Summary: Ms W complained on behalf of her sister Miss X about poor care from a Care Provider arranged by the Council because it did not meet her complex needs, put her at risk, and did not provide appropriate meals. We find the Council at fault for poor standards of care it commissioned from a Care Provider which caused significant distress to Miss X and Ms W. The Council has agreed to apologise and make a symbolic payment to remedy the injustice.

The complaint

1. Ms W complains on behalf of her sister Miss X about care arranged by the Council between December 2024 and April 2025 delivered by a care provider Cherish Able Care Ltd (the Care Provider). In particular Ms W complains the Care Provider failed to:
1. Provide care that met Miss X’s complex behavioural needs.
2. Put her at risk of harm.
3. Provide appropriate meals.
2. She says the poor care caused significant and lasting harm and distress to Miss X, herself and her family.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. 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)
6. We normally expect someone to notify the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
7. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
8. 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.
9. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

10. I considered evidence provided by Ms W and the Council as well as relevant law, policy and guidance.
11. Ms W, the Council and the Care Provider had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
12. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Legal framework

The fundamental standards of care and role of the CQC

13. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
14. The CQC has guidance on how to meet the fundamental standards. The fundamental standards include:

• Person-centred care
• Safety
• Food and drink
• Good governance
• Staffing

Safeguarding enquiries

15. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

16. This is a summary of key events. It is not a detailed chronology of everything that happened. I have included more information where necessary in the analysis section.
17. Miss X is an adult. She has a learning disability and complex care, support and health needs. She lives in her own home. The Council have assessed her as requiring constant 1:1 care and support. Her care plan explains her needs. She often sees her sister Ms W and other family.
18. In mid-December 2024 the Council commissioned the Care Provider to provide Miss X’s care.
19. At the end of December Ms W contacted the Council. She was concerned poor care meant Miss X was not accessing the community, and had a lack of routine.
20. At the beginning of January 2025 the Council organised an urgent review meeting with the Care Provider and Ms W. They discussed the concerns. The Care Provider agreed to improve the routine and reduce unhealthy food.
21. In mid-January Ms W contacted the Council. She raised further concerns about food shopping, unhealthy meals, not accessing the community and carers not always engaging with Miss X.
22. The Council promptly had an internal meeting. It decided to raise the concerns with the Care Provider. It noted the option of starting the process to commission a new care provider if necessary.
23. Later in January Ms W contacted the Council. She raised concerns Miss X’s behaviour was getting progressively worse. She described Miss X becoming distressed, crying, scratching the walls and hurting herself.
24. The Council contacted the Care Provider and arranged a meeting that happened at the end of January. The record of the meeting shows the Council raised concerns from Ms W, from a Council social worker and about the level of training the care staff had. They discussed plans to improve the care and arranged a meeting for two weeks.
25. The Council decided to look for an alternative care provider for Miss X and started the process to do so.
26. At the end of January and beginning of February Ms W became more worried about Miss X’s nutrition. She told the Council there was very little food in her home. Miss X’s family had found out of date food that had gone mouldy. She was worried about the meal planning by the Care Provider. She noted regular unhealthy meals and snacks and only four servings of vegetables in a month.
27. Ms W raised concerns with the Care Provider and the Council. She thought Miss X’s diet was making her ill.
28. Ms W said she and her family decided to take over food shopping and planning Miss X’s meals because they were worried she was at risk.
29. Ms W also raised concerns about other aspects of the care. It included the carers’ administration of some of her prescribed medicine that is applied via a patch. She was worried the carers were not ensuring the correct dose.
30. The Council decided to make a safeguarding referral at the beginning of February. It recorded the referral was due to concerns Miss X may be at risk because of lack of food, mouldy food, emotional neglect because of the lack of effective communication with carers. It recorded Miss X was experiencing distress and anxiety exhibited through crying, biting herself, rocking, hitting her head on the wall, removing medication patches as well as looking ‘grey’ and ‘exhausted’.
31. The Council sent safeguarding enquiries to the Care Provider.
32. On 7 February Ms W reported Miss X’s distressed behaviour had escalated significantly. She reported an incident outside Miss X’s home when she was screaming, self-harming and other examples of heightened distress. She recorded the incident on video.
33. The Council progressed its process to commission a new care provider.
34. Later in February Ms W repeated concerns Miss X’s routine was not consistent. She was concerned this was causing further negative behaviours and distress.
35. On 13 March there was an incident when Miss X was outside the front of her home standing on the pavement near to the road. Ms W said Miss X was distressed and at risk of harm from traffic because no carers were close by. She took photographs of the incident.
36. In mid-March the Council told the Care Provider that it would be commissioning a different care provider to start in April.
37. At the end of March one of Miss X’s family members found a box of 100 paracetamol capsules not secured in her home. They took photographs of the paracetamol and Ms W notified the Council.
38. Ms W asked the Council to cease the care from the Care Provider straight away. It agreed to do so. Ms W and her family stepped in to provide care before a new care provider started.
39. In May the Care Provider wrote to Ms W and responded to the concerns she had raised. It said it did not accept the allegations as indicative of malpractice or poor care.

Analysis

40. As a publicly funded body we must be careful how we use our resources. We conduct proportionate investigations; completing them when we consider we have enough evidence to make a sound decision. This means we do not try to answer every single question a complainant may have about what the organisation did.
41. The amount of information provided by Ms W and the Council was considerable. In this decision, I have not referred to every element of that information, but I have not ignored its significance.
42. I address each part of Ms W’s complaint in turn below.

Care of Miss X’s complex behavioural needs

43. Miss X’s care plan says she can sometimes exhibit challenging behaviours and self-harm (such as biting herself) when frustrated. It says she has routines that need to be followed to support her being calm. It says her carers should use positive behavioural plans and strategies to support her to cope with anxiety and outbursts of anger and frustration. It also says her carers are encouraged to use Makaton, a sign and symbol language, to help communication.
44. I have considered the care records. I find the entries made by the carers detailed and I have seen no evidence of duplicated entries. I note regular instances in the records that are evidence the carers took a calm approach to Miss X when she appeared angry or frustrated. I find the records are evidence the carers took a general approach of deescalation when Miss X demonstrated challenging behaviours.
45. In its response to Ms W’s concerns the Care Provider said the majority of the concerns appeared to stem from misunderstandings, communication gaps or differences in expectations rather than neglect or misconduct. It said it stood by the diligent efforts of its team to provide safe, respectful and person-centred support to Miss X throughout their time with her.
46. I have considered this against Ms W’s account and evidence. Ms W raised written concerns with the Council regularly in which she described poor care and negative impacts on Miss X that she said she witnessed. She also recorded on video the event on 7 February 2025 when she described Miss X screaming, self-harming and very distressed. She provided photographs of Miss X outside on the pavement without carers providing close supervision on 13 March, and scratch marks on walls in Miss X’s home.
47. I have seen no entries about these events in the care records.
48. I have also considered evidence generated by the Council. This evidence includes its records, actions and decisions. The Council held urgent review meetings, noted concerns about staff training, recorded the care fell below an adequate standard, decided it needed to commission a new care provider and made a safeguarding referral.
49. I note in particular the record of the meeting at the end of January which Ms W, the Council and the Care Provider attended. The record states a senior social worker for the Council said they knew Miss X and her complex needs very well. They said the current presentation of Miss X was not the person they knew and she was sitting on her bed, rocking, and knocking her head on a wall. They went on to say the care staff were not trained well enough to work in a supported living environment with a person with such complex needs.
50. I also note there is no evidence that any of the staff are trained in Makaton.
51. Based on all the evidence I have seen I find, on the balance of probabilities, the Care Provider failed to provide an adequate standard of care to Miss X given her complex needs. This is because I have decided the evidence of poor care outweighs the Care Provider’s account and care records. This was fault which caused Miss X and Ms W injustice in the form of significant distress.
52. I have decided the evidence shows the Care Provider might have breached the following fundamental standards of care:

• Person centred care because the care may not have met Miss X’s complex needs.
• Staffing because the staff may not have been trained sufficiently.
• Good governance because the care records have no entries for the instances on 7 February or 13 March, or in line with Ms W’s accounts and the Council’s records, that Miss X was displaying negative behaviours and suffering distress.

53. Ms W also raised concerns about other matters including, but not limited to, a visit made to Miss X by senior members of the Care Provider’s staff, inappropriate car journeys and care staff behaviour. I have decided there is not enough evidence to find, even on balance, whether there was any fault regarding those other parts of her complaint.

Risk of harm

54. Miss X’s care plan says she has no awareness of dangers or hazards and requires support and monitoring from her carers to maintain her safety. She is not free to leave her flat alone.
55. In its response to Ms W’s concerns the Care Provider said there was no evidence to support the claim that 100 paracetamol tablets were left unsecured. It did not directly address the concerns regarding mouldy food and events on 7 February and 13 March.
56. I have considered this against the accounts and photographs Ms W provided regarding Miss X being outside her flat in a distressed state on 7 February, standing on the pavement without close supervision on 13 March 2025, mouldy food in Miss X’s fridge, and photographs of the box of 100 paracetamol tablets left unsecured in her home.
57. I have seen no entries about these events in the care records.
58. Based on the evidence I have seen I find, on the balance of probabilities, the events happened in line with Ms W’s accounts.
59. I therefore find the Care Provider failed to provide care that was adequately safe because the events presented a risk of harm to Miss X in light of the care needs recorded in her care plan. This was fault which caused Miss X and Ms W injustice in the form of significant distress.
60. I have decided the evidence shows the Care Provider might have breached the following fundamental standards of care:

• Safety because Miss X may have been at risk of harm from the mouldy food, when outside her home if the supervision was not adequate, and from the unsecured medication.
• Staffing because the staff may not have been trained sufficiently to avoid Miss X being at risk.
• Good governance because I have seen no entries in the care for the instances on 7 February or 13 March, the mouldy food, or unsecured paracetamol.

61. Ms W also raised safety concerns about administration of prescribed medicine applied via a patch. I have decided there is not enough evidence to find, even on balance, whether there was any fault regarding this part of her complaint.

Appropriate meals

62. Regarding her meals Miss X’s care plan says she is at risk of malnutrition without support to shop and cook. It says her meals should align with a menu to promote healthy eating. It says her carers should expose Miss X to a variety of foods as she tends to ask for the same sort.
63. In its response to Ms W’s concerns the Care Provider said while some cultural misunderstandings around meal preferences were acknowledged, staff confirmed Ms W generally enjoyed the meals provided, with efforts made to include fruits and vegetables consistent with her preferences and nutritional needs. The diet included snacks by choice, and no excessive or harmful eating patterns were observed or recorded.
64. I have considered this against the care records that detail the meals and snacks Miss X was provided, Ms W’s reports of mouldy food and the empty fridge, and the Council’s records including its decisions to commission a new care provider and make a safeguarding referral.
65. Based on the evidence I have seen I find the Care Provider provided meals and snacks with a high proportion of unhealthy elements such as sausages, bacon, ham, coleslaw, potato salad, crisps and hot chocolate. I find the frequency of unhealthy elements was too high to be described as promoting healthy eating as required by her care plan.
66. I note the Care Provider provided healthy elements such as salad, mixed bean salad, vegetables and fresh fruit. However, I find the healthy elements were not provided often enough to be described as promoting healthy eating.
67. Based on this evidence I find the Care Provider failed to provide Miss X meals in line with her care plan. In doing so it failed to provide an adequate standard of care. This was fault which caused Miss X and Ms W injustice in the form of significant distress. It also caused injustice to Ms W because I find the Care Provider’s fault understandably led her to step in to manage Miss X’s food shopping and meal planning.
68. I have decided the evidence shows the Care Provider might have breached the fundamental standards of care regarding:

• Food and drink because the unhealthy elements of the meals provided to Miss X may not have kept her in good health
• Person centred care because the meals may not have aligned with Miss X’s care plan.

The Council’s response to Ms W’s concerns

69. Ms W’s complaint was about the actions of the Care Provider. This investigation is a Part 3 case. In these cases, we treat the Care Provider’s actions as if they were Council actions, as explained in paragraph 4 above.
70. I also decided to investigate the Council’s direct response to Ms W’s concerns.
71. I note the Council promptly acted on Ms W’s concerns about the care Miss X was receiving by calling an urgent review meeting with the Care Provider. It started the process to commission a new care provider in case it decided it needed to do so.
72. As Ms W raised further concerns the Council escalated the matter with the involvement of more senior members of staff, further meetings with the Care Provider, and decided to commission a new care provider. It also decided to make a safeguarding referral.
73. The Council has subsequently explained its lessons learnt regarding quality assurance from its providers. They included the importance of following the brokerage process to assure accountability, and the involvement of Commissioners in meetings between the families and care providers. 
74. Based on this evidence I find the Council’s response was timely and appropriate. I therefore find no fault in the Council’s response to Ms W’s concerns.

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Action

75. 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 commissioned by the Council and make the following recommendations to the Council.
76. Within four weeks of the date of this final decision the Council should:
1. Apologise to Ms W and Miss X for the distress caused by the poor care delivered by the Care Provider it commissioned. 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.
2. Make a symbolic payment of £1000 to acknowledge the injustice caused. This is made up of two separate payments of £500 each to Ms W and Miss X. This is at the top of our scale for injustice payments and reflects the significant injustice caused to both. I recommend Ms W receives the total payment, and exercises her discretion to use Miss X’s part of the payment for Miss X’s benefit.
77. The Council should provide us with evidence it has complied with the above actions.

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Decision

78. I find fault with the Care Provider’s actions for the reasons explained in the analysis section, causing injustice. The Council has agreed actions to remedy the injustice. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman