s response, she accepted its offer of £500. The Provider made the remedy payment to Ms Z in March 2026.

Findings

29. Following Mrs Y’s fall, the care home staff told team leaders, checked Mrs Y for injuries, spoke to an out-of-hours GP and called Ms Z to tell her about the incident. The evidence showed the Provider took reasonable steps to get medical advice and follow its guidance for what actions staff should take after a resident has a fall. The Provider was not at fault.
30. Mrs X said after coming out of care, Mrs Y smelt of urine and had a bruise on her leg which staff had not noticed. Mrs X believed this was evidence the Provider was not meeting Mrs Y’s hygiene and care needs. The Provider said the bruise was delayed and so was not as visible when Mrs Y was in care. The evidence showed that apart from a small number of occasions when Mrs Y declined support, staff regularly washed Mrs Y and helped her with personal care and continence. There was no evidence of fault in the support provided to Mrs Y. Mrs X and the Provider have different views on when the bruising appeared on Mrs X’s leg. I cannot make a finding, even on the balance of probabilities, of when this occurred.
31. The Provider accepted there were creases in Mrs Y’s clothing and that it lost some items of clothing, including her shoes. The Provider was at fault. The Provider apologised and paid Ms Z £500. I consider this to be a suitable remedy for the frustration caused to Mrs X and the costs of replacing lost items of clothing.
32. The Provider accepted that on one occasion, staff left Mrs Y waiting for over 30 minutes while they washed and dressed her. The Provider was at fault. It appears to have been an isolated incident, and the Provider has apologised to Mrs X. I consider this to be a suitable remedy for the frustration caused.
33. The Provider accepted its stage two complaint response was delayed by around 20 working days. It explained the reason for this and apologised to Mrs X. The Provider was at fault. Its responses at stages one and three of its complaints process were in line with its guidance. On balance, I consider the Provider’s apology to be a suitable remedy for the frustration caused to Mrs X.

Injustice

34. Mrs Y has since died so any injustice to her cannot now be remedied. The Provider has already taken action to address the faults identified so I am satisfied no further remedy or service improvement recommendations are required.

Back to top

Decision

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

Back to top

Investigator's decision on behalf of the Ombudsman