Summary: Mrs Z complained Care UK Community Partnerships Ltd (the care provider) moved her brother, Mr X into unsuitable residential care accommodation without properly assessing his needs and ended his stay without giving notice. She says this distressed Mr X and his family and financially impacted them. We uphold the complaint. The care provider did not properly assess Mr X’s care and support needs and did not properly respond to Mrs Z’s complaint. Mr X and Mrs Z suffered injustice. The care provider has agreed to apologise, make a financial payment and improve its service.

The complaint

1. Mr X’s sister, Mrs Z, says the care provider placed Mr X in unsuitable residential care accommodation and ended his stay without notice. She says this distressed Mr X and his family and financially impacted them.

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The Ombudsman’s role and powers

2. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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 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. 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. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
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 read Mrs Z’s complaint and spoke to her on the phone.
9. I have considered evidence provided by Mrs Z and the care provider as well as relevant law, policy and guidance.
10. Mrs Z and the care provider had the opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Background information

11. 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.
12. Regulation 9 of the Health and Social Care Act 2008 requires care providers to make sure each person receives appropriate care and treatment based on an assessment of their needs and preferences. It says providers must take account of people’s capacity and ability to consent.
13. Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires care providers to take all reasonable steps to ensure the health, safety and welfare of service users. This includes assessing and managing risks, and maintaining safe premises and equipment.
14. Regulation 16 says the care provider must take appropriate action on complaints without delay.
15. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
16. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be in that person’s best interests. The decision-maker also has to consider if there is a less restrictive choice available that can achieve the same outcome. Section 4 of the Act provides a checklist of steps decision-makers must follow to determine what is in a person’s best interests.
17. The care provider’s admissions agreement says it may give written notice to a resident to leave a care home immediately where there is behaviour that may be seriously detrimental to the home or welfare of other residents.
18. The care provider’s complaints policy says it will respond to stage one complaints within 23 working days (including three working days to acknowledge it) and to stage two complaints within 23 working days (including three working days to acknowledge it).

What happened

19. This is a summary of events, outlining key facts and does not cover everything that has occurred in this case.
20. In February 2025 Mr X was in hospital and his brother referred him to the care home run by the care provider. Mr X visited the care home. The care provider’s visit notes recorded Mrs Z had lasting power of attorney (POA) for Mr X.
21. Following Mr X’s visit, the care provider visited Mr X in hospital and completed an assessment before he moved to the care home. The care provider’s completed assessment form said Mr X did not appear to fully understand what the assessment was for. The following section of the form for detailing concerns was not completed. The assessment form went on to say Mrs Z had lasting POA for Mr X and recorded Mr X had no issues with distressed behaviour. The final section of the assessment required the care home manager to complete an assessment outcome. This section was not completed. The care provider also got a copy of Mr X’s GP record which did not record any distressed behaviour by Mr X.
22. At the end of February 2025 the local Council assessed Mr X did not have capacity to make decisions on his care needs and leaving hospital. The Council decided to hold a best interests meeting.
23. In March 2025 the Council held a best interests meeting about Mr X with the hospital and Mr X’s family. The Council did not invite the care provider to the best interests meeting. The hospital told the meeting Mr X had sometimes been declining medication and support. The meeting decided Mr X needed to move to a care home. Mr X’s family said it wanted Mr X to move into the care provider’s care home. The Council said it could not fund this until the home was CQC registered. Mr X’s family decided to privately arrange and fund Mr X’s move to the care home until the Council could provide funding at a later date.
24. Mr X moved into the care home shortly afterwards. On the day he moved in, Mrs Z told the care provider that she did not have a lasting POA for him. Mr X signed the admissions agreement with the care provider and Mrs Z witnessed his signature.
25. One week later the care provider carried out a mental capacity assessment of Mr X and assessed he had capacity to make a decision about his care and accommodation.
26. Later in March 2025, Mr X’s brother told the care provider the Council was responsible for decisions on Mr X’s welfare and there had been a best interests meeting. The care provider responded to Mr X’s brother by email. The email made no reference to what he had told them about the Council’s involvement or best interests meeting.
27. In early April 2025, Mr X started showing distressed behaviour in the care home and was physically and verbally aggressive towards staff and other residents.
28. The care provider got medical advice and then met Mr X’s family in mid-April 2025. The family told the care provider Mr X was under the Council’s care and had previously had a best interests meeting. The care provider said it did not know this. The care provider said it would be ending Mr X’s stay in early May 2025 because of his behaviour.
29. Later that day the care provider spoke to the Council. The Council confirmed a best interests meeting had taken place and sent the meeting notes to the care provider.
30. A week later the care provider reported extreme and challenging behaviour by Mr X over several days. The care provider told Mr X’s family that he would have to move out of the care home by the end of the day.
31. On the following day Mr X moved to another care home.
32. In May 2025 Mrs Z complained to the care provider. She said the hospital told the care provider about Mr X’s challenging behaviour. She said the care provider’s admissions agreement with Mr X was invalid because he did not have capacity to sign it. She also said the care provider had been unreasonable in giving short notice to Mr X to leave the care home.
33. In June 2025 the care provider replied to Mrs Z’s complaint. It said nobody told the care provider of concerns about Mr X’s behaviour during the pre-admission assessment and the home manager did not complete the assessment’s final section because they were on leave. It said there was no evidence it had intentionally mis-led the family and Mr X’s admissions agreement terms allowed it to end his stay at short notice. It also said it only found out the family had no lasting POA for Mr X on the day he was due to move in and at that point it deemed he had capacity to sign the admissions agreement. The care provider said it would amend its pre-admission assessment procedures and ask for copies of lasting POAs before admission.
34. Mrs Z was not satisfied with the care provider’s response and asked it to escalate her complaint in July 2025. She also said the care provider had mis-sold the care home placement and Mr X was not given the care and support he needed.
35. In August 2025, the care provider responded to Mrs Z’s stage two complaint. It said its assessment did not give a full picture of Mr X’s needs, did not fully review hospital documentation and was not signed off by care home management. It said Mr X’s admissions agreement allowed it to give short notice on exceptional circumstances, but it could have communicated better with Mr X’s family. It also said it could have better recorded the process around Mr X’s capacity and verifying power of attorney. The care provider apologised to Mrs Z for the distress caused and said it would revise its procedures.
36. Mrs Z was not satisfied with the care provider’s response and has asked the Ombudsman to investigate. She wants the care provider to improve its admission procedures and refund some of Mr X’s care fees. She says she did not tell the care provider Mr X had a lasting POA before he moved in.
37. In response to my enquiries, the care provider said it placed Mr X in the care home as a privately funded respite placement pending Council funding. It said it missed the contact from Mr X’s brother in March 2025 and did not know about Mr X’s prior behaviour or best interests meeting until it met Mr X’s family in mid-April 2026. It also said it safely discharged Mr X to another care home because his behaviour meant he needed a more specialised care setting.

My findings

Care home

38. Paragraphs 12 and 13 say the care provider must provide appropriate care and treatment for service users based on a proper assessment of their needs. The care provider’s pre-admission assessment in February 2025 did not properly review Mr X’s hospital information and was not agreed and signed off by management. This caused uncertainty for Mr X and his family about whether the assessment outcome would have been different if the care provider had complied with the fundamental standards.
39. Paragraph 12 says the care provider must take account of people’s capacity and ability to consent. In February 2025 the care provider’s pre-admission assessment said Mr X did not understand why it was carrying out a care and accommodation assessment. In March 2025 the care provider then decided Mr X had capacity to sign his admissions agreement without carrying out a mental capacity assessment. The care provider did not carry out a mental capacity assessment of Mr X until one week later when it concluded he had capacity to make a decision about his care and accommodation. Prior to Mr X’s admission, the care provider recorded Mrs Z had a lasting POA for Mr X. Mrs Z denies telling the care provider this. I cannot say whether the care provider wrongly recorded what it was told by Mr X’s family during the assessment process. I acknowledge Mrs Z then countersigned Mr X’s admissions agreement. However, the care provider had noted one month before admission that Mr X may lack capacity for understanding his care and accommodation needs. Therefore, when the care provider found no POA was in place, it should have carried out a mental capacity assessment of Mr X before deciding whether he had capacity to sign the agreement. The fact Mrs Z countersigned the agreement does not remove the care provider’s responsibility to assess whether Mr X had capacity to sign. It did not do so, contravening regulation nine of the fundamental standards. This did not cause injustice to Mr X or Mrs Z. It is unlikely the outcome would have been different if the care provider had assessed Mr X’s mental capacity on his admission day instead of a week later.
40. I acknowledge the care provider did not take part in Mr X’s best interests meeting in early March 2026 and was given no details at the time. However, later in March 2025, the care provider did not act following an email from Mr X’s brother saying the Council was managing Mr X’s welfare and had held a best interests meeting. This caused uncertainty for Mr X and his family about whether the care provider could have acted on this information and reviewed the care home’s suitability before Mr X’s behaviour deteriorated.
41. Paragraph 17 says the care provider’s admissions agreement allows it to end someone’s residence immediately if they are behaving in a way that may be seriously detrimental to the home or welfare of other residents. The care provider asked Mr X to leave by the end of the day. I recognise this distressed Mr X and his family. However, the care provider was allowed to do this under the terms of its admissions agreement with Mr X. The care provider followed its correct process.

Complaint handling

42. The care providers complaint procedure, detailed in paragraph 18 says it should respond to stage one complaints within 23 working days. Mrs Z complained to the care provider in May 2025. The care provider replied 37 working days later in June 2025. This is 14 working days late, contravening regulation 16 of the fundamental standards detailed in paragraph 14. This frustrated Mr X and Mrs Z.

Action

43. To remedy the outstanding injustice caused to Mr X and Mrs Z by the faults I have identified, the care provider has agreed to take the following action within 4 weeks of my decision:
• Apologise to Mr X and Mrs Z for the uncertainty caused by the failure to properly assess Mr X’s care and support needs and the frustration caused by the complaint handling delay. 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.
• Pay Mr X £250 to recognise the uncertainty caused by the failure to properly assess his care and support needs.
44. The care provider should take the following action within two months of my decision:
• Review and revise its pre-admission process to ensure all professional views and assessments are considered and all care home placement decisions are subject to management agreement and sign off.
• Review and revise its procedures to ensure any power of attorney is verified prior to agreeing a care home placement.
45. The care provider should provide us with evidence it has complied with the above actions.

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Decision

46. I have completed my investigation. I uphold parts of Mrs Z’s complaint which caused injustice to Mr X and Mrs Z.

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Investigator's decision on behalf of the Ombudsman