Summary: Mr X complained the Care Provider did not correctly follow its falls policy following Mr Y's fall at the care home prior to his death. The Care Provider's actions in communicating with Mr X following the fall, the lack of clear and consistent falls procedures, and its complaint handling caused Mr X uncertainty, frustration and distress which is fault. The Care Provider will apologise and make a symbolic payment to Mr X and undertake service improvements to ensure there is a single, consistent falls policy and associated guidance in use across its services.

The complaint

1. Mr X, complained on behalf of his father, Mr Y. He said the Care Provider did not correctly follow its falls policy when Mr Y had a fall at the care home prior to his death.
2. Mr X says this has been upsetting and distressing for him and his family.

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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 complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences. Under our information sharing agreement, we will share this decision with it. 
6. 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)

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How I considered this complaint

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

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What I found

Policy and guidance

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12, requires care and treatment to be provided in a safe way. Providers must assess risks to people's health and safety and do all that is reasonably practicable to mitigate those risks. The Care Quality Commission's guidance says providers should have arrangements to take appropriate action in a medical emergency and should investigate incidents affecting people's health, safety and welfare.

Care Provider complaint policy

10. The Care Provider policy states that it will resolve complaints within 28 days of them being received.

Telemeds

11. This decision refers to ‘telemeds’ or ‘telemedicine’ throughout. This is a clinical telephone advice line for care homes which enables these care homes to get a quicker response and clinical advice when calling NHS 111. There’s an option for some care homes to convert to a video call for additional support.

Care Provider falls policy

12. The Care Provider has a ‘Falls Management Policy and Procedure’. It includes direction for professionals which says,
• “The Home Manager will ensure that the Post Falls Decision Making Tool is easily accessible.
• Special care is taken if a Service User has a fall while taking anticoagulant due to increased blood loss and internal bleed. Staff will follow the Post Falls Decision Making Tool.
• Staff will inform the service user’s next of kin, unless the service user has refused permission.”

What happened

13. In June 2025, Mr Y moved into respite care.
14. In mid-June, Mr Y had an unwitnessed fall in his room. Staff became aware of the fall when Mr Y called for assistance. He told staff he hit the back of his head during the fall and had sustained a small cut. The responding staff contacted the telemedicine service for a consultation.
15. The telemedicine service advised that staff should continue to monitor Mr Y and phone them back later that afternoon to provide an update on his condition. The staff monitored Mr Y every 30 minutes. Case notes show that Mr Y was eating and stated he was feeling fine.
16. The staff contacted telemeds again at the advised time and said that Mr Y could remain in the care home and to report back if any further concerns arose.
17. The Care Provider did not contact the next of kin about the incident.
18. The day after the fall, Mr Y called his son, Mr X, and told him he had a fall yesterday which he was still struggling with pain from. He told said he was experiencing ongoing pain.
19. Following the call, Mr X attended the care home to check Mr Y’s wellbeing. Whilst there, the Care Provider phoned the medical line again due to Mr Y complaining of lower back pain, and Mr Y was subsequently transferred to hospital.
20. During Mr Y’s hospital admission, Mr X complained to the Care Provider. He raised concerns that there were no shower grab rails in the room, and that the care home did not follow appropriate procedures following Mr Y’s fall. The manager met with Mr X to discuss these concerns and started an investigation.
21. In July, the manager of the care home contacted Mr X with an update on its investigation. She also provided a copy of the falls protocol used. This tool states that where a resident has had an unwitnessed fall, sustained a head injury and is taking anticoagulant medication, staff should call 999. It also states that relatives should be informed of the incident. She told Mr X the policy would be amended to state 999 should be called for any head injury and agreed that relatives should be contacted immediately following an incident.
22. Mr X responded and provided some recommendations to improve the service, including a checklist system for calling relatives, and more communication with families of residents. He also requested a breakdown of a refund received from the home. The care home thanked him and confirmed it would provide a breakdown of the refund.
23. Mr Y was then discharged from hospital to a different care home. He subsequently died in August.
24. Following his death, Mr X asked for an update on the investigation. In response, he received an out of office messaging stating the manager dealing with the investigation had left the Care Provider. Mr X contacted the Care Provider directly and was informed they were not aware of his complaint. It said it would submit a new complaint and issue a response by September.
25. In September, the Care Provider issued its complaint response and investigation outcome. It said:
• On the day of the fall, Mr Y was assessed by the staff who were aware of the head injury. Mr Y was offered hospital admission but declined, and as he had capacity his wishes were respected.
• The falls protocol Mr Y had shared, allowed staff an option between contacting telemedicine service or 999. However, it said any injury to a person using blood thinners, should have 999 phoned as an outcome.
• Next of Kin were not notified and apologised for this.
26. In October, Mr X complained to us.
27. In response to my enquiries the Care Provider provided a different post-falls policy which it says was in place at the time of the incident. This policy differs from the version shared by the manager. Under this policy, staff should seek advice from a GP or NHS 111 rather than automatically calling 999. The Care Provider also stated that since the incident the policy has been reviewed and not calling 999 continues to be the policy in place to date.

My findings

28. The manager during the initial investigation provided a protocol which stated staff should call 999 where a resident had sustained a head injury while taking anticoagulant medication. The evidence shows staff did not follow this protocol following Mr Y's fall, as 999 was not called. The Care Provider also did not notify Mr X of the incident, and he only became aware of it when Mr Y contacted him the following day. The failure to follow the protocol identified by the manager caused Mr X uncertainty, which is fault.
29. In response to Mr X's complaint, the Care Provider's head office also stated staff should call 999 where a resident had sustained a head injury while taking anticoagulant medication.
30. However, the Care Provider has since stated a different protocol was in place at the time. This stated staff should call 111 and seek advice. The records show staff sought advice from a healthcare professional following Mr Y's fall and followed the advice given. Therefore, if this was the policy in force at the time, staff acted in accordance with its requirements.
31. However, this protocol contradicts the understanding of the manager at the time, the protocol shared with Mr X, and the complaint response from head office.
32. These conflicting explanations create uncertainty about what procedure was in force at the time and indicate a lack of clear and consistent guidance. Although the provider has since reviewed its falls policy, a discrepancy remains between the written policy and the explanations provided by the previous manager and in the complaint response. This inconsistency caused Mr X significant frustration and uncertainty, which is fault.
33. Following Mr Y’s death, Mr X did not receive an update on his complaint and was later informed that no complaint record could be found because the manager handling the matter had left the organisation. This indicates a failure in complaint record-keeping and oversight. As a result, Mr X experienced avoidable uncertainty and was required to re-raise his concerns, causing frustration and distress. This is fault.

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Action

34. To remedy the injustice caused by the above faults, within four weeks, the Care Provider will:
• Apologise to Mr X, in line with our guidance on Making an effective apology; and
• Pay Mr X £250 in recognition of the uncertainty, distress and frustration caused by the failure to notify him of Mr Y’s fall, the inconsistent information it provided about its fall procedures, and the delay in responding to his complaint.
35. Within three months of my final decision, the Care Provider will:
• Carry out a full review of its falls policy and post-falls decision-making tools to ensure all homes operated by the Care Provider are using accurate, up-to-date and consistent guidance; and
• Remind staff to remove any outdated versions from circulation and ensure they know where the current policy and guidance can be accessed.
36. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

37. I find fault causing injustice. The Care Provider has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman