A Croydon care home's failures in hygiene and medication supervision led to a life-threatening hypoglycaemic episode for a diabetic man, according to the Local Government and Social Care Ombudsman. The watchdog found serious failings in complaint handling and delays in safeguarding procedures during a two-week respite stay at Orford House in Coulsdon, commissioned by Sutton Council. The council has apologised to the resident, referred to as Mr X, and paid him £500 in recognition of the distress caused. However, the care home, managed by Friends of the Elderly, does not accept the Ombudsman's full findings.
Failures in care and medication supervision
Mr X began his respite placement at Orford House on May 27, 2025, to give his carer a break. He had significant ongoing care needs, including assistance with all personal care and diabetes requiring district nurses to administer insulin. According to a multi-agency safeguarding review, there was a "severe risk in the care home's dietary and insulin supervision because of a life-threatening hypoglycaemic episode within 24 hours of Mr X leaving the home." Investigators also found "reports of cardiac medicine being marked as administered on medication charts when medication was found unswallowed." The Ombudsman criticised this "task-focused rather than person-centred approach" to clinical safety.
Hygiene concerns and early termination
A relative of Mr X, referred to as Mrs X, raised concerns with the council in early June 2025 after finding him with "faeces on the sacrum, ingrained dirt, black, dirty swollen feet and cracked skin on the legs." A subsequent review confirmed a "failure in pressure care and hygiene," posing an increased infection risk to diabetic residents. The placement was terminated early. Orford House had requested immediate discharge, citing incidents of physical and verbal aggression, including lunging at others with pens and knitting needles.
Friends of the Elderly rejected the findings, stating: "We do not agree that the care provided fell below the standards expected." The care home noted that the Ombudsman's findings of fault were directed at Sutton Council, the commissioning authority. It also said it was not contacted directly by the Ombudsman during the investigation and submitted a detailed response contesting the findings. "Some of our comments were noted, but we do not believe the final report fully reflects the context or evidence we provided. This was a complex situation," the statement said.
Ombudsman criticises complaint handling and safeguarding delays
The Ombudsman labelled the care home's response to the family's formal complaint as "unhelpful" and "flawed" for focusing on the resident's behaviour rather than taking a conciliatory approach. Sutton Council faced criticism for significant delays in the safeguarding process: although Mr X left Orford House in June 2025, a multi-agency safeguarding review was not held until January 2026. The Ombudsman stated that "safeguarding processes should not be left in abeyance where there are potential wider risks to other residents."
Council action and apology
The council has agreed to apologise to Mrs X, make a £500 payment for distress, and complete outstanding reviews into the care home's practices. A Sutton Council spokesperson said: "The council accepts the Ombudsman's findings and is completing all required actions. In line with the Ombudsman's recommendations, the council has supported Orford House to make the necessary changes. A full quality assurance visit was carried out and the council liaised with the CQC, which confirmed it had no concerns within the home. The council would like to apologise to the resident; their experience fell short of the high standards we set ourselves."
Following the complaint, the Care Quality Commission inspected Orford House and rated the service as 'Good'.
