Summary: Mr X complained Baycroft Flitwick Care Home wrongly refused to allow Ms Y to return to the Care Home when she was fit to be discharged from hospital. He complains the Care Home did not discuss concerns about Ms Y’s behaviour, her care needs, or its intention to terminate her placement with the family before making this decision. We found the Care Home’s failure to document the decision to terminate Ms Y’s placement and the reasons for it, or to give formal written notice to Ms Y or her family is fault. This has caused Ms Y and her family distress and uncertainty.

The complaint

1. Mr X complained Baycroft Flitwick Care home wrongly refused to allow Ms Y to return to the Care Home when she was fit to be discharged from hospital in October 2025. Mr X complained the Care Home made the decision based on alleged behaviour prior to Ms X being admitted to hospital and used Ms Y’s stroke as an excuse to remove her from the home.
2. Mr X complains the Care Home did not discuss concerns about Ms Y’s behaviour, her care needs, or its intention to terminate her placement with the family before making this decision. Mr X disputes the Care Homes reasons for terminating the placement.

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The Ombudsman’s role and powers

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 that could cause injustice to others in the future we may recommend a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
4. 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)
5. 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)
6. 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

7. I considered evidence provided by Mr X and the Care Home as well as relevant law, policy and guidance.
8. Mr X and the Care Home 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

9. Ms Y had been a resident at the Care Home since December 2024. On 13 October 2025 Ms Y was admitted to hospital having had a stroke. The Care Home’s records note the hospital contacted the home on 14 October 2025 to ask whether they could accept Ms Y back into their care. As Ms X was experiencing a brain bleed and required a higher level of nursing care the Care Home said it was unable to take Ms X back at that time.
10. Ms Y was deemed medically fit for discharge on 20 October 2025. A Trusted Assessor completed an assessment of Ms Y’s care needs on 21 October 2025.
11. Mr X says he contacted the Care Home on 24 October 2025 and was told Ms Y could not return to the home. The Care Home told him this decision was based on the Trusted Assessor’s report which said Ms Y now needed one to one care, had a catheter fitted and her medication needs had changed. Mr X says a manager told him that as the Care Home could no longer meet Ms Y’s care needs they had discharged her from their care.
12. Mr X made a formal complaint to the Care Provider on 26 October 2025. Mr X complained the Care Home had refused to obtain or consider an updated report detailing Ms Y’s needs. He disputed the Care Home’s view it could not meet Ms Y’s needs and said Ms Y no longer needed one to one supervision, her catheter would be removed once discharge from hospital was confirmed and Ms Y’s medication was the same as pre-admission.
13. Ms Y’s family considered the Care Home’s decision was detrimental to Ms Y’s health and that it would not be in her best interests to move to another care home. Mr X asked for an explanation of the Care Home’s decision and questioned why it would not consider a revised report or carry out its own assessment of Ms Y’s needs.
14. The Care Provider’s response confirmed it had reviewed the Trusted Assessor report which set out Ms Y’s needs as of 20 October 2025, when she was medically fit for discharge. The Care Provider considered it was unlikely Ms Y’s needs would improve any more than where they were at the time of the assessment. The Care Home was concerned Ms Y would require one to one care which it could not provide.
15. It noted that prior to Ms Y’s admission to hospital the Care Home had highlighted concerns about Ms Y’s behaviour. The Care Provider said a manager had discussed this with the family and there were occasions when Ms Y threw a butter knife at other residents, became physically aggressive towards the care home staff and other residents and displayed verbal aggression. The Care Provider noted the hospital had also reported concerns about Ms Y’s behaviour and had implemented one to one care and had prescribed medication.
16. The Care Provider said that in response to Mr X’s complaint the Care Home manager had visited Ms Y in the hospital to assess her current needs. The manager had noted there were ongoing concerns about Ms Y’s behaviour. The Care Provider maintained Ms Y required one to one care which the Care Home could not provide. It supported the Care Home’s decision and said it had no option but to end Ms Y’s placement at the home.
17. Mr X remains dissatisfied and has asked the Ombudsman to investigate his complaint. He complains the Care Home made decisions about prior alleged behaviours issues and used the hospital admission as an excuse to remove Ms Y from the home when she was at her most vulnerable. Mr X says the Care Home did not inform the family of the decision to end Ms Y’s placement and would not meet with the family to discuss Ms Y’s care needs. The family disputes the reasons for ending Ms Y’s placement.
18. Ms Y was in hospital for six week, before moving to another care home. Ms Y subsequently died in early December 2025.
19. In response to our enquiries the Care Home has provided copies of its behaviour charts and incident logs in relation to Ms Y since April 2025. These detail numerous incidents of verbal and physical aggression by Ms Y. The Care home has also provided details of its contact with Ms Y’s family in October 2025.
20. These records include details of conversations on 8 and 10 October 2025 regarding Ms Y’s behaviour. They also detail a phone call with Mr X on 24 October 2025, in which the home said it could not continue to meet Ms Y’s needs and a phone call on 29 October 2025 to discuss Mr X’s complaint. The Care Home has not provided evidence of any other correspondence or communication with Ms Y’s family regarding her behaviour or the decision to terminate the placement.

Analysis

21. Care Providers can terminate a resident’s placement but should follow a proper process in doing so. The Competition and Markets Authority (CMA) has issued guidance to UK care home providers with advice on their consumer law obligations. This says the circumstances in which the care home can terminate a contract with a resident must be clearly explained in the contract. And must be limited to valid reasons such as where they can no longer meet the resident’s care needs even after making reasonable adjustments.
22. The guidance also says care homes should not ask a resident to leave without first consulting with them and their representatives, and any other relevant independent professionals, and after efforts have been made to meet the resident’s needs. And that care homes should give the resident at least 28 days’ written notice to leave.
23. Ms Y’s contract with the Care Provider states the Care Provider may terminate the contract if in its reasonable opinion it is no longer able to provide the type of care Ms Y requires in accordance with her assessed needs. The contract says the Care Provider will give at least 14 days’ written notice of its intention for termination.
24. Based on the documentation available I am not persuaded the Care Home followed a proper decision making process.
25. It is unclear exactly when the Care Home made the decision that Ms Y could not return to the Care Home. The Care Home has not provided a record of this decision or confirmed when and by who it was made. It did not discuss Ms Y’s care needs or any possible adjustments with Ms Y or her family prior to making this decision. Nor has it provided evidence it sent the family written notice of intention its terminate the placement in line with terms and conditions of its contract with Ms Y.
26. The failure to discuss or document the decision to terminate Ms Y’s placement and the reasons for, or to give formal written notice to Ms Y or her family is fault. This has caused Ms Y and her family distress and uncertainty.
27. The decision that Ms Y could not return to the Care Home also meant Ms Y remained in hospital for longer than she otherwise would have. This was a significant injustice to Ms Y for which we would generally recommend a symbolic payment. However as Ms Y died late last year we are unable to remedy her injustice. We do not normally recommend symbolic payments to the person’s estate or a nominated charity.
28. The faults identified also caused distress, frustration and uncertainty to Ms Y’s family and Mr X was put to unnecessary time and trouble in trying to resolve this matter. I consider the Care Provider should apologise and make a symbolic payment to Mr X.

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Action

29. Within one month of the final decision the Care Provider will:
• apologise to Mr X for the distress, frustration and uncertainty caused by the faults identified. 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 £100 as a symbolic gesture for the distress, frustration and uncertainty caused by the faults identified.
30. Within three months of the final decision the Care Provider will review its practices around terminating contracts and giving notice to residents to ensure it:
1. consults with residents and their representatives prior to giving notice;
2. retains an accurate written record of all decisions to terminate a contract and the reasons for the decision; and
3. gives appropriate written notice of termination of the contract.
31. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

I have completed my investigation and uphold Mr Y’s complaint. I have made recommendations the organisation has agreed to carry out.

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Investigator's decision on behalf of the Ombudsman