Summary: Priority Care Home (the Care Home) which provided services on behalf of the Council was at fault in how it cared for Ms G. The Care Home failed to adequately communicate with Mrs X or other professionals about Ms G’s deteriorating behaviour before giving her notice to leave the Home. This caused Mrs X and Ms G distress and uncertainty. The Council has already apologised to Mrs X for the injustice caused and has ensured the Care Home has carried out some service improvements to prevent recurrence of the fault. The Council agreed to ensure the Care Home now reviews how it communicates with a resident’s Next of Kin/family members going forward.

The complaint

1. Mrs X complained on behalf of her relative Ms G.
2. Mrs X complained about the care provided to Ms G by Priority Care Home (the Care Home) which was commissioned by the Council. She said Ms G lived at the Care Home between October 2024 and February 2025 and it failed to listen to concerns she raised before unfairly gave Ms G notice to leave the home.
3. Mrs X said the matter has caused her distress and meant Ms G had to move to a new care home which caused her health to deteriorate. Mrs X wants the Council to ensure the Care Home improves its services.

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The Ombudsman’s role and powers

4. 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)
5. 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). The Care Home acts on behalf of the Council in providing care and support in accordance with the Council’s duties in the Care Act 2014. We can investigate the Care Home.
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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

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

Relevant law

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. When investigating complaints about care in council-funded care placements, the Ombudsman considers the 2014 Regulations. Relevant to this complaint are:
• Regulation 12 of the 2014 Regulations says care must be provided in a safe way including assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks and working with health professionals to ensure the health and welfare of residents.
• Regulation 10 requires care providers to treat people with respect and dignity.
• Regulation 11: consent. Where a person lacks mental capacity to make a decision or give consent about care and treatment, staff must act in line with the Mental Capacity Act and in line with their best interests.
11. The Mental Capacity Act provides the legal framework for decisions about adults who lack mental capacity to make their own decisions and choices. The Act requires Care Homes to consult with family members and Next of Kins about the persons best interests and involve them in any significant decisions

What happened

12. Mrs X’s relative is Ms G. Ms G has dementia and following a spell in hospital she moved into the Care Home in October 2024 which was arranged and commissioned by the Council. The Care Home recognised Mrs X as Ms G’s next of kin although Mrs X does not hold Power of Attorney (Power of Attorney is a legal document giving someone the legal authority to act on someone else’s behalf for all legal or financial matters where the person lacks mental capacity).
13. Prior to Ms G moving into the Care Home Mrs X said she advised the home that Ms G’s dementia was severe and she was at risk of trying to abscond from the home. The day after Ms G moved into the Care Home she climbed over the wall of the Care Home and went missing. The Care Home had a Herbert Protocol for Ms G in place (a Herbert Protocol is a form that provides the police and other emergency services with essential information about a person with dementia if they go missing) and police were able to find her and bring her back to the Care Home safely.
14. Records show Ms G’s social worker visited the Care Home during November 2024 and January 2025 when Mrs X was also present. Care Home records show entries at times describing Ms G as being upset and agitated and asking to go home. Ms G would also wander and sleep in the Care Home lounge rather than her room.
15. In late January 2025 the Care Home served notice on Ms G as it no longer believed it could meet her needs. This appears to be following Ms G displaying physical and verbal aggression and lashing out at a member of staff. The Care Home notified Mrs X that it had given Ms G four weeks’ notice to leave. Ms G’s social worker assisted in finding her a new care home which she moved to during February 2025.
16. In March 2025 Mrs X complained to the Council. She complained:
• The Care Home failed to put appropriate safeguards in place to stop Ms G absconding over the fence
• The Care Home unfairly gave Ms G notice because of one incident.
• The Care Home refused to show her CCTV of the incident.
• There was a constant lack of communication from the Care Home and that Ms G never properly settled there
• The Care Home failed to treat Ms G with dignity by putting her belongings in a bin bag rather than the case she arrived with when she moved out.
17. The Council investigated Mrs X’s complaint. In doing so it completed visits to the Care Home, inspected records and interviewed members of staff. It wrote to Mrs X in April 2025 largely upholding her complaint. The Council said:
• The Care Home was aware of the risks about Ms G absconding and took Mrs X’s concerns seriously and details of this was included on the pre-admission notes. Ms G managed to climb the wall outside however as the home had the Herbert Protocol in place she was returned safely. The Care Home then took appropriate measures to increase the height of the fence.
• Mrs X was recognised as Ms G’s Next of Kin and care notes show she participated in meetings with Care Home managers and Ms G’s social worker who kept in contact with her via telephone. The Council however found there were gaps in the Care Home’s communication with Mrs X between November and January. The Council said there could have been clearer processes in place to ensure information was shared more regularly with Mrs X.
• The Care Home said the incident which led to it giving Ms G notice was not an isolated incident. It said her behaviour and aggression had escalated which brought the concerns that it could not manager her care safely any longer. The Council found however that measures could have been put in place to manage her challenging behaviour.
• The Care Home should have taken more steps to mitigate risks caused by Ms G via risk assessments and care planning. The Council said it should have sought further clinical advice so more measures could have been put in place.
• Ms G slept in the Care Home lounge on occasions and her behaviour meant she was sometimes restless and wandered. With regards to her belongings it is likely her bag was thrown away and so bin bags were used. The Council said the Council should have made different arrangements to ensure her belongings were packed in a more dignified way.
• The Council had considered the Data Protection laws when deciding not to share CCTV with Mrs X.
18. The Council made recommendations to the Care Home including:
• Ensuring all relevant professional agencies are involved in a resident’s care
• Ensuring regular communication with families and professionals, especially when a resident displays challenging behaviour.
• Keeping spare containers to ensure a resident’s belongings are kept when a room as vacated.
19. The Council apologised for both hers and Ms G’s experiences. It said it had upheld the complaints around the management of Ms G's care, care planning and risk assessments. It said it would share the findings with the Care Home for learning points to be considered.
20. Mrs X remained unhappy and complained to us.

The Council’s response to us

21. The Council said it had shared the outcome of its investigation with Care Home senior management who had accepted and implemented recommendations. This included involving wider healthcare professionals in cases where the home is struggling to meet a resident’s needs. It has also purchased moving bags for residents that do not their own bags or suitcases.
22. The Council said the Care Home has now updated welcome packs to show what happens if notice is given. The Council said it has carried out compliance visits and is satisfied the Care Home continues to be dementia friendly.

My findings

23. There was fault by the Council in Ms G’s care, which the Council identified in its own complaint response. This included:
• Accepting the Care Home could have done more to try and manage Ms G’s behaviour before giving her notice. Her care was not in line with Regulation 12 because there was a failure to seek advice from clinicians around behaviour management
• Acknowledging the Care Home could have been clearer and more consistent in its communication with Mrs X. Care was not in line with Regulation 10: there was no agreement about what was in Ms G’s best interests around communication and information sharing given Ms G’s probable lack of mental capacity to give consent in this area.
• The Care Home could have made arrangements to store Ms G’s belongings in a more dignified way. Storing a person’s personal possessions in bin bags was not dignified and not in line with Regulation 11
24. The faults outlined above caused Mrs X and Ms G an injustice. It leaves uncertainty around whether the Care Home cold have done more to support Ms G in remaining at the Care Home. The lack of clear and consistent communication with Mrs X caused her distress and uncertainty. The Council has already apologised to Mrs X for the injustice this caused which is appropriate.
25. The Council has also taken appropriate action with the Care Home to minimise the faults occurring again. The Care Home has put measures in place to ensure it consults with various professionals when it has concerns about a resident’s care and has taken steps to update its welcome pack around how it gives notice.
26. I do however have concerns about how the Care Home communicates with a resident’s Next of Kin where no Power of Attorney is in place. The Council upheld this element of the complaint but there is not any clear recommendation in place to ensure the Care Home improves how it communicates with a resident’s Next of Kin, regardless of whether a Power of Attorney is in place. I have therefore made a recommendation around this below.

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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 there is fault with the actions/service of the Priority Care Home and I make the following recommendations to the Council.
28. Within one month of the final decision the Council should ensure Priority Care Home updates resident’s care plans to include a written communication agreement with the resident’s family/Next of Kin. This is to ensure the Care Home communicates with Next of Kins and family members in line with the principles of the Mental Capacity Act.
29. The Council should provide us with evidence it has complied with the above actions.

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Decision

30. I find fault causing injustice. The Council has already apologised to Mrs X to remedy the injustice caused to her and Ms G. It agreed to carry out further service improvements with the Care Home.

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Investigator's decision on behalf of the Ombudsman