Summary: There was fault by the Care Home in its care of Mr X, a failure in complaint handling and a delay in completing safeguarding processes. This caused avoidable distress. The Council will apologise and make a symbolic payment. The Council will also complete the systematic review of the Care Home agreed as an outcome to the safeguarding enquiry.

The complaint

1. Mrs X complained about her relative Mr X’s care in Orford House (the Care Home) which the Council commissioned as respite provision for Mr X for two weeks. She complained about poor personal, continence and skin care and about medication administration and nutritional care.
2. Mrs X also complained about poor complaint handling and about safeguarding processes.
3. She said this caused avoidable distress.

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The Ombudsman’s role and powers

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. The Council commissioned the Care Home under duties and powers in the Care Act 2014. We can investigate the Care Home’s service to Mr X.
6. 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)
7. 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)
8. 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

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

11. Our Principles of Good Administrative Practice (January 2025) set out our expectations of councils and organisations who deliver services on their behalf. We expect them to put things right, which includes operating an effective complaints procedure which offers a fair and appropriate remedy when a complaint is upheld.
12. Councils must make enquiries (or arrange for others to do so) if they reasonably suspect an adult with care and support needs is, or is at risk of, being abused or neglected (Care and Support Statutory Guidance (CSSG), paragraph 14.76 and Care Act 2014 section 42)
13. An enquiry is action taken in response to a concern about abuse. It could be a conversation with the adult through to a multi-agency plan. The purpose is to decide whether someone should do something to help or protect the adult (CSSG paragraph 14.78)
14. The objectives of an enquiry into abuse or neglect are to:
• establish facts;
• ascertain the adult’s views and wishes;
• assess the needs of the adult for protection, support and redress and how they might be met;
• protect from the abuse and neglect, in accordance with the wishes of the adult;
• make decisions as to what follow-up action should be taken with regard to the person or organisation responsible for the abuse or neglect; and
• enable the adult to achieve resolution and recovery. (CSSG paragraph 14.94)
15. 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. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care. I have set out the relevant regulations below:
• Regulation 9: requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
• 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. Guidance explains medicines should be given accurately and in line with the prescriber’s instructions and at suitable times to ensure the person is not placed at risk. Staff must follow policies and procedures about managing medicines and these should address supply and ordering, storage, preparation and dispensing, administration, disposal and recording.
• Regulation 17: requires a care provider to keep accurate, complete and contemporaneous records of care and treatment and decisions taken about care and treatment
• Regulation 14: says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.

What happened

16. The Council commissioned Mr X’s respite placement at the Care Home for two weeks and he was admitted on 27 May.
17. A body map with the date of Mr X’s admission described visible cracks in Mr X’s feet, pitting and swelling to both legs (shins and calves). The body map said the district nurse was going to check his feet and legs.
18. The Care Home completed assessments and care plans for Mr X. The documents have several dates on them including 27, 28 and 29 May 2025. They were amended on 13 and 14 January 2026 (six months after Mr X left the placement) by two different members of staff.) The Care Home told us the amendments were clerical corrections only and were made before disclosure to the LGSCO.
19. The care plans said:
• Mr X had diabetes and needed support from the district nurses for insulin administration
• He ate independently and needed encouragement to eat. He could use cutlery and ate well. Mrs X said not to leave dessert with the main course as Mr X would eat dessert first, but if he refused dinner, to let him have dessert
• It was reported Mr X needed pull up pads for accidents only, but he rarely used the toilet and would smear faeces on the floor and walls. Staff needed to show him where the toilet was as he had urinated in pot plants and in sinks
• He arrived with cracked feet which were swollen and the district nurse examined them and advised it to continue with fluids and to put cream on his feet. He would constantly remove his socks and shoes
• Staff were not told on assessment that he had challenging behaviour however this was noted immediately
• He had partial dentures but kept throwing them in the bin and staff searched for them but could not find them and told Mrs X
• The Council did not mention challenging behaviour and when asked, Mrs X denied the same. He showed unsafe behaviour including lunging at others with pens and knitting needles, kicking and raising fists when walking, hitting staff and refusing care
• Staff were to remove him from groups and carry out individual activities like chatting, providing drinks and using the fidget box. Staff were to note any triggers and look for trends and patterns. He was only on a short-term placement and so no health referrals had been made. The GP had been contacted.
• Staff tried to sit him away from a resident who was shouting out as they were aware the noise upset him.
• Mrs X denied any challenging behaviour and said she was shocked to learn this
• He had tablets for diabetes which were administered by staff with a glass of water
• He needed a carer to assist with all personal care (wash bath or shower). He could choose clothes. He may refuse support and staff were to tell Mrs X so she could assist him with a shower.
• He had dry skin and his legs and feet were to be moisturised daily.
20. On 5 June, the Care Home contacted the Council’s brokerage team saying they wanted to discuss ending Mr X’s placement early as he had been aggressive, reluctant to have personal care and Mrs X had found faeces on his sacrum. The brokerage team noted they had spoken to the Care Home and Mrs X had not yet been made aware of the concerns. The Care Home requested Mr X’s immediate discharge. Mrs X was also requesting an end to the placement and to have been trying to submit a complaint. Records indicate she had tried to submit her complaint but had used an incomplete email address for the Care Home.
21. On 13 June, the Council received a safeguarding alert about Mr X having faeces on the sacrum, ingrained dirt, black, dirty swollen feet and cracked skin on the legs. The protection plan was for Mr X to return home and to attend the day centre (this had already happened).
22. Mrs X’s complaint was received on 24 June. The Care Home’s response to the complaint two days later gave a long list of incidents of verbal and physical aggression by Mr X which it said had caused it to end the placement early. The response said:
• Mrs X sent the complaint to the wrong email address (so it was not received till later)
• It had already ended the placement before she complained
• It thought the Care Home’s environment which was busy and noisy was unsuitable and he was much calmer when Mrs X visited
• He may have been incontinent on the day of discharge after he had received personal care
• HIs medication was not time specific or related to food intake. He spat out a tablet on one occasion
• He wanted dessert on the day she mentioned though he had been offered a main course. He ate well.
23. There were further email contacts between the Council, Care Home and Mrs X in July and August. I have summarised these below in date order:
• The Care Home emailed the safeguarding team attaching statements and incidents
• The Council’s safeguarding team emailed Mrs X saying she was alleged to have said she did not want a safeguarding meeting so the Council would no longer pursue a safeguarding enquiry. Mrs X said she did want a meeting. The safeguarding team apologised and offered further dates.
24. A short review of Mr X’s care and support concluded in August that the current day centre placement was not meeting his needs and he may need a different provision.
25. The Council’s response to the complaint in August said:
• Its commissioning team visited the Care Home and found nothing of concern.
• The Council proposed to wait until the outcome of the safeguarding investigation and it may use the provider concern process and draw up an improvement plan for the Care Home.
• It was sorry for her experience.
• It would ask the Care Home to review its complaint processes as it expected responses to a complaint to be conciliatory and for providers to be receptive to complaints.
26. In December 2025 the Council said it had reopened the safeguarding enquiry into the allegations of omission raised by Mrs X.
27. In January 2026, the Council held a multi-agency safeguarding review meeting which Mrs X attended. Her views are recorded in the minutes. Professionals from the Council’s social care teams attended.
28. The safeguarding plan review evaluated the risks identified during Mr X’s placement. The plan said there were risks that remained a concern for other residents including:
• Risk of neglect and physical harm: there was a failure in pressure care and hygiene with evidence of pressure sores on the buttocks (redness) and poor condition of the feet (dirt and cracked heels.) This posed an increased risk of infection for residents with diabetes (such as Mr X)
• There was a failure in personal care. Contradictory accounts from staff regarding Mr X’s non-compliance suggested risks were not mitigated with alternative approaches and were instead left unaddressed.
• There was a severe risk in the Care Home’s dietary and insulin supervision because of a life-threatening hypoglycaemic (low blood sugar) episode within 24 hours of Mr X leaving the home.
• Reports of cardiac medicine being marked as administered on medication charts when medication was found unswallowed, indicated a task-focussed rather than person-centred approach to clinical safety.
• Without the implementation of behavioural tracking and specialist liaison, there was a high risk of future incidents escalating into physical harm.
• There were gaps in body mapping, fluid intake recording and incident reporting. If incidents were not recorded accurately, they could not be analysed to prevent recurrence.
29. The Council set out a revised safeguarding plan including the following actions:
1. The Council’s quality improvement manager would initiate a systemic review of the Care Home to include consideration of its policies and procedures; infection control and hygiene audit; review of staffing levels and rotas, liaison with Mrs X to include her observations.
2. The Council’s commissioning manager will check with the Care Quality Commission to clarify the status of a September 2025 report and will inform the CQC the Care Home is advertising a dementia specialism despite an apparent lack of staff training. The commissioning manager would also determine if there had been contractual breaches regarding care and documentation.
3. There would be a further multi-agency meeting (including Mrs X) to finalise lessons learned and agree on desired outcomes and formally conclude the safeguarding enquiry. The meeting would be scheduled once Mrs X had chance to review the records the Care Home had been asked to provide her with.

The suggested date for completion of (a) to (c) was March 2026.

30. I have not been provided with a record of the further multi-agency meeting in paragraph 29(c). However, Mrs X told me she had been offered a meeting, but she did not wish to attend.

Comments from the Care Provider

31. The Care Provider told us it rejected the Council’s findings in the safeguarding enquiry and considered Mr X’s care was in line with the 2014 Regulations. It said:
• Its approach to managing Mr X’s challenging behaviours was consistent with a person-centred approach. Staff used de-escalation, supervision, reassurance, diversion and environmental management
• There was only one incident where Mr X spat medicine into a glass
• Mr X ate well, grazed and was offered regular meals, snacks and fluids
• The placement ended due to safeguarding risk. It did not get Mrs X’s complaint until almost three weeks after he left. The approach to ending the placement was proportionate.

Findings

Personal, continence and skin care, medication administration and nutritional care.

32. The Council’s safeguarding enquiry found evidence of poor practice in the Care Home’s service to Mr X including pressure care, continence, medicine administration, recording and skin care and a failure to take steps to address Mr X’s non-compliance with personal care. There was also a failure to seek specialist clinical support with Mr X’s behaviour, and concerns that the Care Home did not have suitably trained staff in caring for those with dementia with behavioural issues. The Care Home’s records indicate Mr X’s care plans were reviewed and amended retrospectively. This indicates his care was not in line with Regulations 9, 12, 14 and 17 of the 2014 Regulations which was fault causing avoidable distress.

Complaint handling and safeguarding processes.

33. The Care Home’s complaint response focussed on Mr X’s behaviours. This approach was unhelpful. The Council’s later complaint response said it would ask the Care Home to review its complaint procedures as it expected providers to be conciliatory and receptive to complaints. We expect councils and organisations acting on their behalf to operate an effective complaints procedure which includes identifying areas of fault and offering an effective remedy. The Care Home’s complaint response did not do this and so was flawed which caused avoidable distress.
34. The safeguarding enquiry took too long to complete: Mr X’s respite ended in June 2025 and the safeguarding review did not take place until January 2026. This was fault which caused avoidable distress. I note Mrs X said she did not want to attend a meeting and then changed her mind, but safeguarding processes should not be left in abeyance where there are potential wider risks to other residents. The Council did not need Mrs X’s input to comply with its responsibilities under Section 42 of the Care Act.
35. The Council has not yet completed the actions it said it would take in the revised safeguarding plan (see paragraph 29). Mrs X has been offered a further meeting, but she declined. At the time of writing, the Council is outside its suggested timescale, but only just. I have made a recommendation about this below, which the Council has agreed to complete.

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Agreed Action

36. 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 service of the Care Home and make the following recommendations to the Council.
37. Within one month of my final decision, the Council will:
• Apologise to Mrs X for the avoidable distress she has suffered. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology I have recommended in my findings.
• Make Mrs X a payment of £500 to reflect her and Mr X’s avoidable distress
• Provide the LGSCO with copies of the further reviews of the Care Home the Council said it was going to take (see paragraph 29), namely:
1. The quality improvement manager’s systemic review of the Care Home to include consideration of its policies and procedures; infection control and hygiene audit; review of staffing levels and rotas.
2. The commissioning manager’s checks with the Care Quality Commission to clarify the status of a September 2025 report and informing the CQC the Care Home is advertising a dementia specialism despite an apparent lack of staff training.
3. The commissioning manager’s determination of whether there had been contractual breaches regarding care and documentation.
4. The Care Home’s review of its complaint processes (as set out in the Council’s complaint response).
38. The Council should provide us with evidence it has complied with the above actions.

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Decision

39. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman