Summary: Mrs X complained the Council did not properly investigate complaints and safeguarding concerns about home care it commissioned for her mother, Mrs Y, from Cera Care Operations Ltd in Old Stratford in 2021 and 2022. There was fault in how the Council considered Mrs X’s complaints and safeguarding concerns, which caused avoidable distress for Mrs Y and her family. It also may have caused Mrs Y a financial loss. The Council agreed to apologise and pay Mrs Y and her family a financial remedy. It will also review some of its adult safeguarding documentation, issue reminders to relevant staff, and share its learning points from our decision with its adult safeguarding staff.

The complaint

1. Mrs X complains the Council did not properly investigate complaints and safeguarding concerns about home care it commissioned for her mother, Mrs Y, from Cera Care Operations Ltd in Old Stratford in 2021 and 2022. Mrs X says because of this, issues with the quality of care continued, and the Care Provider gave Mrs Y a 15-day medication overdose in mid-2022. This resulted in hospital admission and lasting physical damage and Mrs Y now must live in residential care. Mrs X says this caused the whole family significant distress. She wants the Council to apologise, accept its failings, and compensate Mrs Y by paying for her residential care and recovery.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
4. 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, section 25(7), as amended)
5. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council or care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
7. The law says we cannot normally investigate a complaint unless we are satisfied the council 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 council of the complaint and give it an opportunity to investigate and reply. (Local Government Act 1974, section 26(5), section 34(B)6))
8. We have the power to start or discontinue an investigation into a complaint within our jurisdiction. We may decide not to start or continue with an investigation if we think the issues could reasonably be, or have been, raised within a court of law. (Local Government Act 1974, sections 24A(6) and 34B(8), as amended, section 34(B))
9. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
10. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
11. 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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How I considered this complaint

12. I considered:
• information provided by Mrs X and discussed the complaint with her;
• documentation and comments from the Council;
• relevant law and guidance; and
• the Ombudsman’s Guidance on Jurisdiction and Guidance on Remedies.
13. Mrs X, and the Council, and Cera Care Operations Ltd, had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
14. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

Our powers to investigate adult social care complaints

15. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)

The Care Quality Commission (CQC)

16. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

Safeguarding enquiries

17. Section 42 of the Care Act 2014 says a council must make necessary enquiries if it has reason to think a person:
• may be at risk of abuse or neglect; and
• has needs for care and support which mean they cannot protect themself.
18. 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.
19. Whenever a council receives a complaint or allegation of abuse, it should keep clear and accurate records of the action taken. There should be a clear record of past incidents, concerns, risks, and patterns. (Care and Support Statutory Guidance, Section 14)
20. Safeguarding is not a substitute for providers’ responsibilities to provide safe and high quality care and support. (Care and Support Statutory Guidance, Section 14)

The Council’s adult safeguarding investigation policy

21. The Council’s interagency safeguarding adults policy and procedures sets out the process it will follow when responding to safeguarding concerns. The investigation process is set out below.
1. Safeguarding notification received by the Council – the Council will:
• gather information as needed and decide the same day whether the concerns appear to justify making enquiries under its safeguarding procedures; and
• record the steps it has taken.
2. Decision making – If the Council decides it needs to undertake initial enquiries, it will:
• gather more information to formally identify any risks and actions already taken to reduce them; and
• decide if there is a need for formal investigation within 5 working days of receipt of the notification. If it decides it does not need to make statutory enquiries, it must record the reasons for this decision. It must also consider any other appropriate actions to support the adult, such as advice and support, or an assessment of need.
3. Section 42 enquiry – if the Council decides a section 42 safeguarding enquiry is necessary, it will:
• carry out a strategy discussion or formal strategy meeting and gather enough evidence to make a decision on the balance of probabilities;
• agree and implement a safeguarding plan and if it considers risks remain it will consider holding a case conference;
• issue its decision within 60 days of the section 42 enquiry being requested; and
• record the steps it has taken and notify all relevant parties of the plan.
4. Ongoing protection planning and review – if the Council decides following completion of its section 42 enquiry that risks remain, it will:
• hold a case conference to discuss the case and consider how remaining risks should be managed and reviewed;
• complete this review process within 1 month of completion of its section 42 enquiry, and hold a further case conference to decide next steps; and
• record the steps taken and outcomes in a Safeguarding Adults Plan.
22. The Council’s procedure says it may end a safeguarding enquiry at any stage of the above process, if it considers risks are being managed and the adult’s desired outcomes have been met as far as possible. When ending a safeguarding enquiry, it says it will:
• discuss the outcomes with the adult and/or their representative, and send them a letter confirming the outcomes; and
• ensure any Safeguarding Adults Plan is agreed by all relevant parties, including the adult and/or their representative.
23. The Council’s procedure also says:
• it will acknowledge receipt of the concern to the person who raised it, and where appropriate tell them about the outcome;
• at every stage of the process, it will liaise with the adult who is the subject of the concern and/or their representative;
• at the outset, the person coordinating the enquiry should decide what timescales will be necessary to respond to the concern(s) and clearly record the reasons for this. If at any stage the timescales need to be reviewed, the Council should record the reasons for this, seek agreement from the adult and/or their representative, and record their views; and
• it must always have in place clear systems for monitoring and reviewing the progress of enquiry actions to avoid undue delays.

Background

24. In 2020, the Council arranged home care for Mrs Y from Cera Care Operations Ltd (Cera Care).
25. In 2021 and 2022, Mrs Y’s daughter, Mrs X, raised multiple concerns and complaints with the Council about the care provided by Cera Care. The Council investigated the concerns under its procedures for safeguarding adults.
26. In early-October 2022, Mrs X made a complaint to the Council about how it had handled its safeguarding enquiries into her reports. The Council issued its final response to Mrs X’s complaint in early-February 2023, and she then came to the Ombudsman.

My findings

27. The Ombudsman is not an appeal body, and it is not our role to decide whether neglect or abuse has taken place; that is the Council’s responsibility. We do not take a second look at a decision to decide if it was wrong. We investigate the processes the council followed in making its safeguarding enquiries, to assess whether it made its decision properly. I have considered this for each of the relevant safeguarding concerns, below.

Safeguarding concern raised in June 2021

28. In June 2021, Mrs X raised a safeguarding concern with the Council about Mrs Y’s care. The law says we cannot investigate events which happened more than 12 months before somebody complained to us, unless we decide there are good reasons to do so. Mrs X came to the Ombudsman in February 2023. I have decided there are good reasons to investigate what happened from June 2021 onwards, when Mrs X first raised a safeguarding concern with the Council. This is because it took Mrs X longer to complain due to the Council’s actions and delays, which in turn delayed her in coming to the Ombudsman.
29. When Mrs X raised the June 2021 concerns, she said care workers were not carrying out visits at the agreed times, for the agreed duration, or following Mrs Y’s care plan. She told the Council she had tried to raise a complaint about this directly with Cera Care but received no response. The Council wrote to Mrs X the following day. It said, “the issues raised in this notification do not meet the requirements under Section 42(2) but have been recorded as a Notification of Concern and forwarded to the Adult Quality Team for further action”.
30. The Council considered this within the timescales set out in its policy and recorded the reasons for its decision. However, it was at fault in how it investigated this safeguarding concern for the following reasons.
1. The outcome letter sent to Mrs X was not clear enough. The language used was more suited to a response to a safeguarding referral from a professional. It was not appropriate for a member of the public raising concerns about their mother’s care, who may well have no knowledge of the safeguarding process. The Council also did not speak to Mrs X about her concerns or discuss its decision with her, as it states in its policy. It provided Mrs X with no meaningful feedback about what its quality team would do with her concerns, or whether she should expect to hear further from them.
2. I consider it was clear Mrs X was raising a complaint about the quality of the care commissioned by the Council. The Council should have considered this via its complaints procedure and investigated the alleged issues with Mrs Y’s care specifically, rather than passing it to its quality team as general feedback.
3. Statutory guidance requires that councils keep clear and accurate records of actions taken where they receive allegations of abuse. There was no evidence the Council recorded the action the quality team took after it was passed this information.

Safeguarding concern raised in April 2022

31. In April 2022, Mrs Y was admitted to Hospital A, a hospital within the Council’s area. An NHS service involved in the hospital admission raised a safeguarding concern with the Council about Mrs Y’s care. It said care workers from Cera Care had:
• failed to give Mrs Y pain relief medication as directed by the NHS service’s clinicians;
• kept inadequate records of medication they had given to Mrs Y;
• lied when asked about Cera Care’s medication records for Mrs Y; and
• failed to read relevant paperwork about Mrs Y’s care.
32. The NHS service also reported concerns raised by Mrs X, on her behalf. Mrs X had said care workers were not staying for the agreed duration of care visits, and she was concerned Mrs Y was not safe at home due to risk of falls.
33. On the same day it received the concern, the Council decided it should undertake section 42 enquiries. It spoke to Mrs X and Cera Care and considered some of Mrs Y’s daily care notes and medication records provided by Cera Care.
34. Within four weeks, the Council ended its safeguarding enquiries and decided it should take no further action. It recorded that it considered there was a miscommunication between the NHS service and the care workers, and the risk had now been reduced because Mrs Y was still in hospital.
35. The Council was at fault in how it investigated this safeguarding concern for the following reasons.
1. Cera Care told the Council it did not support Mrs Y with medication as it had agreed with Mrs X she would administer this herself. The Council asked for copies of Mrs Y’s medication records to verify this. The records it received contradicted this and recorded that Cera Care would provide Mrs Y the highest level of support with medication, and care staff would administer this for her. Also, the daily care notes of the day in question did not have any record of the visit where care workers interacted with NHS clinicians, which led to the safeguarding referral. I am not satisfied based on the Council’s records it properly questioned or considered these discrepancies.
2. The medication records the Council considered were for March 2022, so did not cover the date of concern in mid-April referred to by the NHS service. Therefore, the Council did not seek the correct information to make its decision properly.
3. The Council spoke to Mrs X as part of its enquiries. However, Mrs X said, and the Council’s records showed, it did not speak to her about the incident reported by the NHS service, or the medication issues. It only spoke to her about the issues she reported with the duration of care visits.
4. When the Council spoke to Mrs X about the issues with the duration of visits, it told her it had passed her concerns about this to its quality team a year earlier. It did not take any further action even though Mrs X said the issues were still happening. It had also sought records from Cera Care about visit times and duration, presumably to address Mrs X’s comments, but it did not consider or comment on this as part of this investigation. Again, it was clear Mrs X was raising a complaint about the quality of the care commissioned by the Council. It should have considered this via its complaints procedure and investigated the alleged issues.
5. There was no evidence the Council considered Mrs X’s concerns about Mrs Y being at risk of falls. It did not ask Mrs X about this or record it made any decision about whether it should take further action to address it via any of its procedures.
6. Although it wrote to the NHS service about the outcome of its investigation, it did not write to Mrs X about this, or discuss the outcome with her, in line with its policy.
7. The Council provided no evidence that it recorded the concern and outcomes as is set out in its policy, or agreed this with Mrs X, in line with its policy.

Safeguarding concern raised in May 2022

36. After a month in Hospital A, Mrs Y was discharged in mid-May 2022 and the Council increased her package of home care with Cera Care.
37. A couple of weeks later, Mrs Y was admitted to hospital again, this time in Hospital B, outside of the Council’s area. She remained in Hospital B for a couple of days. The same NHS service raised another safeguarding concern with the Council about Mrs Y’s home care. It said:
• Mrs X had reported the care workers delayed contacting emergency medical services for three hours despite Mrs Y being severely unwell and completely unresponsive. She also said they refused to wait with Mrs Y while support arrived; and
• Cera Care’s daily care notes did not properly reflect the severity of Mrs Y’s condition, as observed by clinicians from the NHS service.
38. Around a week after the Council received the concern, it decided it should not undertake section 42 safeguarding enquiries. It passed concerns about the quality of Mrs Y’s care to its quality team and asked her social worker to urgently review her care needs.
39. The Council was at fault in how it investigated this safeguarding concern for the following reasons.
1. It sought the views of Mrs X, and of Cera Care, and received contradicting accounts of what happened on the relevant date. However, it sought no further information, such as an account of what happened from the NHS service, or care records from Cera Care. The Council had discretion to decide whether it needed more information, if it can evidence it properly considered this. However, it did not record any reasons why it did not seek any further information. Therefore, I am not satisfied the Council properly considered the conflicting information, or what information it needed to make its decision properly.
2. I do not consider the Council’s records explained its reasons for not taking any further safeguarding action, or how it made this decision.
3. When the Council spoke to Mrs X, she again raised further concerns about the quality of Mrs Y’s care. The Council said it would pass this information to its quality team but did not direct Mrs X to its complaints procedure. It should have considered this via its complaints procedure and investigated the alleged issues with Mrs Y’s care specifically, rather than passing to its quality team as general feedback.
4. Although it wrote to the NHS service about the outcome of its investigation, it did not write to Mrs X about this, or discuss the outcome with her, in line with its policy. It provided Mrs X with no meaningful feedback about what its quality team would do with her concerns, or whether she should expect to receive feedback from them.

Safeguarding concern raised in June 2022

40. In mid-June 2022, Mrs Y was admitted to Hospital B again, where she remained for almost four months. When she left Hospital B, she could no longer live at home, so was discharged to a residential care home.
41. Four days after Mrs Y was admitted to Hospital B, Mrs X raised a safeguarding concern with the Council. She said Cera Care had wrongly administered Mrs Y’s medication, resulting in an overdose of one of her prescribed medications. Two days later, the Council told Mrs X it had decided it should undertake section 42 enquiries.
42. Over the next three months, the Council:
• received a further safeguarding concern from CQC about the same issues, because Mrs X had made a report to CQC. It included the information from CQC as part of its investigation. This included concerns Mrs X reported to CQC about pressure sores Mrs Y had from May 2022;
• spoke to Mrs X and Cera Care several times to gather their comments;
• spoke to NHS district nurses who visited Mrs Y at home from mid-May to mid-June 2022, to provide medical care for her pressure sores;
• considered photographs provided by Mrs X of Mrs Y’s pressure sores, which she said were taken when leaving Hospital A in mid-May 2022, and then 10 days later after home care by Cera Care;
• considered daily care notes and client file notes provided by Cera Care covering the period of the overdose in early-June 2022;
• considered evidence from Mrs X about the correct prescribed dosage for the medication in question. Mrs X also provided copies of Cera Care’s medication records for Mrs Y for the relevant period because the Council had not received this from Cera Care despite chasing; and
• spoke to Hospital B about its medical investigations after it admitted Mrs Y in mid-June 2022, following the overdose.
43. In early-October, around the same time as Mrs Y was discharged from Hospital B to residential care, the Council recorded it had ended its safeguarding enquiries. Its records showed the following.
1. It had identified an error in the administration of medication to Mrs Y by Cera Care, resulting in an overdose of prescribed medication for 15 days at the start of June 2022. Cera Care had accepted it made an error and explained actions it had already taken to prevent future errors. The Council did not consider it should take any action to safeguard Mrs Y because she would not be returning to Cera Care’s care, so the risk had been removed. Therefore, it did not progress the case to the “ongoing protection plan and review” stage of its process. It asked Cera Care to provide evidence of the actions it had taken to address the medication issues. It then referred this to its quality team for further investigation as part of a wider ongoing review into the services Cera Care provided for the Council.
2. It was not able to evidence neglect by Cera Care regarding the concerns raised about pressure sores. It was satisfied Cera Care had properly escalated concerns about pressure sores when Mrs Y was discharged from Hospital A in mid-May 2022, and sought support from the district nurses. It was also satisfied the records showed Cera Care then properly monitored this and followed advice from the district nurses. The information it had received from the district nurses indicated the pressure sore issues worsened when Mrs Y was in hospital for three days at the end of May. It decided to seek further information from Hospital A so it could make an initial assessment about whether it should open a different safeguarding enquiry. It noted Mrs Y was now in Hospital B, so any potential risk presented by Hospital A had been removed. It then followed this up with Hospitals A and B, and established the end of May hospitalisation had been in Hospital B. Because Hospital B is in a different council’s area, the Council passed the issue to that other council and did not investigate further.
44. I consider the Council was at fault in how it investigated the June 2022 safeguarding concern for the following reasons.
1. The Council recorded it ended its enquiries in early-October 2022, 105 days after it decided it should undertake section 42 enquiries. This is considerably longer than the 60 days outlined in its policy. The Council did not properly monitor or record the reasons for these delays, or agree any revised timescales with Mrs X, as is described in its policy. It then did not properly tell her the outcome in writing until late-January 2023, after she had chased this many times and made a complaint.
2. When the Council spoke to Mrs X as part of its investigation, she again raised various concerns about the quality of Mrs Y’s care. The Council again said it had passed the concerns to its quality team instead of recognising it should consider this as a complaint about Mrs Y’s care specifically. The referral from the CQC also included comments from Mrs X about complaints she had made directly to Cera Care, including that over 70 care visits had been missed altogether. There was no evidence the Council considered this or asked Mrs X about it.
3. When it wrote to Mrs X about the outcome of its investigation, the Council told her its quality team would update her about the outcome of its further investigation into the medication errors. This did not happen.

Care charges for missed visits

45. As described at paragraph 44b, CQC told the Council Mrs X had said care workers missed many care visits. Mrs X told us the Council also carried on billing Mrs Y for the care after she had stopped receiving it and was in hospital.
46. The Council provided evidence it had corrected its mistake in billing Mrs Y after the care package ended and adjusted her account accordingly. However, it provided no evidence it had considered Mrs X’s complaint that Mrs Y missed care visits she paid a contribution for when the care package was still in place.
47. As described at paragraph 7, we cannot investigate a complaint unless we consider the Council has had reasonable opportunity to investigate and reply. I decided we can consider the issue of missed care visits because the Council had several opportunities to consider Mrs X’s various concerns via its complaints procedure and repeatedly failed to do so. On the balance of probabilities, I consider it likely Mrs Y did not receive all her care calls. As she was paying a contribution to her care costs, this may mean the terms of her contract with the Council for contributing to her care costs were not met, and she suffered a financial loss because she paid for care she did not receive. The Council’s failure to properly investigate this, was fault.

The Council’s responsibilities for care it arranges or commissions from other providers

48. As I have described above, I consider the Council was at fault because it repeatedly failed to recognise it should consider Mrs X’s concerns about the quality of Mrs Y’s care via its complaints procedures.
49. Also, in response to our enquiries, the Council said:

“The responsibility of medication administration lies with the provider. Whilst we had a lot of oversight with this service, due to the size and progression of their action plan; it is not possible or within our remit to look at individuals on a case by case basis… The Quality Team look at the organisation and the structures and processes they have in place to provide a good service to all customers, and would not be able to pick up medication errors at any given point for almost 70 customers…This is not the responsibility of the Local Authority but that of the provider to ensure their processes do not fail people and that staff [are] well enough trained and competent to be able to complete the delegated task of medication administration.”

50. I do not agree with the Council’s position about this. For the avoidance of doubt, I will make clear the Ombudsman’s position.
1. As described at paragraph 15, the law says where a council arranges or commissions care services from a provider, we treat the provider’s actions as if they were the council’s actions. This is the case even when the person receiving the care is charged a financial contribution.
2. The Council commissioned Mrs Y’s care from Cera Care and decided via its safeguarding procedure that Cera Care had failed to administer her medication properly. This means the Council is responsible for this fault, because it is responsible for the actions of the care provider where it is delivering services on the Council’s behalf.
3. I accept the Council’s quality team manages its processes for maintaining overall oversight of the care it commissions from third-party providers. I also accept this oversight does not extend to individually checking all medication or care records where no concerns have been raised. However, this does not take away the Council’s responsibility to investigate and provide a full response to complaints raised by individual service users, or their representative(s), about the quality of care provided to them specifically. As described in the Ombudsman’s Guide to Effective Complaint Handling October 2020, we expect councils to put things right for the individual and take steps to put right any injustice caused. Without a complaint investigation, a council cannot do this.
4. The Council may delegate to a care provider to investigate and respond to complaints on its behalf, if it considers this appropriate. However, the Council retains responsibility for care it commissions, and must assure itself it is satisfied with any complaint response from a care provider about services it delivers on the Council’s behalf. In these cases, the Ombudsman will consider the complaint response as if it is a response from the Council.
51. Mrs X made complaints both to Cera Care, and directly to the Council, about the quality of Mrs Y’s care, which were not properly considered or responded to. This was fault by the Council.
52. I cannot say what outcome the Council may have reached had it investigated the complaints about quality of care. I am satisfied there is no value in the Council, or the Ombudsman now investigating the issues raised by Mrs X about the quality of care provided by Cera Care. This is because:
• Mrs Y has not received care from Cera Care since June 2022, and will not do so again;
• the Council has evidenced it has since carried out a wider quality review into the services Cera Care provided on its behalf. In doing so it considered concerns raised by multiple service users and outcomes of a CQC inspection. It also carried out several inspections and interventions, set actions for Cera Care and monitored compliance with those actions; and
• Mrs X is seeking compensation to pay for Mrs Y’s residential care and recovery. Compensation is not something we can achieve for complainants. We may recommend symbolic financial payments where we find fault causing injustice, and I consider the recommendations I have outlined below are appropriate in line with our Guidance on Remedies. Mrs X told me she was pursuing a claim against Cera Care via private court proceedings. As described at paragraph 8, we may decide not to continue with an investigation if we consider the issues have been, or reasonably could be, raised within a court of law. Mrs X is instructing a solicitor and taking private court action to seek the remedy she wants.

Injustice caused by the Council’s fault

53. The Council’s failure to communicate with Mrs X and respond to her concerns properly caused her frustration and confusion, for which it should provide a remedy. There also remains uncertainty for Mrs Y and her family about whether things may have been different for her had the Council properly considered all safeguarding concerns and complaints. This uncertainty caused Mrs Y and her family distress, for which the Council should provide a remedy.
54. Mrs X is of the view that had the Council investigated the April 2022 safeguarding concern about medication administration properly, this could have prevented the later medication errors in June 2022. I cannot say, even on the balance of probabilities, what the Council may have decided had it carried out its April 2022 investigation without fault. I also cannot say whether this would have changed anything and prevented later errors. However, as explained in the paragraph above, I consider there remains uncertainty for Mrs Y and her family about how things may have been different, which the Council should remedy.
55. Mrs X is also of the view that the June 2022 medication errors directly caused Mrs Y permanent physical damage which has substantially changed her quality of life because she now requires residential care. The Ombudsman cannot decide whether this is the case, that would be a matter for the courts. However, my view is the uncertainty that remains for Mrs Y and her family about this caused them significant distress, which the Council should remedy.
56. As described at paragraph 47, I consider it likely Mrs Y did not receive all her care calls. As she was paying a contribution to her care costs, this may mean the terms of her contract with the Council for contributing to her care costs were not met, and she suffered a financial loss because she paid for care she did not receive. The Council should remedy any injustice caused.

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Agreed action

57. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. Therefore, I have made recommendations to the Council only, not Cera Care.
58. Within one month of our final decision, the Council will:
1. apologise to Mrs Y and her family for the faults we have identified and the impact those faults had on them;
2. pay Mrs Y and her family £1,500 to recognise the avoidable distress caused by the uncertainty that remains about whether things may have been different for Mrs Y had it properly considered all safeguarding concerns and complaints;
3. pay Mrs X £300 to recognise the avoidable distress caused by the Council’s repeated failure to communicate with her and deal with her concerns properly; and
4. establish whether the terms of Mrs Y’s contract with the Council for contributing to her care costs were not met because care calls were missed. If this means Mrs Y suffered a financial loss because she paid for care she did not receive between June 2021 and June 2022, the Council should repay her for this.
59. Within three months of our final decision, the Council will:
1. review any letter templates it uses for adult safeguarding outcomes, to ensure outcome letters use language which can be understood by both professionals and members of the public;
2. share our final decision with relevant adult safeguarding staff to ensure they are aware of the Ombudsman’s findings in this case. It should ensure staff are aware of the Council’s learning points from our decision and the importance of:
• gathering accurate and relevant information;
• properly considering evidence;
• clear and accurate record-keeping, including recording decision reasons;
• keeping to timescales, monitoring delays, and keeping the subject of the concern and/or their representative(s) informed;
• communicating outcomes to the subject and/or their representative(s); and
• telling people how to make a complaint via the Council’s complaints procedure where they are raising concerns it considers to be about the quality of Council-commissioned care, rather than safeguarding issues.
3. issue a reminder to relevant quality staff that where people raise concerns about the quality of Council-commissioned care they should be told how to make a complaint via the Council’s complaints procedure.
60. The Council should provide us with evidence it has complied with the above actions.

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Final decision

61. I have completed my investigation. There was fault by the Council which caused avoidable distress for Mrs Y and her family. It also may have caused Mrs Y a financial loss. The Council has agreed to our recommendations to remedy this injustice, review some of its adult safeguarding documentation, issue reminders to relevant staff, and share its learning points from our decision with its adult safeguarding staff.

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Investigator's decision on behalf of the Ombudsman