Summary: I find fault in the care provided by a care provider acting on behalf of the Council. The Council has agreed to provide a remedy.

The complaint

1. Mr C complains on behalf of his mother, Mrs D. He complains about the care Mrs D received from a Council appointed provider. In particular that its carers hit Mrs D’s foot, multiple times, when using a hoist. And this had the potential for her to lose her toe.
2. Mr C says this affected Mrs D’s physical and psychological wellbeing. He wants an apology, compensation and a waiving of the care provider’s fees.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available, relevant, evidence and decide what was more likely to have happened.
5. We can investigate complaints about actions by adult social care providers that can be regulated by the Care Quality Commission (CQC) . Such activities include giving personal care or other practical support in the place where the person lives. But where a care provider is providing services on behalf of a council, we find that any fault is by the council. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
6. The CQC’s Fundamental Standards gives guidance to home care providers (among others) on complying with the requirements of the Health and Social Care Act 2008 in carrying out regulated activities. This provides useful detail about what care providers are expected to do. We can use these to highlight potential breaches of standards.
7. 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)
8. Under our information sharing agreement, we will share this decision with the CQC.

Back to top

How I considered this complaint

9. I considered evidence provided by Mr C and the Council as well as relevant law, policy and guidance.
10. Mr C and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

Back to top

What I found

Legal and administrative background

11. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. A council has a duty to arrange care and support for those with eligible needs.
12. The CQC’s fundamental standards are standards below which care provision should not fall. They include standards around:

• person-centered care;
• visiting and accompanying;
• dignity and respect;
• consent;
• safeguarding from abuse;
• food and drink;
• premises and equipment;
• complaints;
• good governance;
• staffing;
• fit and proper staff;
• duty of candour;
• display of ratings.

What happened

13. What follows is summary of key events and does not detail everything that happened.
14. At the end of 2024 Mrs D was discharged from hospital after an operation. She initially had a short-term package of care provided by the NHS.
15. In January 2025 the Council carried out a Care Act assessment. It agreed a package of care for carers to attend to Mrs D four times a day. It commissioned Springfield Healthcare (“the care provider”) to provide the care.
16. A few days after the care started, Mr C contacted the Council with concerns about the way the carers were moving and handling Mrs D. He was particularly concerned that, when the carers were transferring Mrs D using a hoist, they were hitting her toe, which was risking further injury to her. The Council’s officer spoke to the care provider. It said it would speak to the carers and ask its moving and handling trainer to visit Mrs D.
17. Shortly after, the Council’s officer visited to provide advice with the moving, handling and transfers. It later chased the care provider for its completion of a risk assessment.
18. Mr C contacted the Council again over the following days listing further concerns about:
• the time carers visited, which were sometimes not at the agreed times;
• a delay in carrying out the review of the risk assessment;
• an incident when a carer spilt urine in the home;
• a carer visiting wearing earphones, so not being fully attentive to Mrs D;
• an incident where a carer raised her hand towards them;
• concerns from the hospital about Mrs D’s bruised and bleeding toe, which needed a district nurse to visit and concerns this could lead to a need for a further operation;
• carers not attending.
19. Mr C says they were patient and tried to make the package of care work. But towards the end of the month the family asked the Council to change the care provider.
20. Mr C says:
• they have had no further issues since the new provider started to deliver Mrs D’s package of care;
• Mrs D did need a further operation, but thankfully this was not the major surgery they feared she might need.
21. Mr C complained about the care. The Council also conducted a safeguarding investigation. These investigations found:
• one incident where, after a carer banged Mrs D’s toe, she failed to file a report;
• the care provider’s view was that the raised hand was an expressive, not aggressive, gesture;
• the Council found the care provider’s risk assessment was poor and did not provide information about how to care for Mrs D. It considered whether this was an isolated incident or evidence of a more systemic issue with the care provider.
22. After Mr C complained to the Ombudsman the Council advised us that, due to the seriousness of the case, it had begun some wider work with the care provider about its risk assessments. It has also provided some information about steps the care provider took to investigate matters internally.
23. In response to my draft decision:
1. the care provider noted it:
• had been unaware of missed calls;
• did have a conversation about timing of calls, but after this, there were no further concerns raised;
• did have a risk assessment in place from service commencement. Its supervisor booked, but failed to attend, a review meeting. It did later make some amendments to the assessment and said it appreciated feedback provided;
• understood that the knock to Mrs D’s toe was an isolated incident, although it acknowledged the repeated knocks were reported to the safeguarding investigation;
• acknowledged leaning from the complaint, including better communications and relationship with the Council;
• noted in its most recent inspection (in May 2025) the CQC had rated the care provider as “good”.

b) the Council accepted my findings;

c) Mrs D wanted it noted she had to have an unnecessary operation on her toe, after being hit by several different carers when they were moving and handling her.

Was there fault by the Council?

24. Mrs D had a legitimate expectation she would receive care that met her needs and was safe and effective. And to meet the CQC’s fundamental standards.
25. If we find evidence that this was not so, that is fault. From the evidence I have seen my decision is that, at times, the care provided did not meet that expectation. Many of the issues Mr C raised concerns about were, on the balance of probabilities, instances of where the care provided amounted to fault. There were also instances of potential breaches of the CQC’s fundamental standards relating to person-centred care, safeguarding from abuse and duty of candour.
26. Part of the explanation for the poor care may be because, as the Council found when it investigated, the care provider delayed reviewing a risk assessment. And when it did complete the assessment, the Council view was it was not an adequate, personalised, assessment of risk. That was fault.
27. The care provider’s response to my draft decision suggests that part of the issue may also have been around its communications with the Council. But I do not need to investigate this further. For the reasons set out in paragraph 5, whatever the balance of fault between the Council and the care provider, the Ombudsman considers the Council as the responsible party.

Did the fault cause an injustice?

28. Mrs D was likely caused distress by examples of poor care where I have found fault. These are injustices that warrant a remedy.
29. And the incidents will also have caused Mr C avoidable distress which demands its own recognition.
30. Mr C asks we recommend that Mrs D should not pay for the poor care. But to do that I would need to conclude all of the care provided was inadequate and/or amounted to negligence. I cannot decide whether the care provider or the Council has been negligent and the Ombudsman has no powers to enforce an award of damages for negligence. We would usually expect someone in Mrs D’s position to seek a remedy in the courts, directly or through her insurers for that part of the remedy that Mr C is seeking. I consider it is reasonable to expect Mrs D to use the courts if she wants to achieve that remedy.

Back to top

Agreed action

31. 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 service of the care provider and made the following recommendations to the Council.
• Provide an apology to Mrs D. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• Make Mrs D a symbolic payment of £400 in recognition of the avoidable distress caused by the fault in the care she received.
• Make Mr C a symbolic payment of £200 in recognition of the avoidable distress to him in having to witness and then deal with the issues in the care Mrs D received.
32. The Council has agreed to my recommendaitons. It should provide us with evidence it has complied with the above actions.
33. I have not made any recommendations about service improvements, as I can see the Council is working with the care provider to improve parts of its service delivery. And the CQC carried out an inspection of the care provider after the dates this complaint relates to.

Back to top

Decision

34. I find fault causing injustice. The Council has agreed actions to remedy injustice.

Back to top

Investigator's decision on behalf of the Ombudsman