Summary: The Council was at fault for the poor standard of care Mrs X received in Frindsbury Hall, a Council commissioned Care Home. The Care Home failed to carry out some of Mrs X’s care in line with her care plan. This has caused distress, frustration and uncertainty about the care Mrs X was receiving and impacted Mrs X’s dignity. The Council has agreed to apologise and make a symbolic payment to remedy the injustice caused. It has also agreed to provide us with a copy of its follow up visit to the Care Home from November 2025.

The complaint

1. Mrs Y complained about the standard of care her friend (Mrs X) received in a Council commissioned residential Care Home during a six week period in July and August 2024.
2. This has caused distress, frustration and uncertainty about the care Mrs X was receiving.

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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. 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.
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(i), as amended).
7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

8. I considered evidence provided by Mrs Y and the Council as well as relevant law, policy and guidance.
9. Mrs Y 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

Relevant law and guidance

10. Under section 42 of the Care Act 2014, councils have a duty to make safeguarding enquiries if they reasonably suspect an adult who has care or support needs is at risk of being abused or neglected and cannot protect themselves.
11. The main purpose of a safeguarding enquiry is to decide whether or not the council, or another organisation, or person, should do something to help and protect the adult.
12. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement.
13. 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 include:
• Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be (regulation 9)
• Providers must make sure that they provide care and treatment in a way that ensures people's dignity and treats them with respect at all times (regulation 10).
• Providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe (regulation 12).

My findings

14. The information below is not a comprehensive overview of everything that happened. It is a summary of key information.
15. Mrs X has a number of health issues and requires full-time care. Mrs Y and her mother were caring full time for Mrs X but due to a change of circumstances they could no longer do this. Mrs X moved into Frindsbury Hall, a Council commissioned Care Home in July 2024 where she stayed until August 2024.
16. During this time, Mrs Y complained about the following aspects of Mrs X’s care:
• Failure to provide Mrs X with the care she required on occasion relating to personal and oral hygiene;
• Failure to leave the call bell and drinks within Mrs X’s reach on occasion;
• A member of staff smacked Mrs X’s hand when it got in the way;
• Failure to maintain Mrs X’s dignity and privacy whilst carrying out personal care;
• Failure to maintain Mrs X’s dignity by giving her a beaker for drinks when she did not need this;
• Staff not aware of Mrs X’s condition or care needs;
• Poor communication from staff;
• Failure to assist Mrs X at mealtimes despite her only having use of one hand;
• Failure to change dirty bedding; and
• Failed to ensure clothes were labelled and stored properly after being washed.
17. The Care Home issued two complaint responses upholding most of the concerns. It did not uphold the concern around a member of staff smacking Mrs X’s hand when it got in the way.
18. A Council Officer made a safeguarding referral about this and the Council undertook a safeguarding enquiry. Mrs X could not remember a member staff smacking her hand. The Council did not find any evidence of a member of staff mistreating her. It closed the investigation in late September 2024 as it said Mrs X had not suffered harm and had since left the Care Home. However, it said it had uncovered some systemic issues which it would address via the complaints and quality assurance team.
19. Mrs Y remained dissatisfied with the Council’s handling of the matter and complained to us.

Council’s response to our enquiries

20. The Council said the Care Home has put in place measures to address the upheld elements of Mrs Y’s complaint. This includes but is not limited to the following:
• All staff members have had new customer service training;
• The online care planning system now includes a question every staff member must answer about whether the call bell is in reach for the resident during each well-being check;
• Maintaining privacy and dignity during personal care has been addressed in 1:1 meetings with staff members;
• Staff members have undertaken person centred care and mental capacity assessment training;
• Reminders sent to all staff members about the importance of reading all preadmission documents;
• Reminders sent to all staff members about ensuring oral and personal care is recorded. The manager is overseeing this process to ensure residents needs are met; and
• The manager is completing spot checks on resident’s rooms and bedding.
21. The Council has provided evidence it completed quality assurance visits to the Care Home in June and October 2024 to discuss the complaints. It also provided training on care planning and risk assessments.
22. In September 2025, the Council initiated a formal review of the Care Home to assess current care practices. Following this, the Council made the following recommendations for the Care Home to undertake:
• Improve its consistency and accuracy of care plans and risk assessments;
• Ensure call bell accessibility and response protocols are followed;
• Reinforce staff training around dignity, privacy and communication with residents and families;
• Adress environmental cleanliness and personal care standards; and
• Review and improve record-keeping.
23. The Council said it was undertaking another visit to the Care Home in November 2025. It said it would assess the Care Home’s implementations of the Council’s recommendations and the measures it put in place to address the upheld elements of Mrs Y's complaint.

My findings

24. Mrs Y complained about the standard of care Mrs X received in a Council commissioned residential care home during a six week period in July and August 2024. The Care Home investigated the concerns through its complaints procedure and upheld all but one of the elements of complaint in paragraph 16. The care given to Mrs X in July and August 2024 was not in line with the CQC fundamental standards and was fault. The faults caused Mrs Y distress, frustration and uncertainty about the care Mrs X was receiving and impacted Mrs X’s dignity.
25. Mrs Y raised to a Council Officer her concerns about the quality of care provided to Mrs X and that a member of staff smacked Mrs X’s hand. The Council undertook a safeguarding enquiry. When the Council spoke to Mrs X, she could not remember the incident with a staff member. The Council was unable to evidence the mistreatment from the staff member and there was no evidence Mrs X was caused harm. It decided the systemic issues were best addressed through the complaints or quality assurance process and so it closed the enquiry. There was no evidence of fault in the way the Council investigated Mrs Y’s concerns through the safeguarding procedure.
26. The Council in response to the safeguarding carried out quality assurance visits and has recently completed a review of the care home. It has made further recommendations to the care home which it is following up in November 2025. These actions were appropriate to prevent recurrence of the faults.

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Action

27. 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 home and make the following recommendations to the Council.
28. Within one month of the final decision, the Council has agreed to take the following action:
1. Apologise to Mrs X and Mrs Y for the distress, frustration and uncertainty caused to them by the standard of care Mrs X received. 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 X £200 to recognise the impact on her dignity caused by the faults identified.
3. Pay Mrs Y £100 to recognise the distress, frustration and uncertainty caused to her by the standard of care Mrs X received.
29. Within two months of the final decision, the Council has agreed to take the following action:
1. Provide a copy of the Council’s record of its follow up visit to the Care Home from November 2025.
30. The Council should provide us with evidence it has complied with the above actions.

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Decision

31. On the evidence considered I find fault causing injustice. I have made recommendations to the Council to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman