Care home incident, audit systems
Systems for audits, incidents, and accidents monitoring in care homes are not fully embedded or mature.
317 items
8 sources
1 inquiry
Source spread
Where this theme appears
Care home incident, audit systems has been flagged across 8 independent accountability sources:
1 inquiry rec
60 PFD reports
39 CQC actions
1 IMB rec
1 detention investigation rec
14 PHSO decisions
199 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
PFD Reports (60) — showing 50 strongest matches
Derrick Rivers
Concerns: The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Overdue
Peter Furness
Concerns: The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.
Response (Nant Y Gaer Hall): Nant Y Gaer Hall has implemented a new alert system for changes in residents' conditions, with training and supervision for staff. The new system includes forms, flow charts, and posters, …
Responded
Jean Gillespie
Concerns: Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.
Response (MMCG): Senior Care Assistants received further medication training and competency assessments, including a supervision after the inquest. The new manager introduced handover and medication count down sheets for improved communication and …
Responded
Marie Quinn
Concerns: Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to query excess medication.
Overdue
Rebecca Gilbank
Concerns: A check was missed because staff were busy with other service users, and staff lacked knowledge about how to obtain an outside telephone line to call emergency services; the coroner suggests providing sufficient staffing resources and clear guidance on obtaining an outside line.
Response (Independence Homes): The organisation has changed its telephone system so staff no longer need to dial 9 for an outside line when calling emergency services. This change was communicated to staff verbally, …
Responded
Norman Beard
Concerns: Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.
Overdue
Robert Davidson
Concerns: Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour was not transferred between facilities.
Response (Priory Group): Priory Group will raise the need for effective communication at resident transfer in their Safety 1st bulletin and highlight the requirement to complete Form AM32 Transfer/Discharge record.
Response (Avery): Avery acknowledges shortcomings at Aran Court under previous management and has implemented an additional action plan and timetable to fully embed Avery's policies and procedures.
Response (NHS England): NHS England outlines its commissioning role and refers to the Care Certificate as a new minimum standard for care workers. They state that the commissioning organisation should be satisfied that …
Response (CQC): The CQC details inspections carried out at Aran Court Care Centre and Jubilee Gardens, noting expectations around risk assessments and handover documents when patients transfer between services.
Response (Department of Health): The Department of Health acknowledges the importance of workforce skills development and highlights the introduction of the Care Certificate and funding for training.
Responded
Geoffrey Spencer
Concerns: A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.
Response (The Lakes Care Centre): The care centre has created a corrective action plan to optimise resources by changing work patterns to reduce risk and increase safety. A review of the incident showed that changes …
Responded
Sheila Ross
Concerns: The report is incomplete and does not contain any specific concerns from the coroner.
Overdue
Mildred Griffiths
Concerns: The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing lesions and uses an inverse scoring method.
Response (Avery Health Group): Avery Health Group states they will continue to use the Braden pressure ulcer risk tool but will keep this under ongoing review considering national guidance and standards.
Responded
David Sketchley
Concerns: The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Response: The CQC is gathering evidence into this matter with a view to deciding whether there has been a failure by BUPA and/or the Registered Manager to comply with the Health …
Overdue
Lea Hunsley
Concerns: The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.
Response (EAM Care Group): EAM Care Group completed a root cause analysis with commissioners, will obtain post-operative care plans prior to admission, and introduced new handover procedures including lunchtime handovers and archiving of staff …
Responded
George Goldby
Concerns: Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.
Response (HC One): HC One allocated an Operational Project Manager, reviewed care plans, allocated staff to supervise eating and drinking, completed swallowing risk assessments, referred residents to SALT, and increased senior management cover; …
Responded
Sophie Bennett
Concerns: The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.
Overdue
Ruth Gregory
Concerns: Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.
Response (Borough Care): Borough Care has increased staffing levels in their homes, including a deputy manager and senior carer on each shift, to reduce the time communal areas are left unattended.
Responded
Patrick Kelly
Concerns: Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care needs.
Response (Roseberry Care): The care home has implemented a Resident of the Day procedure for care file updates, reviews of care plans, and a diary record for tracking residents' dental care; staff have …
Responded
Yong Hong
Concerns: The observation regime advised by the GP was not implemented, and no interpreter was sought to assist with assessment of his needs. Also, no risk assessment was carried out prior to making the decision to return his call bell.
Overdue
Margaret Melia
Concerns: The report cites inadequate discharge and pre-assessment processes between Lakeview Care Home and Dovetail Care Home regarding the requirement of subcutaneous fluids.
Response (HC One): HC-One reviewed and updated their Admission, Transfer and Discharge Procedure to include clearer guidance for colleagues when a delay occurs between the pre-admission assessment and admission, ensuring further information is …
Overdue
Dylan Henty
Concerns: Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication compliance systems, and inconsistent reporting/monitoring for absconding incidents.
Response (Pentree Lodge Care Home): The care home will encourage residents with seizures to be escorted in the bathroom. The home will review its Risk Assessments and Care Plans and put in place the relevant …
Responded
Arnold Ward
Concerns: Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There was no system to follow up on unresponsive referrals.
Response (Stockport NHS): Stockport CCG reports that Fernlea Nursing Home now uses photographs to track the progress of pressure sores, and referrals to the Tissue Viability Team are escalated if not actioned within …
Response (CQC): The CQC inspected Fernlea Care Home and found the service had failed to send a statutory notification regarding Mr. Ward's pressure ulcer. They will consider further enforcement action regarding this …
Response (Fernlea Care Home): Fernlea Care Home has arranged for all Registered Nurses to undertake third party wound management refresher training and has extended "React to Red" training to 87% of the care team. …
Responded
Barry Liffen
Concerns: A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.
Response (Borough Care Ltd): • All home managers will be reviewing falls on the PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequently. • Managers will …
Responded
Keith Whetton
Concerns: The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.
Response (Hunters Lodge Care Centre): Following a review of the coroner's report, staff have been supervised and completed falls training. The falls policy has been updated, and staffing levels have been increased to improve observation …
Responded
Elaine Renshaw
Concerns: Inadequate controlled drug check processes in care homes resulted in unaccounted drugs and inaccurate stock sheets, highlighting a national lack of clear guidelines for controlled drug handling and recording.
Overdue
Norman Baxter
Concerns: No specific concerns were detailed in the provided text for this report beyond a general statement of risk.
Response (Lynmere Nursing Home): Following the inquest, the nursing home implemented the News Scoring System, NEWS 2 Charts, Algorithm for managing suspected sepsis, and Sepsis guidance implementation advice. One-to-one discussions were held with nursing …
Responded
Peter Howarth
Concerns: The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.
Response (Borough Care): Borough Care implemented extra measures to review falls on a weekly/monthly basis after a previous PFD report, including weekly falls analysis, GP/falls clinic referrals for residents with more than 2 …
Responded
Edward Mallaby
Concerns: The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls detection. Observation protocols were unclear, and no rapid learning exercise followed the incident.
Response (Roseberry Care Centres): Roseberry Care Centres updated policies regarding residents' belongings, admission of residents, and falls management, issuing them to all homes with 'read and sign' sheets and discussing changes in small group …
Responded
Marion Glover
Concerns: Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was unsuitable for confused residents, posing a wandering risk.
Response (Able Care and Support Services Ltd): Able Care and Support Services Ltd, under new ownership, has implemented enhanced pre-admission risk assessments, weekly meetings with authorities, multi-disciplinary meetings, and a falls management reporting form. Scheduled annual reviews …
Responded
Clara Freeman
Concerns: Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, accurate medical recording, and awareness of post-fall complications.
Response (Hart Care): All staff members in charge of shifts have attended First Aid Training, which included calling the emergency services, managing falls, fractures, choking, bleeding, dressings, CPR, anaphylaxis, the recovery position and …
Responded
Rachel Johnston
Concerns: The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, investigating, or suspending staff misconduct.
Response (Holmleigh Care Homes Ltd): Following a death, the care home introduced training for all nurses and reviewed its policies. They have since implemented the Staff Retention policy to ensure agency workers under investigation do …
Overdue
Pauline Brumfitt
Concerns: The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and neglecting timely reporting or investigation of incidents.
Response (Anchor Hanover Group): Anchor Hanover Group has reviewed and updated training, policies and procedures, introduced more formal triage arrangements, additional handover guidance, and improvements to Care Quality Indicators.
Overdue
Catherine Jux
Concerns: A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, which staff did not notice, indicating an inadequate auditing process.
Response (Elvy Court Nursing Home): The home has revamped its first aid training to include suicide, self-harm, and overdose response, and is providing ligature cutting kits in every office by the end of July 2021. …
Overdue
Eldine Lashley
Concerns: The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately recorded the frequency of checks performed.
Overdue
Tripta Bhanote
Concerns: Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced care teams, and accurate identification of Do Not Attempt Resuscitation (DNAR) status.
Overdue
Henry Doll
Concerns: Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.
Overdue
Colm McCabe
Concerns: Care home staff failed to follow policies on recruitment, training, and patient reviews. Ineffective auditing missed significant care omissions, and investigations lacked candour.
Response (Four Seasons Healthcare Group): Four Seasons Healthcare details actions taken, including revising the policy for observations, undertaking reviews and audits, launching a revised incident reporting system (RADAR), simplifying the Root Cause Analysis function, and …
Overdue
Dorothy Spiby
Concerns: A resident's fall incident was poorly documented, not investigated, lacked a formal incident report, and showed no evidence of learning to prevent future occurrences.
Response (Prime Life Ltd): Prime Life Ltd has taken several actions, including Defensible Documentation Training for Registered Nurses (completed by 15.4.22), conducting competency checks, and initiating monthly reviews and safeguarding audits with action plans. …
Responded
Margaret Greenacre
Concerns: The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely missed. Record-keeping was very poor, hindering staff's understanding of resident needs.
Response (Alcyone Healthcare): The care home is under notification to close and transitioning to a new provider. The new management team is developing safe operation of the home including enhanced leadership, new compliance …
Responded
Karen Redding
Concerns: Care staff failed to check medication contents upon request and did not ensure a doctor's review after the resident disclosed an overdose, despite her declining help.
Response (Cherish Home Care Ltd): Cherish Home Care now conducts spot checks with carers every 3 months (increased from annually) which will cover medication. During double up calls, carers are required to work together when …
Responded
Shona Campbell
Concerns: Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had access to ligatures, and risk assessments were not properly updated.
Pending
Beryl Ellison
Concerns: Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's fatal overdose of oxycodone.
Response (Four Seasons Health Care Group): Four Seasons Health Care Group has implemented improved communication, incident escalation, and medication risk assessment processes to prevent future medication errors. These include notifying management of incidents promptly, regular clinical …
Responded
Jennifer Rackley
Concerns: A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, and involved staff could not be identified.
Overdue
Irene White
Concerns: Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative measures like TED stockings, and inadequately mobilized her post-discharge.
Overdue
Sylvia Nash
Concerns: Insufficient understanding and communication between agencies regarding multi-disciplinary decision-making for patient care, particularly observation removal, led to confusion over responsibilities and incorrect procedures.
Response (Birmingham City Council): BCC has conducted staff engagement sessions and provided a template for recording multi-disciplinary decision making. The ICB is leading on developing procedures around 1 to 1 support in P2 beds, …
Response: Connaught House states they assessed Sylvia required 1:1 supervision and communicated this, but that funding for 1:1 observations is a wider issue. They claim the Regulation 28 order is unfair …
Response: Connaught House has cascaded information about a new ICB process for removing 1:1 support to their staff and placed posters in each nursing station to ensure awareness.
Responded
Victor Costello
Concerns: Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, despite the manager being informed.
Response (Stockton Care LTD): The care home communicated the coroner's concerns to all staff and is implementing an upgraded cloud-based electronic documentation system by June 1, 2024. They are also ensuring effective handovers between …
Responded
Frederick Boyd
Concerns: Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures for deteriorating patients created significant safety risks.
Response (Lakes Care Centre and CQC): The Lakes Care Centre has ceased to deliver the regulated activity of ‘Treatment for Disease, Disorder or Injury’. The CQC is following up with the manager to register them as …
Responded
Sylvia Prichard
Concerns: The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues were compounded by ineffective oversight and auditing.
Response (Avery Healthcare Group): Avery Healthcare has appointed a new Regional Director and Home Manager, conducted a lessons learned workshop across the organisation, completed a full audit of care plans, introduced a care plan …
Responded
Sheila Nicholls
Concerns: The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient and performed by untrained staff.
Response (Mandeville Grange Nursing Home): Mandeville Grange Nursing Home has engaged Care4Quality to rewrite its policies, implemented Bright HR for policy distribution, transitioned training to Access Learning for Care, engaged four additional trainers, and ordered …
Responded
James Siddons
Concerns: A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning from the incident and future death prevention.
Response (London Borough of Bromley): The London Borough of Bromley addressed delays in sharing PLE forms by reiterating the importance of timely safeguarding actions with the social worker involved. They are launching a Prevention and …
Response (Mills Family Ltd): Mills Family Ltd has re-emphasized notification and escalation procedures for serious incidents to senior management and implemented a Root Cause Analysis policy. Managers will receive training on updated Accident & …
Responded
June Phillips
Concerns: Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure to learn from incidents and properly monitor patient deterioration.
Response (Willow Grange Care Home): The care home has implemented a root cause analysis tool, uses body maps and photos for injuries, calls 999 in specific fall scenarios, implemented weekly GP ward rounds with detailed …
Responded
Javed Iqbal
Concerns: Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and did not follow GP advice, compounded by inadequate post-death investigation and training.
Response (All Care In One Ltd): The company hired consultants to oversee staff retraining and monitor compliance with care standards, including regular audits and alerts. Safeguarding training was revisited to ensure staff can identify early signs …
Responded
CQC Inspection Actions (39)
Verve Health
The service must ensure service user safety incidents are managed, staff report incidents appropriately and managers investigate incidents and share lessons learned with the whole team.
Must Do
Suite 4, Jason House
The provider must ensure audits carried out are effective.
Must Do
Roky Care Ltd
The provider must ensure effective auditing systems are in place to identify areas of improvement.
Must Do
Unit 4 Cornishway Industrial Estate
Ensure incidents that affect the health, safety and welfare of people using services are appropriately recognised and reported. Incidents must be reviewed and thoroughly investigated by competent staff and monitored to make sure that action is taken to remedy the …
Must Do
Orton Manor Nursing Home
Implement overall analysis of accidents and incidents to identify any trends or patterns.
Should Do
Oak Tree Manor
Accidents and incidents needed to have remedial actions taken recorded and a system for identifying themes and trends needed to be developed to ensure it was robust.
Should Do
Copperfields Residential Home
There are audit processes and other systems in place but these are not robust enough to assess, monitor and continually improve the service.
Must Do
Aspirations (Northampton)
not all audits had been completed within the timescale set out by the provider. For example, we found not all infection control audits had been completed monthly as per the providers procedure.
Should Do
Aaron Abbey Care Services Limited
The registered manager's systems and processes to monitor quality and safety in the service were not established and operated effectively to ensure compliance with their legal requirements. This was a continued breach of Regulation 17 of the Health and Social …
Must Do
Rosecroft Residential Care Home
The provider must send CQC a report detailing the action they are going to take to ensure compliance with Regulation 18 Registration Regulations 2009 regarding notifications of other incidents.
Must Do
Barton Park Nursing Home
Oversight was not being managed appropriately as there was no registered persons who were accountable for the day to running of the home. Auditing and record keeping was poor, and there were numerous gaps and inadequately recorded information regarding people's …
Must Do
Brushwood
However, further improvements were needed to make this more robust, effective and sustainable. For example, records and analysis relating to accidents and incidents needed to be improved with greater detail and accuracy.
Should Do
Oak Tree Manor
whilst information on for example falls had been recorded it did not link to any action being taken.
Should Do
St Paul's Lodge
The registered person must submit notifications to the Commission in relation to people who have sustained serious injuries as required by Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.
Must Do
Rosecroft Residential Care Home
The provider must send CQC a report detailing the action they are going to take to ensure compliance with Regulation 16 Registration Regulations 2009 regarding notification of death of a person who uses services.
Must Do
Linda Lodge
The provider must notify CQC of the death of a person who uses services.
Must Do
B&H Care Ltd
The provider must ensure all reportable incidents and events, including alleged abuse, are reported to the Care Quality Commission (CQC) as required under Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.
Must Do
Sunnyside
Improvements were needed in relation to infection prevention and control and risk management and the audits in place to assess these areas had not fully identified the concerns recorded in this report.
Should Do
Ivydene Care Home
They told us a member of staff had been given this responsibility during 2016 and they would make sure that these audits were recorded in the future to show where improvements were needed where required.
Should Do
Ivydene Care Home
The registered manager told us they would review the audit to make sure that all actions had been undertaken.
Should Do
Ivydene Care Home
The registered manager told us they would use their incident forms more thoroughly in the future to detail their investigations.
Should Do
Bromsgrove
The service should ensure all hand hygiene audits are maintained.(Regulation17).
Should Do
Rosecroft Residential Care Home
The provider is required to send us information on a monthly basis to evidence the systems in place are effective in monitoring and assessing the quality of the service.
Must Do
Clare House Residential Home
The manager agreed to rectify this immediately.
Should Do
Chesapeake House
The registered manager agreed to discuss this issue with the provider.
Should Do
Chesapeake House
The registered manager agreed to put these in place.
Should Do
Chesapeake House
The registered manager agreed to put these in place immediately.
Should Do
Boniface House
We issued a Warning Notice which required the provider to be compliant by 21 February 2022
Must Do
Baby Bump Limited
The registered manager should consider having minuted meetings with the other director for the service.
Should Do
The Homestead (Crowthorne) Limited
The registered manager said it would be reported immediately.
Should Do
The Homestead (Crowthorne) Limited
The registered manager who undertook to follow these up.
Should Do
The Homestead (Crowthorne) Limited
The registered manager agreed to address them immediately.
Should Do
Willow Brook House
This needed to be implemented and embedded before we could fully assess its effectiveness.
Should Do
Willow Brook House
The registered manager was receptive to our comments and planned to review the tasks checked.
Should Do
Willow Brook House
These needed to be developed further.
Should Do
The Olde Coach House
The provider reviews best practice guidance for the issues above and updates their practice accordingly.
Should Do
Ivydene Care Home
The registered manager told us they would make sure these were all in place.
Should Do
Ivydene Care Home
The provider said they would put these checks in place.
Should Do
Holly Court Care Home
There were references to the previous provider in some notices and signs still on display around the home. We discussed the removal of these with the deputy manager.
Should Do
Health Investigations (2)
Independent investigation into the care and treatment of Mr L — Rec 4
The Trust must assure itself that risk assessments and risk management plans are reviewed when new information comes to light. The Trust must also implement an ongoing audit programme to provide assurance about organisational compliance with this requirement.
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr L — Rec 4
The Trust must assure itself that risk assessments and risk management plans are reviewed when new information comes to light. The Trust must also implement an ongoing audit programme to provide assurance about organisational compliance with this requirement.
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
PHSO Casework Decisions (14)
P-003058 — Care Quality Commission
Mr and Mrs B complain the Care Quality Commission failed to properly inspect the Nursing Home. The also say It failed to act on intelligence it received about the Nursing Home before the inspection and it did not take account of relevant evidence during the inspection. They also complain about …
UK Government
Partly Upheld
Oct 2024
P-002389 — An independent provider in the Redcar and Cleveland …
Miss Y complains that between December 2020 and April 2021 the care home left Mr Y on the floor unconscious.
NHS in England
Aug 2023
P-003732 — Mid and South Essex NHS Foundation Trust
Mr M complains that during his mother's 10-day admission to the Trust, she developed and was discharged to her care home on 27 February 2024 with eight separate pressure sores.
NHS in England
Jul 2025
P-001283 — Birmingham and Solihull Clinical Commissioning Group
Mr A complained about aspects of his late mother's care and treatment at a care home in the Birmingham area. He also complained about the actions of Birmingham and Solihull Clinical Commissioning Group, following a Continuing Healthcare assessment.
NHS in England
Jan 2022
P-001447 — A care home in the Warrington area
Mrs X complains staff at a care home in the Warrington area lost her father's dentures.
NHS in England
Jun 2022
P-001725 — Kent Community Health NHS Foundation Trust
Mrs D complains about the care community nurses gave to her mother. She complains about the way they monitored and cared for a pressure ulcer on her mother's lower back.
NHS in England
Not Upheld
Jan 2023
P-002447 — A care home in the Birmingham area
Mr O complains that staff at the care home did not properly monitor his mother when she was moving and this led to her having several unwitnessed falls.
NHS in England
Feb 2024
P-003028 — A practice in the Leeds area
Mr and Mrs R complain the care home provider failed to provide good end of life care to their mother in 2019. They also complain the Practice failed to address their concerns about care during this time.
NHS in England
Oct 2024
P-001900 — The Chaseley Trust
Mrs R complains about the care and treatment provided by a care home funded by the Trust. She says it gave her too much antibiotic cream for her eyes, did not give her eye drops properly and did not communicate details of her hospital appointment.
NHS in England
Mar 2023
P-002962 — Black Country Integrated Care Board
Mrs L complains about the care and treatment the care home provided to her husband before he died and that his death was unexplained. She complains about how the ICB considered this.
NHS in England
Sep 2024
P-004434 — An independent provider in the East Hampshire area
Mrs U complains about aspects of her mother's care and treatment in March 2024. Specifically, she complains the Nursing Home did not provide her mother with end of life care medication, did not use her oxygen machine or monitor this appropriately, and used a hoist to move her out of …
NHS in England
Partly Upheld
Nov 2025
P-002306 — The Dudley Group NHS Foundation Trust
Mrs D complains about the Trust's care and treatment of her mother. She complains the Trust allowed her mother to develop pressure sores, neglected her, kept moving her to different wards and did not communicate well with her family.
NHS in England
Nov 2023
P-002345 — University Hospitals Dorset NHS Foundation Trust
Mrs T complains about the pressure sore care her mother had from the Trust in March 2023. She complains her mother developed pressure sores that could have been avoided.
NHS in England
Dec 2023
P-003401 — Manchester University NHS Foundation Trust
Ms C complains about her mother’s care and treatment in November and December 2021. She complains about poor pressure ulcer management and treatment, barrier cream products not being used and poor hygiene and personal care when dealing with her mother’s incontinence.
NHS in England
Partly Upheld
Mar 2025
LGO / SPSO Decisions (199)
22-000-526a — Akari Care (22 000 526a)
Summary: Mr B complained about the actions of a Care Provider because he says his late mother’s rings went missing in one of its nursing homes. He also said the Council did not do enough to investigate the matter. We did not find fault by the Council. The Care Provider …
LGO (Local Government & …
Health
Upheld
Oct 2022
NIPSO-16874 — Belfast Health and Social Care Trust
The Ombudsman has found that the Belfast Health and Social Care Trust made a concerted attempt to resolve a complainant’s concerns about the care and treatment provided to her father while he was the resident of a Belfast nursing home.
NIPSO (NI Public Service…
Health & Social Care
Mar 2018
PSOW-202106081 — A Care Home
Mrs A complained about the actions of Aneurin Bevan University Health Board (“the Health Board”) in relation to the care provided to her late mother, Mrs B. Specifically, Mrs A complained that Mrs B’s needs (as set out in her Care Plan) were not met, there was a failure to …
PSOW (Public Services Om…
Upheld
Oct 2023
21-002-727 — Salford City Council
Summary: Ms X complained the Fountains Nursing Home failed to provide adequate care to her father in the hours prior to his death and that the Council’s safeguarding investigation was flawed. The Council has already identified fault, mainly around communication with the family and the Nursing Home’s recording of events. …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-007-659 — Cumbria County Council
Summary: Mrs X complained about the level of care provided to her mother, Ms Y, in the last few days of her life by the care home. She also complained about the clearing of Ms Y’s room and the way her belongings were handled. There were failings in the care …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-018-066 — Saima Raja AKA Braemar Care Centre
Summary: We will not investigate this complaint about the Care Provider refusing to issue a refund. This is because the Care Provider has now issued the refund. This remedies the claimed injustice and an investigation could not achieve anything more.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-018-569c — The Coach House Residential Home (21 018 569c)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-018-569a — Norfolk & Suffolk NHS Foundation Trust (21 018 …
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or …
LGO (Local Government & …
Health
Not Upheld
Oct 2022
21-017-330a — Rutland House (21 017 330a)
Summary: Mrs B complained to the Ombudsmen that a Care Home provided inadequate care to her son. She complained this led to significant, life-changing consequences for him. We decided not to investigate Mrs B’s complaint. This is because it is unlikely we would reach meaningful, evidence-based findings that the Care …
LGO (Local Government & …
Health
Nov 2022
23-013-793a — High Peak Lodge (23 013 793a)
Summary: We uphold Mrs Y’s complaint about her grandmother’s care. We found fault with Mrs X’s continence care and some aspects of her end of life care. We also found fault with the Care Home’s record keeping and the Council’s communication. As a result, Mrs X did not always receive …
LGO (Local Government & …
Health
Upheld
Aug 2024
24-007-003 — Oldham Metropolitan Borough Council
Summary: We will not investigate this complaint about the way the Council arranged access for Mr B to remove his personal belongings from his former home when his tenancy ended. We will not investigate Mr B’s complaint about the bed in his care home and having access to his mobile …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2025
24-006-556 — Ideal Care Homes Ltd
Summary: Ms A and her sister Ms B complain that the care provider gave notice on their late father’s placement without due reason and they had to find another placement at short notice for their elderly father who has dementia. The care provider failed to meet Mr X’s needs and …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2025
24-018-961 — Sefton Metropolitan Borough Council
Summary: Mrs B complained about the standard of care her mother, Mrs X, received when the Council organised a placement at Lakeside View Care Home. We uphold the complaint, having identified several areas of fault with the care provided to Mrs X, and inaccurate care records. There was also fault …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
24-019-982 — Sheffield City Council
Summary: There was significant fault on the part of the Council’s commissioned care provider which caused considerable injustice to the late Mr X. The Council has acknowledged the failings by the care provider and overseen service improvements and will now make a payment to acknowledge the distress and anxiety caused …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
25-002-861 — Borough Care Ltd
Summary: The Care Provider was at fault for not maintaining Y’s personal hygiene and for delaying its response to Mr X’s concerns about the matter. The Care Provider further failed to keep adequate records about the issue. It also failed to record how it assessed Y’s capacity when obtaining consent …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
24-021-792 — Cambridgeshire County Council
Summary: The Council’s commissioned care provider failed to provide a good standard of care for the late Mrs X, failed to keep proper records in accordance with the regulations and did not provide her nutrition in accordance with the hospital discharge instructions. The Council agrees to recognise the considerable distress …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
NIPSO-21518 — Northern Health and Social Care Trust
We found that the Northern Health and Social Care Trust carried out a safeguarding investigation broadly in line with its procedures, but were critical that the investigation did not find out how the resident sustained bruising during her time in the home.
NIPSO (NI Public Service…
Health & Social Care
Aug 2021
NIPSO-20903 — Western Health and Social Care Trust
We asked the Western Health and Social Care Trust to use the newly appointed Learning Disability Acute Liaison Nurse to ensure that appropriate training is provided to staff who care for patients with disabilities. We also recommended it develop an online information resource for staff to help them care for …
NIPSO (NI Public Service…
Health
Aug 2021
25-025-498 — HC-One Limited
LGO (Local Government & …
Adult Care Services
Upheld
24-022-122 — Welford Healthcare MC Ltd
LGO (Local Government & …
Adult Care Services
Upheld
24-018-019 — Barchester Healthcare Homes Limited
LGO (Local Government & …
Adult Care Services
Upheld
21-002-153 — Leicestershire County Council
Summary: Mrs Y complains about the failure of a care provider to ensure a sore on her mother’s leg was appropriately cleaned, dressed and treated. We find fault because there is no evidence to show the care provider properly assessed the sore or sought medical help. This fault creates distress …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-001-913 — B & M Care/Colleycare Ltd
Summary: Mr C complains about the way the care provider dealt with notice period charges and the return of belongings after his mother left the care home. Mr C says the care provider did not try to mitigate its financial loss when his mother left the home and should waive …
LGO (Local Government & …
Adult Care Services
Not Upheld
Feb 2022
21-004-180 — North Tyneside Metropolitan Borough Council
Summary: There was fault by the Council in failing to audit Ms Y’s direct payment or carry out yearly financial assessments. This caused Ms Y and her family avoidable confusion. The Council will apologise, write off an overspend, reclaim an overpayment, reduce the outstanding client contribution and take action to …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-012-668a — Royal Wolverhampton Hospital NHS Trust (20 012 668a)
Summary: The Ombudsmen find a Nursing Home, Hospital Trust and Ambulance Trust responded appropriately when a Nursing Home resident became unwell in March 2020. Based on the evidence seen to date, professionals completed appropriate assessments and acted in line with guidance in place at that time. There was fault in …
LGO (Local Government & …
Health
Not Upheld
Mar 2022
21-005-089 — Country Court Care Homes 3 OpCo Limited
Summary: Mrs X complained on behalf of Mrs Y, about the care she received at Tallington Care Home (the Care Provider). She says Mrs Y was put at risk and when family raised concerns, staff were aggressive. We found the Care Provider did cause injustice to Mrs Y and Mrs …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-010-548 — Willow Tower Opco 1 Limited
Summary: Mr U complains that despite his warnings, the care provider left his wife unsupervised near to another resident. This led to his wife falling and breaking her leg. He says the care provider should pay for the cost of adaptations to their home. We uphold the complaint. But we …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-011-877 — Longfield (Care Homes) Limited
Summary: Ms Z complained about an inaccurate invoice for outstanding care fees. Based on the information available, I intend to find fault in the actions of the Care Provider for failing to identify and prevent an accumulation of arrears. This fault has caused an injustice to Ms X, and we …
LGO (Local Government & …
Adult Care Services
Not Upheld
Aug 2022
22-005-146 — Northumberland County Council
Summary: We will not investigate this complaint about a care home. That is because we could not add to the Care Providers previous investigation.
LGO (Local Government & …
Adult Care Services
Aug 2022
21-004-973 — Barchester Healthcare Homes Limited
Summary: Mrs D complains about the standard of care and support her father (Mr H) received while in residential care. Among other things, Mrs D says the Care Provider failed to meet Mr H’s health and care needs and provided him medication he was not prescribed. We found some fault …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-017-704 — Solent Cliffs Nursing Home Limited
Summary: Mr C complained about the care his (late) mother received at the care home she lived. He said this resulted in distress to him and his mother. We found there was a delay by the care home in ensuring Ms X had heating in her room, and the staff …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-013-244 — The Franklyn Group Limited
Summary: Mrs X complained about the care her mother, Ms Y, received at the Care Provider’s Gatehouse Care Home in Harrogate, and its decision to end her contract. The Care Provider was at fault, and this caused Ms Y a financial loss and caused her family avoidable confusion and distress. …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-011-711d — CSH Surrey (21 011 711d)
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Upheld
Sep 2022
21-011-711c — Woking and Sam Beare Hospice and Wellbeing Care …
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Not Upheld
Sep 2022
21-014-368 — Avery Homes (Nelson) Limited
Summary: Mr X’s condition deteriorated while he was at the home for respite care. There is some evidence this was due to poor care and treatment on the part of the care provider. There was also an unexplained pressure sore on discharge which the care provider did not notice. The …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
23-011-659 — Barchester Healthcare Homes Limited
Summary: Mrs X complains, on behalf of her father, Mr Y, Barchester Healthcare Homes Limited mishandled the pre-admission process and failed to ask relevant questions before her father moved into in the home. She says the Care Provider failed to engage with her or social services to complete a re-assessment. …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2024
23-004-006 — Macc Care (Boldmere) Ltd
Summary: Mrs X complained the care provider failed to provide adequate care and support to her late mother Mrs Y. The care provider was at fault for poor record keeping relating to Mrs Y’s meals and dental care, for failing to follow up attempts to take a urine test and …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
23-010-449 — Avery Homes (Cannock) Limited
Summary: Ms X complained about issues with the service and care provided by Avery Homes Limited. We find Avery Homes Limited at fault for providing insufficient care which caused distress to Ms X and her family. Avery Homes Limited has apologised to Ms X, refunded care homes fees and made …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-020-716 — Bupa Care Homes (AKW) Limited
Summary: We will not investigate this complaint about adult social care in a residential care home. The Care Provider has accepted failings in communication and record keeping, has apologised, and has spoken with staff to improve service. It is unlikely an Ombudsman investigation would add to this or lead to …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-013-390 — City of Bradford Metropolitan District Council
Summary: Mr X complained Norwood House Care Home breached the terms of their agreement by increasing his mother, Ms Y’s, top up fee several times without proper notice or consultation and without notifying the Council. We found there was fault causing injustice when the Care Home failed to follow the …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-015-722 — Staffordshire County Council
Summary: A care home, owned by the Council, failed to take appropriate action to manage the falls risk for Mrs Y, despite her vulnerability.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
24-001-036 — Burlington Care (Yorkshire) Limited
Summary: We will not investigate this complaint about Mrs D’s care provider charging for care. This is because the Care Provider has remedied the injustice caused by fault and we are satisfied with this remedy.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
24-000-547 — Brighton & Hove City Council
Summary: We will not investigate this complaint about lost items within a care home. This is because it is unlikely we could add to the care provider’s investigation which could not identify how and when the items went missing. It would be more suitable for the police or insurance company …
LGO (Local Government & …
Adult Care Services
Jun 2024
24-005-088 — Hampshire County Council
Summary: We will not investigate this late complaint about care provided in a residential home. There is not a good reason for the delay in complaining and we could not carry out a meaningful investigation given the time that has passed since events.
LGO (Local Government & …
Adult Care Services
Aug 2024
23-016-681 — New Care Nottingham (Opco) Limited
Summary: Ms G complained about the care and support provided to her late father, Mr D by the Care Provider. We found fault with the Care Provider’s record keeping and the accuracy of information it recorded in Mr D’s care records. Some of the care Mr D received fell below …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2024
24-017-338 — North Yorkshire Council
Summary: We will not investigate Mrs X’s complaint the Council misled her sister into thinking she would be moving to a care home. This is because an investigation would not lead to any worthwhile outcomes. In addition, we are not likely to find fault.
LGO (Local Government & …
Adult Care Services
Mar 2025
24-015-525 — Avery Homes Grove Park Limited
Summary: We will not investigate this complaint about the standards of care and level of service the complainant received while in residential care. This is because there is insufficient evidence of any actions by the Care Provider having causing the complainant to suffer a significant and personal injustice.
LGO (Local Government & …
Adult Care Services
Mar 2025
23-020-500 — Heathfield Care Homes Limited
Summary: Mrs B complains about the care home’s delay in calling an ambulance for her mother and says her mother suffered dehydration and pressure sores because of the care home’s failures in care. We have not found fault in the way the care home decided to call an ambulance or …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2025
24-012-697 — Revitalise Respite Holidays
Summary: Ms X complained about the care Revitalise Respite Holidays (the Care Provider) provided to her daughter, Ms Y. Ms X is unhappy about how care workers treated Ms Y’s tightly coiled hair when it was in braids. The Care Provider was at fault for poor record keeping, a flawed …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
24-020-592 — Barchester Healthcare Homes Limited
Summary: We will not investigate this complaint about adult social care during a short respite break at a care home. The Care Provider accepted some fault, apologised, offered £200, and gave staff training to improve future service. We are satisfied with its actions in response to the complaint, and it …
LGO (Local Government & …
Adult Care Services
Upheld
May 2025