Summary: Mrs X complains on behalf of Mr Y the Council failed to advise of issues with Mr Y’s placement with a care provider. Mrs X complains the Council did not advise that Mr Y would not be allowed to return to his care provider’s property following being admitted to hospital. Mrs X also says the Council failed to ensure a member of staff was with Mr Y when he was admitted to hospital. Mrs X says this caused the family distress. We have found fault in the care providers actions in failing to advise the Council of issues with Mr Y’s behaviour and terminating his placement without notice. The Council has agreed to apologise to Mrs X and complete a service improvement.

The complaint

1. Mrs X complains on behalf of Mr Y the Council failed to advise of issues with Mr Y’s placement with a care provider. Mrs X complains the Council did not advise that Mr Y would not be allowed to return to his care provider’s property following being admitted to hospital. Mrs X also says the Council failed to ensure a member of staff was with Mr Y when he was admitted to hospital.
2. Mrs X says this caused the family distress.

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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. 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)
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. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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How I considered this complaint

7. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
8. Mrs X and the Council were invited to comment on my draft decision. I have considered any comments before making a final decision.

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What I found

9. 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.

Contract between the care provider and the Council.

10. The contract between the care provider and the Council states if a resident is required to leave the Home permanently at the request of the Provider, the Provider must give the Trust 28 days’ notice of the intention to terminate.
11. The contract between the Council and the care provider says that staff must ensure a safe transition of care to the follow-on responsible service provider, which may be the Ambulance Service or Hospital Service.

What happened

12. The Council placed Mr Y at a care provider in May 2024. The care provider put one to one care in place when Mr Y first arrived at the placement. The Council stopped this in around late June 2024 following an assessment.
13. The care provider contacted Mr Y’s family in mid-January 2025 to say he was showing signs of distress but was ok. The following day the care provider contacted the family to say it was sending Mr Y to hospital. But when the ambulance crew arrived, they decided Mr Y did not need to attend hospital.
14. The care provider contacted Mr Y’s family two days later to say it had sent Mr Y to hospital. Mrs X says she arrived at hospital and hospital staff told her the care provider had said Mr Y could not return to his placement with it.
15. Mrs X raised a complaint at the end of January 2025 which she sent to the care provider and said she was unhappy no-one had told the family about issues the care provider was having with Mr Y’s behaviour. Mrs X also said she was unhappy no-one had not told the family Mr Y could not return to the placement and found this out from hospital staff.
16. The care provider issued a response to the complaint which said Mr Y had become increasingly agitated and had displayed physical aggression to staff. The care provider apologised that Mrs X had to find out from hospital staff about its decision to not allow Mr Y back to its placement.
17. The Council spoke to Mrs X in late January 2025 about a new placement for Mr Y. The notes record that Mrs X felt it would be in Mr Y’s best interest to move nearer to his family and was not too worried that he could not return to the original placement.

Analysis

18. I have not seen any evidence to show the care provider told the Council about its concerns with Mr Y’s behaviour prior to him being admitted to hospital. The first contact the Council received about the care provider’s concerns was an email advising it was terminating Mr Y’s placement and saying he could not return to its property from hospital. This is against the terms set out in the contract the care provider has with the Council and is fault.
19. The care provider contacted Mrs X in the week before Mr Y was admitted to hospital and did not mention it was considering terminating Mr Y’s placement with it. When Mrs X arrived at the hospital she would have been shocked to find out that Mr Y could not return. I have also not been able to see the care provider advised Mrs X of its decision despite having her contact details. This is fault.
20. I have noted Mrs X told the Council she was not too worried about Mr Y not being able to return to his placement. This is because she said a placement closer to Mr Y’s family would be better for him. Therefore, any injustice to Mrs X has been limited.
21. The care providers contract says it should ensure a safe transition of care to the follow-on responsible service provider, which may be the Ambulance Service or Hospital Service. Mr Y was transitioned into the care of the Ambulance Service or Hospital service and as such I cannot find fault in this element of the complaint.

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Action

22. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the care provider, I have made recommendations to the Council.
23. Within one month of the date of a final decision, the Council should:

• Write to the care provider to remind it of its responsibilities when terminating a placement and the importance of keeping families up to date with any concerns it has.
• Write to Mrs X to apologise for the distress caused by the faults identified. 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.

24. The Council should provide us with evidence it has complied with the above actions.

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Decision

25. I find fault causing injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman