Summary: On behalf of Mrs X, Mr Y complained about the communication, staff conduct, and quality of care provided by a Care Home commissioned by the Council. Mr Y also complained the Council’s safeguarding investigation did not fully address his concerns. We found the Council took too long to complete its safeguarding investigation. We also found the Council at fault for not considering Mr Y’s concerns in full as part of its safeguarding investigation. This caused avoidable frustration, distress and uncertainty. We also believe Mrs X was exposed to the avoidable risk of harm due to the Council’s faults. The Council has already taken some action to address concerns about the Care Home. To address the remaining injustice, the Council has agreed to apologise and pay a symbolic financial remedy to Mrs X. The Council has also agreed to review the faults identified and confirm to the Ombudsman what action it will take to prevent recurrence.

The complaint

1. Mr Y complained about the quality of care provided by a Care Home the Council commissioned for Mrs X. Mr Y also complained about the Council’s subsequent investigation of his concerns.
2. Mr Y said the Care Home:
• Failed to investigate concerns about an incident in which Mrs X was subject to a distressing and incorrectly performed procedure;
• Failed to address concerns about other aspects of Mrs X’s care provision; and
• Failed to communicate effectively or respond to complaints.
3. Mr Y said the Council’s safeguarding investigation did not fully address the concerns raised. This has caused Mrs X avoidable distress and upset, and avoidable frustration and uncertainty for Mrs X’s family.

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The Ombudsman’s role and powers

4. 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)
5. The law says we cannot normally investigate a complaint unless we are satisfied the organisation knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the organisation of the complaint and give it an opportunity to investigate and reply. (Local Government Act 1974, section 26(5), section 34(B)6)
6. 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)
7. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
8. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
9. 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.
10. 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

11. The Council told the Ombudsman it had not considered Mr Y’s concerns through its complaints procedure, but had instead considered them through its safeguarding procedure. Having considered the Ombudsman’s jurisdiction as set out in paragraph 5, I do not consider it would be reasonable for Mr Y to have to complete the safeguarding procedure and then make a further complaint about the same substantive matters. The Council was also aware of Mr Y’s concerns about Mrs X’s care and opted to use the safeguarding procedure, rather than the complaints procedure. I am therefore satisfied I can investigate the matters raised.
12. During the investigation, Mr Y provided information about a new safeguarding concern being considered by the Council. I have not considered these newer matters, or the Council’s safeguarding investigation pertaining to them. These occurred after Mr Y’s approach to the Ombudsman and the restriction set out in paragraph 5 applies. It would be open to Mr Y to bring a separate complaint to the Ombudsman about these matters, if he or Mrs X was dissatisfied with the Council’s consideration.
13. While I have not investigated these newer matters, some of the Council’s recent actions are relevant and supersede actions the Ombudsman might have asked the Council to take. I address these points elsewhere in this statement.
14. Part of Mr Y’s complaint concerned poor coordination and practice between the health professionals involved in Mrs X’s support. The NHS and health services are not bodies within the Ombudsman’s jurisdiction. Complaints about these matters would be better considered by the Parliamentary and Health Services Ombudsman (PHSO). Mrs X did not want the Ombudsmen to consider the matters as a joint investigation. It would be open to Mrs X or Mr Y to make a separate complaint about these matters.

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How I considered this complaint

15. I considered evidence provided by Mr Y and the Council as well as relevant law, policy and guidance.
16. Mr Y, Mrs X 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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Relevant legislation, guidance and policy

Safeguarding

17. 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. 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)
18. The aims of adult safeguarding are to:
• prevent harm and reduce the risk of abuse or neglect to adults with care and support needs;
• safeguard individuals in a way that supports them in making choices and having control in how they choose to live their lives;
• promote an outcomes-led approach in safeguarding that works for people resulting in the best experience possible; and
• raise public awareness so professionals, other staff and communities as a whole play their part in preventing, identifying & responding to abuse and neglect.
19. When making enquiries, councils should focus on:
• establishing facts;
• finding out the person’s views and wishes and seeking consent;
• assessing the needs of the adult for protection, support and re-dress; and
• make decisions about what follow-up action should be taken regarding the person or organisation responsible for any abuse.

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What I found

Key events

20. Below is a summary of the relevant key events. It does not detail every exchange between parties. Where necessary, I have expanded on some of these events in the “analysis” section of this decision statement.
21. In September 2023, Mrs X was admitted to the Care Home as an interim resident, so she could continue with proscribed physiotherapy, with the aim of increasing her mobility and strength while receiving care and support. The Council commissioned Mrs X’s placement and contributed financially towards Mrs X’s care.
22. In February 2024, there was an incident in which Mrs X was subject to a distressing and incorrectly performed procedure, administered by Care Home staff. Mr Y said Mrs X objected to the procedure at the time, but these concerns were ignored. Mr Y said Mrs X reported the incident to Care Home staff the following day, but the Care Home did not escalate these concerns, or tell Mr Y and other members of Mrs X’s family.
23. Mr Y found out about the incident a few days later. He raised concerns verbally with the Care Home and followed these up in writing by email on 11 March 2024. Mr Y posed questions about the Care Home’s failure to notify Mrs X’s family, about how it would investigate the incident, and about what action it would take to prevent a recurrence.
24. On 18 March 2024, Mr Y wrote to the Care Home, setting out separate concerns about the quality of care being provided to Mrs X. There were several separate concerns, around Mrs X’s mobility and toileting needs, how the Care Home administered medication, and Mrs X’s wellbeing and daily routine. Mr Y again posed a series of questions to the Care Home. He sought information, updates and reassurance. Mr Y said he then met with the Care Home to discuss his concerns directly.
25. On 9 April 2024, Mr Y wrote to the Care Home to follow up on the meeting. Mr Y sought updates on:
• The Care Home’s investigation of the incident in February.
• The Care Home’s review of Mrs X’s care needs and how it would meet these.
• How coordination between health and care practitioners would be improved.
26. Mr Y copied the Council into this email. The Council wrote to Mr Y, noting the seriousness of his concerns. The Council asked whether a safeguarding concern had been raised by either Mr Y or the Care Home. Mr Y said he was unaware of the procedure. The Council asked the Care Home to raise a safeguarding concern about the incident in February 2024 and about concerns around Mrs X’s daily care and support.
27. On 11 April 2024, the Care Home sent the Council a safeguarding referral about the incident in February 2024. This referral stated the Care Home was conducting an internal investigation to establish what happened. It said the relevant staff members had been removed from caring for Mrs X in the interim.
28. On 16 April 2024, Mr Y wrote to the Council to make his own safeguarding referral. Mr Y specified two concerns: the incident in February 2024, and concerns about the quality of the care being given to Mrs X in other areas.
29. In late April 2024, the Council sought an update from the Care Home on its internal investigation. Around this time, Mr Y told the Council the Care Home had not updated the family as to what was happening. Mr Y said the Council discussed the possibility of undertaking safeguarding enquiries (section 42 enquiries).
30. On 7 May 2024, Mr Y told the Council the Care Home had still not provided a response on either of his concerns. Mr Y sought clarity from the Council about section 42 enquiries and asked for an update on a new social worker for Mrs X, as her previous social worker had left. On the same day, the Care Home sent the Council a report on its investigation of the incident in February. The Council decided the Care Home’s report was insufficient, as it did not wholly address the concerns raised and the Care Home’s action appeared insufficient. The Council felt a meeting between the Care Home, the Council and Mrs X’s family would be beneficial, given the lack of communication from the Care Home to Mr Y.
31. In May 2024, the Council asked the Care Home whether it had updated Mr Y. The Council asked the Care Home to meet with Mr Y, which I understand it did. The Care Home then told the Council it would be taking disciplinary proceedings against the staff involved in the incident from February 2024. The Care Home told the Council these proceedings would take place in early June 2024.
32. In June 2024, Mr Y asked the Care Home to confirm the dates for the disciplinary proceedings and asked whether a representative from Mrs X’s family could attend. Mr Y also sought updates on the concerns raised about Mrs X’s daily care and support, and about coordination between healthcare practitioners.
33. In July 2024, Mr Y wrote to the Care Home. Mr Y said he understood the disciplinary proceedings had been concluded, but said the family had not been informed when they took place or what the outcome was. He said the Care Home had not responded to his previous email. Mr Y asked for an update. A few days later, the Care Home responded. It said the matter had been passed onto senior staff, who would provide an update.
34. On 12 August 2024, the Council wrote to Mr Y. The Council said the Care Home had confirmed its investigation led to disciplinary proceedings against the staff members, who had since left the Care Home. The Council asked Mr Y whether he was satisfied with the enquiry and the outcome. Mr Y said the Care Home had not provided an update, so he could not say if the outcome was satisfactory. The Care Home had also not responded to Mr Y’s other concerns.
35. On 9 September 2024, the Care Home wrote to Mr Y with the outcome of its investigation into the incident in February 2024. The Care Home confirmed the relevant staff no longer worked there. It said it had implemented staff training, so there could not be a recurrence of what happened. It apologised to Mrs X and her family.
36. In November 2024, the Council held a safeguarding meeting with Mr Y and other family members, and the Care Home. The record of this meeting shows expansive discussion around the incident in February 2024. Summarised:
• The Care Home confirmed it had since reviewed its care practices and, where it identified gaps, it had acted to mitigate future risks.
• Mrs X’s family set out their concerns, stating the Care Home had only belatedly investigated the matter. The family said the Care Home assuring them the staff no longer worked there was inadequate. They sought more detail on what had happened and what the Care Home had done to prevent recurrence.
• The Care Home provided more detail about what happened and how sanctions were applied before the staff members left. The Care Home said it had since implemented new training for staff.
• The Council asked the Care Home to disclose details of the sanctions applied and Mrs X’s family sought the details of the specific staff members. The Care Home was reluctant to disclose this information, citing concerns about data protection. The Care Home provided some clarifying detail about the sanctions applied and what happened before the staff members left the Care Home. Both the Council and Mrs X’s family expressed concern the Care Home did not appropriately escalate the concerns on becoming aware of them.
• The Care Home apologised and accepted the situation was unacceptable. In addition to no longer being employed, the Care Home said it had reported the staff in question to the Disclosure and Barring Service (DBS), preventing them from working with vulnerable people in care. The Care Home also advised new management was now in place at the Care Home.
• Mrs X’s family said their other concerns had not been addressed. The Council said this meeting was only to discuss the incident in February 2024. It said any findings here could contribute to a review of Mrs X’s care plan.
• The record of the meeting shows agreed actions. The Care Home would provide a copy of its formal response and follow up on safeguarding training for its staff. The Council would set a date to review Mrs X’s care plan. There would be a further meeting in January 2025 to review progress.
37. The Council provided the Ombudsman with a copy of a document from January 2025, which stated the safeguarding procedure was closed. However, it does not appear the planned meeting took place then.
38. On 9 May 2025, a further safeguarding meeting was held between all parties. The record of the meeting showed:
• Mrs X’s family continued to be dissatisfied with the Care Home’s perceived lack of openness around its actions following the February 2024 incident and its investigation. This included its decision not to provide the details of the staff.
• The Council was satisfied the concern was upheld. All present agreed the Care Home’s actions had been wrong. The Care Home apologised and said it had acted to prevent recurrence.
• Mrs X’s family said her care plan had been updated, but they still had concerns about delivery. The Council said this was for the Care Home to address.
• Final actions were agreed. The Council said it would obtain evidence of the Care Home’s training and referrals to the DBS. The Council said it would write to Mr Y once the report was finalised and the procedure would be closed.
39. On 30 May 2025, the Council sent its report to Mr Y. In July 2025, Mr Y provided some comments and corrections to the report on Mrs X’s family’s behalf.

Analysis

Did the Council act with fault?

40. The Care Home acknowledged the incident in February 2024 was unacceptable. The eventual conclusion – specific staff members no longer working for the home and being referred to DBS, preventing further care work in future – was significant. The Ombudsman could not add anything further to this. I recognise Mr Y and Mrs X’s family wanted the Care Home to disclose specific details about the staff members in question and were disappointed this did not happen. The Ombudsman could not compel the Care Home or the Council to disclose this information. It is legitimate to consider what information should be disclosed to strike the balance between the privacy of individuals in employment matters and what is necessary for an effective safeguarding investigation. Complaints about decisions not to disclose information of this kind would be better considered by the Information Commissioner’s Office.
41. The Council was initially proactive when alerted to Mr Y’s concerns and the decision to start section 42 safeguarding enquiries was correctly taken. However, I have identified some concerns in how the Council managed the safeguarding referrals it received in this case:
• The Council initiated enquiries in April 2024 and quickly identified the need for a discussion with all parties. However, this discussion did not take place until November 2024, around seven months after the referral was made. The process did not conclude until May 2025, over a year after the referral was made. I recognise the Council might allow the Care Home some time to investigate, and that the prospect of disciplinary proceedings might extend this timescale. However, the Council’s response disproportionately drifted once it was notified of the disciplinary proceedings. On the balance of probabilities, I find there was avoidable delay in the Council conducting its enquiries.
• From the outset, Mr Y was clear there were two safeguarding concerns: the incident in February 2024 and wider concerns about the quality of care the Care Home provided for Mrs X. The Council asked the Care Home to make a referral on both matters. However, the Care Home only made a referral for the incident in February 2024. The Council did not follow up the lack of referral about Mrs X’s care.
• The Council’s safeguarding investigation focused on the incident from February 2024 to the exclusion of any substantive consideration about Mrs X’s care on a day-to-day basis. This was despite Mr Y repeatedly confirming there were two specific concerns and asking the Council to address both.
42. For these reasons, I have found the Council at fault for how it conducted its safeguarding investigation.

Did the Council’s faults cause an injustice?

43. The Council’s delay in progressing its safeguarding enquiry into the February 2024 incident does not appear to have affected its consideration of it. The Council pressed the Care Home to provide as much detail as possible and was critical of the Care Home for not properly escalating Mrs X’s concerns. The Council’s follow-on actions focussed on outcomes to prevent recurrence. Nonetheless, this delay contributed to Mrs X and Mr Y’s prolonged distress, frustration and uncertainty as to what action was being taken to address the serious concerns raised. This distress, frustration and uncertainty are injustices and I have recommended the Council act to address them.
44. The Council not considering Mr Y’s concerns about Mrs X’s care as a safeguarding matter, despite this being a specific concern raised, is a significant omission. The Council included a review of Mrs X’s care plan as an action in November 2024, but this was seven months after Mr Y first raised concerns. Reviewing and updating the care plan would also be distinct from investigating concerns about the quality of current care. The Council appears not to have considered that Mr Y’s concerns about the quality of Mrs X’s care were ongoing throughout the whole period.
45. The Council failing to consider these concerns as a safeguarding matter means it missed opportunities to investigate the quality of Mrs X’s care between April 2024 and May 2025. There is some uncertainty as to what the Council would have found, had it investigated, and what action it would then have taken. During this period, Mr Y reports Mrs X had to wait long periods to use the toilet and was unable to shower daily, which in turn exacerbated risks from existing health conditions. Mr Y also said Mrs X’s mobility worsened due to the quality of care provided.
46. I note Mr Y’s assertions. The Council not properly considering this matter means I cannot now say whether harm occurred as a result of the Council’s fault. However, I consider the Council’s lack of investigation exposed Mrs X to the avoidable risk of harm, which is an injustice to Mrs X in itself. I have recommended the Council act to recognise this injustice.
47. If the procedural faults identified in this case are replicated in other cases, this could cause injustice to others in the future. I have recommended the Council act to address this.

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Action

48. Mrs X no longer lives at the Care Home and so the scope to provide a remedy is affected to an extent by the changing circumstances. From evidence Mr Y provided, I also note the Council has recently acted to address concerns identified with the Care Home. These actions include:
• Ensuring the CQC was notified of the specific safeguarding incidents investigated.
• Implementing contract monitoring meetings with the Care Home every quarter, to review progress on agreed actions around health follow-ups, staff training, communication and escalation procedures.
• A planned audit of the Care Home contract, to assess the Care Home’s compliance with its contractual obligations, particularly around safeguarding, incident reporting and the quality of care given to residents.
• Providing oversight to ensure the Care Home develops clear guidance for families and residents on how to report concerns, and that the Care Home addresses issues around staffing levels and the continuity of care for residents.
49. In taking these actions, the Council has already taken some steps the Ombudsman might have recommended, which I note positively. I have not therefore duplicated recommendations in these areas.
50. Within four weeks of the final decision being issued, the Council has agreed to:
1. Provide a written apology to Mrs X and Mr Y for the faults and injustice identified in this statement. The Council should have regard to the Ombudsman’s guidance on “Making an effective apology", set out in our published Guidance on Remedies.
2. Share the findings of this investigation with senior officers to identify points of learning and improvement. The Council should prepare a written report setting out its findings, conclusions and any improvements it proposes to make to its safeguarding procedures. It should share this with the Ombudsman.
3. Pay Mrs X a symbolic financial remedy of £500 to recognise the avoidable risk of harm caused by the Council failing to investigate a safeguarding concern about the quality of Mrs X’s care.
51. The Council should provide us with evidence it has complied with the above actions.

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Decision

52. I have completed my investigation with a finding of fault causing injustice. I have made recommendations to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman