Summary: Ms X complained about the standard of her reablement care after she suffered a stroke. The Council was at fault because the care provider failed to follow its no reply policy when Ms X fell at home. This caused Ms X uncertainty and avoidable distress which the Council agreed to provide a financial remedy for.

The complaint

1. Ms X complained about the standard of her reablement care after she suffered a stroke. She said carers were unprofessional, poorly trained, and lacked compassion.
2. Ms X said there were several days where she received no support, and her carer failed to follow proper procedures when she fell and was left alone for nearly 24 hours.
3. Ms X also said the Council failed to monitor carers and did not carry out follow ups or quality checks after complaints.
4. Ms X said she suffered loss of dignity, fear, pain and distress as a result of the poor care she received.

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The Ombudsman’s role and powers

5. 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)
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)
7. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
8. 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

9. As part of the investigation, I considered the complaint and the information Ms X provided.
10. I made written enquiries of the Council and considered its response along with relevant law and guidance.
11. Ms X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has issued guidance on how to meet the fundamental standards.
13. Regulation 9 says care and treatment must be appropriate and meet service users’ needs.
14. Regulation 10 says service users must be treated with dignity and respect.
15. Regulation 12 says care and treatment must be provided in a safe way for service users, preventing avoidable harm, managing risks, and managing medicine properly.
16. Regulation 13 says care providers must protect users from abuse, neglect, and improper treatment.
17. Regulation 17 says care providers should maintain accurate, complete, and contemporaneous records in respect of each service user.

What happened

18. I have summarised below some key events leading to Ms X’s complaint. This is not intended to be a detailed account of what took place.
19. Ms X was discharged from hospital for reablement care in February 2025 following a stroke. The Council commissioned the care through Graceful Care Ltd, Ealing, London (the care provider). Ms X’s package of care included three 45-minute visits from a carer each day. A single carer gave support with mobility and transfers, meal and drink preparation, washing, dressing and with Ms X’s night time routine. Ms X had care visits at 08:30, 12:30 and 18:30. Carers also visited for one hour, once a week, to clean and tidy Ms X’s home.
20. Ms X’s cognition was assessed in hospital, highlighting reduced attention and right sided inattention. The plan for Ms X’s reablement care was to increase her awareness and scanning techniques to her right side. The aim was for Ms X to have use of her right arm in two weeks, to be able to wash and dress independently in three to four weeks, and to be independent with meal preparation in four to five weeks. Ms X could then progress with stairs, outdoor mobility and community integration, using public transport in six weeks.
21. The Council reduced the time of Ms X’s afternoon and evening care visits to 30 minutes after a review.
22. The Council telephoned Ms X on 10 February and Ms X confirmed reablement care was going well.
23. Ms X reported her carer did not attend on the morning of 12 February and her friend had to give personal care.
24. The Council visited Ms X on 12 February to assess her reablement care. Ms X told the Council 30 minutes was not enough time for carers in the afternoon and evening as she is slow and needs support with transfers. The Council observed Ms X had difficulty with sit to stand transfers. She was unable to use her right arm or hand to support her push up and her right leg was not strong enough to support her balance. The Council observed Ms X engaging well and keen to participate with reablement and goals. Ms X was assessed to have capacity, with no difficulties other than reduced processing speed, particularly with verbal instructions where a response is needed. The Council increased care visit times back to 45 minutes in the afternoon and evenings.
25. Ms X’s carer sent Ms X a text message at 11:23am on 16 February 2025, asking if everything was OK. The carer said they came to the door that morning and there was no answer. They asked if Ms X was at home, and to text her carer.
26. The care provider contacted the Council on 17 February advising Ms X had a fall at home on 16 February and her niece asked for a key safe to ensure her safety.
27. Ms X telephoned the Council on 17 February to report that she had a fall the previous day trying to reach for the electric blanket switch and was bruised. The Council arranged to visit Ms X that day. The Council also ordered Ms X a key safe.
28. The Council visited Ms X, and she explained how she fell. She said she used the bed to pull herself up slightly and made her way to the hallway by shuffling. She tried to use a radiator to help pull herself up but fell again and ended up near the entrance to the bathroom. She was on the floor for some time until her friends arrived to pick her up.
29. The Council telephoned Ms X on 20 February. Ms X confirmed she was feeling a lot better and her key safe was installed.
30. The Council visited Ms X on 24 February for a review of her reablement care. Ms X reported she was progressing well and was able to do a lot more for herself than the previous week. She no longer needed a lunch visit from carers and asked for it to end. She could access snacks and drinks and heat up food her friends brought. She still needed assistance with washing and dressing. The Council ended Ms X’s lunchtime care visit.
31. Ms X cancelled her morning and evening visits on 27 February after her carer called in sick.
32. Ms X cancelled her evening care visit on 4 March to stay with family.
33. Ms X telephoned the Council on 5 March to say she had been given a new carer and they were not giving the support she needed. The carer was turning up before 8am and waking Ms X up, but the visit should not start until 8:30am. Ms X also said she had cancelled the evening visit as it was too much and she was managing better with dressing for bed. She wanted to continue with just one visit in the morning. She said no carer could come the previous day unless they came before 8am. The Council ended Ms X’s evening care visit.
34. The Council visited Ms X on 10 March for another review of her reablement care. Ms X was able to open the door independently and was observed mobilising well within her home. She safely transferred into a recliner chair. Ms X said she felt well and was making progress. She said she was managing without difficulty with only one care visit a day. She only needed minimal help from carers now using the shower. Her carers were mostly just supervising. Her friends were still visiting daily and giving her food to heat up. Ms X said she took the keys out of the key safe as she did not like carers just turning up. The Council discussed long term care options, and it was agreed this was not needed. Ms X had improved significantly and achieved almost all goals.
35. The Council visited Ms X on 18 March for the final reablement review. Ms X again gave access by opening the door. Ms X said she was managing well to have a shower and had carers in the room to supervise and help with confidence. Ms X also confirmed she was managing well with meals. The Council extended Ms X’s reablement care by three days to make up for care visits she missed when the care provider had no carers available for an 08:30am call.
36. Ms X’s reablement care ended on 26 March 2025.
37. The Council spoke to Ms X on 1 April after her care ended. Ms X confirmed she was managing well without carers. The Council recorded Ms X was very grateful for the care she received.
38. Ms X then made a formal complaint about her reablement care, which she said caused anxiety and impacted her wellbeing, safety and recovery. Ms X raised several points, including:
• A carer asking to pray during her shift.
• Careless and sloppy care.
• Towels inappropriately used on the floor and later to wipe Ms X’s feet.
• Clean clothes put in the wash basket.
• Rushed personal care tasks like showering and dressing.
• Care visits lasting only 20 minutes when 45 was allocated.
• A lack of compassion and awareness for Ms X’s circumstances.
• Carers entering Ms X’s home without ringing the bell first.
• A carer arriving too early for a morning call, waking Ms X up.
• No care being provided for days when Ms X asked for a new carer.
• Ms X’s fall, that could have resulted in injury, was not reported.
39. Ms X requested £60,000 compensation for the poor quality of care and the impact on her physical and mental health. She said there had been a failure in duty of care, and lack of monitoring which allowed the behaviour to continue unchecked.
40. The Council responded to Ms X’s complaint on 23 April. It said it increased the time for care calls at Ms X’s request and contacted the care provider when she reported a missed morning visit. It also ordered a key safe at Ms X’s request, so she did not have to keep answering the door to carers. Carers were advised to let Ms X know they were there by knocking on the door or ringing the bell.
41. The Council acknowledged there were a few occasions during the reablement period where Ms X raised concerns about carers, and it contacted the care provider to address them. There was a concern about a carer arriving too early in the morning and the Council asked for the carer to be changed to one who came at the expected time. The Council was aware there were three days following this when carers did not visit and the care provider advised it did not have anyone who could attend at the time Ms X needed. It took them three days to find someone who could. The Council arranged for three extra days reablement to be added at the end to make up for the missed days. The Council apologised for the distress this caused Ms X at the time.
42. The Council understood Ms X had a fall around 16 February and the carer arrived shortly afterwards. Ms X raised concerns the carer did not escalate the fall to anyone. The Council said it did receive an email from the care provider on 17 February advising of the fall and passing on the message that Ms X’s niece had contacted them asking for a key safe to ensure her safety. The Council’s urgent community response team arranged for Ms X to be medically checked by a nurse. The Council also ordered an alarm pendant in case Ms X had another fall.
43. The Council said it was not aware of any inappropriate comments from carers, unsanitary use of towels, washing clean clothes, rushing through visits, or a carer asking to pray. If it had been aware of these concerns, it would have worked with the care provider to address them and offered to move Ms X to a different care agency.
44. The Council apologised for Ms X’s negative experience and said it was reviewing which care agencies it used for reablement, taking Ms X’s feedback on board.
45. Ms X was not satisfied with the Council’s complaint response, and sent a further statement of complaint, including some of the following points:
• A carer rearranged their schedule to come at a different time, 11am, which was too late for Ms X to take her morning tablets. This meant Ms X’s niece had to come in the morning.
• A carer told Ms X a family member died, and she would be off work for a few days. The care provider offered another carer, but Ms X declined as she did not want more change.
• A supervisor from the care provider visited and Ms X agreed to change carer. The new carer came the next day, but Ms X was not informed. The new carer had not been given the key safe number. At first, the new carer came as expected, but then they turned up early, at 06:45am, waking Ms X up. The following night Ms X did not sleep well, so sent the carer a text message asking her to come at 8am or 9am. The carer said they could only come at 06:45am, so no one came. It took the care provider until the end of the week to find a carer who could attend at 08:30am, and they arrived without anyone calling Ms X to inform her, and without knowing the key safe. A neighbour had to let them in the building.
• Ms X raised concerns with the care provider supervisor during their visit. The first concern was about a carer asking to pray in her room on the day of Ms X’s fall. The second concern was about a carer inappropriately commenting on Ms X’s age.
• Ms X said she was alone on the floor for 11 hours on the day she fell, and the carer did not contact the office or raise the alarm.
46. The Council started safeguarding enquiries on 3 June 2025 over concerns the care provider had not followed the correct protocol following Ms X’s fall, which could be neglect. When discussing Ms X’s complaint about the care provider, she disclosed she was on the floor for approximately 12 hours when she fell in February. Ms X said the carer did not escalate this as a no reply when they did not get an answer from Ms X that day.
47. Ms X agreed to the safeguarding enquiries. Ms X mentioned a time a carer arrived late, after 9am, so Ms X had gone to church. On that occasion, the carer called the office when Ms X did not answer the door. However, on the occasion she fell and was not able to answer the door, the carer did not call the office.
48. Ms X gave the Council an account of falling in the toilet on a Sunday morning at around 6am. She said the carer did not raise the alarm when Ms X did not answer the door for her morning care call. Ms X said she did not get any help until her friend visited at 3:30pm and notified her niece. A neighbour was then able to gain access at around 6pm. She said the care provider telephoned her the next day to ask if she was OK, but that was it.
49. The Council gave Ms X a further complaint response on 16 July 2025. It said, following its telephone discussions with Ms X on 3 and 5 June, it contacted the care provider to address the issues.
50. The care provider said Ms X’s account did not align with its records. Text messages showed Ms X asked carers to attend at different times or not at all, and asked them not to tell the office. It said after Ms X’s request for a change in carer, which came after a visit from its field care supervisor, it completed a handover. The new carer had all the necessary information, including details of the key safe. Also, a member of the team contacted Ms X directly to confirm the new arrangements.
51. The care provider acknowledged that during the visit from its field care supervisor, Ms X raised issues about a carer asking to use her bedroom to pray, and about another carer speaking to her inappropriately. It said the carer was adamant they did not ask to use Ms X’s room to pray, as they live nearby so would not need to pray in Ms X’s home. It also said the second carer did not recall making the inappropriate statement Ms X alleged.
52. The Council said it has a quality assurance team working with care agencies that carry out spot checks. They try to complete four to six visits a month across the board and referrals are made to them via complaints, safeguarding, and the Council’s social work team. The Council said it would ask them to look at packages with the care provider, though it will not be able to share any outcomes with Ms X due to confidentiality.
53. The Council ended its safeguarding enquiries. It concluded Ms X was safe, and lessons learned from the incident had been discussed with the care provider. The Council noted there was a conflict between Ms X’s account and the that of the care provider, but decided it was not the role of its enquiry to adjudicate over the two versions of events.
54. Ms X remained dissatisfied with the service she received.
55. The Council sent its final complaint response on 20 August 2025. It said it asked the care provider to review the matter and passed on their findings.
56. The care provider said there were text message exchanges showing Ms X initiated cancellations or asked for different visit times. She also asked carers not to tell the office.
57. Ms X’s carer denied asking to pray in Ms X’s bedroom. They live only four minutes away and can pray in their own home. The care provider also said the allegation was different from Ms X’s earlier complaint.
58. The care provider said Ms X’s carer was scheduled to visit her at 11am on the day she fell. They sent Ms X a text message at 11:23 after receiving no reply at the door. Ms X did not answer the door or her carers calls. No emergency contact was notified until the afternoon, when a friend arrived and contacted Ms X’s niece. The incident was not reported to the care provider as a medical emergency until later. The care provider said Ms X repeatedly cancelled visits at short notice or declined entry, which reasonably informed the carer’s assessment that Ms X may have been unavailable rather than in distress. It said the records did not show deliberate neglect or intent to cause harm.
59. The carer said they supported Ms X at the time of the incident and notified the office. The care provider said that in its follow up call to Ms X the following day, neither Ms X or her niece said Ms X had been on the floor for 11 hours, and she also did not say this in her initial statement. This information was only raised in Ms X’s complaint from July 2025.
60. The care provider said it gave Ms X’s key safe code to new carers when it assigned them. One carer gained entry to the building via a neighbour because the internal door chain was on. The care provider also said it told Ms X about replacement carers at each changeover, and it had call logs confirming outbound contact.
61. The Council concluded by saying it did not uphold Ms X’s complaints, and due to significant inconsistencies in her accounts it could not investigate any further. However, it did say it would recommend the care provider gives refresher training on professionalism, boundaries and dignity in care, as well as strengthening their monitoring and oversight to ensure punctuality. The care provider is also looking at its communication protocols so there is a clearer process for reporting concerns.

My investigation

62. Ms X told me her stroke impacted her memory, which she has recovered in stages and has still not fully recovered. She gave me an updated account of the incident where she fell at home. Ms X told me she fell in the evening at around 7.40pm. She was able to get to the wet room but could not reach her telephone. She sat on the floor in the wet room all night, and the next day until her daughter and a neighbour gained entry at around 5pm. She had been incontinent during that time. Ms X said the carer came at about 11:30am but did not call the care agency, emergency services, or the Council when they got no response from Ms X and could not gain entry. They left without raising an alert or checking Ms X’s welfare.
63. Ms X told me about the impact this had on her, including loss of dignity, fear, cold, pain and distress. She considers she was at risk of hypothermia, shock, dehydration and physical collapse. She also said she may not have survived if her friend had not come when they did and raised the alarm. Since the incident, Ms X said it has affected her sleep and her sense of safety at home.
64. The Council told me, according to the care provider, Ms X’s niece contacted Ms X’s carer at 11:40am on 16 February 2025, asking them to return to the property. The carer said they arrived back at Ms X’s home at about 12pm.
65. The carer said they strongly advised Ms X and her niece to contact the Ambulance service for an assessment, but Ms X was adamant she did not need to.
66. The carer contacted the care provider’s office at 17:57 to report the incident. This was the earliest they were able to. Following the incident, the carer experienced significant disruption to their rota, which caused a delay in their ability to notify the office. Once they carer had a moment free, they reported the matter.
67. The care provider said it contacted Ms X’s niece on 17 February at 11:17am to check on Ms X’s wellbeing. Ms X’s niece said a key safe and pendant alarm would be beneficial to ensure Ms X can alert people promptly in the event of future incidents. The care provider escalated this request to the Council and a key safe was installed.
68. The Council provided me with a copy of the care provider’s ‘no reply’ policy. The policy states: “Graceful Care recognise the urgency in all situations where access cannot be made to Service User’s home at the time of a scheduled visit and the Service User does not respond to requests for entry. Care workers will consider there to be a possible emergency situation requiring immediate action to establish the well-being and safety of the Service User, or to alert the emergency services where appropriate. It is Graceful Care’s policy that under no circumstances, will the attempt to establish the Service User’s safety be discontinued until the exact circumstances are known, or the matter has been placed in the hands of the emergency services. Where appropriate to do so, the Service User’s family or representative will be informed of the situation”.
69. The policy says care workers are required to:
• Repeat the usual method for gaining entry at least three times.
• Contact the Service User by telephone if able to.
• Attempt to establish if the Service User is at home, by looking through the letterbox or windows.
• Consider talking to neighbours to establish the Service User’s whereabouts.
• Contact the Agency by telephone and speak to their manager or manager in charge at the time. If out of hours, the worker should call the on-call team. The worker must not just leave a message but should explain their concerns for a manager to act on them. The worker must not leave the Service User’s home until instructed to do so by the agency.
70. The manager responsible will then consider whether this is sufficient concern to contact the emergency services. The manager should attempt to contact the Service User’s emergency contact or representative, or their family or friends.
71. Where a no reply occurs and the Service User is harmed or has been put at risk of harm because of a failure by a care worker, a safeguarding notification must be made. Graceful Care should ensure all staff are aware that a no reply can be a safeguarding matter.
72. The Council said it is important to note Ms X frequently contacted care workers directly to request changes to visit times or to cancel visits altogether. She also asked care workers not to tell the office about these changes. The Council provided me with copies of text messages between Ms X and her carers as evidence.

Analysis

73. I found Ms X managed well with reablement care and made good progress. She reported this herself after two weeks at the review meeting and asked to end the lunchtime visit. She then asked to end the evening visit less than two weeks later at another review meeting.
74. The only issues I saw reported to the Council were about the 30-minute care calls not being long enough, and about a carer arriving before 8am that had to be changed - and that did not arise until nearly four weeks into the reablement care. Less than a week later Ms X then reported carers were only supervising, and the Council considered Ms X had improved significantly to the point where she had almost achieved her goals and would not need long term care.
75. Ms X did miss some days of care while the care provider found a new carer for Ms X’s call times. However, the Council made up for the missed days by extending Ms X’s reablement care.
76. There was also an occasion where a carer was sick and could not attend. However, on the evidence seen, Ms X declined having a replacement carer that day as she did not want more people in her home.
77. I have not seen evidence Ms X raised any issues about the standard of care with the Council at the relevant time. And Ms X did not raise any issues at the review meetings, where it was reported the reablement care was going well. Ms X did not raise any complaints until after reablement care ended.
78. The Council did investigate Ms X’s complaints with the care provider, but they were not upheld. Carers disputed Ms X’s allegations, and the care provider said her complaints were inconsistent with its records. I have not seen clear evidence of fault to question the Council’s findings in this regard.
79. It is appreciated Ms X cancelled or rearranged some of her care visits and told carers not to tell the office or to delete messages. But that was not what happened on the day she fell. When the carer did not get a response from Ms X they sent her a text message, but that is not enough in circumstances where someone may have had an accident or a fall. The carer should have made attempts to establish whether Ms X was home and then informed the care provider’s office.
80. It is unknown whether the carer tried to gain entry three times, whether they looked for signs Ms X was at home, or whether they checked her whereabouts with neighbours. We do know that the carer left the premises without establishing contact with Ms X, without ascertaining her whereabouts, and without notifying the care provider’s office. That is not in line with the no reply policy and is fault. I found the carer did not take sufficient steps to find out where Ms X was or whether she was safe, and left her home without establishing the circumstances or contacting the office.
81. That meant Ms X was left alone after her fall for longer than necessary. If the carer had followed procedure, they could have contacted Ms X’s niece and gained entry sooner. However, I cannot say exactly when or how much sooner. There are significant differences between Ms X’s account and that of the care provider. And neither has provided sufficient proof to establish an exact timeline. That is a failing in itself, as the care provider cannot show what time the carer arrived that day or what steps they took other than sending a text message. Nevertheless, by not following policy, the care provider delayed Ms X receiving help, and I consider Ms X was placed at the risk of harm for longer than she should have been. This also caused Ms X distress, and there is uncertainty about what the outcome may have been if the carer had followed policy.

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Agreed Action

82. When a council commissions or arranges for another organisation to provide services, we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of the care provider and make the following recommendations to the Council.
83. Within six weeks of my final decision, the Council will:
• Apologise to Ms X that the care provider failed to follow its no reply policy when she fell, recognising the risk of harm, distress, and uncertainty this caused.
• Pay Ms X £300 for the uncertainty and avoidable distress she suffered.
• Feedback to the care provider with my findings, and on the importance of carers following the no reply policy correctly, to avoid exposing service users to the risk of harm.
84. The Council should provide us with evidence it has complied with the above actions.

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Final Decision

85. I found the Council at fault because the care provider failed to follow its no reply policy when Ms X fell at home.

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Investigator's decision on behalf of the Ombudsman