Summary: Mrs B complained that the Council had not properly investigated safeguarding concerns she raised about the care provided to her mother in a care home. We find that there was no fault in the way the Council carried out its investigations, but there was fault in the Council’s failure to involve Mrs B in the enquiries and in its communications. This left Mrs B with the impression that her concerns were not taken seriously. The Council has agreed to apologise and to carry out a service improvement.

The complaint

1. Mrs B complains on behalf of her mother, Mrs C, who lives in a care home (the Home).
2. Mrs B complained that the Council had not properly investigated safeguarding concerns that had been raised about her care at the Home.

Back to top

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. 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/care provider has done. (Local Government Act 1974, sections 26B and 34D, 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)

Back to top

What I have and have not investigated

6. Mrs B has complained about the care the Home provided to Mrs C. The care is funded by a different council so this council would have to address any complaints about the care.
7. Ealing Council has a safeguarding duty towards Mrs C as the Home is in Ealing. The safeguarding duties are determined by where the home is, but the duties under the Care Act lie with the authority which is funding the care.
8. Mrs B says she has raised concerns since 2019. I have investigated complaints relating to events from the beginning of 2024.
9. Although I have commented in this decision on information sharing in the context of the Mental Capacity Act, I have not investigated any complaints about disclosure of information specifically as these would be better investigated by the Information Commissioner's Office which specialises in complaints about the disclosure of information.

Back to top

How I considered this complaint

10. I have discussed the complaint with Mrs B and I have considered the evidence that she and the Council have sent as well as relevant law, policy and guidance.
11. Mrs B and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

Back to top

What I found

Law, guidance and policies

Safeguarding duty

12. Section 42 of the Care Act 2014 says the local authority should start a safeguarding enquiry if an adult in its area:
• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
13. The local authority must make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken.
14. The Care and Support Statutory Guidance emphasises the importance of putting the adult at risk of abuse at the centre of the enquiry. ‘Making safeguarding personal’ means safeguarding should be person-led and outcome-focused.
15. What happens because of an enquiry should reflect the adult‘s wishes wherever possible, as stated by them or by their representative or advocate.
16. The adult should always be involved from the beginning of the enquiry unless there are exceptional circumstances that would increase the risk of abuse.
17. If the adult has substantial difficulty in being involved, and where there is no one appropriate to support them, then the local authority must arrange for an independent advocate to represent them for the purpose of facilitating their involvement.

Mental Capacity Act 2005

18. The Mental Capacity Act 2005 and the Code of Practice 2007 are the framework for acting and deciding for people who lack the mental capacity to make decisions for themselves.
19. The Act says a person must be presumed to have capacity unless it is established that he does not.
20. A local authority must assess someone’s ability to make a decision when that person’s capacity is in doubt. An assessment of someone’s capacity is specific to the decision to be made at a particular time.
21. Any decision made on behalf of a person who lacks capacity must be in that person’s best interests.
22. A Lasting Power of Attorney is a legal document, which allows a person (‘the donor’) to choose one or more persons to make decisions for them, when they become unable to do so themselves.

What happened

23. Mrs C is an older woman who has dementia and physical disabilities. Mrs C moved into the Home in 2018. She has been assessed as lacking the mental capacity to make decisions about her daily living needs, where to live, taking medication, agreeing to a sensor mat and locked doors.
24. On 18 August 2024 the Home noticed that Mrs C had a bruise on her arm and a bruise on her leg. The Home informed Mrs B of the bruises and made a safeguarding referral to the Council. The Council made enquiries and closed the matter on 10 September 2024. The Council said there was no evidence of neglect or abuse and said the Home had taken appropriate measures to reduce the risk of bruising.
25. Mrs B visited Mrs C on 19 September 2024. Mrs B raised concerns that Mrs C had a small cut on her left upper lift and that she was wearing a shirt that was the wrong size.
26. A staff member said Mrs C developed a small spot on her lip on 13 September 2024 and this had been reported. Staff apologised for Mrs C wearing the wrong size clothing. Mrs B did not accept the apology. She said Mrs C took blood thinning medication and could not wear tight clothes as she easily bruised. Mrs B said staff were abusing her and Mrs C.
27. The Home took a photo of the lip and the GP examined Mrs C’s lip during their rounds on the same day. The GP did not raise any concerns.
28. In October 2024 the Home made a safeguarding referral to the Council regarding a small bruise on Mrs C’s right cheek and right lower eye lid and bridge of the nose, Mrs C’s eyes were itchy and she had a pimple on her nose. In November 2024 the Home made a referral as there were new petechiae (tiny burst blood vessels under the skin) on Mrs C’s right corner of the eye.
29. The Council carried out safeguarding enquiries into the concerns raised. The Council officer noted that Mrs C lacked mental capacity to give consent to the enquiry.
30. The social worker obtained the GP records and conversations, the risk assessments, care and support plans, medication charts and incident reports and considered these documents as part of the investigation. The Council noted that the Home contacted the GP about the bruises and the eye condition.
31. The GP said Mrs C had been prescribed eye medication for an eye condition and said Mrs C was on blood thinning medication which could be the cause of bruising. The enquiry was closed on 19 December 2024 and the Council concluded that there was no evidence of abuse or neglect by the Home.
32. The officer noted that Mrs B had asked for an ‘investigation to be completed against the Home, due to dissatisfaction of outcomes of previous safeguarding referrals.’
33. Mrs B complained to the Council in November 2024 and said she did not agree with the outcome of the safeguarding enquiry. Mrs B also pursued her complaint via her MP. The Council responded and said it did not have Mrs C’s consent to share information with Mrs B so it could not respond to the complaint because of confidentiality.
34. The social worker sent an email to Mrs B on 24 December 2024 and responded to Mrs B’s concerns about the safeguarding enquiry. The social worker provided details on how the Council had carried out the recent safeguarding enquiries and why it had come to its conclusions. The social worker said the referrals had been properly investigated. The social worker also provided a timeline of previous safeguarding referrals and enquiries that had taken place.
35. In February 2025 Mrs B sent a 34-page chronology regarding Mrs C to the Council which dated back to 2018.
36. Mrs B continued to send complaints and said she did not need a consent form to complain on behalf of her own mother who had dementia.
37. The Council responded on 8 April 2025 and said that it had caried out a safeguarding enquiry into this matter and it would not reopen the enquiry. It would not log Mrs B’s complaint as a new complaint.
38. The Council responded to the MP and said it could not respond to Mrs B’s complaint because of issues of confidentiality as Mrs C had not given consent to Mrs B to disclose information and Mrs B did not hold a Lasting Power of Attorney for Mrs C.
39. Mrs B continued to complain to the Council in the following months about the care provided by the Home and about the alleged failures by the Council to carry out an appropriate safeguarding enquiry.
40. Mrs B took her complaint to the Ombudsman. The Council told the Ombudsman it could not respond to Mrs B’s complaint because of confidentiality issues as Mrs C had not given her consent. The Ombudsman pointed out that Mrs B probably lacked capacity to sign the consent form as she had been assessed as lacking capacity in other areas. The Council said it could not say that as the MCA had to be decision specific and also said, as Mrs B did not have a Lasting Power of Attorney for Mrs C, it would not be able to share information even if Mrs C lacked capacity in this area.

Further information

41. I asked the Council whether it had involved Mrs B in the safeguarding enquiries and whether it had carried out MCAs of Mrs C’s capacity to decide on sharing information with Mrs B or agreeing for Mrs B to represent her in complaints.
42. The Council said:
• It had not carried out MCAs for those specific decisions, but admitted it should have done.
• It had focused on providing a ‘timely resolution’ on the concerns raised and ‘addressing the safeguarding concerns as quickly as possible’.
• It recognised ‘that not involving [Mrs B] directly in the safeguarding process was an oversight, and we sincerely regret any anxiety or inconvenience this may have caused.’

Analysis

43. I have not investigated the care provided by the Home or any complaints relating to the care, as explained in paragraph 6. I have also explained to Mrs B that it is not the Ombudsman’s role to carry out a safeguarding enquiry, as that is the role of the Council.
44. I have investigated whether there was any fault in the way the Council considered the safeguarding referrals and carried out safeguarding enquiries. I have done so by comparing what the Council should have done according to the law, guidance and policies with what it had done.
45. I note the Council did not involve Mrs B in the safeguarding enquiries even though it had assessed Mrs C as lacking the mental capacity to engage with the enquiries.
46. The Council had a duty to put Mrs C at the centre of the enquiries and, as Mrs C lacked the mental capacity to engage in the enquiry, it should have put her representative at the centre of the enquiry. Or if the Council it had decided that there was no suitable representative, it should have explained its reasons why and provided Mrs C with an advocate. The Council’s failure to take those actions was fault. I note that the Council has upheld this complaint in its response to the Ombudsman.
47. However, I find no fault, apart from the above, in the way the Council carried out the safeguarding enquiries. I note the following:
• The Council considered the safeguarding referrals and carried out appropriate enquiries of those concerns which it said met the section 42 safeguarding threshold.
• The Council obtained relevant evidence including all the relevant documents (see paragraph 30) from the Home and the GP.
• The social worker spoke to the relevant professionals.
• The social worker considered the evidence and explained their decisions in the safeguarding enquiry report.
48. So overall I cannot say that, apart from failing to involve Mrs B in the enquiries, that there was fault in the way the enquiries were carried out.
49. I appreciate that Mrs B does not agree with the outcome of the enquiries, but the Ombudsman cannot question the merit of a decision if there is no fault in the way the decision was made.
50. There was also some fault in the later communications with Mrs B about her complaint. In particular, the Council gave confusing reasons why it would not respond to her complaint.
51. In April 2025 the Council said it would not respond to Mrs B’s complaints about the Home as it had already investigated this matter, as part of its safeguarding enquiries.
52. I find no fault in that approach. We would not normally ask councils to reinvestigate the same complaint/concern twice. It is not unusual for councils to carry out a safeguarding enquiry instead of a complaint investigation.
53. And in terms of Mrs B’s complaint about the safeguarding enquiry itself, I note that the social worker wrote an email to Mrs B on 24 December 2024 where she provided details of the safeguarding enquiries the Council had made. It would have been helpful if the Council had explained that this was, in essence, its response to Mrs B’s second complaint about the safeguarding enquiry itself.
54. I therefore do not know why the Council then confused matters by repeatedly saying that it could not respond to Mrs B’s complaints because of confidentiality issues.
55. Firstly, the Council had a duty to carry out an MCA to determine whether Mrs C had the capacity to share information. Mrs C had been assessed as lacking capacity in a lot of other areas so her capacity to sign a consent form was clearly in doubt. And, if Mrs C had been assessed as lacking capacity to share information, then the Council should have made a best interest decision to decide what information it could share with Mrs B, rather than saying that, because Mrs B did not hold a Lasting Power of Attorney, it could not share information with her.
56. But, in any event, the statement that the Council could not share information contradicted the Council’s previous actions. The Council had responded to the complaints about the Home (by carrying out safeguarding enquiries) and it had responded to the complaint about the safeguarding enquiry in the email of 24 December 2024.
57. So, overall Mrs B’s injustice caused by the fault is small. It left Mrs B feeling that the Council refused to respond to her complaint when, to a large extent, it had already responded.

Back to top

Action

58. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise to Mrs B in writing for the fault I have identified.
• Ensure all frontline staff understand the Council’s duties under the Mental Capacity Act. It will provide training or guidance as needed.
59. The Council should provide us with evidence it has complied with the above actions.

Back to top

Decision

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

Back to top

Investigator's decision on behalf of the Ombudsman