Summary: Mrs C complained the Care Provider failed to provide support as agreed and in line with her mother’s (Mrs X) care and support plan, and how it handled and responded to her concerns. We found there was some fault by the Care Provider which caused Mrs C and Mrs F an injustice. The Care Provider agreed to apologise, make a symbolic payment, and complete service improvement recommendations to remedy the injustice caused.

The complaint

1. Mrs C, complained about the care provided to her mother (Mrs X) by Cherish UK Limited, a domiciliary Care Provider. She said:
• carers attended each day but never completed the full hours allocated and it wrongly suggested to reduce the care hours. She therefore only paid part of the agreed care costs;
• the care was poor and unsafe as carers did not provide support in line with the care and support plan, and Mrs X was verbally abused; and
• she raised her concerns with the provider and a meeting took place, but this did not improve the service. She subsequently ended the agreement and complained but did not get a response.
2. Mrs C said, as a result, Mrs X had costs for care support which was not provided and had been at risk of harm. Mrs C also said she experienced distress and uncertainty.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social Care Providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) 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. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
6. We cannot investigate a complaint if it is about certain contractual or other commercial transactions. (Local Government Act 1974, Schedule 5/5a, paragraph 3, as amended)
7. The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended)
8. If an adult social Care Provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
9. 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)
10. 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

11. I have investigated Mrs C’s complaint about the Care Provider’s handling of Mrs X’s care support in Autumn 2024, and how it responded to her concerns. While she did not bring her concerns to our attention until July 2025, this was within 12 months of the matters complained about.
12. I have not investigated:
• any concerns about safeguarding as part of this complaint. This is because Mrs C’s safeguarding concerns has been considered in a separate investigation, and the care arrangement ceased with the provider before she made her complaint.
• whether the Care Provider’s actions amount to a breach of contract. This is because such matters are for the courts to consider. I cannot therefore reach a view on whether Mrs C is liable to pay the outstanding care charges for the period the care arrangement was in place.

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How I considered this complaint

13. I considered evidence provided by Mrs C and the Care Provider as well as relevant law, policy and guidance.
14. Mrs C and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
15. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC). 

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What I found

Relevant law

Fundamental standards of care

16. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered Care Providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. The standards includes:
• Regulation 9: Person centred care. Providers must do everything reasonably practicable to make sure service users receive a person centred care and treatment that is appropriate, meets their needs and reflects their personal preferences.
• Regulation 10: Dignity and respect. Providers must treat service users with dignity and respect at all times, which includes how the they communicate with a service user.
• Regulation 12: Safe care and treatment. Providers must provide care and treatment in a safe way, which includes having regard to risk assessments, care plans, and mitigating risks. It also set out how medicine should be administered and ensuring places & equipment is safe.
• Regulation 13: Safeguarding service users from abuse and improper treatment. Concerns raised in complaints may identify potential concerns or abuse. Systems and processes must be in place to handle such concerns.
• Regulation 14: Meeting nutritional and hydration needs. Providers must include service users’ nutrition and hydration needs when making initial assessments and ongoing reviews should be carried out which includes risk considerations. Strategies should be in place to address people’s needs.
• Regulation 15: Premises and equipment. Providers must make sure these are clean and suitable for the intended purposes. This does not include a service users own home and equipment where it is not provided as part of their care or treatment.
• Regulation 16: Receiving and acting on complaints. Providers must have efficient and accessible systems in place for dealing and responding to complaints. Information must be available to complainants about how to escalate complaints internally or externally.
17. Regulations do not say how long a complaint investigation should take. But they do say an expected timescale must be explained at the start, usually in discussion with the complainant. If the complainant does not want to discuss this, the responsible body must decide the timescales and confirm them to the complainant in writing. The body must keep the complainant informed of progress during the investigation ‘as far as reasonably practicable’. If the responsible body has not provided its response after six months (or after a longer period agreed with the complainant), it must write to the complainant to explain why. (Regs 13 and 14, Local Authority Social Services and National Health Service Complaints (England) Regulations 2009)
18. 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.

What happened

19. Mrs X has been assessed to have care and support needs due to her mental and physical disabilities. She has a care plan which sets out the support she should receive. Mrs C is a relative of Mrs X and supports her with managing her care arrangements.
20. In September 2024 the Care Provider started providing care and support for Mrs X. This was for two daily visits and to bring her to a weekly appointment. Arrangements had previously been commissioned by the local council, but this agreement was arranged directly with the Care Provider by Mrs C. Key support in the care plan included:
• to ensure Mrs X had food prepared and available to her on each visit including drinks and snacks. Mrs C normally arranged for pre-cooked meals which only had to be made ready and placed in front of or near Mrs X. Prompting was needed to encourage her eating as she may otherwise not get the nutrition she needs;
• to prompt Mrs X with personal care, support with medication, and take her to her weekly appointment;
• to do light domestic tasks including washing dishes, wiping surfaces, checking for and disposing of old and out of date food, and emptying bins; and
• to sit and chat with Mrs X if time allowed and report any wellbeing issues.
21. A risk assessment had also been completed for Mrs X which highlighted the importance of significant encouragement and prompting to ensure she had enough nutrition and personal care was completed.
22. On several occasions in October 2024 Mrs C raised concerns to the Care Provider about its carers not spending the allotted time with Mrs X and it had failed to take her to her weekly appointment. She asked for a meeting with the Care Provider. The concerns included some tasks had not been completed, and old food and meals had not been disposed of. She said this caused a risk to Mrs X’s health and wellbeing.
23. In its responses the Care Provider apologised for Mrs X missing her weekly appointment. It suggested she may not need the full allocated hours if her needs were not significant enough, and explained part of the allocated time included carer’s driving time. It acknowledged the care provided may not always have been as set out in the care and support plan and would address this with the carers.
24. A review meeting with the Care Provider took place in late October 2024. The Care Provider assured Mrs C it would bring the concerns to its carers attention to ensure Mrs X received care and support as set out in her care plan.
25. However, Mrs C said the care did not improve and she brought her concerns to the Care Providers attention again. This also included a carer had spoken inappropriately to Mrs X and an invoice had incorrectly been sent to Mrs X instead of Mrs C.
26. Mrs C ended the care arrangement with the Care Provider in November 2024 when she had not had a response to her concerns. She asked for details about its complaint procedure.
27. The Care Provider apologised for its delayed response. It explained its manager had been busy and complaints responses can take up to four weeks. It shared its email for complaints.
28. Mrs C sent her complaint to the Care Provider’s a week later. She said:
• carers attended each day but never completed the full hours allocated and it wrongly suggested to reduce the care hours. She shared a breakdown of the care times as evidence by Ring cameras in Mrs X’s home. She therefore only paid part of the agreed care costs;
• the care was poor and unsafe as carers did not provide support in line with the care and support plan, and Mrs X was verbally abused. She had shared evidence of food and leftovers which had not been disposed of or cleaned up, and questioned what processes was in place to record Mrs X’s nutrition; and
• she raised her concerns with the provider and a meeting took place, but this did not improve the service. She subsequently ended the agreement as she had not received a response or seen improvements to her ongoing concerns.
29. Shortly after the Care Provider invoiced Mrs C for the care costs up to the end of the agreement. A further invoice was sent in early 2025. Mrs C has not made any further payment, and she told the provider she would not pay.
30. Mrs C asked the Ombudsman to consider her complaint about the Care Provider’s support for Mrs X, its charges, and its failure to respond to her complaint in July 2025.
31. In response to my enquiries the Care Provider explained:
• how it had responded to Mrs C’s concerns in October 2024. It said Mrs C rejected its suggestion to reduce care hours, and the missed appointment had been resolved;
• it found its care was not poor or unsafe. It shared its records of visits to Mrs X which set out what was done by carers during visits. It also shows the length of the care visits. Several visits were as little as a third of the expected duration and only on rare occasions lasted the full visit;
• it acknowledged care visits did not last the full duration. It said this was because travel time was included in the care hours, Mrs X sometimes refused support, and because Mrs C or other family members often completed tasks before its visits;
• it had no record of receiving a complaint from Mrs C in November 2024. This was because she has sent her complaint to its generic email address rather than its complaints inbox; and
• it uses an electronic system where carers check in and out of care visits to record times. It disputes Mrs X’s Ring camera is accurate evidence as carers may leave and return. It also said Mrs C did not account for travel time in her calculations.

Analysis and findings

The care support and care visit duration

32. Mrs C and the Care Provider agree the support Mrs X received was not always the full duration as set out in the care agreement.
33. The evidence from Mrs C and the Care Provider’s own records show it was very rare its carers supported Mrs X for the agreed period of time. In the majority of visits the care support lasted significantly less time than set out in the agreement, even when considering the allowed travel time.
34. The fact a Care Provider does not provide care and support for the full duration set out in a care agreement is not necessarily fault. This is because the aim and purpose of the arrangement is to deliver the support set out in a care plan. It may be possible to complete the required tasks to a reasonable standard within a shorter period of time, or some tasks may not be required as family members have already completed them, or the service user declined the support.
35. In Mrs X’s case, it is clear the family’s assistance made the tasks to support her easier, and some tasks were at times already completed when a carer visited. This meant on occasions carers were not needed for the full duration of the care call, and Mrs X’s needs and support were met.
36. It was not fault by the Care Provider to suggest a reduction in the agreed care hours. This is because it was for Mrs C to decide whether in her view this was appropriate.
37. However, on balance, I am not satisfied the care and support Mrs X received from the Care Provider always met the expected standards, nor was all parts of her care plan always adhered to. In reaching my view, I was conscious Mrs C shared evidence to the Care Provider of instances:
• where carers failed to dispose of old food and leftovers, which meant Mrs X had access to food which was unsafe to eat. This was contrary to the instruction in her care plan and risk assessment;
• general tidying up and cleaning surfaces were not always done. While equipment used by carers may have been clean and safe, this failure meant risks were not mitigated in regard to the equipment Mrs X may have used on some occasions;
• some carers who visited were not fully familiar with Mrs X’s needs as set out in her care and support plan. In particular the need to prompt her to eat and placing food next to her, and to encourage her to complete personal care; and
• carers did not always engage with Mrs X or sit and talk with her when time allowed as set out in the care plan. However, I acknowledge Mrs X may not have engaged with such attempts.
38. Also, I acknowledge Mrs C said a carer spoke inappropriately to Mrs X. However, I do not have enough evidence to reach a view on this and understand this may have been an isolated incident.
39. I found the Care Provider caused an injustice. This was:
• Mrs X experienced a loss of opportunity to receive care and support as set out in her care plan. I acknowledge this was on occasions as much of the care support was provided, and it lasted for a relatively short period;
• Mrs X was put at unnecessary risk of harm due to food safety and may not have had the nutrition she needed on some occasions when task such as disposing of food and prompting was not properly completed; and
• Mrs C experienced some distress and uncertainty from witnessing the care Mrs X received and having to do some tasks herself to clean or dispose of food.

Communication and complaints handling

40. Mrs C raised her concerns with the Care Provider soon after it started providing care and support for Mrs X. The evidence shows the Care Provider did respond to her and arranged a meeting to discuss her concerns. I also acknowledge some delay in considering her concerns were due to Mrs C being away and the availability of the Care Provider.
41. However, I found the Care Provider failed to respond and act on her concerns after the meeting in October 2024 had taken place. This is because, despite the assurances it had made, Mrs C subsequently contacted the provider several times to raise concerns about the ongoing support Mrs X was receiving.
42. While the Care Provider believed it had resolved the concerns in its previous communication and meeting with her, this was clearly not the case as her concerns were ongoing and had not been resolved. It should therefore have responded to her concerns without delay.
43. She also complained shortly after ending the agreement with the Care Provider in November 2024. She never received a response to her complaint or information about who she could escalate her complaint to. I understand the Care Provider believes it never received a complaint, and Mrs C did not follow up on her complaint to it.
44. However, Mrs C has shared evidence her complaint was sent to the Care Provider. This was to its generic email address and not its complaints inbox. However, it should still filter the correspondence received and pass complaints to its relevant team for a response. Its failure to respond was therefore fault. I am satisfied the Care Providers lack of communication and failure to respond to her complaint caused her some additional frustration and uncertainty.

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Action

45. To remedy the distress and uncertainty the Care Provider caused to Mrs X and Mrs C, the Care Provider should, within one month of the final decision:
1. apologise in writing to Mrs C to acknowledge the injustice its faults caused her and Mrs X.

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. pay Mrs C a symbolic payment of £500 to acknowledge the loss of some care support and risk of harm Mrs X experienced on occasions during the eight-week period the care arrangement was in place.
3. pay Mrs C a further £200 to acknowledge the distress and uncertainty she experienced as a result of the Care Provider’s faults, including how it handled her complaint.

In total the Care Provider should pay £700. As Mrs X has outstanding care charges it may decide to provide the remedy in the form of a write-off of all or part of the outstanding charges.

46. Within three months of the final decision the Council should also:
1.  
2.  
3.  
4. review Mrs X’s case and share with the Ombudsman the steps it intends to take to ensure:
1. timely investigations and responses into alleged poor care support which may cause a service user a risk of harm. This includes when a manager is unavailable to avoid unnecessary delays; and
2. it responds to complaints and informs complainants about their right to escalate complaints internally or to external bodies. This includes cases where it believes it has already addressed issues through informal discussions, but a complaint is subsequently received.
47. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

48. I have completed my investigation with a finding the Care Provider caused Mrs X and Mrs C an injustice as a result of its failure to complete some care tasks as agreed and how it handled Mrs C’s concerns. The Care Provider agreed to apologise, make payment a symbolic payment, and complete service improvement recommendations to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman