Summary: Minster Care Group, acting on the Council’s behalf was at fault for failing to protect Mr Y’s dignity, respect and privacy following an incident in which he fell and injured himself. It caused Mr Y’s son, Mr X, distress. It was not at fault for the way it considered Mr Y’s risk assessment or for its complaint response. The Council has agreed to apologise and make a payment to Mr X.

The complaint

1. Mr X complained a care provider, Minster Care Group, Wordsley Hall Care Home in Stourbridge (the Provider), acting on the Council’s behalf failed to properly supervise and safeguard his late father, Mr Y, following an incident where another resident pushed him to the ground. Mr X said care home staff left Mr Y on the floor with a broken arm for hours while waiting for paramedics and failed to protect his privacy and dignity. Mr X was also unhappy with the Provider’s response to his complaint and believed the care home’s risk assessment did not properly consider Mr Y’s high fall risk or his ability to retain information.
2. Mr X said this caused him and his family distress. Mr X would like the Council to recognise the failings, hold care home staff accountable where appropriate, and improve its safeguarding, supervision, and risk assessment procedures within the care setting.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I 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. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future 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. 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 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 Council as well as relevant law, policy and guidance.
9. Mr X, the Council and the 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 and safeguarding

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set 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. The standards include that providers must make sure people are always treated with dignity and respect, including providing privacy when needed (regulation 3).
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).

Adult Social Care complaints

12. Councils should have clear procedures to deal with social care complaints. Regulations and guidance say they should investigate and resolve complaints quickly and efficiently. A single stage procedure should be enough. The council should include in its complaint response:

• how it considered the complaint;
• the conclusions reached about the complaint, including any required remedy; and
• whether it is satisfied all necessary action has been or will be taken by the organisations involved; and
• details of the complainant’s right to complain to the Local Government and Social Care Ombudsman.
  (Local Authority Social Services and National Health Service Complaints (England) Regulations 2009).

What happened

13. In early June 2025, Mr Y moved into a residential care home, with his care provided by the Provider, who was acting on the Council’s behalf. The NHS transfer of care note stated Mr Y needed 24-hour care due to increased falls and frequent hospital admissions. The note also stated Mr Y did not retain information about risks at home, including falls.
14. Around this time, the Provider completed a mobility assessment for Mr Y. The assessment stated Mr Y was a high risk of falls and used a walking frame to walk. The assessment also stated staff would need to help Mr Y and make sure he wore suitable footwear.
15. The Provider also completed a risk assessment, which stated Mr Y was a high risk of falls and needed assistance to walk, get in and out of chairs and get in and out of his bed. The Provider said it had encouraged Mr Y to walk every day using his walking frame and staff support. It also noted Mr Y sometimes got in and out of bed without staff support, and although it told him to ask staff for help, it was not convinced he would do so.
16. In early July 2025, an incident occurred in the care home in which another resident pushed Mr Y to the floor. Mr Y broke his arm because of the fall. The Provider completed a safeguarding incident log and an incident and monitoring form about the incident. The Provider recorded Mr Y and the resident had a verbal disagreement, and Mr Y allegedly raised his fists to the resident. The resident allegedly then pushed past Mr Y, which caused him to fall.
17. Staff from the care home removed the resident from the room and called emergency services as Mr Y said he was in pain. The Provider also called Mr Y’s family to tell them what happened. The Provider’s records stated it used cushions and blankets to make Mr Y comfortable on the floor, as emergency services had said to keep him still on his back. The care home staff took turns staying with Mr Y until his family arrived. Staff then left Mr Y with his family members to tend to other residents while waiting for paramedics to arrive.
18. Around three and a half hours after the incident, paramedics arrived and took Mr Y to hospital for an x-ray examination. Hospital staff said Mr Y had a suspected fractured arm and he returned to the care home the following morning.
19. The care home staff reported the incident to police and asked Mr Y if he wanted to press charges against the resident, which he said he did not. The Provider also made a safeguarding referral to the Council, who responded the incident did not meet its safeguarding threshold.
20. Two days after the incident, the Provider called emergency services due to concerns about Mr Y’s health. A few hours later, the Provider called emergency services again to say Mr Y’s condition had worsened. Paramedics arrived and took Mr Y to hospital. Mr Y died in hospital a few days later.
21. A few weeks later, Mr X complained to the Provider about its actions following the incident. Mr X complained that after the incident, the Provider allowed the resident who pushed Mr Y to continue walking around and trying to get into the room where Mr Y was on the floor. Mr X also complained the Provider failed to remove another resident from the room where Mr Y was and did not shield him or protect his dignity.
22. Mr X said the care home staff also left him and his relative alone with Mr Y for an hour while waiting for the paramedics to arrive. Mr X said the staff asked if they could leave him with Mr Y, which he agreed to at the time but has since recognised he did not have training to be left in that situation. Mr X also complained that while Mr Y was on the floor waiting for paramedics, he needed to use the toilet. Mr X said the care home staff did not have anything prepared for this situation and Mr Y had to urinate in a plant pot.
23. Shortly after Mr X complained, the Provider held a staff meeting to discuss his complaint. The meeting notes stated that staff often helped Mr Y to move around but he sometimes asked them to leave him alone. Staff also noted Mr Y did not always ask for help before getting up and walking around, but he had capacity and could retain information. The meeting notes also stated staff should have used a privacy screen to protect Mr Y’s dignity and they could not find a suitable urine bottle for Mr Y to use. The Provider said it had arranged for more urine bottles to be ordered and placed around the care home for future use.
24. A few weeks later, the Provider responded to Mr X’s complaint, stating it had encouraged Mr Y to ask for staff to help him when moving around, but he sometimes got up by himself. The Provider said on the day of the incident, Mr Y moved to another room without asking for help or using a bell to call staff. The Provider said it had completed thorough and up-to-date risk assessments for Mr Y and it had no concerns about altercations with other residents as Mr Y had not been involved in any previous incidents.
25. The Provider accepted it did not put a privacy screen up for Mr Y while he was waiting for paramedics. The Provider apologised to Mr X and said it had reminded staff about maintaining people’s dignity during emergencies. The Provider also said it could not remove the other resident from the room where Mr Y fell, as they needed hoisting. The Provider also accepted it should have found a suitable toilet aid for Mr Y to use and apologised for not doing so. It said it had reminded staff of the available resources and the process for managing toilet needs in emergency situations.
26. In its response, the Provider also stated an appropriate number of trained staff were working on the night of the incident. It accepted it left Mr Y with his family members while they waited for paramedics and although staff were available on the same floor, it would have been better for staff to stay with Mr Y. The Provider said it addressed this through internal guidance.
27. Mr X remained unhappy and complained to the Ombudsman in September 2025. Mr X said the Provider’s complaint response did not contain enough information and suggested Mr Y had caused the incident by raising his fists, when staff accounts said Mr Y raised his fists in response to the resident’s behaviour. Mr X also complained the Provider did not fully consider Mr Y’s high fall risk or his ability to retain information when it wrote its risk assessment.
28. The Council told the Ombudsman that after Mr X’s complaint, the Provider had acted to reduce the risk of similar incidents in future. It said this included the Provider having reviewed and reminded staff of its incident response and safeguarding processes, reviewed the care plans of residents with behavioural complexities, updated guidance and provided all staff with refresher training on dignity in care and conflict resolution.

My findings

29. The CQC standards state that providers must always treat people with dignity and respect, as well as providing privacy when needed. The Provider has accepted it did not provide Mr Y with a privacy screen or a toilet aid while he was on the floor waiting for paramedics to arrive. This was fault. It was not in line with the standards and caused Mr X and Mr Y distress. It also meant other residents could see Mr Y injured on the floor and he did not have privacy when going to the toilet.
30. The Provider’s risk assessment said Mr Y was at high risk of falls, needed some assistance for his own help and staff would place a nurse call near him, which staff had reminded him to use. The risk assessment stated Mr Y had capacity and could retain information. On balance, the Provider was not at fault for its risk assessment. It recorded Mr Y was a high risk of falls and set out the steps staff should take to support him. There is no evidence to suggest the Provider should have supported or monitored Mr Y on a one-to-one basis, and it found he had capacity and ability to retain information about asking for help. The Provider confirmed Mr Y had a nurse call system near him on the night of the incident and so it acted in line with the risk assessment.
31. Mr X was unhappy with the Provider’s complaint response. It responded to Mr X’s concerns and told him of his right to complain to the Ombudsman. In its response, the Provider explained what it thought happened during the incident based on staff accounts. I acknowledge Mr X was unhappy with the Provider’s summary of the incident, but I cannot say what happened during the incident. On balance, the Provider was not at fault.

Injustice

32. Mr Y has since died so any injustice to him cannot now be remedied. However, the Provider’s faults have caused Mr X distress and frustration for which I have recommended a remedy. The Council has provided evidence the Provider has already taken action to address the faults identified so I am satisfied no further service improvement recommendations are required. We have shared the final decision with CQC, the statutory regulator of care services, who can use it to inform future inspections.

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Action

33. Within one month of the final decision, the Council has agreed to:
1. Apologise to Mr X for the distress caused by the Provider’s actions when it failed to provide Mr Y with a privacy screen and toilet aid after the incident. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology.
2. Pay Mr X £200 for the distress and frustration caused by the Provider’s actions after the incident. This is in line with our guidance on remedies.
34. The Council should provide us with evidence it has complied with the above actions.

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Decision

35. I find fault causing injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman