Summary: Ms X complained about the home care arranged by the Council for her late mother. We found the Council failed to ensure a smooth transition of care it had commissioned between providers which caused Ms X distress and uncertainty about her mother’s care. The Council has agreed to apologise, make a symbolic payment and review its procedures.

The complaint

1. The complainant, Ms X complains the home care arranged by the Council for her late mother, Mrs W, was inadequate and it failed to investigate her concerns about this and is now billing her estate for that poor care. Ms X says this has caused her distress, time and trouble and direct financial loss.

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The Ombudsman’s role and powers

2. 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)
3. 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.
4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2) and 34C(2), as amended)

5. We can decide whether to start an investigation or whether to only investigate part of a complaint made to us. When someone complains on behalf of a person who lacks mental capacity, we may decide not to investigate because the events happened too long ago, meaning we are unlikely to be able to reach reliable conclusions and/or are unlikely to achieve meaningful outcomes. (Local Government Act 1974, sections 24A(6) and 34B(8), 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)

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What I have and have not investigated

7. I have investigated the period from November 2023 to June 2025.
8. I have not investigated earlier events from 2022. Ms X complained to the Ombudsman in June 2025. This complaint included concerns about the period of care provided by a previous provider during 2022. We are unlikely to be able to reach reliable conclusions about this period and are also unlikely to achieve a meaningful outcome. Although my statement refers to earlier events to provide necessary context, I have only investigated events from November 2023 when the new care provider took over Mrs W’s care.

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How I considered this complaint

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

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What I found

Background and legislation

11. A council has a duty to arrange care and support for those with eligible needs, and a power to meet both eligible and non-eligible needs in places other than care homes. A council can choose to charge for non-residential care following a person’s needs assessment. Where it decides to charge, the council must follow the Care and Support (Charging and Assessment of Resources) Regulations 2014 and have regard to the Care Act statutory guidance. (Care Act 2014, section 14 and 17)
12. 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. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
13. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.

14. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.
15. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.

What happened

16. The following is a summary of key events. It does not include everything that happened.
17. Mrs W was receiving care at home from a care provider which consisted of four care calls a day. The Council commissioned this care but invoiced the full cost to Mrs W due to her financial circumstances.
18. The Council completed an assessment of Mrs W’s needs in April 2022 which noted Ms X would order shopping online and liaise with the care provider for someone to be at Mrs W’s property to take in the delivery and put the food away. It was also noted that care workers would make a list of any food which was running low and would either provide Ms X with the list or would pick up odd pieces of shopping for Mrs W as and when she needed it. It was left to Ms X to arrange how Mrs W would pay the care worker for any supplies purchased. It was also noted that there was sufficient time in the contract for the required laundry and cleaning. The Care and Support Plan dated 3 May 2022 set out the provider would make four care calls a day in the morning, lunchtime, afternoon and evening plus time for shopping and domestic support.
19. The Council had to commission a different provider in 2023. This was an unplanned transfer of care following a provider failure.
20. In response to an earlier draft of this statement, the Council has provided a copy of a letter dated 1 November 2023 sent to affected clients about the change to care. This stated the existing provider would continue until another provider was in place. The Council set out that once it had arranged a new provider it would provide further details and the name of the new provider. This letter was addressed to Mrs W.
21. The Council has provided a record of a telephone call on 3 November 2023 which appears to have been with Mrs W although this is unclear. The note says the Council would be in touch about the changes and acknowledged it would be worrying for Mrs W to have a change. There are no further details or update.
22. The existing care package stopped on 12 November 2023. The new provider started to provide care on 13 November 2023.
23. There is a note that Ms X spoke with the Council on 13 November 2023 about the reason for the change in provider.
24. Ms X contacted the Council in November 2023 to say the change in care provider had led to additional costs and the new provider was charging extra to shop for Mrs W when this service had previously been completed during the paid hours. Ms X also said her mother was unhappy with the way the new provider was preparing her meals and was not eating properly as a result. Ms X explained the previous provider had been flexible in shopping nearby to meet her mother’s food choices and Ms X would then reimburse the receipts.
25. The Council responded to Ms X on 21 November 2023 and provided the following information:

• when Mrs W was discharged from hospital she received funding via the COVID scheme which at the time meant she paid nothing towards her care for four weeks which consisted of four daily calls with two carers attending for 45 minutes each visit plus 1.5 hours shopping support
• when the four-week COVID funding ended the Council continued to arrange the care but as Mrs W had over the eligibility criteria of £23,250 she had to pay for this herself
• the care at that point changed to a morning call of 45 mins and Lunch, Tea and evening calls of 30 minutes with care provided by two carers and no additional domestic support.
• it was unclear why the arrangement stayed with social services commissioning the care as normally where someone is self-funding the arrangement would be direct between the care agency and the person involved or their family acting on their behalf
• it was also unclear why the original care provider carried on doing the shopping within their core hours as 30 minutes to cover the tasks that had been requested of them – moving and handling, washing, dressing, meal preparation and medication prompt would normally consume this time.
• although departure from the plan in an emergency was acceptable this should not be on a routine basis as the tasks were matched to a time period so that they were completed fully and safely
• the new provider did have the availability to do a shopping call and had suggested an hour, and one carer should be sufficient but that unless it was a cash payment that carers could produce a receipt for any purchases then a pre-paid card would be a better idea to protect everyone
• the additional hour would be charged at £24.12.

26. The Council confirmed to Ms X on 23 November of the tasks the new provider would complete during their daily calls. Within the additional weekly hour for shopping the carer would check food stocks, throw outdated food away, shop in preferred shops locally and put shopping away. A cleaner or commissioning a further domestic contract from the agency would be needed for more routine domestic tasks to be completed.
27. Ms X contacted the Council on 27 November 2023 to confirm she had made an arrangement for a supermarket delivery for 29 November and would cancel the shopping arrangement with the provider and would continue the delivery arrangement going forward to ensure her mother had the quality and quantity of food required. Ms X noted the transition from the previous care agency had been vey difficult for her mother to deal with.
28. The Council completed a review of Mrs W’s care and support needs in early December 2023.
29. Mrs W passed away on 17 January 2024.
30. Ms X complained to the Council in April 2024 about being charged despite there being an unresolved complaint with the care provider.
31. The Council provided a response to Ms X at the end of July 2024 and apologised for the delay in responding. This included the following information:

• the failure by the care provider to respond to Ms X’s complaint was a matter she would need to address to the care provider directly
• the Council had written to all affected clients about the transition from one provider to another
• there was a record of a discussion with Ms X on 13 November 2023 about the change in provider
• there were legal reasons why the Council could not provide more information about the reason for the change
• the previous provider had been completing food shopping for Mrs W which was not part of the contract and this raised concern about the care package in place for essential care tasks was not being followed
• the Council had worked with Ms X to find a solution to there being no food in Mrs W’s home and ensured going forward there was a formal arrangement in place to ensure the care provider had allocated time each week to shop for Mrs W
• the social worker had explained that adding an additional hour to the package of care for the purposes of food shopping would increase the charge to Mrs W
• on the weekend that followed the change in care provider it had completed a basic food shop to ensure there was food in the home and subsequently completed a further shop for food preferred by Mrs W

32. Ms X remained unhappy with the Council’s response and raised further concerns in early September 2024.
33. The Council responded at the start of February 2025 and apologised for the delay. The Council included the following information:

• the care provider had advised the Council it had spoken to Ms X and provided a written response to her complaint
• both the Council and previous care provider had written to Ms X about the change of provider and Ms X spoke with the Council about this on 13 November
• there were legal reasons why the Council could not share all the information about the change of provider with Ms X
• the previous provider had been completing shopping which had not been agreed with the Council and so the new service would not have been like for like
• the case was allocated to a social worker on 18 November 2023
• the social worker was made aware of issues around shopping on 19 November and arranged an additional hour a week to support this which remained in place until the alternative arrangement of a supermarket delivery was put in place by the family
• emergency shopping was completed in the meantime
• the purchase of a tablet crusher had been suggested to Ms X by the care provider to address her concerns about Mrs W being able to swallow her medication

34. Ms X complained to the Ombudsman in June 2025. Ms X explained she had not been notified about the transition to a new care provider and the process was chaotic and distressing for Mrs W. In particular, Ms X highlighted that her mother had been without adequate food for several days.
35. In its response to the Ombudsman, the Council accepted the annual review of Mrs W’s care should have taken place in June 2023. The Council has explained that due to demand and capacity it has to prioritise cases. The Council further explained that once it was made aware of concerns in November 2023 it allocated a social worker promptly and the review was completed in December 2023.

Analysis

36. The Council has accepted delay in the review of Mrs W’s care and support plan. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. The failure to do so is fault.
37. The Council commissioned the care being provided to Mrs W at home. It is clear from the documents provided that there was an expectation that this care would include occasional shopping tasks and keeping Mrs W’s home clean and tidy. The initial care provider appears to have completed these tasks over a sustained period. I am satisfied that it would have been a reasonable expectation for Mrs W and Ms X that the new care provider would continue to provide the same tasks.
38. The transition to a new care provider should normally involve careful planning to ensure continuity of care and mitigate any anxiety about this. This would include a handover introducing new care workers and shared support plans and clear communication. However, in this situation the change in care provider was unplanned and due to a provider failure. The Council has confirmed that as a result of the complaint it is reviewing its current provider failure protocol. The Ombudsman would welcome this action.
39. The Council has belatedly provided a copy of the written notification provided to Mrs W about the change in care provider referred to in its complaint correspondence. There is also a brief note of a telephone call which appears to have been made to Mrs W. There is no record of contact with Ms X about the proposed change of provider before this took place despite her involvement in the care planning process at the outset. I consider it would have been good practice to have ensured Ms X received clear and timely information about the change in care provider and the failure to do so in the circumstances of this complaint is fault.
40. I note the Council suggested in its complaint correspondence with Ms X that an apparent failure by the care provider to respond to a complaint was a matter for Ms X to raise directly with the care provider. However, as the Council had commissioned the care and maintained oversight it should have ensured the care provider responded to complaints.

41. Unfortunately, we can no longer provide a remedy to Mrs W to address any shortfalls in the quality of her care during the transition period. However, I am satisfied that the above fault will have caused Ms X distress and uncertainty about her mother’s care.
42. There was delay in the Council’s responses to Ms X’s complaints. I consider the apologies previously provided by the Council are a suitable remedy.

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Action

43. 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.
44. The Council has agreed to take the following action within one month of my final decision:
1. write to Ms X to apologise for the failure to ensure a smooth transition between care providers for Mrs W and her family; and
2. pay Ms X £500 to acknowledge her distress and uncertainty (this payment should not be offset by the Council against any outstanding balance).
45. The Council has also agreed within three months of my final decision to provide the Ombudsman with details of its actions to ensure:
1. care and support plans are reviewed in accordance with the Care Act 2014 and the Care and Support Statutory Guidance;
2. clear and timely information is provided to clients and their families as appropriate when there is a change in care provider; and
3. relevant staff are reminded of the Council’s responsibility to ensure commissioned care providers respond to complaints.
46. 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.
47. The Council should provide us with evidence it has complied with the above actions.

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Decision

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

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Investigator's decision on behalf of the Ombudsman