Summary: Miss Y complains the Council failed to properly consider the concerns she raised about the care and support her late mother received and the suitability of the care home placements commissioned by the Council. We find the Council consulted Miss Y and listened to her concerns. However, the Council did not relay the outcome of one safeguarding concern. It has already made a service improvement for this and we do not recommend anything further.

The complaint

1. Miss Y complains that:
1. Despite having Lasting Power of Attorney (LPA), the Council has not involved Miss Y in key areas of decision-making regarding her late mother’s care and support. This includes times when Miss Y requested her mother to move between placements.
2. The Council failed to properly consider safeguarding concerns and did not relay the outcome of any investigations to her.
3. The Council did not properly investigate her complaints. Although the Council commissioned her mother’s placements, it directed her back to the care providers to raise complaints directly with the service.

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The Ombudsman’s role and powers

2. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. 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)
3. 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(i), as amended)

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What I have and have not investigated

4. I have investigated what happened between February 2024, when Mrs W first went into hospital, and 9 December 2024 when Miss Y approached the LGSCO. I have not investigated what happened after December 2024 because the LGSCO’s Investigation Manual suggests that, where there are on-going issues, we should specify an end date beyond which we will not investigate. This should be no later than the date when the complaint was submitted to us and may well be earlier.
5. I have not considered Miss Y’s request for a refund of Mrs W’s care home fees. This is because the issue of fees was not in Miss Y’s original complaint to the Council. Furthermore, we have not investigated the complaint from Mrs W’s perspective for reasons which I have explained to Miss Y. Additionally, even if we did find the care provided was not to the required standard, we would not recommend payments to an estate where we have to make a judgment about the quality of care provided. This is because these are remedies for injustice to that person and as such cannot have that effect once the person is dead.

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How I considered this complaint

6. I considered evidence provided by Miss Y and the Council as well as relevant law, policy and guidance.
7. Miss Y and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

What happened

8. Mrs W previously lived at home with Miss Y. In February 2024, and after a short period of illness, Mrs W went into hospital and presented with symptoms of delirium. The records show a ‘Mental Capacity Assessment’ completed on 20 February 2024 concluded that Mrs W lacked capacity to understand her care needs and make decisions about her discharge. As no LPA was in place at the time, the Council undertook a ‘Best Interests’ decision alongside Miss Y to decide the plans for Mrs W following her hospital discharge.
9. Notes of a call between the Council and Miss Y on 26 February 2024 show she mentioned a local care home near to her home address which the Council agreed to consider but said that it could not make any assurances. The Council also confirmed its intention was to find a short-term placement to assess Mrs W in the community for an eventual return to her home. Miss Y told the Council she did not feel it was safe or appropriate to have Mrs W back at home with a package of care.
10. The records show that Miss Y spoke with the local care home, and it confirmed there was a waiting list for placements.
11. Mrs W moved into a care home on 5 March 2024. I will refer to this as ‘Home One’. Miss Y quickly raised concerns about the suitability of the home and said that most residents were bed-bound and receiving nursing care. She said that Mrs W was isolated and had no opportunity to socialise. The Council noted that: “[Mrs W] is recorded as being settled overnight and independently mobile”.
12. Two days after Mrs W moved into Home One, Miss Y asked the Council to move Mrs W to the alternative care home which she had previously contacted as she felt Home One was not unable to meet her mother’s needs.
13. On 25 March 2024 the Council contacted another home, which I will call Home Two. Mrs W moved to Home Two on 26 March 2024.
14. Five days after Mrs W moved into Home Two, Miss Y contacted the Council to say the home was not suitable for Mrs W. She raised concerns about some of the staff and Mrs W refusing to accept care from them. Miss Y said Home Two was too large for Mrs W and she did not like using the communal areas. Miss Y also said Mrs W told her she had been “thumped” by a carer and raised a safeguarding concern.
15. The Council relayed its view that moving Mrs W again, and so soon, may have a detrimental effect on her wellbeing and cognition. In the meantime, the Council agreed to contact Home Two to discuss the issues reported by Miss Y.
16. On 2 April the Council visited Home Two, along with Miss Y, to review the placement. The Council assessed Mrs W’s Mental Capacity again and decided that she continued to lack capacity to make decisions about her care, support and accommodation. The records show a discussion with senior staff, who said that Mrs W was eating well but choosing to stay in her room. Mrs W dressed independently and mobilised around the home. She did not need support overnight. Staff said Mrs W became agitated and abrupt if things were not done in the way she liked.
17. The Council asked Home Two to ensure that Mrs W did not receive personal care from male staff members and recommended that two carers were present when delivering care to Mrs W.
18. The following day, the Council called Miss Y to relay its decision to pursue the safeguarding alert about the alleged assault on Mrs W. The Council also relayed to Miss Y that her mother needed more time to settle at Home Two and it would not be in Mrs W’s best interests to move to another home so soon. Notes of that call say: “[Miss Y] in agreement that it is in [Mrs W’s] best interests to remain at [Home Two] in the short term and be allowed to settle in”.
19. Six days later, Miss Y called the Council to say she remained concerned about her mother and would like the placement at Home Two to be reviewed. Miss Y said the home was not suitable and staff did not regularly change Mrs W’s clothes or bedding. Miss Y raised a safeguarding alert. The Council reminded Miss Y that the placement was short-term pending a review of Mrs W’s longer-term needs. Two days later, the Council called Miss Y to book a review for Mrs W.
20. The review took place on 16 April 2024 with Miss Y present. Staff at Home Two explained that Mrs W needed minimal to no assistance overnight. The Council therefore suggested a step-down for Mrs W with a move to ‘Extra Care’ housing and shared details with Miss Y. The Council also suggested the possibility of Mrs W moving back home with a package of care, which Miss Y said would not be suitable.
21. The Council completed a safeguarding visit at Home Two on 26 April 2024. Miss Y was also present. The Council tried to discuss the placement and any incidents with Mrs W, but she had difficulty engaging with the discussion.
22. On 2 May 2024 the Council emailed Miss Y to confirm it had contacted two other care homes with vacancies and would send Mrs W’s assessment to both. One of the homes was the one initially suggested by Miss Y but was previously full. I will call this Home Three.
23. Miss Y took Mrs W to visit Home Three. The management at Home Three said they had difficulty speaking with staff at Home Two to complete a pre-admission assessment.
24. Home Three later agreed a placement and Mrs W moved on 15 May 2024.
25. After discussions about whether Mrs W had 24-hour needs, the Council agreed to send Mrs W’s assessment to an extra care provider. The provider later refused the application due to concerns that Mrs W’s dementia was too advanced.
26. Miss Y said her mother was isolated at Home Three and chose to remain in her room most of the time. Miss Y also raised concerns about the cleanliness of bedding and issues with laundry.
27. The Council completed another Mental Capacity assessment on 12 July 2024 which concluded that Mrs W continued to lack capacity to make decisions about her living arrangements, care and support. The Council again suggested the possibility of Mrs W returning to the home she shared with Miss Y along with a package of care due to Mrs W not requiring support with continence or overnight care. The Council agreed that an OT assessment could be arranged to assess the suitability of Mrs W’s house and discuss any necessary adaptations.
28. Due to the differing opinions about the best type of long-term placement for Mrs W, the Council arranged a Multi-Disciplinary Team (MDT) meeting on 7 August 2024 which Miss Y attended. During the meeting, professionals discussed that Mrs W’s continence needs had recently increased, and she needed regular checks throughout the day and night and could not use the toilet independently. Staff also said that Mrs W’s dementia appeared to have worsened, and her nutritional and fluid intake had decreased.
29. At this point, professionals decided that Mrs W had 24-hour care needs.
30. Mrs W became a permanent resident at Home Three on 5 September 2024. The Council carried out a review meeting on 13 September 2024 and Miss Y attended. Miss Y expressed concerns about Mrs W remaining in her room and another resident wandering. Staff at Home Three said there were no other rooms which Mrs W could move to. The records show a discussion about Mrs W’s recent weight loss and changes which could be made to help her at mealtimes.
31. The Council completed another review at Home Three on 11 October 2024 and Miss Y attended. Those in attendance discussed some concerns about Mrs W not wanting to leave her room due to being scared by another resident. Staff said there were no recorded incidents involving the resident in question. Miss Y says this is inaccurate because she reported the incidents. While Mrs W’s nutritional intake continued to be low, staff provided their view that this improved on days when Mrs W went into the dining room for meals rather than staying in her room.
32. At the end of the meeting, Miss Y presented a list of alternative care homes which she wanted the Council to consider for Mrs W. The Council discussed the need for any decisions to be made in Mrs W’s best interests.
33. Following continued concerns raised by Miss Y throughout early November 2024, the Council arranged an unannounced visit to Home Three. The social worked noted that Mrs W’s room was clean and that she also presented as clean, smart and wearing appropriate clothing. The home manager agreed to send a copy of the recent care notes to Mrs W’s social worker.
34. The Council recorded its view that Mrs W did not present as unsafe or in a state of distress. Whilst there were areas of improvement for Home Three, there was no evidence to suggest the home was not meeting Mrs W’s assessed care and support needs.
35. The Council reviewed Mrs W’s needs again on 15 November 2024. Miss Y attended the meeting. The conclusion was that: “There is no immediate concern that [Mrs W] is not safe, and it is felt her care needs are being met. It is felt it is not in her best interests to move currently as there is a risk [Miss Y] will want to potentially move [Mrs W] once she has been safely housed and has a secure job especially if it is out of the area”.
36. On 25 November 2024 the Council emailed Miss Y to provide information about the safeguarding enquiries for the concerns raised about Home Three. The investigation into those concerns remained ongoing at the time of Miss Y’s approach to the Ombudsman.

Was there fault causing injustice to Miss Y?

37. Our investigation has focussed on the alleged injustice to Miss Y. We have not investigated the complaints about the quality of care at the three care home placements and whether those placements met Mrs W’s assessed care needs. This is because we have not accepted Miss Y as a suitable representative for a complaint made on behalf of Mrs W for the reasons we have explained to her directly.
38. Instead, we have considered whether the Council maintained appropriate contact with Miss Y and how it responded to any safeguarding concerns Miss Y raised. In my view, the Council maintained a good level of contact with Miss Y and listened to her concerns. While the Council may not have always agreed with Miss Y’s views, I am satisfied it properly considered them and regularly reviewed Mrs W’s care to ensure it met her needs and any problems were addressed. The records show that the Council always invited Miss Y to any reviews and allowed her to express her views and advocate for Mrs W.
39. In terms of safeguarding, the records show the following recorded incidents during the period covered by this investigation:
• April 2024 – Miss Y raised concerns about the standard of care at Home Two including a failure to ensure Mrs W was clean and appropriately dressed. Miss Y also reported an assault by another resident. The Council decided to take no further action following unannounced visits to Home Two, reviewing care records and asking staff to review CCTV footage. The Council also considered other placements and agreed a move to Home Three.
• 31 July 2024 – Miss Y reported that a male resident at Home Three punched her with both hands in the face. Miss Y said the same resident sometimes entered Mrs W’s room and she was concerned for her mother’s safety.
• Various dates in November and December 2024 – Miss Y reported several concerns about staff at Home Three being forceful with personal care when Mrs W refused care and some staff speaking to her in a loud and inappropriate way. Miss Y also said that care staff were not changing Mrs W’s clothes, incontinence pads or bedding when needed.
40. Councils 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)
41. Councils have a duty to keep family members or representatives appropriately informed during safeguarding cases in adult social care, provided it does not increase risk to the adult or breach confidentiality. In response to Miss Y’s complaint, the Council acknowledged it did not relay the outcome of the safeguarding enquiries made for Home Two and that it would feed that back to the enquiry officers as part of their learning and development. I am satisfied the feedback was successful because the Council’s communication with Miss Y improved and she received the outcomes relating to her further concerns.
42. Councils should also provide timely updates and explain decisions made, especially if they differ from family concerns. All communication should be clearly documented, demonstrating transparency and accountability in how safeguarding is managed. In my view, the records show the Council maintained regular and appropriate contact with Miss Y about her safeguarding concerns and I do not uphold this part of her complaint.

Complaint handling

43. When a council arranges adult social care services or placements through a private or independent care provider, that provider is seen as acting on behalf of the council. This means we have the legal power to investigate complaints about those services, under section 25(7) of the Local Government Act 1974.
44. If a care provider is delivering services on a council’s behalf, any complaint response it sends is from the council. The response counts as the final reply to the complaint under the law. Councils must have clear agreements in place with care providers about how complaints are handled. This includes making sure it is clear who is responsible for responding to complaints.
45. Under the regulations, the final complaint response must be signed by a “responsible person” and show that the council agrees with any actions taken. This means councils should allow the care provider to act on their behalf but must check and approve any proposed actions before a response is sent. Councils must closely monitor how complaints are being handled in these cases.
46. In response to our enquiries, the Council said its commissioned care providers are responsible for the day-to-day delivery of care and are required to have their own complaints procedures. As such, Miss Y was advised to raise specific concerns directly with the providers to ensure resolution of operational issues. The Council says it followed up any concerns with the providers and escalated through safeguarding or contract monitoring processes. The Council also facilitated communication between Miss Y and care home managers when relationships became strained.
47. The Council’s complaints procedure says: “If your complaint is about a private care home or agency, you should contact them in the first instance as they will have their own complaints procedure to follow. If you are unhappy about their response and your care has been arranged and funded by health and adult services, we may be able to look into your complaint further”.
48. From the records I have seen, the Council did not maintain oversight of the complaint, nor did it offer to look at the complaint when Miss Y expressed her continued dissatisfaction. I consider this is fault. However, in my view, the fault caused limited injustice because Mrs W’s social worker and other key officers maintained a good level of contact with Miss Y, regularly reviewed the placement and addressed concerns with both the home and Miss Y. Therefore, due to the lack of injustice, I do not recommend a remedy for this part of the complaint.

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Decision

49. I find some fault in the Council’s handling of the first safeguarding concern for which the Council has already provided a remedy for. I also find some fault in the complaint handling. However, this fault did not cause significant enough injustice to recommend a remedy for Miss Y.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman