Summary: Mrs X complained to the Council that her father, Mr Y, was not properly cared for at a residential home. She said the care provider, acting on behalf of the Council, failed to properly acknowledge or address her concerns. We found the Council at fault because the care provider it commissioned did not consistently meet Mr Y’s identified care needs. The Council has already taken appropriate action to resolve the situation, including supporting a move to a more suitable residential placement. It has also agreed to apologise and make a symbolic payment to remedy the injustice caused.

The complaint

1. Mrs X complained to Buckinghamshire Council (the Council) that her father, Mr Y, was not properly cared for at a residential home, where he was placed by the Council. She reported concerns including poor hygiene, unexplained injuries, inadequate staffing, and a failure to prepare his food appropriately. She said the care provider failed to properly acknowledge or address these concerns which caused distress and uncertainty to her and her family and placed Mr Y at risk of harm and neglect.

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The Ombudsman’s role and powers

2. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
3. 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)
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)

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How I considered this complaint

5. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
6. 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

Fundamental Standards of Care

7. 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.

Complaints about local council commissioned services

8. Where a council has commissioned adult social care services or a placement and these are being delivered by a private or independent care provider we consider the care provider is acting on behalf of the council. We have the power to investigate these complaints under section 25(7) of the Local Government Act 1974.
9. Where a social care provider is acting on behalf of the council we consider that any complaint response sent by the provider is provided on behalf of the council under the regulations. Therefore, a response sent by a care provider would be considered the final response to the complaint.
10. Councils should have suitable contracting and commissioning arrangements in place to ensure care providers respond appropriately to complaints about commissioned services and placements. This should include clear arrangements about complaint handling responsibility.

Safeguarding

11. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)
12. The process can be closed at any stage if it is agreed that an ongoing enquiry is not necessary or if an enquiry has been completed and a protection plan put in place.

What happened

13. Mr Y moved into Care Home A in March 2025. The Council arranged and funded the placement, subject to a client contribution.
14. Care Home A reviewed Mr Y’s needs in April 2025. His wife, Mrs Y, attended and asked the home to ensure his food was cut up to support him to eat. No other concerns were reported and the record shows that Mrs Y said the family were overall happy and satisfied with the care Mr Y was receiving.
15. The Council completed a six-week review in early May 2025. Mrs X and Mr Y’s wife attended. The family did not raise any concerns at that time.
16. In late June 2025, Mrs X emailed Care Home A and the Council raising concerns about Mr Y’s care. These included hygiene and toileting, food preparation, staffing levels and unexplained bruising. The Council logged a safeguarding concern the same day and progressed it to a section 42 safeguarding enquiry two days later.
17. The provider for Care Home A held a meeting with Mr Y’s family in early July 2025, around one week after Mrs X raised her concerns. It shared notes of the meeting with the Council. Shortly afterwards, Mrs X told the Council the concerns remained and the meeting had not resolved the issues. She said they felt the provider did not take appropriate responsibility for the concerns raised.
18. Around two weeks after the concerns were first raised, the Council contacted Care Home A as part of its safeguarding enquiry. The home responded the following day. The Council also visited the home, including observing Mr Y at mealtimes, where it noted his food had not been cut up. The Council also considered the other concerns, including staffing levels, emergency procedures and record keeping.
19. As part of the enquiry, the Council reviewed Mr Y’s needs. While it found no ongoing risk requiring further safeguarding action, it concluded the relationship between the family and Care Home A had broken down.
20. The safeguarding enquiry concluded the bruising was likely due to age-related skin changes. Care Home A agreed to cut up Mr Y’s food and make use of continence pads. It also agreed to improve its record keeping, including around refusals of care. The Council found staffing levels and emergency procedures were appropriate. It closed the safeguarding enquiry in late July 2025.
21. Following the safeguarding enquiry, the Council’s safeguarding team shared the outcome with its commissioning team. A contracts officer reviewed the information and decided there was no evidence of ongoing risk to other residents at Care Home A.
22. The provider for Care Home A responded to Mrs X’s complaint in late July 2025. Its response set out the same measures agreed as part of the safeguarding enquiry.
23. The family remained concerned about Mr Y’s safety at Care Home A. The Council therefore agreed to support a move to a different residential placement. Mr Y moved to Care Home B in mid-August 2025.

Analysis

24. Records show that Care Home A was aware from at least April 2025 that Mr Y needed his food to be cut up. The concerns raised by Mrs X in June 2025, together with the Council’s observations during the safeguarding enquiry, indicate this need was not consistently met. This was fault, which put Mr Y’s health and wellbeing at risk.
25. Mrs X also raised concerns about record keeping and the reporting of incidents. The Council’s safeguarding enquiry identified shortcomings in record keeping, particularly in relation to refusals of care. This was fault as the provider, acting on behalf of the Council, should maintain clear and accurate records and report concerns appropriately.
26. The safeguarding enquiry found staffing levels at Care Home A were appropriate and that it had suitable emergency procedures in place. There is no evidence the Council failed to properly consider these issues when reaching its decision. I therefore cannot question that conclusion.
27. The Council responded to Mrs X’s concerns promptly by raising a section 42 safeguarding enquiry. It completed its enquiries within around one month, which included a review of Mr Y’s needs. The Council gathered information from the provider, Mr Y’s family, and medical professionals, and took appropriate steps to consider the concerns raised. I find no fault in how the Council carried out the safeguarding enquiry and I cannot question its outcome.
28. The provider also responded promptly to Mrs X’s concerns. It held a meeting with Mrs X and other family members around one week after the concerns were raised. Mrs X said the provider minimised her concerns and did not take responsibility for the issues discussed. However, there is no independent evidence to resolve these differing accounts. I cannot therefore make a finding on how the meeting was conducted.
29. The provider engaged appropriately with the safeguarding enquiry and agreed to take action to address the issues identified, including improving food preparation and record keeping. There is no evidence of fault in how it responded to the concerns once they were formally raised.
30. The safeguarding enquiry resulted in measures to address the identified risks, including ensuring Mr Y’s food was cut up and improving record keeping. The provider agreed to implement these measures. In addition, when it was clear the relationship between the provider and Mr Y’s family had irrevocably broken down, the Council acted appropriately by supporting a move to a new placement.
31. I am satisfied these actions remedied the injustice caused by the faults identified. The Council has also agreed to formally apologise to Mrs X and make a symbolic payment in acknowledgement of the distress caused to Mr Y and his family.

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Action

32. In recognition of the injustice caused, within one month, the Council should:
• Apologise to Mrs X in accordance with our guidance on making an effective apology.
• Pay Mrs X £300 in acknowledgement of the risk to Mr Y and the distress caused to his family.
33. The Council should provide us with evidence it has complied with the above actions.

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Decision

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

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Investigator's decision on behalf of the Ombudsman