Date of decision: 03 November 2025
Summary
A family complained that the Council did not warn them about growing concerns over an older man’s behaviour in a residential placement or that the care provider might refuse to take him back after a hospital admission.
The Ombudsman found fault by the care provider for secretly deciding to terminate the placement without notice and failing to tell either the Council or the family directly, which caused avoidable distress. The Council, as commissioner, was responsible for the wrongdoing.
What happened
In May 2024, the Council arranged a residential care placement for an adult man, Mr Y, and initially funded one-to-one staffing when he first moved in.
Around late June 2024, the Council ended this one-to-one arrangement after reviewing his needs, leaving Mr Y supported within the provider’s usual staffing ratio.
In mid-January 2025, the care provider contacted Mr Y’s family, including his relative Mrs X, to say he was showing signs of distress but was otherwise said to be all right.
The next day, the provider told the family it was getting him admitted to hospital, but when the ambulance crew arrived, the crew decided he did not need to go and he remained at the care home. Two days later, the care provider again contacted the family to say it had now sent Mr Y to hospital.
When Mrs X arrived at the hospital, she said hospital staff told her that the care provider had already said Mr Y could not return to his placement at the care home.
At the end of January 2025, Mrs X made a complaint which she sent to the care provider, stating she was unhappy that no one had warned the family about any escalating issues with Mr Y’s behaviour. She also complained that she had to find this out from hospital staff. There was no evidence the home notified her directly of its final decision despite having her contact details.
In its written response, the care provider apologised that Mrs X had to learn from hospital staff about its decision not to allow him back but said that Mr Y had become increasingly agitated and had shown physical aggression towards staff.
The Council’s own records showed that the first time it was told of the provider’s concerns about Mr Y’s behaviour was an email from the care provider stating it was terminating Mr Y’s placement and that he could not return to the home from hospital.
This was despite the Council’s contract requiring 28 days’ notice if the provider wanted a resident to leave permanently and a term requiring staff to ensure a safe transition of care to the next responsible service, such as the ambulance or hospital.
In the week before hospital admission, when the provider spoke to Mrs X about distress, it did not tell her it was considering ending the placement, and
In late January 2025, the Council spoke with Mrs X about arranging a new placement for Mr Y. The Council’s notes recorded that she felt moving him closer to his family would be in his best interests and that she was not overly worried that he could not return to the original placement on that basis.
The Ombudsman applied the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which sets fundamental standards for registered providers, and considered the contract clauses on termination and safe transition.
The Ombudsman concluded there was no evidence of fault in the way Mr Y was transferred to the ambulance or hospital services, but there was fault in the provider’s failure to notify the Council of behavioural concerns before hospital admission and in terminating without contractual notice and without telling the family directly.
Since the Council had commissioned the placement, the Ombudsman treated the failings of the provider as the Council’s responsibility in terms of public law.
What was found
The Ombudsman found the care provider at fault for breaching the contractual requirement to give 28 days’ notice of permanent termination. The provider was also at fault for failing to tell Mrs X directly that it was considering, and then had decided on, terminating the placement, which meant she learned of the decision from hospital staff and suffered avoidable shock and distress.
However, because Mrs X told the Council she felt a move closer to family would benefit Mr Y and that she was not too worried about him not returning to the original home, the Ombudsman assessed the injustice to her as limited.
The Ombudsman did not find fault in the transition of Mr Y into the care of the ambulance and hospital services, because this met the contract requirement to ensure a safe transfer to the follow-on responsible provider.
As the commissioning body, the Council remained responsible for the contracted service and accepted recommendations that, within one month of the final decision, it should write to the care provider reminding it of its responsibilities when terminating placements and the importance of keeping families informed of concerns, and write to Mrs X to apologise for the distress caused, using the Ombudsman’s published guidance on effective apologies.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The service of notice or a refusal to resume a placement for someone with care and support needs engages clear Care Act duties around assessment, eligibility and care planning, as well as human rights principles about proportionality and procedural fairness. In this decision, the focus falls mainly on contractual notice and CQC standards. The investigator did not mention the Competition and Market Authority’s good practice on fair contract terms for care home residents.
For example, Regulation 21(4) of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 provides that “If, as a result of a change in the individual’s assessed needs, the service provider is no longer able to meet those needs, even after making any reasonable adjustments, the provider must immediately give written notification of this to the individual, any representative, the service commissioner and the placing authority”.
There may be no direct English regulations but CQC guidance can be read as requiring that when the provider cannot safely meet needs, it must act to protect the person, which will typically include informing commissioners.
The CMA’s guidance also focuses on the legitimacy of termination if there is a need for the resident to move to accommodation that can better meet their care needs, even though the provider has made reasonable adjustments to try to meet those needs.
But there was no registration difficulty as such, here, and one wonders whether this dispute was once again driven by a refusal to pay higher fees, behind the scenes, by Salford.
Another reason for legitimate notice being served according to the CMA Guidance is “Where the resident is violent towards your staff or other residents and there is a significant risk of serious harm to staff, other residents or the resident themselves if they remain in the home”.
The Guidance says that “Where your terms allow you to terminate the contract on short notice or without any notice at all, this is likely to infringe consumer law, as the resident (who may be vulnerable) may not have sufficient time and opportunity to make arrangements for suitable alternative accommodation. […] Furthermore, most care home residents in England and Wales are legally entitled to a minimum of 28 days’ written notice to vacate a care home under the Protection from Eviction Act 1977 (or the period set out in your contract, if longer).”
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Salford City Council (24 021 328) report. If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
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