The investigation

The complaint

1. Mrs Z complained about the care Mrs Y, her late mother, received from Radis leading up to her death.

2. Mrs Z said the treatment of her mother in the months prior to her death was inadequate, negligent and inhumane. She said the family are devastated and feel unable to move on with their lives and grieve properly for Mrs Y.

Legal and administrative background

The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this report, we 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. We 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)

4. Part 3 of the Local Government Act 1974 gives 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 3 Local Government Act 1974; section 25(6) & (7) of the Act)

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

Relevant law and background Fundamental Standards of Care

6. 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) 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. The CQC also has guidance on how to meet the fundamental standards.

7. The concerns raised in this complaint engage several of the CQC’s fundamental standards.

• Regulation 9 – Person-centred care. Providers must ensure care and treatment meet people’s needs and reflect their preferences.

• Regulation 10 – People must be always treated with dignity and respect.

• Regulation 12 – Safe care and treatment. Care and treatment must be provided in a safe way, with proper assessment and mitigation of risks.

• Regulation 13 – Safeguarding service users from abuse and improper treatment.

• Regulation 17 – Good governance. Providers must have systems to assess, monitor and improve the quality and safety of services.

• Regulation 18 – Staffing. Providers must ensure it has enough suitably qualified, competent and experienced staff.

Safeguarding

8. 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. Councils 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)

9. The ‘4LSAB Adult Safeguarding Multi-Agency Policy, Process and Guidance (July 2023)’ is a local policy which sets out indicative timescales to ensure timely and well-managed safeguarding enquiries. The policy sets out the following timescales:

• concerns to be raised the same working day;

• initial information gathering and the Section 42 decision within 48 to 72 hours;

• if needed, an enquiry plan within seven working days; and

• where possible, enquiry completion within 28 days.

10. Throughout this process, the policy says the council retains full responsibility and oversight, even when it asks other agencies to undertake parts of the enquiry.

Human Rights Act

11. The Human Rights Act 1998 sets out the fundamental rights and freedoms that everyone in the UK is entitled to. This includes the right to life, freedom from torture and inhuman or degrading treatment or punishment, liberty and security of person, a fair hearing, respect for private and family life, freedom of expression, freedom of religion, freedom from forced labour, and education. The Act requires all local authorities - and other bodies carrying out public functions - to respect and protect individuals’ rights.

12. Not all rights operate in the same way. Instead, they break down into three separate categories:

• Absolute rights: those which cannot be interfered with under any circumstances.

• Limited rights: those that can be interfered with in certain circumstances; and

• Qualified rights: those rights where interference may be justified in order to protect the rights of others or wider public interest. Note that any interference with a qualified right must be in accordance with the law; in pursuit of a legitimate aim; no more than necessary to achieve the intended objective; and must not be arbitrary or unfair.

13. The Ombudsman’s remit does not extend to making decisions on whether a body in jurisdiction has breached the Human Rights Act – this can only be done by the courts. But the Ombudsman can make decisions about whether a body in jurisdiction has had due regard to an individual’s human rights in their treatment of them, as part of our consideration of a complaint.

14. Article 3 is the right to be free from torture and inhuman or degrading treatment. This is an absolute right, which means public authorities must not include torture, inhuman or degrading treatment or punishment against individuals. It also means that public authorities must act if someone else is treating an individual in this manner.

15. Article 8 protects a person’s right to respect for their private life, family life, home, and correspondence. It allows people to live their lives with privacy and to maintain family relationships without unnecessary interference from public bodies. This is a qualified right, which means organisations can interfere with it when they have a legitimate reason.

How we considered this complaint

16. We have produced this report following the examination of relevant files and documents and from speaking with the complainant.

17. We gave the complainant and the Council a confidential draft of this report and invited their comments. The comments received were taken into account before the report was finalised.

What we found

What happened

18. Mrs Y was an older adult and met the criteria for care and support under the Care Act. At the time of the matters complained about, she received domiciliary care from a provider commissioned by the Council - Radis.

19. Following a fall in April 2024, Mrs Y experienced reduced mobility and received most of her care while in bed. Care workers visited several times each day to support her needs, including providing food and fluids, personal care, and administering medication.

20. Shortly after, Mrs Y’s son, who we will call Mr W, sent an email to raise a formal safeguarding concern about a lack of management oversight at Radis. In the email, Mr W also raised concerns about how care workers positioned Mrs Y, issues relating to food hygiene and the administration of Mrs Y’s medication.

21. Mr W explained that care workers did not refer to Mrs Y’s care plan and sometimes recorded their visits inaccurately. He said family members had discovered the ‘Do Not Attempt Resuscitation’ (DNAR) document scrunched up in a cupboard and that care workers had no knowledge of the DNAR requirements.

22. Following receipt of the concerns, a social worker contacted Mr W and Radis. They requested copies of care plans and care notes and relayed that the family found the care plan and DNAR stored away in a cupboard.

23. The Council opened a Section 42 safeguarding enquiry to investigate the alleged omissions in care. The social worker contacted the manager at Radis and asked them to complete an internal investigation into the concerns raised by Mr W. The social worker also contacted Mr W to provide an update.

24. The social worker booked a review for mid-May. As part of the review, the social worker noted the need to receive the care plan and notes as previously requested from Radis. The social worker sent a chaser email for the outstanding documents.

25. Prior to the review the social worker met and spoke with Mrs Y about her care. The social worker also met with the manager at Radis. The manager said staff were updating Mrs Y’s care plan to reflect the recent change in her mobility and needs. However, the manager also acknowledged that staff had not previously amended the care plan due to management absence.

26. The manager spoke about staffing issues, lack of spot checks, cultural differences affecting communication, concerns around medication found on the floor, and issues with the recording of domestic tasks such as washing up.

27. The review went ahead as planned. Mrs Y’s family outlined their ongoing concerns about care quality and inadequate leadership. The social worker drew up an action plan and emailed Radis to request that all actions be completed before the next meeting in four weeks.

28. In the meantime, the social worker escalated outstanding concerns to the Council’s quality improvement and safeguarding teams. This included concerns about a lack of training and leadership failures as well as poor communication and care planning.

29. In late May 2024 the social worker made an unannounced visit to Mrs Y’s home. They reported that Mrs Y appeared comfortable. During the visit, care workers responded promptly to Mrs Y’s buzzer when pressed and demonstrated knowledge of her needs. However, the social worker found the care plan in Mrs Y’s home was outdated and did not reflect her needs. Care workers incorrectly believed the plan was current. The social worker relayed concerns to the care provider.

30. Some days later the family raised further concerns about food being left out for Mrs Y. The family also expressed frustration because they had not received any updates about the safeguarding enquiries.

31. Mrs Y suffered a mini-stroke and both her family and Radis agreed she needed a soft diet due to the increased risk of choking. Radis updated Mrs Y’s care plan in early June 2024 to reflect this. However, Mrs Z raised concerns that care workers appeared unaware of this important change. Following this, the social worker visited Mrs Y’s home to review the care charts. These showed gaps and inconsistent entries, including days where Mrs Y had eaten almost nothing.

32. In mid-June 2024 two care workers attended to support Mrs Y. We will call them Care worker 1 and Care worker 2. During the visit, Care worker 1 cooked and fed a meal to Mrs Y and recorded this in the daily logs as a “lamb dinner”.

33. One week later, Care worker 2 raised concerns about the events of the visit. In summary, Care worker 2 said:

• they witnessed Care worker 1 feed dog food to Mrs Y. Care worker 2 was initially unaware it was dog food because Care worker 1 referred to the meat as lamb;

• they only realised the meat was dog food when they noticed the packaging in the kitchen. After the visit, Care worker 2 said they tried to call a senior colleague to report the incident but there was no answer. One week later, they saw their line manager in person and relayed what happened; and

• a senior manager spoke to them to clarify what happened and to ask why they did not remove the dog food from Care worker 1. The manager said they would remove the dog food from Mrs Y’s freezer to prevent any other care workers doing the same. The manager also queried why they did not report the incident on the day it happened.

34. Radis started an internal investigation, made a safeguarding referral to the Council and notified CQC. It explained that Care worker 1 had fed three mouthfuls of microwaved dog food to Mrs Y. This was vacuum packed dog food stored by Mrs Z in Mrs Y’s freezer. The food was labelled as "fresh take on dog food” and “for adult dogs and puppies”.

35. The social worker raised another safeguarding alert and spoke with Mrs Z to discuss the incident and to arrange a meeting the following day. The meeting took place in late June 2024. The family raised concerns that the care provider had continued to make serious errors, despite the safeguarding referral made nine weeks ago. The family decided they wanted a new care provider.

36. Following the decision to source a new care provider, the social worker completed a Care Act assessment and arranged an urgent referral for a new care provider to start from July 2024. The social worker emailed the family to provide an update. Around this time, Mrs Z also made a formal complaint to Radis.

37. In early July 2024, Mrs Z reported that Mrs Y’s health had deteriorated significantly. Because of this decline, Mrs Z decided to delay the start date of the new care provider. Radis delivered end of life care to Mrs Y.

38. Around this time, Mrs Z alleged that footage from Mrs Y’s home camera showed evidence of a care worker force feeding Mrs Y. The social worker informed Radis of the allegation and raised an additional safeguarding alert.

39. The Council held a safeguarding meeting in July 2024. The allegation regarding the dog food incident was discussed and confirmed. The meeting also considered further concerns including leadership, documentation clarity, and a need for weekly updates.

40. Sadly, Mrs Y died in July 2024. The coroner concluded that Mrs Y died from frailty of old age.

41. Radis provided its response to Mrs Z’s complaint in late July 2024. It accepted fault in the care provided, confirmed the action taken against Care worker 1 and 2 and apologised. However, Radis did not agree to the remedies sought by Mrs Z.

42. On 21 October 2024 the Council concluded its investigation into the safeguarding concerns received between April and July 2024 about the care provided to Mrs Y. The concerns related to poor standards of personal care, unsafe practices, weak management oversight and failures in record keeping, as we summarise below.

• Poor repositioning of Mrs Y and lack of support with mobility.

• Inadequate food provision, including stale or inedible food.

• Failure to monitor and accurately record Mrs Y’s food and fluid intake.

• Medication provided in a way Mrs Y could not independently access.

• Mrs Y left unattended for prolonged periods and on occasions left wet or in darkness overnight.

• Inconsistent staffing and concerns about staff attitude, compassion and respectful communication.

• Staff unintentionally prepared and fed dog food to Mrs Y.

• CCTV footage alleged to show a care worker feeding Mrs Y in a manner the family considered forceful.

• Concerns that staff did not follow the Speech and Language Therapy plan for a soft diet.

• Care plans significantly out of date and did not reflect Mrs Y’s increased needs following a stroke.

• Staff did not know how to access care plans, and key documents such as the DNAR were not properly stored.

• Families could not access electronic care records.

• Allegations that staff falsified records and that some visits had not taken place despite being recorded.

• The allocated Section 42 enquiry had not started seven weeks after allocation. The manager at Radis reported not knowing how to progress the enquiry and did not seek support.

• Lack of clarity about management cover during absence, including uncertainty about who to contact in an emergency.

• High staff turnover and concerns the registered manager did not receive sufficient oversight or support.

43. In conclusion, the Council found: “As a result of the enquiry, it has been identified that there was a catalogue of errors in relation to the care and support [Mrs Y] received from Radis in the last few months of her life. The enquiry identified concerns such as inaccuracies recorded in [Mrs Y’s] care plan, inconsistencies in care visit recordings and documentation, unclear escalation protocols and procedures for staff, poor handover communication tools, care staff not adhering to [Mrs Y’s] care plan, a carer unintentionally feeding [Mrs Y] a meal made from dog food, a lack of compassion during interventions with [Mrs Y] on two occasions, a significant delay in commencing an allocated Section 42 enquiry from the Local Authority and an overall reduced quality of care”.

44. Although Mrs Y had died and no action was by then possible for her, the Council notified CQC to ensure monitoring and oversight of Radis. It also made several recommendations for Radis to reduce risk to other service users, in addition to any actions already undertaken by Radis. The recommendations covered care planning and record keeping, training and staff development, safeguarding and governance and communication and quality assurance.

45. Mrs Z made a further complaint, this time to the Council, on 27 March 2025, having previously complained to Radis. She complained about how the Council handled the safeguarding process and its lack of oversight.

46. The Council responded on 24 April 2025. It partly upheld the complaint because the Council accepted fault in how it managed the Section 42 safeguarding enquiry. The Council apologised, identified some service improvements and signposted Mrs Z to us.

Conclusions

47. The Council has already acknowledged there was extensive fault which caused significant injustice to Mrs Y and her family. This injustice arose from considerable shortcomings in the care Radis provided. Our focus, therefore, is to consider the impact of that fault and decide on a remedy which properly and proportionately reflects the significance of the injustice caused.

48. Our guidance on remedies explains that we would not usually recommend reimbursement of care fees where a service user has died. However, it also makes clear that we may do so where the service provided was so poor that the provider effectively failed to deliver the service paid for.

49. In Mrs Y’s case, the evidence shows the care fell below an acceptable standard over a sustained period. The shortcomings were significant and involved potential breaches of the CQC’s fundamental standards. This meant Mrs Y did not receive the level or quality of care she was entitled to expect. We find the care was so poor that Mrs Y’s estate should receive a full refund of any client contributions she paid to the Council between April and July 2024.

50. While only a court can decide whether the Council breached the Human Rights Act, the evidence shows that aspects of Mrs Y’s care engaged her rights under Article 3 (protection from inhuman or degrading treatment) and Article 8 (respect for private life, dignity and family life). The sustained failings in basic care and incidents that compromised Mrs Y’s safety meant the Council did not have due regard to these rights. This contributed directly to the injustice we have identified.

51. There was also significant delay in the Council’s completion of its safeguarding investigation. Under Section 42 of the Care Act 2014, a council must make whatever enquiries it considers necessary to decide what action to take and by whom. The accompanying Care and Support Statutory Guidance says councils should complete safeguarding enquiries in a timely way and keep the person and their family informed. While the law does not set a fixed deadline, the Council’s local policy suggests a 28-day deadline for the completion of enquiries.

52. In Mrs Y’s case, the Council received the safeguarding concern on 23 April 2024 but did not conclude the enquiry until 21 October 2024. That is around six months in total. While the Council refers to delay by Radis in completing an internal investigation and sharing relevant records, the Council remains the lead safeguarding authority and holds overall responsibility for ensuring enquiries progress promptly and without drift.

53. In this case, the records show the Council treated Radis’ internal investigation as if it discharged its own duty. It did not put in place clear oversight or scrutiny, despite the provider’s recent involvement in a ‘Large Scale Safeguarding Enquiry’ which is an investigation carried out when there are serious safeguarding concerns affecting several people, usually linked to the same provider. This enquiry related to wider concerns and was separate to the complaint raised about Mrs Y’s care. The Council’s lack of oversight led to significant delay and uncertainty for Mrs Y’s family during an already difficult time.

54. The Council has agreed to complete the actions recommended in the section below to remedy the significant injustice caused both to Mrs Y and her family.

Recommendations

55. The Council must consider the report and confirm within three months the action it has taken or proposes to take. The Council should consider the report at its full Council, Cabinet or other appropriately delegated committee of elected members and we will require evidence of this. (Local Government Act 1974, section 31(2), as amended)

56. In addition to the requirements set out above, the Council has agreed to take the following action within three months of the date of this report to remedy the injustice identified.

• Apologise to the family for the failings identified in this report. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology we have recommended in our findings.

• Refund the client contributions Mrs Y paid for the care Radis delivered between April and July 2024.

• Make a symbolic payment of £750 to Mrs Y’s family to recognise the significant

  distress caused by the care provider’s failings.

• Make a further symbolic payment of £250 to Mrs Y’s family to recognise the uncertainty, frustration and inconvenience caused by the significant delays in the Section 42 safeguarding investigation.

57. We have not recommended any service improvements in this case because the Council has accepted fault in its handling of safeguarding concerns and confirmed that it has strengthened its safeguarding processes. This includes enhanced monitoring of providers following Large Scale Safeguarding Enquiries and improved escalation protocols for serious incidents. Furthermore, the Council no longer commissions services from Radis.

Decision

58. We have completed our investigation into this complaint. There was fault by the Council which caused injustice to Mrs Y and her family. The Council has agreed to take the action identified in paragraph 56 to remedy that injustice.

Print this page