Summary: Mrs X complained about the Council’s safeguarding investigation into allegations she made about her care provider. There was no fault in the Council’s handling of Mrs X’s safeguarding concerns.

The complaint

1. Mrs X complained about the Council’s safeguarding investigation into allegations she made about her care provider.
2. Mrs X was unhappy with the outcome of the Council’s enquiries, which she said were poorly led and did not include all her needs, wishes, feelings and desired outcomes, and did not include her ongoing concerns. Mrs X said the Council failed to prevent her suffering continuing harming. This caused her frustration and distress.
3. Mrs X wanted the Council to review her concerns and establish whether she did experience significant harm.

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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. 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)

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How I considered this complaint

6. As part of the investigation, I considered the complaint and the information Mrs X provided.
7. I made written enquiries of the Council and considered its response along with relevant law and guidance.
8. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Safeguarding

9. Safeguarding means protecting an adult’s right to live in safety, free from abuse and neglect. It is about people and organisations working together to prevent and stop both the risks and experience of abuse or neglect, while at the same time making sure that the adult’s wellbeing is promoted including, where appropriate, having regard to their views, wishes, feelings and beliefs in deciding on any action. (Paragraph 14.7, Care and support statutory guidance)
10. Safeguarding is not a substitute for:

• providers’ responsibilities to provide safe and high-quality care and support
• commissioners regularly assuring themselves of the safety and effectiveness of commissioned services
• the Care Quality Commission (CQC) ensuring that regulated providers comply with the fundamental standards of care or by taking enforcement action
• the core duties of the police to prevent and detect crime and protect life and property

(Paragraph 14.9, care and support statutory guidance)

11. The Care Act requires that each local authority must make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by who. (Paragraph 14.10, Care and support statutory guidance)
12. The aims of adult safeguarding are to:

• prevent harm and reduce the risk of abuse or neglect to adults with care and support needs
• stop abuse or neglect wherever possible
• safeguard adults in a way that supports them in making choices and having control about how they want to live
• promote an approach that concentrates on improving life for the adults concerned
• provide information and support in accessible ways to help people understand the different types of abuse, how to stay safe and what to do to raise a concern about the safety or well-being of an adult
• address what has caused the abuse or neglect

(Paragraph 14.11, Care and support statutory guidance)

What happened

13. I have summarised below some key events leading to Mrs X’s complaint. Mrs X raised many concerns and sent a numerous, detailed communications to the Council and the care provider. I have included what I consider are the most salient details. This is not intended to be a detailed account of what took place.
14. Mrs X is bed bound and has complex care needs. She received a package of care from a care provider consisting of four visits each day (one in the morning, two in the afternoon, and one at tea time). The morning visit was from two carers. All other visits were from a single carer. Carers help with feeding, washing, dressing, personal care, and medication.
15. Part of the carer’s role is to feed Mrs X through her feeding tube. The clinical name for the feeding tube is a Percutaneous Endoscopic Gastrostomy. I have referred to this in my decision statement as PEG feeds.
16. Mrs X has a urinary catheter fitted and which carers must empty. Carers must be mindful of Mrs X’s catheter when moving her or performing care duties.
17. A carer accidentally pulled out Mrs X’s catheter on 6 June 2024. It took several attempts by district nurses to reinsert a new catheter, causing Mrs X pain, bleeding and emotional trauma. The carer apologised.
18. Mrs X raised a complaint with the care provider. The care provider asked a carer to visit and photograph the catheter without Mrs X’s consent. Mrs X asked for a face-to-face meeting with the deputy manager of the care provider, but did not get one.
19. Mrs X reported the incident to the Council on 10 June. She asked a social worker to contact her.
20. A social worker telephoned Mrs X on 13 June 2024. Mrs X again described the incident and the impact on her. The social worker recorded Mrs X’s desired outcomes as: A visit to discuss her concerns; an independent enquiry; an acknowledgement from the care provider that policies and procedures were not followed; an acknowledgement her dignity was not preserved; confirmation photographic evidence was taken without her consent; for the photograph to be deleted; and an up to date care plan produced in consultation with her.
21. The social worker telephoned Mrs X again on 17 June 2024. They arranged to visit Mrs X on 20 June and said they would send her concerns to the care provider for answers.
22. The social worker met Mrs X on 20 June and confirmed they would carry out a safeguarding investigation.
23. Mrs X emailed the social worker after their meeting. She thanked the social worker and said they were very helpful. Mrs X also listed her preferred outcomes from the safeguarding investigation. This included a home visit from the manager of the care provider; prompt, transparent and respectful communication; preservation of her dignity; her wishes and feelings to be considered; and for carers to receive appropriate catheter training.
24. The social worker telephoned Mrs X on 24 June confirming they were considering paperwork Mrs X provided. They arranged to update Mrs X on 28 June.
25. The social worker spoke with Mrs X again on 28 June. They agreed to contact the district nurses and arranged to visit Mrs X to agree her outcomes before putting enquiries to the care provider.
26. Mrs X emailed the social worker on 30 June with a list of outcomes she asked to be reviewed and concerns she asked to be answered. This included emails and calls answered in 24 hours, her wishes and feelings considered, and all her complaints to the care provider to be completed. She also referred to amendments to her care plan and risk assessment being outstanding since December 2023, duty of care, and her human rights.
27. The social worker spoke to a district nurse on 2 July 2024. They did not know how the catheter came out but they were able to replace it. Mrs X was in pain and the district nurse said she telephoned about her catheter every day. They had a record of one previous incident where Mrs X’s catheter came out.
28. The social worker noted Mrs X repeatedly contacted the care provider asking for feedback and calls. The social worker asked Mrs X to stop sending emails, as she had reported her concerns and the Council was investigating.
29. Mrs X emailed the social worker on 10 July thanking them for visiting her home that day. She said she recently emailed a chronology of dates when care calls were missed or late. She asked the social worker to visit her again once the care provider responded to the Council’s enquiries.
30. The Council sent safeguarding enquiries to the care provider on 10 July. The enquiry form detailed the catheter incident, and the subsequent photographing of the catheter without Mrs X’s consent. The Council asked the care provider to explain what happened and how Mrs X’s inflated catheter balloon came out. It also asked the care provider to confirm what training staff receive on catheters and PEG feeds, and what mitigation needs to be in place in future.
31. The Council asked what mitigation the care provider would take regarding photographing the catheter, and what education staff may need.
32. The Council also raised the issue of Mrs X’s complaints about missed PEG feed calls, carers arriving late, or only single handed when she should receive double handed calls, and some calls missed altogether. The Council said these complaints were still outstanding and asked the care provider how it will ensure carers visit as planned.
33. The care provider told the Council it was considering giving notice on Mrs X’s care package. Due to the attitude of Mrs X and her husband, and threats they made, carers did not want to attend calls, and some refused.
34. The care provider wrote to Mrs X on 17 July, apologising for the catheter incident. It said it was an accident. It sought safeguarding advice, and the local safeguarding team did not think it met the criteria for investigation. The carer completed a reflective practice session and was put back through the provider’s learning process. It referred to previous similar incidents and asked to speak to Mrs X about different ways of working to mitigate the risk.
35. The care provider sent its safeguarding enquiry response to the Council on 24 July. The care provider explained how Mrs X’s catheter accidentally came out and said it conducted a full internal investigation. It said all carers receive incontinence and catheter care training. In future Mrs X would allow carers to carefully reposition her catheter bag before moving and assisting support. This was in line with feedback from district nurses and should mitigate against risks of a repeat. It also said it would ensure verbal communication and authorisation before taking any photographs. It said it would review its induction training accordingly.
36. The care provider explained one of Mrs X’s visits was single handed because a carer’s car broke down and Mrs X declined a later double crewed visit. It said there had been a breakdown in relations with Mrs X, and her manner made carers uncomfortable. Some carers asked not to be assigned to Mrs X. The care provider said it can provide carers for Mrs X, but she will need to accept new carers.
37. The care provider said it would review the multiple complaints Mrs X raised and ensure it finalised them.
38. The social worker telephoned Mrs X on 26 July to discuss the care provider’s response. Mrs X wanted the social worker to visit her to discuss the response before replying to the care provider. The social worker said they were going on leave, and the Council could allocate this to someone else. Mrs X said she would wait. The social worker arranged a home visit for 28 August.
39. The social worker visited Mrs X on 28 August, and they reviewed the care provider’s reply. Mrs X disagreed with it. She wanted to reply, highlighting her concerns and how the care provider failed to meet her care needs. The social worker noted Mrs X was not happy with how the care provider dealt with her complaints. She said it missed many calls and sent one carer for double handed calls. She wanted the care provider to investigate all her complaints and concerns. She also wanted to move to a different care provider. Mrs X agreed to have a joint meeting with the manager of the care provider as an outcome.
40. Mrs X emailed the social worker after their meeting on 28 August, asking the Council to start giving her direct payments so she could use a new care provider.
41. Mrs X emailed the social worker on 30 August stating the care provider had not assigned a carer for her morning call. She said the district nurse raised her concerns with the care provider’s manager.
42. The social worker spoke with Mrs X on 2 September to discuss issues with her care provider. Mrs X felt there was no response from the care provider about what happened, and she was not happy with the response it gave about photographing her catheter. Mrs X said she was not given safe and appropriate care by the care provider and there was no plan to mitigate future harm.
43. There was a joint meeting on 3 September with Mrs X, the social worker, and the care provider’s manager. Mrs X highlighted all her complaints the care provider had not addressed. There were 11 in total, including missed PEG feeds, missed care calls, and an outstanding risk assessment and care plan. The social worker discussed the fact the care provider did not report the catheter incident to the Council, and the care provider had a duty to ensure it attended and delivered Mrs X’s care. The care provider said carers were seemingly not confident to complete PEG feeds due to issues with Mrs X’s catheter. The care provider agreed to provide PEG trained staff.
44. Mrs X wanted the care provider to complete its investigations of her complaints, and complete a care plan and risk assessment, before she moved to a new care provider. The care provider agreed to complete this by 13 September.
45. The social worker agreed to do a written report with recommendations to the care provider on future learning and development. They also agreed to review Mrs X’s care needs for a change of care provider. Mrs X wanted a direct payment.
46. Mrs X agreed to stop sending emails to the care provider and accepted their apologies on her complaints, but she still wanted them investigating. The care provider agreed a two-week termination period for Mrs X’s care package.
47. After the meeting, the social worker reviewed Mrs X’s care and support plan and needs assessment, ready for her move to a new provider.
48. Mrs X emailed the social worker on 5 September with details of her complaints to the care provider. This listed missed PEG feeds and several missed care calls. She also said her care plan and risk assessment were outstanding since 2023. Mrs X posed numerous questions to the care provider and sought explanations for why things happened.
49. The care provider telephoned the social worker on 11 September. It was worried it would not be able to complete its investigations as Mrs X continued to send emails.
50. The care provider responded to Mrs X’s complaints on 13 September. It apologised for the delay responding to the complaints, citing an overwhelming, almost unmanageable, number of emails received from Mrs X. It then gave a response for each of the nine complaints it said Mrs X raised, seven of which related to miss care calls or PEG feeds. It said it would put employees through any necessary training and development.
51. The social worker telephoned Mrs X to discuss the care provider’s response. Mrs X said the care provider had not completed some investigations of her complaints, with four complaints not addressed. The social worker felt the care provider’s report was sufficient and addressed the points raised. Mrs X insisted the social worker followed up her requests with the care provider. The social worker explained they completed a safeguarding enquiry into her complaints, the care provider recognised its failings and identified lessons learned, including training for staff. It also apologised to Mrs X. The care provider then completed investigations into Mrs X’s complaints, and it was not required to complete another investigation.
52. The social worker then telephoned the care provider and discussed recommendations for future incidents, including completing untoward incident forms and sending them to the Council for things like incidents, accidents, injuries, and missed or cancelled care calls. The social worker also advised the care provider to escalate service user behavioural concerns and inform the Council if it was unable to provide staff to meet a service user’s needs.
53. Mrs X emailed the social worker again about her complaints to the care provider on 14 September. She said the care provider substantiated four complaints of missed calls. She said these should have been referred to safeguarding as failure in duty of care and neglect. She also said two of her complaints were still outstanding and asked the social worker to follow up with the care provider about them. She said the care provider had not addressed all her points of concern in their investigations so far.
54. The Council updated Mrs X’s care and support plan on 19 September 2024.
55. Mrs X emailed the social worker on 20 September asking for their meeting on 24 September to be audio recorded, like some previous meetings with the care provider had been. She said, due to her disability, it was reasonable to ask for written minutes and documentation so she can digest and reflect on the information.
56. The care provider also emailed Mrs X on 20 September. It said, as agreed with the social worker, it gave Mrs X one complaint resolution outcome and considered it had done what was required for her complaints. It would not take further action. It said it raised relevant safeguarding matters, but they did not meet the threshold for investigation.
57. The social worker visited Mrs X on 24 September to discuss the outcome of the safeguarding investigation. They recorded Mrs X was supported with all outcomes identified and moved to a new care provider. Mrs X acknowledged she received an apology letter from the care provider about the catheter incident, photographs of the catheter, and missed or cancelled care calls. Mrs X asked for another visit to discuss conclusions. The social worker advised Mrs X to contact the care provider if she wanted to follow up anything further.
58. The social worker emailed Mrs X after the meeting confirming they would send a copy of the outcome by post. If Mrs X disagreed with the outcome, she could complain. If she wanted to follow anything up with the care provider, then to use their complaint process. The social worker said the safeguarding investigation was closed and no further conversations or visits were needed.
59. The social worker then wrote to Mrs X with the outcome of their safeguarding investigation. They listed the outcomes discussed with Mrs X, including mitigation action by the care provider; learning for care provider staff; an up-to-date care plan, and then latterly to terminate care with the care provider in September 2024 and have a new provider.
60. The social worker said they sent enquiries to the care provider addressing all Mrs X’s complaint, and the care provider replied to explain the incident and their internal investigation. The care provider apologised to Mrs X. They also put the carer through training and reflective practice to improve skills and mitigate further incidents. The care provider is also aware it needs to ask for consent and explain the reasons if it wants to take photographs following any incidents in future. The care provider reviewed its induction training and ensured this is covered in data protection training. The care provider also deleted the photographs.
61. The social worker said Mrs X raised other complaints during their visits, such as missed care calls, carers not attending to deliver some care calls without informing her, and single carer visits which should be double handed. The calls involved personal care and PEG feeds. She also said the care provider failed to update her care plan or risk assessment.
62. The social worker stated they told the care provider it was unacceptable to send one carer for double handed calls. The care provider apologised for its poor communication and agreed to provide Mrs X a weekly rota so she would know in advance who will deliver her care each day. The care provider investigated Mrs X’s complaints about missed calls. It established some carers declined to attend calls with Mrs X due to catheter issues and personality clashes. The care provider said it would reimburse funding for missed or cancelled calls and improve its communication with Mrs X over this.
63. The social worker said the Council supported Mrs X to review her care and support plan and have a direct payment for a new care provider.
64. The social worker concluded by saying the care provider acknowledged its failings, showed learning from the incident, and identified staff training was needed to improve service delivery and reduce risk of harm in future. They said the outcomes Mrs X wanted were addressed and the Council would close the investigation.
65. Mrs X submitted a 31-page complaint to the Council on 31 October 2024, raising many points. The following are points I consider most relevant to my investigation:
• Mrs X’s care plan and risk assessment were not updated annually.
• Mrs X did not consider she was safeguarded. She did not feel safe from abuse or neglect.
• Mrs X questioned whether the safeguarding enquiry was well led and whether it identified risks and acted to safeguard her from future incidents.
• Mrs X frequently received no personal care in the morning, and carers arrived late. This left her at risk because she is bed bound, and she questioned the standard of care received. She said this was not addressed in the safeguarding report and the care provider has not been held accountable.
• Mrs X said there was a failure to meet contractual obligations and failings in duty of care by the care provider. This included missing many PEG feeds and was down to inadequate staffing. She raised this with the Council, but it did not include it in the safeguarding investigation.
• Mrs X said the safeguarding social worker did not consider her needs, wishes, feelings or desired outcomes and did not promote her independence. They failed to work with her and the care provider to establish what being safe means to Mrs X. She said the Council closed the case prematurely and did not discuss the conclusion and recommendations with her as promised.
• Mrs X said the Council would not accept a second safeguarding referral from her in August 2024 as it said it was similar to her previous complaints. She also said the Council only referred to one incident where her catheter came out, when it happened more than once. Mrs X tried to raise two more incidents of her catheter coming out and two where it partially came out, but the Council would not include them.
• Mrs X said the social worker asked her not to send any more emails to her or the care provider.
• Mrs X said the Council ignored her communications and did not consider her human rights.
66. The Council sent its complaint response on 10 December 2024. Its investigation into Mrs X’s complaint found:
• The social worker sent a detailed account of the safeguarding enquiry and reason for its closure to Mrs X. Their actions were appropriate and met safeguarding requirements.
• The social worker recorded Mrs X’s desired outcomes, and these were met through the enquiry. The enquiry demonstrated the principles of empowerment, protection, prevention, partnership, proportionality, and accountability.
• The risk to Mrs X was mitigated, it supported her to arrange a new care provider, and she is no longer in need of protection. The social worker worked with Mrs X to support her complaints against the care provider and try to resolve the issues she raised. The safeguarding enquiries were proportionate to the risk identified. The social worker ensured the care provider investigated, apologised and acted to address issues in care quality.
• There was a delay between the social worker’s visit to Mrs X on 24 June and sending the safeguarding enquiry form to the care provider on 10 July. However, the Council was aware Mrs X had already complained to the care provider, and it was looking into her complaints.
• The social worker discussed the care provider’s response with Mrs X and arranged a joint meeting with her and the care provider where Mrs X detailed the issues and her concerns. The care provider agreed to complete its complaint investigation and Mrs X would move to a new care provider. The social worker acted promptly and responsively, ensuring Mrs X’s identified outcomes were met.
• It may have helped clarify the scope and limitations of safeguarding enquiries if the social worker had produced a formal protection plan and shared it with Mrs X. However, the social worker did act to ensure Mrs X’s protection.
• The risks were mitigated and the outcomes Mrs X initially identified were met. That being the case, further safeguarding plans were unnecessary, and the investigation was closed as the Council considered it met its statutory duty.
• The social worker made several visits to Mrs X’s home and worked towards resolving the issues identified in the safeguarding enquiry, and the general quality issues Mrs X raised about the care provider. The social worker also worked with the care provider to address the issues, supported Mrs X with her complaints, and to arrange a direct payment with a new provider. The social worker was responsive to Mrs X’s phone and email communications, and the investigation was not affected by caseload pressure.
• Mrs X had a Care Act assessment on 11 September 2024, and a review of her care and support needs was completed on 19 September 2024.

Analysis

67. The social worker met Mrs X at the start of the process, to take her account of what happened, to understand the impact on Mrs X, and find out what outcomes she wanted to achieve.
68. Mrs X’s desired outcomes evolved over the course of the investigation. The social worker recorded the outcomes initially discussed with Mrs X. Mrs X then sent numerous emails during the investigation where she stated different or more outcomes. However, these outcomes still centred around the same themes as the outcomes discussed and agreed initially.
69. The social worker spoke to Mrs X throughout the investigation, keeping her updated, and met with her several times. They discussed their enquiries to the care provider, and the enquiries were drafted with input from Mrs X. The enquiries covered the issues Mrs X complained about and the outcomes she sought. The social worker raised the issue about missed PEG feeds and missed care calls in their enquiries, asking how the care provider would ensure it made visits in line with Mrs X’s care plan. They also highlighted that Mrs X’s complaints on this were outstanding.
70. The social worker then discussed the care provider’s response to their enquiries with Mrs X, and arranged a joint meeting with the care provider so Mrs X could raise issues directly and receive direct feedback.
71. The social worker considered the care provider gave a suitably comprehensive account of what happened, and what action it took to train staff and mitigate future risk. As a result, the social worker was satisfied there was no significant continuing risk to Mrs X. This was particularly the case as Mrs X wished to change care provider, which the Council supported her to do after reviewing Mrs X’s care and support plan.
72. Mrs X said she reported another incident where her catheter came out in August 2024. She said the Council did not include this in its enquiries and failed to keep her safe. I found issues with moving and handling were highlighted as part of the safeguarding investigation, and the care provider suggested a new process to minimise the risk. The Council was satisfied with this approach. Risks such as this cannot be completely eliminated. Mrs X’s catheter had come out before and the Council cannot guarantee it will not happen again. However, it was satisfied with the care provider’s investigation into how the incident happened, and how it intended to try to avoid a repeat. I found no fault in that decision.
73. Mrs X wanted the care provider to investigate several ongoing complaints in addition to the catheter incident. She was not satisfied with its response. I found some of these issues were included in the Council’s formal enquiries to the care provider, and the issues that arose later were discussed between Mrs X, the social worker and the care provider at their joint meeting. The care provider then sent a complaint response addressing the issues. Mrs X raised many points of complaint, and went into great detail about the issues and her desired outcomes. The social worker considered the care provider properly addressed the issues Mrs X raised, and I did not find fault in this regard. Mrs X told me the social worker said the care provider did not need to respond to all her complaints. I found no evidence to support this assertion.
74. Mrs X also said she was blocked from communicating about ongoing concerns, and her emails throughout the investigation were not acknowledged. I found that, during the joint meeting, Mrs X was asked to pause sending emails to the care provider while it completed its complaint investigation. I did not find the Council told Mrs X to stop sending emails or reporting incidents. I found Mrs X sent many emails throughout the investigation. While the Council may not have responded to each email, it was in regular contact and included the issues Mrs X raised in its investigation.
75. The social worker followed up with the care provider after it responded to Mrs X’s complaints. They gave recommendations on how the care provider should report incidents to the Council in future, including staffing issues and service user behavioural concerns.
76. The social worker also met with Mrs X to discuss the outcome of the safeguarding investigation. Mrs X wanted a further meeting to discuss things. I do not criticise the social worker for not agreeing this. They explained the outcome to Mrs X and the reasons why they were satisfied with the care provider’s actions.
77. Mrs X asked the Council to record the outcome meeting. She said she needed to be able to digest and reflect on the information. I am satisfied the Council met this need by summarising the outcome meeting in writing, as well as sending a written copy of the final outcome report.
78. I found the social worker fully involved Mrs X in the safeguarding process at every step and took account of her wishes and desired outcomes. They made relevant enquiries in line with the issues raised, and considered the care provider’s responses with the input of Mrs X before reaching a decision to end the investigation. The Council is satisfied its safeguarding investigation was proportionate to the identified risks and Mrs X’s desired outcomes. It was also satisfied the care provider addressed Mrs X’s complaints, and mitigated the risk. I found no fault in the Council’s decision-making.
79. I am satisfied the Council demonstrated it acted in line with the Care and support statutory guidance, and with the aims and requirements of the Care Act 2014, when responding to Mrs X’s safeguarding concerns.

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Final Decision

80. There was no fault in the Council’s handling of Mrs X’s safeguarding concerns.

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Investigator's decision on behalf of the Ombudsman