Summary: Miss X complained about how the Council supported her as her son’s carer and how the Council and a care provider dealt with safeguarding matters. We found there was no fault in the way safeguarding matters were handled. However, we found delay in assessing Miss X’s needs as a carer, mishandling of her complaint and a need for improved record keeping by a care provider. We recommended an apology and actions to put things right.

The complaint

1. Miss X complains that:
1. The Council has not properly carried out a carers assessment to determine her needs, the latest (2025) carers assessment does not reflect her needs and has not been shared with her.
2. The support the Council provided in her role as carer for her son has not been sufficient.
3. The complaint she raised in December 2024 was mishandled and the response delayed.
4. She reported concerns to the duty social work team about Y’s care provider causing distress to him (by not communicating their intentions and not understanding his requests). She considered these should have been dealt with as safeguarding concerns and they were not.
5. Neither Miss X or Y were made aware of safeguarding reports made against her by his care provider prior to 30 January. She considered these were malicious and made because of the concerns she had raised about the care provider. She complains that these existing safeguarding reports on record likely led to the significant actions that occurred after the end of January.
6. The Council should have carried out an Occupational Therapy (OT) assessment in 2020.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
4. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
5. 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(1), as amended)

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What I have and have not investigated

6. We expect complaints to be brought to the Ombudsman within 12 months of the person having knowledge of them. We are investigating the events of the complaint from April 2024 to June 2025 when the Council responded. We will not investigate part f) of Miss X’s complaint relating to an OT assessment in 2020 as a result.

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How I considered this complaint

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

What I found

Safeguarding

9. The Care Act 2014 sets out a clear statutory framework for protecting adults with care and support needs from abuse or neglect. It places a strict legal and professional duty of care for care workers to report potential abuse.
10. A council 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.

Council Guidance on Safeguarding

11. The Council provides guidance on reporting safeguarding incidents. This is detailed and provides examples of things that should be reported formally.
12. The guidance is extensive but includes:

• Isolated incidents of accidental over or under prescribing of medication. It states these should not be reported as safeguarding matters if there has been no impact, pain or distress (for example in a near-miss).
• Unexplained marks or injuries and incidents of violent behaviour or physical abuse. These should be reported.
• Sexualised physical contact which causes distress should be reported.

What Happened

13. Miss X lives with her disabled son Y. I understand the Council provides Direct Payments to Y to enable him to employ Personal Assistants (PAs) and, at the time of this complaint, the Council separately commissioned general care and support visits from a care provider. Y needs assistance with personal care, dressing, food preparation and maintaining his home environment.
14. In April 2024, Care Provider A began providing care for Y. They continued to provide care until February 2025. Miss X also provides care and support to Y.

Miss X’s complaint

Carers Assessment

15. Miss X explained that caring for Y is stressful and at times she had been struggling to cope. She complained that the Council did not properly carry out a carers assessment to determine her needs. She stated the latest carers assessment in 2025 does not reflect her needs and has not been shared with her. She also complained that overall, support provided for her, as a carer, was insufficient.
16. Miss X contacted the Council on 15 May 2024 requesting a copy of the latest carers assessment. The Council noted that this was sent to Miss X by post.
17. I understand Miss X called the Council in October to request a carers assessment. The Council’s response to her complaint stated it had no record of this call, but it acknowledged not all contacts with the relevant social work team were uploaded to its systems so accepted it took place.
18. On 2 January 2025 Miss X contacted the Council and expressed concern about a decline in Y’s mental health. She was signposted to the crisis team. Miss X also raised concerns about what was in her carers assessment and the Council noted a request for a new carers assessment.
19. A referral for a carers assessment was made on 9 January and it took place on 19 February. A copy of the assessment was sent to Miss X on 21 February, and following a quality inspection the assessment was finalised on 6 March.
20. I acknowledge that Miss X considered the final carers assessment was not complete and that she wished the Council to make amendments. The Council agreed there was evidence Miss X had stated during April and May 2025 that she wanted changes to be made, but she had not sent details of what she wanted to be amended. This remained the case by the time the Council responded to Miss X’s complaint in June 2025.
21. The Council’s response to Miss X’s complaint accepted Miss X contacted the Council in October, so it partially upheld her complaint that a review of her carers assessment was delayed. However, it stated the carers assessment it subsequently issued had met its quality standards. It did not accept there was an issue with the standard of the assessment as a result. It noted it had not been able to make amendments as it had not received any details of the changes being requested.

B) Support for Miss X as a Carer

22. Miss X also complained that the support the Council provided in her role as carer for her son has not been sufficient. The Council’s records show that Miss X contacted the Council on a number of occasions to express frustration and stress and to tell the council that she was struggling to manage her caring role. The situation was clearly difficult and causing strain on Miss X and Y’s relationship.
23. The Council carried out a review of Y’s care placement in May. Reviews exist to ensure that new packages of care are working and to help deal with and resolve any apparent issues. The review noted some teething issues. The Council provided evidence Care Provider A was responding to resolve issues with care being raised by Miss X and Y.
24. As at July, Y told his social worker that the vast majority of issues had been resolved. However, a further review of Y’s care plan took place in August and it noted some issues remained. The review noted the action being taken to address them, but also noted consideration should be given to a change of provider.
25. In October 2024 Miss X emailed the Council explaining that she and Y were struggling and asked for help and advice. The Council responded, explaining Y’s care assessment was not up for review until August 2025, but she could be reviewed sooner. The Council also signposted Miss X to an organisation that provided carer support.
26. In mid-December Miss X told the Council they were still struggling and Y’s behaviour was difficult. She stated her own health was suffering. The Council arranged a meeting the following day with a duty social worker to establish what would help and to make a plan.
27. As social worker visited to start a further review of Y’s care plan in mid- December. It was noted that Y’s anxiety had increased because of some of the issues with Care Provider A. Most notably the care visit times and communication issues. The review was completed on 10 January. It proposed various actions to reconsider Y’s care which he would prefer to be via Personal Assistants. The review also indicated independent living was discussed and a new carers assessment was to be completed for Miss X.
28. Following the safeguarding reports made in January, a new care provider was sought by the Council while the safeguarding reports were being considered. The Council identified Care Provider B. They made contact with Y and discussed providing his care. After the call, Y told the Council he did not consider that Care Provider B could not meet his needs.
29. Y had a preference for a package of care provided by PAs. He favoured a private brokerage service (Provider C) that could arrange this so that he could be in control of his own care. However, there were difficulties agreeing the terms for Y’s PA based care package as Provider C had a non-standard approach to charging. This caused delays in securing care from Provider C.
30. In early April Miss X expressed frustration that they were not getting updates from Y’s social worker about arranging new care and she was exhausted.
31. A community nurse told the Council in April that the situation for Miss X and Y seemed intense and asked if the Council could arrange respite for Miss X. The Council advised that it had no emergency respite, but that respite was booked for Miss X for June and August.
32. In April the Council provided an update to Miss X and Y and explained that Care Provider B remained an option and could put care in place in the interim, while things were resolved for the longer term.
33. In May the terms were agreed with Y’s preferred care provider and case notes indicate Y’s revised care and support plan was being worked on. This was sent to Y for him to read and make any alterations he wished to. It was not resolved at the point the Council responded to Miss X’s complaint.

C) The complaint she raised in December 2024 was mishandled and the response delayed.

34. Miss X made her complaint to the Council on 28 December 2024. A team manager began investigating, spoke to Miss X and made notes. However, regrettably they were then absent from work for a prolonged period. Miss X explained the notes from the initial work on the investigation were not passed on.
35. The complaint was re-allocated to a member of staff to investigate in April 2025. They proposed to complete the investigation by 15 May, but needed some additional time. The investigation was completed on 29 May.
36. The Council acknowledged that complaints should be responded to within 28 days of receipt. So, its response to Miss X’s complaint was significantly late.

D) Concerns about Y’s care provider causing distress to him should have been dealt with as safeguarding concerns and they were not.

37. Miss X contacted the Council’s emergency social work team towards the end of January 2025 to report concerns about Y’s care package and Care Provider A. The call handler explained these were issues that needed to be discussed with Y’s social worker. They also advised them to contact the district nurses as they also wished to cancel a district nurse visit.
38. After a second call from Miss X the emergency team noted a meeting was organised to discuss Y’s care in around a week. They advised Miss X to contact the crisis team. They also spoke to Care Provider A, and left a ‘significant information record’ for social workers to follow up, which they did the following day. The Council found that the emergency team had dealt with the call correctly and appropriately signposted Miss X to the crisis team and social workers.
39. We have investigated the general concerns that were raised about Y’s care, and whether these should have been safeguarding matters in a separate investigation. We have summarised what we found here:
40. We found that Miss X and Y raised a number of concerns about the way Y’s care was being provided by Care Provider A soon after his care began. He also noted that Care Provider A had considered his care documents to be fairly basic. The points being raised by Y included delays sending him a copy of his moving and handling plan, concerns about how Care Provider A communicated with Y and concerns about the timing of care visits (particularly because this affected when Y’s medication could be taken). There was also an isolated near-miss incident where Care Provider A set out too much medication for Y to take, before Y corrected this. In addition, in early October 2024 there was an issue with Y’s personal care where he felt sexually violated by one of his carers (Carer B).
41. Miss X argued that safeguarding reports should have been made for these issues and incidents and they were not.
42. The Council only became aware of the issues with Y’s personal care (from October 2024), and the medication near-miss when Y complained in 2025. It did consider these as safeguarding incidents at that time.
43. The Council did not consider the other issues raised about Care Provider A met the threshold to be safeguarding issues. It took account of these as quality feedback about Care Provider A.

E) Neither Miss X or Y were made aware of safeguarding reports made against her by his care provider prior to 30 January. She considered these were malicious.

44. Miss X told us that Care Provider A made earlier safeguarding reports about her, which were not made known to her. She considered that this affected how the incident at the end of January 2025 was dealt with.
45. In early January 2025 Care Provider A stated, when carers visited to provide care, Miss X disclosed to carers that her relationship with Y had been strained over Christmas. Y had been verbally and physically abusive to her and she had punched him. Care Provider A raised this as a safeguarding alert. Miss X was not made aware it had been formally reported, however, the Council says it spoke to Miss X on 7 January about stress and how it impacted them. A further meeting took place several days later. The Council noted that Y was aware of the concern that had been raised. It is not clear if Miss X and Y were aware it had been reported formally as a safeguarding alert.
46. It appears this report was being considered when the second report was made at the end of January (which was also reported to the police).
47. In March, after considering the issue and the impact that the investigation was having on Y, the police decided to take no further action. The Council noted ideas for improving Y’s current situation and lowering stress and that these were being incorporated into Y’s new care plan. It noted Y had identified a new care provider and there were ongoing discussions about respite. It also noted Miss X was having a carers assessment and other issues were being considered outside of the safeguarding process. As a result, it agreed it would not consider the incidents involving Miss X any further through safeguarding.

Was there fault by the Council

A) Carers Assessment

48. There was an initial delay in acting on Miss X’s request for a carers assessment. The Council accepted she made a request in October 2024. The assessment was not acted upon until she made another request in January. The delay represents fault by the Council.
49. Once the carers assessment referral was made, there was no undue delay in assessment taking place. The Council’s records indicate that a copy of the carers assessment as sent to Miss X. We found there was no failure to make changes to the assessment, as the evidence suggests Miss X did not make clear what she sought to be added or amended.

Support provided to Miss X

50. As a whole it is evident that the Council did provide support for Miss X as a carer. I say this because there is evidence that the council carried out carers assessments for Miss X and the need for respite was taken into account in Y’s care needs. There is also evidence that the Council signposted Miss X to organisations that could provide support and encouraged her (and Y) to contact the crisis team at key times where that was needed for them.
51. However, I note there was a period from February 2025 until June 2025 (when our investigation ends) when Y only had PA support, and care from Miss X – he did not have care provision.
52. This period followed directly on from the physical altercations that had been reported between Miss X and Y and which indicated a strained relationship between them. There is also evidence that other professionals raised concern about tension between Miss X and Y during this period.
53. Because of the circumstances, I considered whether the lack of care in this period amounted to fault by the Council and affected Miss X as a carer.
54. I found the Council’s overall approach was appropriate. I say this because it:

• worked towards achieving what Y wanted in the long term – care organised by Care Provider C via Personal Assistants and direct payments.
• it offered an alternative care provider (Care Provider B) to meet Y’s needs in the meantime.

55. Unfortunately, Y decided Care Provider B could not provide what he needed and he declined their support. I understand this was because the care would be structured in a similar way to Care Provider A, whereas Y wanted more control and sought PA based care. I found this was Y’s choice to make. Although the situation was difficult, it seems likely that Care Provider B could have met Y’s needs while his preferred care was being put in place. As a result, I do not consider there was a failure by the Council to provide care.
56. However, I would have expected the Council to proceed with agreeing the terms and resolving the complexities of Y using Care Provider C with some urgency given the circumstances Miss X and Y were in. I found there was insufficient progress in achieving Y’s longer-term care via Care Provider B between February and June 2025. I acknowledge this was a non-standard model. However, I found the delay in progressing this was fault, and it is likely to have added stress to a difficult situation. The impact of this fault was limited to a degree because the Council had offered care via Care Provider B in the interim.

C) Miss X’s complaint was mishandled and delayed

57. There was fault in the way the Council responded to Miss X’s complaint. The work carried out by the person originally allocated to consider the complaint was not passed on, and the response was significantly late as a result of the original officer being absent. This was no doubt frustrating for Miss X.

D) Issues not considered through safeguarding

58. There was evidence that various issues were being reported about Y’s care from April 2024 when Care Provider A began providing it. However, I found no fault in the Council’s view that the majority of these would not be sufficient to require safeguarding alerts. For example, issues with the timing of care visits, communication issues and chasing for a copy of the moving and handling plan.
59. I also found the medication near-miss did not meet the safeguarding threshold. The Council’s safeguarding guidance indicates that an isolated incident such as this does not need to be reported as a safeguarding matter. I also note Care Provider A took appropriate action about this incident later in 2024, which the Council then considered as part of its wider safeguarding enquiries. The Council was satisfied with the actions taken by Care Provider A to resolve it.
60. In respect of the October 2024 incident around Y’s personal care, I found, on the basis of the evidence we have seen, it is unlikely, that Care Provider A were made aware of the full details of the incident at the time it occurred. So, I found, again, there was no failure on Care Provider A’s part that this was not reported as a safeguarding report when it occurred. When the extent of the concern was made clear I found the Council considered this appropriately. Safeguarding is concerned with risk and as that this was no longer a risk, no further action was needed.
61. Although we did not find Care Provider A were at fault for failing to report the October 2024 incident, I found that Care Provider A’s records were lacking. The records we were sent did not include reports Y made about being uncomfortable with Carer B in October and November 2024. Care Provider A referred to these contacts when explaining what happened to the Council. I found the failure to keep these records amounted to fault. The lack of these records made it less clear what was said and when.
62. Overall, I found there was some fault in Care Provider A’s record keeping. However, I found this did not cause significant injustice. I also noted that two of the key issues were later considered through safeguarding and responded to appropriately.

E) Neither Miss X or Y were made aware of safeguarding reports made against her by his care provider prior to 30 January. She considered these were malicious.

63. Safeguarding reports are not routinely disclosed to the alleged perpetrator. But, care providers are under a duty to report any potential abuse they become aware of.
64. While Miss X was not aware of the formal report being made in early January, I do not consider this affected the Council’s actions. Both reports in January were significant. There was no doubt that the threshold for the Council considering a safeguarding enquiry was met on both occasions because care workers became aware of physical altercations between Miss X and Y. They were right to make a formal report on both occasions as these incidents clearly met the threshold for a safeguarding report.
65. I have no grounds to question the consideration the Council gave to either report as a safeguarding matter. For the same reason, I have no grounds to question Care Provider A’s decision to contact the police. This was a decision they were entitled to make. We cannot consider the actions of the police or the way they handled the matter.

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Action

66. Within four weeks of our final decision:
67. The Council should send Miss X a written apology for the additional stress and frustration caused by the delay in starting her carers assessment in late 2024, the delay in progressing Y’s chosen care arrangements in early 2025 and for the issues in responding to her complaint. The apology should adhere to our guidance on making effective apologies. This can be found on our website, within our Guidance on Remedy here.
68. The Council should arrange for Care Provider A to review how it records events that occur when it is providing care to service users to ensure full records are kept.
69. The Council should provide us with evidence it has complied with the above actions.

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Decision

70. I find fault causing injustice.

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Investigator's decision on behalf of the Ombudsman