Summary: Lifeways Community Care Limited (the Care Provider), and the Council found that Mr K’s care and support was inadequate. The Council found that this put him at risk of abuse and neglect. Mr K was caused distress and had to move home. The Care Provider did not handle the complaint properly. The Council initially failed to handle the safeguarding concern appropriately. It did rectify this and has taken robust action to make sure that it does not commission further until the Care Provider makes improvements. The Council has agreed to apologise to Mr K’s sister who acts on his behalf, and make a payment to Mr K and his sister in recognition of the distress it has caused them both.

The complaint

1. Mrs B complains on behalf of her brother, Mr K. She says Lifeways Community Care Limited (the Care Provider), who the Council commissioned to provide care to her brother:
• Left him at risk when it did not provide the 1:1 care set out in his care plan; and
• Did not make sure Mr K’s flat was kept to an acceptable standard. It was very dirty, smelly, and there was out of date food.
2. Mrs B says that as a result of these failures, the family decided that Mr K could not stay at his supported living flat. He had to go to live with their parents who are elderly and unwell. The whole family has been caused significant distress by the failings.

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The Ombudsman’s role and powers

3. 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)
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, section 25(7), 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(i), 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)

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How I considered this complaint

7. I considered evidence provided by Mrs B, the Council and the Care Provider as well as relevant law, policy and guidance.
8. Both Mrs B, the Council and the Care Provider have had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

The law and guidance

10. 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.
11. Included in the fundamental standards is that a person must not be put at risk of harm that can be avoided, and must be safeguarded from abuse or neglect. The care provider must have effective governance in place, and sufficient suitably qualified staff, so it can meet these standards.
12. 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)
13. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

What happened

14. Mr K has social care needs and he is non-verbal. He lived in a supported living flat in Somerset, managed and run by the Care Provider. Mr K’s care needs assessment and care plan says that he needs 1:1 support during the daytime. He does not have the mental capacity to make most decisions for himself and he does not have a sense of danger or road safety.
15. Mr K’s sister, Mrs B, went to visit him and found him down the street from his ,, unsupervised, barefoot, and heading towards the road. He had no support worker and after waiting with Mr K for some time, Mrs B found the home manager. The manager was unaware that Mr K had left the premises. She initially told Mrs B that she had been checking on Mr K regularly, but Mrs B said that she had been with him for an hour and nobody had checked. The manager said they were very short staffed.
16. Mrs B went into her brother’s flat. She found it was very dirty and smelly, and there was out of date food there. As a result of her concerns the family decided that Mr K could not stay at his supported living flat. Mrs B took eight hours to clean Mr K’s flat. He has since been living with his parents who are elderly and unwell.
17. Mrs B complained to the Care Provider. She had also alerted the Council and the CQC. The Care Provider spoke to Mrs B and said it would investigate her concerns. Mrs B chased the Care Provider twice and it responded. It said the staff member who was supposed to be supporting Mr K had called in sick, no cover was available and so the manager had tried to step in. The Provider said that Mr K had been alone for around 15 minutes and his care plan does say he appreciates alone time. However, it accepted that he was unattended and reminded managers of the procedure when there is not enough staff, and that it should keep records of alone time.
18. The Care Provider agreed that the flat was below the expected standard and the manager had explained they had not cleaned that day as they would do it when Mr K was away with family that weekend. Similarly, the manager said that Mr K’s food had not been checked that day. It accepted that this was not good enough practice and it should have checked daily. It apologised and said a manager has since left its employment.
19. Mrs B responded to the Care Provider. She confirmed that when she found Mr K unsupervised they had waited for over 30 minutes for a carer to come and no member of staff checked on him, so she had to go and find someone. She pointed out that although her brother might like alone time, he needs to be kept safe too. The flat needed a deep clean and had not been cleaned properly for some time. The food was more than two weeks out of date and so the neglect was more than a day left unchecked. The Provider did not reply to Mrs B.
20. Mrs B had also alerted the Council at the time she found her brother unsupervised. Mrs B chased the Council for a response a further three times in August. The Council notified the Safeguarding Service on 9 October. The Council has acknowledged that this should have happened when it received Mrs B’s concerns. It says that the delay was due to a staff member who no longer works for the Council. The Council notified the individual’s employment agency that the staff member had not dealt with the safeguarding referral properly.
21. The Council started a safeguarding investigation. In line with its process, the Council asked the Care Provider to provide details of what had happened, an explanation, the daily care records and the risk assessments. The Care Provider said that it had responded to Mrs B and did not give the Council any more details for its safeguarding investigation.
22. Due to its poor response, the Council visited the Care Provider twice in December to review the arrangements in place, and to see what improvements it had made since the concerns had been formally raised. It also spoke to Mrs B about what had happened and looked at her photographs of her brother’s flat.
23. On 20 December 2024, the Council wrote to Mrs B with the safeguarding enquiry’s findings. It substantiated the concerns relating to neglect and acts of omission, and organisational abuse. Specifically it found that Mr K had been left unsupported and the manager was not close by to monitor Mr K. It also concluded that the standard of Mr K’s flat was clearly poor such that it was not the result of just one day of missed support, and there were no records of cleaning.
24. The Council’s Quality Assurance Service visited the Care Provider as part of the safeguarding enquiry. The Council raised that the Care Provider had failed to respond appropriately when asked for information, and has worked with it to ensure that the expectations of a safeguarding enquiry are clear.
25. Following the outcome of the safeguarding enquiry, the Council stopped placing people with the Provider. This restriction remains in place and the Council has served notice on the Provider of the significant improvements that are needed. The Council will review the improvements and its contractual position once the notice has expired. This process is in line with the Council’s policy.
26. The Council notified the CQC of the safeguarding outcome and that it had stopped placing residents with the Provider until further notice. In January and March 2025, the Council visited the Provider to review the quality improvement process, the protection plan arrangements and the actions the Provider had agreed to take. The Council shared this further information with the CQC.
27. The Council completed a Care Act Assessment later that month and concluded that Mr K needed a more suitable placement that can support him. Mr K has now moved to a new home.
28. In response to our investigation, the Care Provider acknowledged that it had not provided adequate care to Mr K. The Care Provider says that following Mrs B’s complaint it notified CQC, Mr K’s Social Worker, Mrs B and her MP of the outcome. It has introduced a new management team, new electronic rota system and new arrangements for governance. It says that this has increased its oversight of the care provided so that it can ensure it is safe and effective.

Findings

29. The Council and the Care Provider have acknowledged that Mr K did not receive the care and support he was supposed to. The Council substantiated concerns relating to neglect and acts of omission, and organisational abuse. These are a breach of the Fundamental Standards set out above.
30. There was also further fault by the Care Provider in how it handled Mrs B’s complaint. It was clear by the condition of the flat and the expired food, that Mr K had missed more than one day of care. But the Care Provider did not respond to Mrs B when she challenged its complaint response.
31. There was fault by the Council when it failed to deal with Mrs B’s concerns as a safeguarding incident when she first alerted it. It also missed the opportunity to put this right when Mrs B chased it for a response. The Council only started the safeguarding process two months later.
32. The Council completed the safeguarding process appropriately, and has put several measures in place to make sure the Care Provider makes improvements, including that it did not commission further care placements, and served a formal notice of improvements that needed to be made before it reviews commissioning.
33. Mrs B says that the care had been acceptable for a few years, but had deteriorated in the six months prior to her finding Mr K unsupervised. Although this was just one incident, the state of the flat and the lack of care records show that Mr K had not been receiving the support he needed for at least a few weeks, if not longer. In addition, the incident was so serious, and Mr K is so vulnerable and unable to advocate for himself, that it meant that Mr K lost his home as his family felt they had no choice but to move him. Mr K was caused distress.
34. Mrs B has described to me that it was very distressing to find her brother at risk and his flat so dirty. The shortcomings in the Care Provider’s complaint handling and the initial mishandling of the safeguarding by the Council was also distressing for Mrs B.

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Action

35. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions and service of Lifeways Community Care Limited, I have made recommendations to the Council.
36. Within one month of the date of this decision the Council will:
• Apologise to Mrs B and if appropriate to Mr K. 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 to Mr K a symbolic payment of £750 in recognition of the distress it caused him when the care it had commissioned was inadequate.
• Pay to Mrs B a symbolic payment of £300 in recognition of the distress it caused her when her brother’s care was inadequate and Lifeways Community Care Limited and the Council did not handle her concerns properly.
37. The Council should provide us with evidence it has complied with the above actions.

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Decision

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

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman