Summary: The Council and its commissioned Care Home were not at fault in their assessments of Mrs X’s needs, or in the planning of her care. The Care Home was at fault in its care of Mrs X’s continence and toileting needs in October 2024, which caused Mr X distress and impacted Mrs X’s dignity. It was also at fault in its record keeping at that time, which caused Mr X uncertainty. The Council was not at fault in its enquiries into two safeguarding incidents, but failed to share a detailed outcome with Mr X, which caused him uncertainty. The Council should agree to apologise to Mr X for the distress and uncertainty caused to him by the faults.

The complaint

1. Mr X complained about the standard of care provided to his wife, Mrs X, by the Council commissioned care home, Windmill Lodge (the Care Home). He said the Care Home did not meet her basic care needs and, when two safeguarding incidents occurred, the resulting enquiries did not consider the root causes of these. He complained that the Council should not have placed Mrs X in the Care Home in the first instance, because the section of the Home that could accommodate her could not meet her assessed care needs.
2. Mr X said that the Council and Care Home’s failings caused him and his family worry, distress, and trauma; they felt that had to visit each day to ensure Mrs X’s needs (including her social needs) were met.

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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 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)
4. 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 future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. 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. In this case the Council commissioned the care home so we consider it was acting on behalf of the Council. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
6. 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)
7. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
8. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:
• their personal representative (if they have one), or
• someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
9. 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)
10. 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

11. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance. I discussed Mr X’s complaint with him and Mrs X’s adult daughter on the telephone.
12. Mr X and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Law, policy and guidance

Care Quality Commission and fundamental standards

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.
14. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards which says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9)
• Service users must be treated with dignity and respect, supporting the autonomy, independence and involvement in the community of the service user (regulation 10)
• The care and treatment must be provided in a safe way for service users, ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely (regulation 12)
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service (regulation 17)

Assessment

15. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.

Care Plan

16. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.

Reviews

17. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.

Safeguarding

18. 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).
19. The Care and Support Statutory Guidance sets out what a safeguarding enquiry should look like. The guidance says it is for the council to determine the appropriateness of the outcome of the enquiry. A council can stop a safeguarding enquiry if it is satisfied there are no safeguarding issues, or the risk has been managed effectively.

What happened

20. This section sets out the key events in this case and is not intended to be a full chronology.
21. Mrs X had a diagnosis of dementia. She went into respite care in late August 2024. The respite setting said it could not meet Mrs X’s needs because she consistently refused personal care to the point of being verbally and physically aggressive towards the staff who tried to assist her.
22. The Council carried out a Care Act Assessment of Mrs X’s needs in mid-September. This included that Mrs X:
• Was non-compliant with all aspects of her personal care. She required two carers to assist her with personal care due to the challenging behaviour that she could present towards others;
• Presented verbal and physical challenge towards care staff when she was encouraged to wash, including screaming, nipping, biting, hitting and spitting;
• Would take off soiled sanitary products and leave them where she had taken them off;
• Could refuse to leave her bed and this could result in her lying in faeces and urine for prolonged periods;
• Would often try and sleep in her day clothes and required a lot of encouragement to change into nightwear;
• Did not usually tolerate spending time in the communal areas of the care home unless her family were also present;
• Needed support to maintain relationships and social connections; and
• Care staff had encouraged Mrs X to wash/bathe every day but they were usually only successful once or twice per week.
23. The Council commenced a search for a setting that could meet Mrs X’s needs, specifically a setting that was registered with the CQC as being able to provide care to the Elderly Mentally Infirm (EMI).
24. The Care Home, which was registered with the CQC to provide EMI care, contacted Mr X to say it had a bed available. Mr X informed the Council of this. The Council provided the Care Home with a copy of the Care Act Assessment it had completed in mid-September to provide an overview of Mrs X’s needs. Mr X visited the Care Home. A staff member from the Care Home visited Mrs X and carried out a pre-admission assessment. The Care Home decided it could meet Mrs X’s assessed needs. Mrs X moved into the Care Home shortly after.
25. Mr X was dissatisfied with the care provided to Mrs X from the outset. Within two weeks he told the Council that Mrs X’s basic needs were not being met, she was not receiving the standard of nursing support she required, and staff could not communicate with her effectively. He suggested she was in the wrong section of the nursing home (the first unit), as the other residents in her unit “wandered”, including entering Mrs X’s room. This Council logged this as a safeguarding alert under a heading of “neglect and acts of omission”.
26. Council officer A called Mr X to discuss his concerns and said they would arrange a safeguarding meeting at the Care Home (with Mr X present). Mr X put his concerns in writing to the Council. These included: other residents entering his wife’s room, no social activities being provided or social contact encouraged, and Mrs X’s basic care needs – including dressing, undressing, hygiene, and toileting – not being met by staff. As a result, Mr X felt it necessary to visit Mrs X every day to ensure she was clean and had her essential personal items to hand.
27. Council officers A and B visited the Care Home in mid-October. The safeguarding meeting included Mr X, Mrs X, Mr X’s stepson, the Registered Manager of the Care Home, and the nurse on duty. They discussed Mrs X’s care needs and Mr X’s concerns. The outcome of the safeguarding meeting was that:
• It was agreed that Mrs X’s needs were complex and challenging. She could be resistant and aggressive towards carers trying to help her with personal care. Staff were still learning how best to support her.
• The Council suggested that the Home’s Manager could consider seeking additional funding for a staff member to be present in the corridors to prevents residents entering other rooms, as this could lead to safeguarding incidents.
• Moving Mrs X to another setting was discussed, but the Council explained that any other EMI setting may be at least as noisy and busy, if not more so. It was agreed that Mrs X would visit a second unit within the Care Home that was currently occupied by residents who were less likely to wander into her room. When a bed became available within the second unit, she would move there.
• The Council would review the situation in six weeks. If Mrs X remained unsettled at that point, it would consider whether a change of setting was required.
• The Care Home would: update Mrs X’s Care Plan, share this with Mr X, respond to Mr X’s concerns, and move Mrs X to the second unit when a bed became available.
• Mr X would inform staff at the Care Home of any issues and escalate these to the Council if he remained dissatisfied with the response.
28. Mr X emailed the Council again two days after the meeting, stating his concerns that, when he had visited Mrs X that day,
• She had been wearing the same clothes for the last five days (night and day). He said it “appeared no attempt had been made to change her”.
• She was not wearing a continence pad, which staff were supposed to ensure she did, and so had wet her clothes.
• The Care Home had supplied him with a copy of Mrs X’s care plan. He said it did identify her needs, but he was concerned that it was too detailed for staff to refer to easily.
29. The Council issued the outcome of the safeguarding inquiry to the Care Home on 22 October. The outcome was “unsubstantiated”. The outcome was not shared with Mr X.
30. Mr X emailed the Council later in October. He said:
• The alarm unit on the wall in the corridor next to Mrs X’s bedroom door was missing, meaning that staff would not have been alerted to movement in the room. If Mrs X had fallen in her room it may have not been noticed for some time as her door was closed to prevent other residents from entering. (The matter was rectified when he had alerted staff).
• The Council’s suggestion that a member of staff should patrol the corridor to prevent residents entering other residents’ rooms had been initiated but had stopped after a couple of days, and intrusions were “as frequent as ever”.
• He asked the Council to provide a list of homes “that would accommodate residents like [Mrs X] who have dementia but who can chat”, in case the move to the second unit did not work out.
31. Mr X visited Mrs X at the end of October and found her on the floor, with a bleeding head injury, and another resident in her bed. The Care Home called the Ambulance Service and Mrs X was transported to hospital to be checked. She returned to the Care Home later that day. The Ambulance Service raised a safeguarding concern with the Council, as did Mr X.
32. The Council initiated a second safeguarding enquiry the next day. On the same day, Council officer A responded to Mr X’s October emails and his safeguarding concern. Council officer A also contacted the Care Home to ask for an update regarding the incident, and expressed their concern that it had occurred so soon after the previous safeguarding enquiry had concluded.
33. Council officer A visited the Care Home. He met with the manager, who told him the Care Home was one staff member short on the day of the safeguarding incident, and so there was “limited monitoring in the corridor”. The manager said that the incident had occurred during a six-minute window between checks. Council officer A also carried out a Mental Capacity Assessment of Mrs X and held a Best Interests Meeting with her family. It was agreed that Mrs X would move to the second unit the following day. He told the family that he would notify the Council’s Safeguarding team and Contracts team of the incident, as well as the CQC. They would decide what further action needed to be taken.
34. Mrs X was transferred to the second unit, as an interim measure for her protection.
35. The Council gathered evidence about the incident in early November, including statements from the Care Home, the family, and Mrs X’s clinicians. It held a Safeguarding Risk Assessment and Planning Meeting in November, and a second (multi-agency) meeting in December.
36. The Care Home’s Head of Operations and Head of Specialisms met with Mr X in November to discuss every aspect of Mrs X’s care, and how it could be improved. The Care Home updated the care plans and risk assessments for Mrs X to reflect her care needs at that time.
37. The Council had frequent contact with Mr X and the Care Home during November and December, whilst it sought a new placement for Mrs X. During this time, Mr X expressed his key concern that, although Care Home had accurately described his wife’s needs in her updated care plan, the majority of the Home’s staff did not have the skills to carry out the tasks in a manner that would put Mrs X at ease and encourage her to be helped with tasks such as personal hygiene. The Care Home planned a training programme to take place in January 2025.
38. Mrs X was moved to a different care home in early January 2025.
39. The Council issued the conclusion of the Safeguarding Adults Enquiry to the Care Home in February 2025. It substantiated neglect and acts of omission and found the incident likely could have been avoided. It included that a “lessons learnt exercise” had been completed. The outcome was not shared with Mr X at that time.
40. Mrs X died later that month.
41. In March, Mr X chased the Council for the outcome of the safeguarding enquiry. The Council sent the “conclusion” document to him the same day.
42. Mr X made a formal complaint to the Council in late March 2025. He said that the conclusion document was inadequate in that it did not attempt to identify the root causes of the second safeguarding incident, nor of the home’s inability to deliver adequate care to Mrs X. Mr X said the Council did not look at the root cause of the safeguarding incident which he believed was either a) that his wife’s needs were not correctly assessed in the first instance, and so she was placed in a section of the Care Home that could not meet her needs, or b) her needs were correctly assessed but the Council then knowingly placed her in a section of the Care Home that could not meet her needs.
43. The Council responded to Mr X’s complaint in full in early June. This response included that:
• The first safeguarding alert had concluded in a recommendation to increase staffing to supervise residents and prevent intrusions. Unfortunately, this risk had “materialised again” in Mrs X’s case.
• The Council had conducted the second safeguarding enquiry with rigour, transparency, and multi-agency oversight. It held two formal Adult Safeguarding meetings involving professionals from across the multi-disciplinary team (MDT).
• The minutes of the safeguarding meetings reflected the depth of discussion, the concerns raised by family members, and the commitment to identifying root causes and implementing improvements.
• The second safeguarding enquiry also included a review of Mrs X’s care plan, mobility risk assessments, and consideration of additional equipment needs.
• In response to the findings of the second safeguarding enquiry, the Council had instructed the Care Home to:
1. Continue responding to Mr X’s concerns and to maintain open communication with him and his family regarding any further issues, observations and concerns.
2. Complete a “lessons learnt exercise”. This had been done and shared with all care staff. All care staff were required to review and sign this document to confirm their understanding and commitment to improved practice.
3. Implement closer supervision and monitoring of residents, particularly to prevent incidents involving residents entering others' rooms unnoticed.
4. Review Mrs X’s care plan in collaboration with the family, to be updated continually to reflect Mrs X’s evolving needs, including toileting support, dietary requirements, and emotional wellbeing.
5. Engage with ongoing external oversight from the Care Quality Commission, the Integrated Care Board and Lancashire County Council's Contracts Management Team to monitor the implementation of these actions. This would include announced and unannounced visits.
44. The Council apologised that the letter sent to Mr X in mid-March had not fully reflected the seriousness of the issues raised or the thoroughness of the second safeguarding enquiry.
45. Mr X approached the Ombudsman in July 2025.

Response to my enquiries

46. As part of our enquiries I requested one week of daily records relating to Mrs X’s care from October 2024. This included the five days leading up to one of Mr X’s more specific complaints about dressing and continence care.
47. The records show staff made efforts to engage Mrs X in dressing, undressing, washing/hygiene and toileting. She visited the communal area of the second unit at least three times, listened to music, and watched television with residents in the first unit. On one day the records made no mention of washing, dressing, toileting, or continence care.
48. The records included two mentions of continence pad changes, and these were both on occasions where Mrs X also required a change of clothes due to having toileting accidents.
49. I also obtained the daily records for a week in December 2024. These showed staff offering to take Mrs X to the toilet, and/or changing her pad, between 8 and 11 times each day. Staff offered to shower or wash Mrs X, and help her with dressing, each day, but were often unable to overcome her resistance. In terms of social contact, Mrs X attended a Christmas party in a third unit, and spent time with her family.

My findings

Initial assessment and care planning

50. The Council assessed Mrs X in the respite care setting in September 2024. The assessment included a description of Mrs X’s needs at that time (examples of which are set out at paragraph 22). That assessment was sufficient for the purposes of sharing with care homes in order that they could judge whether they were likely to be able to meet Mrs X’s needs. The Council was not at fault in that assessment.
51. Mr X says he was not consulted as part of the development of the Council’s needs assessment. This is not in line with the Care and Support Statutory Guidance and is fault. Although the assessment accurately reflected Mrs X’s needs and summarised Mr X’s view, this fault denied Mr X the opportunity to give a more detailed view of the support he believed Mrs X required.
52. The Council shared its assessment with all providers on its database that were registered with the CQC to provide EMI care, including the Care Home. There is no statutory requirement for the Council to further sub-divide its searches beyond residential care, nursing care, and EMI care, so it was not fault that it did not do so.
53. The Care Home carried out its own pre-admission assessment of Mrs X’s needs before deciding that it would be able to meet these. That was consistent with the standard we would expect of an initial assessment, and was not fault on the Care Home’s part.
54. Mr X says he was not consulted as part of the development of the Care Home’s initial assessment. This is not in line with the Care and Support Statutory Guidance and is fault. Again, this fault denied Mr X the opportunity to give a more detailed view of the support he believed Mrs X required.
55. It was not fault that the Care Home chose to accommodate Mrs X within the first unit. That is because care homes may divide their provision into low, medium, or high needs sections, or they may not. Neither approach is fault. Further, they are not required to divide their provision for EMI patients into the categories sought by Mr X (such as residents who wander, or residents who are able to converse). Given that people living with dementia may present with differing constellations of needs (that is, high in some areas but low in others), and that these needs may quickly evolve, it would not be practically possible to differentiate needs between units in the way Mr X suggests (for example, some people may “wander” but also be able to converse).

Quality of care

56. Mr X’s main concerns about Mrs X’s care were around social contact and personal care including dressing and undressing, washing and toileting. I have reviewed the Care Home’s assessments, care plans, and daily care records in these areas.
57. My review was limited by the fact that the Care Home is no longer owned by the same company as it was at the time of the events. The Council obtained all available records from the former owner, but these included only the most recently updated care plans, dated December 2024. I therefore cannot make a finding on the extent to which the initial care plans reflected Mrs X's needs. However, the pre-assessment document completed by the care home show it reflected the Council’s assessment of Mrs X’s needs.
58. The Care Home updated Mrs X’s care plan in response to her changing needs over time and Mr X’s complaints. The care plan updated in December included a detailed assessment of every facet of Mrs X’s needs and the care the Care Home needed to provide to meet those needs. It included, for example, that staff should check if Mrs X needed the bathroom 2/3 hourly, and check her pads 2 hourly. The Care Home was not at fault in its assessment of Mrs X’s needs.
59. I reviewed in detail a week’s care records from October 2024 which included the five days leading up to one of Mr X’s more specific complaints about dressing and continence care.
60. The records show the efforts staff made to engage Mrs X in these activities. It was not fault that the staff were sometimes unable to overcome Mrs X’s resistance to washing and dressing, particularly when their attempts to assist Mrs X caused her distress. On one date the records included no mention of washing, dressing, toileting, or continence care. I cannot know, even on balance, what efforts the care provider made on this date, but the failure to keep accurate records is fault and not in line with the CQC fundamental standards. This caused Mr X uncertainty over whether Mrs X received appropriate support on that day.
61. The records only note two occasions when Mrs X’s continence pad was changed. The failure to accurately record the care provided is fault and not in line with the CQC fundamental standards. Mr X found Mrs X without a pad on one occasion and said he frequently found Mrs X soiled in bed. Mr X also said when Mrs X needed personal care and he called for assistance there were a number of occasions when no-one came to support Mrs X. On balance, I consider the Care Home did not meet Mrs X’s assessed needs in terms of continence care and toileting in October 2024. This was fault, that caused Mr X distress at finding Mrs X wet or soiled, and affected Mrs X’s dignity.
62. The care records I reviewed for December 2024 showed a significant improvement in toileting and continence care. There was no evidence of fault in the care provided during that week.

Safeguarding incidents

63. In relation to the first safeguarding enquiry, the Council initiated an enquiry as soon as Mr X raised concerns about neglect, and it promptly arranged a meeting to be attended by all parties. The notes of that meeting included a detailed discussion of Mr X’s concerns and a list of action points intended to improve Mrs X’s care and prevent a recurrence of the matters of concern. The records show the Care Home promptly implemented the recommendations. The Council closed the enquiry as it decided the concerns raised did not meet the Section 42 threshold. The documented outcome of the enquiry was not shared with Mr X, but the documents I have seen show that Mr X declined the Council’s offer to do so as he was content with the outcome having been shared verbally. I find the Council was not at fault.
64. The second safeguarding enquiry was also initiated promptly following the incident where Mrs X was injured in late October 2024. The records show the Council followed all the steps it set out in its complaint response of June 2025. It conducted a robust investigation into Mr X’s concerns. The Council was not at fault in its management of the safeguarding enquiry. However, it was at fault in that it did not share the outcome of the enquiry with Mr X, as it had agreed to do, putting him to the time and trouble of chasing the Council. It was also at fault that, when the “closure” document was shared with Mr X, it did not accurately reflect the thoroughness of the enquiry, leaving him with a falsely negative impression of the quality of the enquiry.
65. The second safeguarding enquiry concluded that, if the increased monitoring of residents’ movements recommended by the first safeguarding enquiry had been in place, the second safeguarding incident might not have occurred. The Care Home was at fault in that, after it implemented increased monitoring following the first safeguarding enquiry, it did not sustain this. This caused injustice to Mrs X in that she suffered an unwitnessed fall and a head injury, and caused distress to Mr X.
66. I will not make a service improvement recommendation to address this fault as the Council did so via the second safeguarding enquiry, and via closer monitoring of the Care Home by its Contracts Management Team and in conjunction with the CQC and the local Integrated Care Board. I am satisfied the care provider has taken appropriate action to address the concerns identified through the safeguarding investigation.
67. Mrs X has since died so I cannot remedy any injustice caused to her by the faults identified. However, the faults caused Mr X and Mrs X’s children distress and uncertainty.

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Action

68. 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 Care Home’s actions and make the following recommendation to the Council.
69. The Council has agreed to apologise to Mr X, within one month of the final decision, for the distress and uncertainty caused by the faults I have identified throughout this investigation.
70. 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.
71. The Council should provide us with evidence it has complied with the above action.

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Decision

72. I find fault causing injustice. The Council has agreed action to remedy injustice.

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Investigator's decision on behalf of the Ombudsman