Summary: Miss X complained about the care commissioned by the Council regarding her son, Mr Y’s supported living accommodation. Miss X says the care provider’s actions caused her significant avoidable distress, negatively impacted her mental and physical health and placed Mr Y at risk of neglect and financial abuse. We found fault by the Council. The Council has agreed to apologise to Miss X and Mr Y, provide a financial remedy and complete a review of Mr Y’s care and support plan.

The complaint

1. Miss X complained about the care commissioned by the Council regarding her son, Mr Y’s supported living accommodation. Miss X complained the care provider:
• Mismanaged Mr Y’s finances and failed to protect him from potential financial abuse.
• Purchased dairy products for Mr Y as part of its provision of shopping support, despite his care plan stating he has a dairy-free diet.
• Relied on the frequent use of ready meals instead of providing healthier food options.
• Failed to adhere to its agreement to make a driver available for Mr Y.
• Failed to maintain cleanliness in Mr Y’s room.
• Failed to respond to Miss X’s requests for the care provider’s complaints policy.
2. Miss X says the care provider’s actions caused her significant avoidable distress, negatively impacted her mental and physical health and placed Mr Y at risk of neglect and financial abuse. Miss X would like the Council to take steps to ensure Mr Y receives appropriate care as well as rebuilding her trust in the care provider.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. Service failure can happen when an organisation fails to provide a service as it should have done because of circumstances outside its control. We do not need to show any blame, intent, flawed policy or process, or bad faith by an organisation to say service failure (fault) has occurred. (Local Government Act 1974, sections 26(1), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
5. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may recommend a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), 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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How I considered this complaint

7. I considered evidence provided by Miss X and the Council as well as relevant law, policy and guidance.
8. Miss X and the Council had an opportunity to comment on a draft of this decision. I considered any comments before making a final decision.

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What I found

Care plans

9. 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.

Safeguarding

10. 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)

Principles of good administrative practice

11. In 2018 the Ombudsman published a guidance document (updated in January 2025), setting out the standards we expect from bodies in jurisdiction “Principles of Good Administrative Practice”. This includes:
• Stating the criteria for decision making and giving reasons for decisions
• Keeping proper and appropriate records
• Explaining clearly the rationale for decisions and recording them

What happened

12. This chronology includes key events in this case and does not cover everything that happened.
13. Miss X’s son, Mr Y lives in supported living accommodation managed by a care provider, AM2PM Quality Care. The Council commissioned Mr Y’s care package and provided Mr Y with a care and support plan.
14. Mr Y receives disability benefits and has a car provided via the Motability Scheme. Mr Y does not drive and relies on other people to drive his car for him. Miss X says the care provider agreed to make a driver available for Mr Y. Miss X says as part of this agreement, the care provider agreed to contact her by 9am on any day when a driver was not available.
15. Between January and July 2025, Miss X raised several issues to the care provider, including concerns about Mr Y’s weight and his diet, the purchasing of dairy products for Mr Y, a lack of available drivers and the lack of cleanliness in Mr Y’s room.
16. On 26 June 2025, Miss X attended a meeting with the care provider and the Council to discuss her concerns. At the meeting, Miss X raised several concerns including:
• Carers using their own supermarket reward cards to collect points on shopping for Mr Y
• Carers buying dairy products for Mr Y despite him being on a dairy-free diet
• Discrepancies regarding the spending made by carers on behalf of Mr Y
• The use of more expensive supermarkets and brand-name products instead of lower cost alternatives

Miss X’s complaint

17. Miss X complained to the care provider on 29 June 2025. She complained:
• Of a discrepancy between the amount of funds provided to Mr Y for his shopping and the total amount spent as recorded by shopping receipts.
• Carers had bought dairy products for Mr Y despite his care plan stating he has a dairy-free diet.
• Carers had bought a large quantity of ready meals for Mr Y despite Miss X’s concerns about his weight and diet.
• Carers had not managed Mr Y’s funds responsibly. She said carers had overspent on more costly brand-name products instead of less expensive alternatives and had credited their own supermarket loyalty cards when shopping for Mr Y.
• About a lack of cleanliness in Mr Y’s room.
• About drivers not being available for Mr Y.
• The care provider had failed to respond to several requests to provide Miss X with its complaints procedure.
18. The care provider responded to Miss X’s complaint on 19 September 2025. Regarding Miss X’s concerns about financial management on behalf of Mr Y, the care provider said it was unable to obtain a full explanation for some transactions because of a change of management at the supported living facility. The care provider acknowledged an amount of Mr Y’s funds was unaccounted for but said it could not provide verification regarding the discrepancy. The care provider offered to provide a refund.
19. The care provider acknowledged Mr Y’s environment should always be maintained to a clean and safe standard and acknowledged the level of cleanliness identified was unacceptable. Regarding driver availability, the care provider acknowledged it had not upheld the agreement on some days; it said it had re-briefed staff to notify Miss X by 9am on any days when there was no driver available. The care provider also acknowledged that the purchasing of dairy products contradicted Mr Y’s plan, and acknowledged an excessive number of ready meals purchased for Mr Y. The care provider said Miss X’s complaint regarding the provision of the complaints policy was due to an administrative error.
20. Miss X remained dissatisfied with the care provider’s response and brought the complaint to the Ombudsman.

Analysis – Miss X’s complaint regarding the mismanagement of Mr Y’s finances and a failure to protect him from potential financial abuse

21. The Care Act 2014 (section 42) says local authorities must make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken in the adult’s case, if it suspects an adult is experiencing, or is at risk of, abuse or neglect. This could include potential financial abuse.
22. The record of the meeting held on 26 June 2025 between Miss X and the care provider shows that representatives of the Council were also present. The Council’s records state Miss X “does not claim that money was taken from [Mr Y] or that he was financially abused, but feels that recording and monitoring of his finances has been insufficient”.
23. Following the meeting, the Council’s contract team carried out a quality assurance visit to the supported living facility, to address the concerns raised. This included consideration of a lack of transparency regarding spending and included a review of the care provider’s documents. The Council recorded no concerns with the placement.
24. The evidence indicates the Council made enquiries following the concerns raised at the meeting on 26 June 2025 and decided not to take further action. This is a decision the Council is able to make. I consider this aligns with the record of the meeting which recorded that Miss X did not claim at that time that Mr Y was being financially abused. As a result, I find the Council is not at fault regarding this aspect of the complaint.
25. However, the care provider acknowledged in its complaint response dated 19 September 2025 that an amount of Mr Y’s money was unaccounted for. This indicates the care provider did not act in accordance with the principles of good administrative practice, namely, to keep proper and appropriate records; this includes records of the spending made on behalf of Mr Y. As a result, the care provider is at fault regarding this matter.

Miss X’s complaint about the purchasing of dairy products on behalf of Mr Y

26. Mr Y’s care plan states Mr Y has no medical diagnosis to necessitate a dairy-free diet and does not explicitly state that his diet must be dairy-free. It does however, state that Miss X advocates a dairy-free diet because of Mr Y’s medical conditions. A care plan review carried out in April 2025 states staff offer dairy-free alternatives where practical but do not impose restrictions without clinical advice.
27. I acknowledge the care plan states Miss X advocates a dairy-free diet for Mr Y. Miss X says this is not a lifestyle choice or her preference but is based on advice received from health professionals.
28. I also acknowledge that dairy-free alternatives are offered by the care provider as this is supported by the evidence provided. I have also considered a text message from Miss X to the care provider dated 6 May 2025 stating that “dairy should be kept to an absolute minimum”, indicating that Mr Y’s diet was not required to be completely dairy-free.
29. I find the care provider is not at fault regarding this aspect of the complaint as the care plan does not state Mr Y’s diet must be dairy-free.

Miss X’s complaint about over reliance on ready meals

30. The care provider’s complaint response acknowledged Miss X’s concerns that carers had purchased 30 ready meals for Mr Y during a three-month period. The care provider found this to be excessive and stated it had implemented a menu plan and rota as a result.
31. I acknowledge Miss X reviewed the receipts of Mr Y’s food shopping. I also acknowledge her concerns about the quantity of ready meals purchased. It is positive the care provider itself acknowledged the number of ready meals was excessive as part of its own complaint investigation.
32. Mr Y’s care plan states staff will support Mr Y to make suitable choices when food shopping to ensure he eats a varied, nutritious and balanced diet. I consider the quantity of ready meals purchased indicates the care provider did not do this, at least for the period reviewed. I acknowledge the care provider’s comments that Mr Y regularly chooses his own food and has previously declined meal plans proposed for him. I also acknowledge Miss X’s comments that carers would carry out Mr Y’s food shopping for him when he was not present. On balance, I agree with the care provider’s findings regarding this aspect of the complaint and find fault as a result.

Miss X’s complaint about driver availability

33. In its response to my enquiries, the Council said there is no contractual obligation to provide a driver, but one can be offered if available. Miss X says the agreement to provide a driver was made with the care provider in 2024, with the care provider agreeing to inform her by 9am if a driver was not available on the day.
34. I acknowledge the Council says there is no contractual obligation; however, the evidence indicates there was an agreement. This is because the care provider’s complaint response refers to it and acknowledges the agreed arrangement for driver availability was not upheld on some days. The care provider’s email to Miss X and the Council on 25 February 2026 also refers to the agreement.
35. The evidence indicates there were occasions where there were no drivers available. I acknowledge the care provider’s own findings regarding this aspect of the complaint, (that a breach of the agreement occurred) and find that this constitutes service failure.

Miss X’s complaint about a failure to maintain cleanliness in Mr Y’s room

36. Miss X has provided photographic evidence of Mr Y’s room to demonstrate a lack of cleanliness. Miss X’s emails to the care provider also refer to this. Miss X says there were problems with the accumulation of dirty clothing, that bedding was not changed regularly and containers with old and mouldy food were left in Mr Y’s room.
37. The care provider responded to Miss X on 25 June 2025 stating it had requested that Mr Y’s room was to be cleaned and that it would check to ensure it was done. However, a further email from Miss X in September 2025 raised the same issues.
38. The care provider’s complaint response found the cleanliness level of Mr Y’s room to be “unacceptable” and stated it was introducing a cleaning rota. I agree with the findings of the care provider and find the failure to maintain cleanliness of Mr Y’s room is fault.

Miss X’s complaint about a failure to respond to requests for the complaints policy

39. The evidence shows Miss X emailed the care provider several times regarding the complaints policy. On 24 June 2025, Miss X told the care provider she had requested this information three times.
40. The care provider says it provided Miss X with its complaints policy on 29 May 2025 and 27 June 2025. However, it does not dispute there was a period of delay in providing this information and that this fell short of what should have happened. In its complaint response, the care provider acknowledged a communication failure and found that the failure to provide the complaints policy was an administrative error. I find that the communication failure and delay in providing Miss X with the information requested is fault.
41. Having identified fault, I must consider if this caused a significant injustice. Miss X says the care provider’s actions caused her considerable avoidable distress and a lack of trust in the care provider. Miss X says she has to arrange or chase things which she considers should be managed through the commissioned support, and that this has placed an ongoing workload on her. Miss X says the impact is also to Mr Y as he was unable to go out on the occasions when a driver was not available. The injustice to Mr Y is also the distress caused by the failure to maintain cleanliness in his room, including the accumulation of unwashed clothes and bedding and potentially unhygienic living conditions.

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Action

42. 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 and make the following recommendations to the Council.
43. To address the injustice identified, the Council has agreed to take the following action within one month of the final decision:
1. Provide an apology to Mr Y and Miss 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. Make a symbolic payment to Miss X of £250 in recognition of the distress caused;
3. Make a separate symbolic payment to Mr Y of £250 in recognition of the distress caused;
4. Provide training to the care provider regarding the need to keep proper and appropriate records, particularly regarding service users’ expenditure, in accordance with the principles of good administrative practice, and
5. Offer a mediated meeting to be held between Miss X, the care provider, and the Council to discuss Miss X’s concerns.
44. The Council has also agreed to take the following additional action within two months of the final decision:
1. Complete a review of Mr Y’s care and support plan to include consideration of the support required regarding Mr Y’s diet, food planning and shopping. Once completed, the Council should issue the completed care and support plan to Mr Y and Miss X.
45. The Council should provide us with evidence it has complied with the above actions.

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Decision

46. I find fault causing injustice. The Council has agreed to take the above actions to remedy the injustice identified and I have therefore concluded my investigation.

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Investigator's decision on behalf of the Ombudsman