Serious failures noted at Croydon care home after diabetic man’s ‘life-threatening’ episode

Sutton Council apologised to the resident for the failings, but the care home does not accept the Ombudsman’s full findings

A Croydon care home’s failures in hygiene and medication supervision led to a “life-threatening” medical episode for a diabetic man, according to the local government watchdog.

Investigators found serious failings in complaint handling and delays in safeguarding procedures during a two-week respite stay commissioned by Sutton Council. While the care home continues to reject the findings, the council has apologised to the resident, referred to as Mr X, and paid him £500 in recognition of the distress he experienced.

The failings during Mr X’s two-week placement at Orford House in Coulsdon were revealed in a recent Local Government and Social Care Ombudsman report.

Mr X began his respite care placement at Orford House on May 27, 2025 to give his carer a break. He had significant ongoing care needs, including the assistance of a carer for all personal care such as washing and bathing, and diabetes that required district nurses to visit to administer his insulin.

However, 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 (low blood sugar) episode within 24 hours of Mr X leaving the home”.

Investigators also discovered “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 the resident’s clinical safety.

A relative of Mr X, referred to as Mrs X, initially raised concerns with the council in early June 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” which posed an increased infection risk to diabetic residents.

As a result, the placement at the care home was terminated early. Orford House — run by Friends of the Elderly — had contacted the council requesting Mr X’s immediate discharge, citing incidents of physical and verbal aggression, including lunging at others with pens and knitting needles.

However, Friends of the Elderly has rejected the council and Ombudsman’s findings, saying: “We do not agree that the care provided fell below the standards expected.”

It also noted that the Ombudsman’s findings of fault were directed at Sutton Council, the commissioning local authority.

In its official statement, the care home said it was not contacted directly by the Ombudsman during the investigation. It added that, on receiving the draft decision, it submitted a detailed response and supporting evidence contesting the findings.

It stated: “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.

“Our team took steps to support and safeguard the individual concerned, while also considering the immediate safety of other residents, and we fully support them.”

In its defence, the care home stated its response to Mr X’s challenging behaviours “was consistent with a person-centred approach” and that staff successfully used “de-escalation, supervision, reassurance, diversion and environmental management”. Following this complaint, the Care Quality Commission inspected Orford House and rated the service as ‘Good’.

‘Unhelpful’ and ‘flawed’

However, the Ombudsman criticised the care home’s handling of the family’s formal complaint. The watchdog labelled the home’s response “unhelpful” and “flawed” because it overly focused on the resident’s behaviour rather than taking a conciliatory approach to the family’s serious care concerns.

Sutton Council also faced direct criticism for significant delays in the safeguarding process. The Ombudsman noted that although Mr X left Orford House in June 2025, a multi-agency safeguarding review was not held until January 2026.

In its final decision, published on May 4, 2026, the Ombudsman stated that “safeguarding processes should not be left in abeyance where there are potential wider risks to other residents”. It added that the council did not need to seek Mrs X’s input in order to fulfil its statutory safeguarding duties.

The council has since agreed to apologise to Mrs X, make a £500 payment for the distress caused, and complete outstanding reviews into the care home’s practices.

A spokesperson for the Sutton Council 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 (Care Quality Commission), 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.”

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