Summary: We have discontinued our investigation of this complaint, about the Council’s handling of safeguarding incidents in a care home. This is because we have already considered and upheld this matter in a previous investigation. We also consider the Council’s own investigation is satisfactory, and so there could be no worthwhile outcome to further investigation anyway.

The complaint

1. I will refer to the complainant as Mrs M. Mrs M is represented in her complaint by her daughter, Mrs P.
2. Mrs P complains the Council did not make adequate enquiries into safeguarding incidents, which occurred during Mrs M’s stay in a care home, which she says led to further incidents of neglect by care workers there. Mrs P says she lost her own job as a result of having to deal with this, and seeks for the Council to recognise the impact on her, as well as to implement service improvements.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide we could not add to any previous investigation by the organisation, further investigation would not lead to a different outcome, or we cannot achieve the outcome someone wants. (Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

4. I considered evidence provided by Mrs P and the Council as well as relevant law, policy and guidance.
5. I also shared a draft copy of this decision with each party for their comments.

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What I found

6. Mrs M was resident in a care home between October 2023 and May 2024. During that period, Mrs P raised a series of complaints about the standards of care Mrs M was receiving, including some incidents which she considered amounted to safeguarding concerns. Mrs M complaints were considered both by the care home itself and the Council, which, between them, upheld much of what she had raised.
7. The Council also undertook formal safeguarding enquiries about two separate incidents, ultimately leading to a substantiated finding in each case.
8. Mrs M made a previous complaint to the Ombudsman, which we upheld in March 2025. She has now made a new complaint, which she says specifically concerns the Council’s handling of the safeguarding enquiries.

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Analysis

9. At paragraph 28, the decision statement arising from our previous investigation said:

“We are satisfied with how the safeguarding investigation was carried out and as the concerns have been upheld, we are relying on the findings which was substantiated allegations of neglect. The care given to [Mrs M] between October 2023-May 2024 was not in line with CQC fundamental standards and was fault. This caused distress, frustration and uncertainty about the care [Mrs M] was receiving.”

10. At our recommendation, the Council agreed to apologise to Mrs P and pay a financial remedy to Mrs M to recognise the distress she had experienced. As the safeguarding element of Mrs P’s complaint has already been considered, we will not investigate it again.
11. In addition to this, the Council commissioned an independent investigation of all of Mrs P’s complaints, including several historic issues, which was completed in January 2025. The report upheld some parts of Mrs P’s complaints, including those concerning the safeguarding enquiries. The report also recommended the Council apologise to Mrs P, and implement several service improvements.
12. The independent investigation was very detailed, and I am satisfied that further investigation at public expense by the Ombudsman will not achieve anything more than this. It is therefore not appropriate.
13. I will also note that, regardless of any other consideration, we cannot make a finding that Mrs P’s loss of her job arose as a result of any fault by the Council. There is no direct connection between these two matters.

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Decision

14. I have discontinued my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman