Summary: Ms X complained the Council has failed to properly investigate or take appropriate action in relation to safeguarding concerns raised in relation to Mrs Y. She also complained about poor communication and a failure to keep her informed. We found there is no evidence of fault in the way the Council responded to concerns about Mrs Y’s wellbeing. However the Council’s poor communication and failure to keep Ms X informed is fault. This fault has caused Ms X distress, worry and uncertainty. The Council will apologise and make a payment to remedy this injustice.

The complaint

1. Ms X complained the Council has failed to properly investigate or take appropriate action in relation to safeguarding concerns raised in relation to her mother. As a result the Council has failed to protect Mrs Y from abuse.
2. Ms X also complained about poor communication and a failure to keep her informed. She complains a social worker has provided inaccurate information about actions taken and blamed the care agency for the inaction.

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The Ombudsman’s role and powers

3. 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)
4. 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)
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I considered evidence provided by Ms X and the Council as well as relevant law, policy and guidance.
7. Ms 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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What I found

Safeguarding

8. Under section 42 of the Care Act 2014, councils have a duty to make safeguarding enquiries if they reasonably suspect an adult who has care or support needs is at risk of being abused or neglected and cannot protect themselves.
9. The main purpose of a safeguarding enquiry is to decide whether or not the council, or another organisation, or person, should do something to help and protect the adult.
10. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement.
11. The Care and Support Statutory Guidance sets out what a safeguarding enquiry should look like. The guidance says it is for the council to determine the appropriateness of the outcome of the enquiry. A council can stop a safeguarding enquiry if it is satisfied there are no safeguarding issues, or the risk has been managed effectively.
12. If someone has concerns about the actions of an attorney acting under a registered lasting power of attorney (LPA) they should contact the Office of the Public Guardian (OPG). The OPG can investigate the actions of an LPA and can also refer concerns to other relevant agencies. It can also make an application to the Court of Protection if it needs to take possible action against the LPA. The OPG primarily investigates financial abuse, but it also has a duty to investigate concerns about the actions of an attorney acting under a health and welfare LPA.
13. The Ombudsman has no jurisdiction to consider the actions of the OPG.

What happened here

14. The following is a summary of the key events relevant to our consideration of the complaint. It does not include everything that happened.
15. In October 2023 Ms X contacted the Council to ask for a care assessment and support for her mother, Mrs Y. Ms X told the Council her sister, Ms Z, who had Lasting Power of Attorney (LPA) for their mother was neglecting her. She was concerned Ms Z did not routinely give Mrs Y her medication.
16. An officer spoke with Mrs Y’s grandchild who lives with her and then visited Mrs Y on 20 October 2023. The records of this visit note Mrs Y said she was well supported by her family and did not require any care at that stage. The officer agreed to send Mrs Y information on cleaning agencies, a befriending service, and dog walking. They would also contact Ms Z regarding Mrs Y’s finances.
17. Ms X contacted the Council again on 24 October 2023 as she was concerned Ms Z had told Mrs Y’s grandchild they had to leave her house and then intended to change the locks. Ms X told the Council Ms Z intended to move in with Mrs Y and remove equity from the property to pay herself as Mrs Y’s full time carer. Ms X was concerned Ms Z was emotionally and financially abusing Mrs Y and was not able to meet her care needs.
18. The Council agreed to raise Ms X’s concerns as a safeguarding referral. It also advised Ms X to seek legal advice if she was concerned about how Ms Z obtained the LPA.
19. A safeguarding triage officer considered the referral and decided it would not proceed to formal section 42 enquiries under the Care Act 2014. They noted Mrs Y had capacity to make decisions and was content with the support she was receiving. The Council did not get involved in family dynamics and had advised Ms X to seek legal support. The Council advised Ms X of the safeguarding outcome and that it would close Mrs Y’s case.
20. In December 2023 a nurse supporting Mrs Y raised a safeguarding concern about her care. They were concerned the informal care was unreliable and resulted in poor or inadequate personal care and erratic medication management. They said Ms Z had her own health and wellbeing issues and could not be relied on to give Mrs Y her medication or provide her breakfast.
21. The Council arranged to visit Mrs Y and Ms Z in early January 2024 to complete a care needs assessment. Following this assessment the Council commissioned a package of care to support Mrs Y with her personal care, breakfast and medication of a morning. Ms X was unhappy she had not been invited to or involved in the assessment.
22. A social worker arranged to join a home visit with the nurse and Ms X on 15 January 2024. Ms X was unable to attend but her other sister, Mrs W attended as did Ms Z. Mrs Y agreed that her care plan could be shared with her three daughters. The social worker noted that during the visit they had no concerns regarding Mrs Y’s welfare.
23. Ms X also raised a further safeguarding concern regarding Ms Z ability to care for Mrs Y in January 2024. A safeguarding triage officer considered the referral and spoke with Mrs Y and Ms X. They decided the concerns would not proceed to formal section 42 enquiries under the Care Act 2014. It noted the Office of the Public Guardian (OPG) was investigating Ms X’s concerns.
24. Ms X raised further safe guarding concerns in March and April 2024. She said Ms Z had taken Mrs Y’s jewellery and a significant sum of money from her account and had not given Mrs Y her medication for four days.
25. The Council completed a safeguarding referral and suggested Ms X contact the care agency regarding Mrs Y’s medication as it was their responsibility to give Mrs Y her medication of a morning. It also advised Ms X to report the missing jewellery and money to the police.
26. An officer considered the safeguarding referral and decided the concerns met the threshold for a s42 safeguarding enquiry. They arranged a multi-agency meeting for late April 2024 and invited the OPG and others involved in Mrs Y’s care. The Council’s records say the meeting was cancelled as the OPG did not confirm their attendance.
27. Ms X raised further concerns about Ms Z’s actions with the Council and the police in June 2024. The Council contacted the OPG on 21 June 2024 with details of Ms X’s concerns, mental capacity assessments and a copy of the police and asked it to investigate. On 1 July 2024 the OPG confirmed it would pass these concerns for further enquiries.
28. Ms X made a formal complaint to the Council in July 2024. She complained she had made safeguarding referrals in October, January and March but nothing had happened. Although the Council has said in early March 2024 that it would commence a section 42 enquiry, this was not started until May 2024.
29. Ms X also complained that although it was agreed, with Mrs Y’s consent that she and Mrs W would be invited to meetings and kept informed this had not happened. Mrs W had travelled a considerable distance for a meeting she was not told had been cancelled. Ms X was concerned she and Mrs W were being excluded from the safeguarding and OPG investigation.
30. An officer discussed Ms X’s concerns with her but did not respond to her complaint at that stage.
31. The Council concluded its s42 enquiry. It noted that while there were concerns about potential financial abuse there was inadequate evidence to establish a definitive conclusion. The Council noted the need for the OPG’s involvement to safeguard Mrs Y’s best interests. It sent additional evidence of its safeguarding enquiries to the OPG on 8 July 2024 and chased an update on 30 July 2024, raising additional concerns.
32. On 31 July 2024 the OPG confirmed it would investigate the concerns raised and would allocate the case to an investigator in due course. It asked the Council for information, including details of any safeguarding referrals made about Mrs Y and copies of mental capacity and financial assessments. The Council responded with this information on 1 August 2024.
33. Following further concerns about Mrs Y’s wellbeing and an injury she had sustained a social worker visited Mrs Y on 2 August 2024. They also attempted to visit Ms Z. As Ms Z was unavailable the social worker wrote to her setting out their concerns regarding the neglect and physical abuse Mrs Y had experienced. The social worker asked Ms Z, as Mrs Y’s LPA to take immediate action and arranged a further visit to Mrs Y’s home and asked Ms Z to attend.
34. The social worker forwarded these additional concerns to the OPG.
35. The Council also arranged a meeting with Ms X for 20 August 2024. At this meeting it was agreed to put a protection plan in place for Mrs Y. This included increasing Mrs Y’s care calls to three visits a day and referrals for assistive technology, an Occupational Therapy (OT) assessment for bathroom adaptations and equipment, and for a befriending service. The carers would also report immediately if there was a lack of food in the house
36. The Council notified the OPG of the protection plan. The long term plan was that following the OPG investigation the Council would explore supported living facilities for Mrs Y.
37. The Council then chased the OPG for an update on 6 September 2024.
38. On 24 September 2024 the Council told Ms X that Ms Z put Mrs Y’s care calls on hold as Mrs Y’s dog had bitten a carer. Carers were attending but were not allowed in. It said Ms Z told the Council she would complete Mrs Y’s care until the matter could be discussed at a meeting arranged for 4 October 2024.
39. In late September 2024 Ms Z changed the locks to Mrs Y’s property so Mrs Y’s grandchildren who live with her could no longer access the property. This also meant Mrs Y did not have a key. Ms X questioned why the protection plan did not over rule Ms Z’s LPA and asked what more could be done to protect Mrs Y.
40. The Council chased the OPG for an update. The OPG confirmed on 30 September 2024 Mrs Y’s case was still awaiting allocation to an investigator.
41. The minutes of the meeting on 4 October 2024 note Ms X raised a number of concerns and wanted to explore how Mrs Y could be protected from further abuse. The social worker advised that the Council’s legal and safeguarding teams had suggested 2 options while the OPG completed its investigation. The least restrictive involved a deep clean of Mrs Y’s property and Ms Z ensuring the dogs were locked away during each care call. The alternative was for Mrs Y to move into a residential short stay placement with the legal team considering an injunction.
42. It was agreed Ms Z would arrange for Mrs Y’s property would be deep cleaned and the carpets removed by 11 October 2024. The care agency would then visit to reassess the care package. The care agency would be responsible for administering Mrs Y’s medication and Ms Z would ensure Mrs Y’s dogs were put away for every care call.
43. The Council sent copies of the meeting minutes to the OPG to include in their investigation.
44. Social workers carried out an unannounced visit to Mrs Y on 10 October 2024. They noted Mrs Y looked well and had received her medication. There was food in the fridge and the kitchen looked clean. The carpets had also been removed and it looked like a deep clean was ongoing.
45. On 14 October 2014 the OPG told the Council it was awaiting information. This included a report by a Court of Protection visitor who had arranged to carry out an assessment in November 2024. They would then prepare a report to the Public Guardian and anticipated this would be in late November/early December 2024.
46. The OPG subsequently told the Council Ms Z had requested an extension of time to submit the information it had requested. It said it had declined her request. The OPG asked the Council for an update, which the Council provided the same day.
47. Once the deep clean and new flooring was installed, a new care agency began supporting Mrs Y at the end of October 2024. A social worker conducted an unannounced visit in early November 2024 and found Ms Z had stopped Mrs Y’s morning care call. The records say the social worker reinstated the calls and advised the agency to continue despite Ms Z’s instructions.
48. As Ms X had not received a formal response to her complaint she contacted the Council’s Chief Executive to chase this in December 2024.
49. Ms X also raised concerns that the new carers had not been told to give Mrs Y her medication or breakfast during the morning visit. Mrs Y had not had her medication for four days, and there was none left. The Council confirmed the care plan states the carers should give Mrs Y breakfast but did not refer to her medication. It sent an updated care plan to the care agency.
50. Ms X contacted the Council again at the end of December 2024 as Ms Z had cancelled Mrs Y’s care calls over the Christmas period and Mrs W had found Mrs Y on the floor on 27 December 2024. She was concerned the protection plan was not working.
51. Ms X was unhappy the care agency were not aware of the protection plan or that if Ms Z attempted to cancel calls this should be confirmed with the Council. The Council contacted the care agency and advised them to continue visiting Mrs Y despite her family cancelling some calls.
52. The Council responded to Ms X’s complaint on 8 January 2025 and apologised for the delay. It explained it had hoped to see the situation advance to a resolution before responding. The Council acknowledged Mrs Y’s current situation was not what they would like to see in place. It had tried to access support in the home and had offered short term stay in care to break the cycle and allow Mrs Y a break. It noted this had been negatively impacted by Ms Z’s actions.
53. The Council confirmed it had passed the concerns to the OPG who were undertaking their own investigation. The Council was restricted in what it could do until the OPG investigation was complete and had no influence over how long this would take.
54. It apologised for the poor communication with Ms X and Mrs W and that meetings had been cancelled without notifying them. The Council also apologised there had been so many changes in social workers and hoped this would improve with the recruitment to permanent roles.
55. Ms X then met with social workers who also apologised for information not being appropriately shared. They agreed to provide Ms X with a copy of the safeguarding enquiry report and current care plan. And advised they would carry out 6 weekly reviews and would invite Ms X to attend. The social worker also confirmed there had been a miscommunication with the current care agency regarding the implementation of the protection plan.
56. As Ms X was not satisfied with the Council’s response to her complaint she has asked the Ombudsman to investigate her concerns. Ms X says she has experienced nearly two years of poor practice and poor communication and is concerned about the consequences of this for Mrs Y.
57. Ms X also says the Council has delayed in responding to the OPG’s requests for information which has held up its investigation. But for these delays Ms X believes the situation could have been different.
58. Since complaining to the Ombudsman Ms X has raised further concerns about Mrs Y’s wellbeing, including there being very little food in Mrs Y’s home and no heating so the house was very cold.
59. More recently Ms X says the OPG has now completed its investigation and decided Ms Z should remain as LPA. Ms X says the decision is based on a lack of information/ evidence from the Council.
60. The events since Ms X raised her concerns with us in January 2025 are outside the scope of my investigation.

Analysis

61. The Ombudsman’s role is not to reach a view on whether the Council’s decisions on safeguarding concerns are correct. Our role is to consider whether the Council followed the Care and Support Statutory Guidance process and considered all relevant information to reach its view.
62. It is clear from the documentation that the Council has responded promptly to concerns raised by Ms X and others regarding Mrs Y wellbeing and allegations of neglect and abuse.
63. In most cases the Council determined the concerns did not meet the threshold for s42 enquiries and noted other action being taken to address or mitigate risks. This included implementing care calls, a protection plan and liaising with the OPG regarding their investigation of Ms Z actions as Mrs Y’s LPA.
64. It is important to recognise this was a complex situation given the family dynamics. It is understandable, given Ms X’s concerns about Ms Z abusing her role as Mrs Y’s LPA, that she considers the Council should have done more. However the Council has no power to remove Ms Z or to override or restrict her role as LPA.
65. Ms X says a council officer told her the Council had delayed in providing information to the OPG and had not provided details of the safeguarding referrals and multiple concerns raised. However the Council’s records show regular contact with the OPG and that the Council repeatedly shared information and requested updates on the investigation.
66. The Council has acknowledged its communication with Ms X was poor. The documentation shows the Council did not routinely keep Ms X updated regarding the safeguarding referrals or provide accurate information about Mrs Y’s protection plan/care plan. The situation was exacerbated by lack of consistency and continuity due to the repeated change in social worker.
67. This poor communication is fault.
68. The significant delay in responding to Ms X’s formal complaint is also fault. The Council’s complaints policy says it will acknowledge complaints within five working days and respond within a further 10 working days. In this instance the Council took almost six months to respond to Ms X’s complaint. Delays of this nature are clearly unacceptable and amount to fault.
69. The documentation suggests there were also failings in the Council’s communication with the second care agency who supported Mrs Y from late October 2024. The care plan shared with this agency did not include carers supporting Mrs Y with her medication of a morning. This omission was corrected in December 2024. The Council also failed to inform this care agency to proceed with care calls where Ms Z attempts to cancel them. This again was clarified with the care agency in December 2024. These failings in communication amount to fault.
70. These faults have caused Ms X distress, worry and uncertainty.

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Action

71. To remedy the injustice caused by the faults identified, the Council has agreed to apologise to Ms X and make a symbolic payment of £500 to recognise the distress, worry and uncertainty caused by the Council’s poor and inaccurate communication.
72. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
73. The Council should take this action within one month and provide us with evidence it has complied with the above actions.

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Decision

74. I find fault causing injustice. The Council has agreed actions to remedy injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman