Ombudsman finds “failures of oversight” by city council in “shocking” adult social care case

The Ombudsman's report into Portsmouth City Council, which commissioned the woman’s homecare from Radis Community Care, found the woman was subjected to what the council itself described as "a catalogue of errors".

According to the report, care workers visited the woman, who was cared for in bed following a fall, several times a day to provide food, fluids, personal care and to administer medication.

However, the council’s own safeguarding inquiry found concerns about staff:

• allegedly falsifying records and not carrying out some visits despite them being recorded as having been undertaken;
• ignoring or not being aware of the woman’s care plan;
• not positioning her properly and not supporting her with her mobility;
• feeding the woman inappropriate food, including stale and inedible food. This also included CCTV footage allegedly showing a care worker feeding the woman in a way the family considered forceful, and staff not following the Speech and Language Therapy plan for a soft diet;
• providing medication in a way the woman could not independently access it;
• not monitoring her or accurately recording her food and fluid intake;
• leaving her for prolonged periods, and on occasions leaving her wet or in darkness overnight;
• unintentionally feeding the woman microwaved dog food - recorded in the daily log as a "lamb dinner".

Meanwhile, the investigation found “failures of oversight” by Portsmouth City Council.

The Ombudsman said: “When safeguarding concerns were first raised in April 2024, the council opened an enquiry. Its own local policy sets a 28-day completion target, but this was not completed till October 2024 - six months later.”

The Ombudsman found that the council had treated Radis' internal investigation as if it discharged its own statutory duty, without putting in place independent scrutiny - despite Radis already being subject to a separate safeguarding enquiry at the time.

The Ombudsman found the failings engaged the woman’s Human Rights under Articles 3 and 8, relating to degrading treatment, dignity and private life.

To remedy the injustice caused, Portsmouth City Council was recommended to:

• apologise to the family;
• refund the woman's care fees for the period April to July 2024;
• make symbolic payments totalling £1,000 to recognise the distress caused.

According to the report, the council agreed to the recommendations.

Local Government and Social Care Ombudsman, Amerdeep Clarke said: "This is a truly shocking case, with abysmal failures. In this case, a vulnerable woman's care deteriorated over many months while a statutory inquiry drifted without proper oversight. It is a stark reminder that a council's safeguarding duty does not end when a contract is signed. Councils must actively scrutinise the care they commission - especially where concerns already exist about a provider.

“For care providers, the message is equally clear: robust care planning, clear escalation, and accurate record keeping are not administrative niceties, they are the foundations of safe care. I urge every organisation working in adult social care to look carefully at the lessons from this case."

A Radis spokesperson said: “Radis Community Care is deeply sorry for the distress caused to the person we supported who was at the centre of this case and her family. We accept that aspects of the care she received, and of our management oversight, fell below the standards they had every right to expect.

“We recognise that the report raises wider and serious concerns about the consistency and quality of the care provided, how concerns were escalated, and the oversight of the service. We are sorry for the cumulative impact these failings had on the dignity and wellbeing of the person we supported, and on her family’s trust in the care she received.

“[…] Once the incident was reported to senior management, we made a safeguarding referral to the local authority, notified the Care Quality Commission, opened a formal investigation and suspended the two support workers involved. The support worker who prepared the meal is no longer employed by Radis. The second employee was subject to disciplinary action following an HR investigation."

The spokesperson added: "Since concerns were first raised, we have taken significant steps to ensure we learn from what happened to mitigate something like this happening again.

“[…] Radis made the decision to give notice on the Portsmouth contract and voluntarily withdrew from providing services on the 1st December 2025. Our priority has been to ensure the learning from this case is embedded across the organisation and to reduce the risk of anything like this happening again.”

Portsmouth City Council has been approached for comment.

Lottie Winson