Summary: Miss X complains the Council failed to respond and effectively deal with the safeguarding concerns reported to it. We have found fault in the Council’s actions for failing to inform Miss X about the progress and outcome of the referrals she had made. The Council has agreed to issue Miss X with an apology and complete service improvements.

The complaint

1. Miss X complains the Council failed to respond and effectively deal with the safeguarding concerns reported to it.

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The Ombudsman’s role and powers

2. 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)
3. 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

4. I considered evidence provided by Miss X and the Council as well as relevant law, policy and guidance.
5. Miss X and the Council were invited to comment on my draft decision. I have considered any comments before making a final decision.

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What I found

6. 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.
7. 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.
8. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement.
9. 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.

What happened

10. Mr Y was placed in the care home where Miss X works in mid-2024. Shortly after Mr Y arrived Miss X raised a safeguarding referral with the Council. The Council reviewed the referral, made enquiries and held a safeguarding planning meeting in late August 2024. The Council communicated with Miss X and Mr Y’s family regarding the referral and confirmed what action had been taken to protect Mr Y. The Council closed the referral in mid-September 2024 after speaking to Mr Y’s family.
11. Miss X raised a further safeguarding referral in November 2024 following an incident involving Mr Y. Miss X also informed the Police about the incident due to its nature.
12. The Council held a safeguarding meeting in early December 2024 which noted it would communicate with Mr Y’s care home to see what action had been taken and confirm how well that had been working. It also noted the Council would communicate with the Police and a different Council.
13. Miss X raised two further safeguarding concerns about Mr Y in late December 2024. The Council reviewed both referrals and decided it would take no further action. However, the Council says it cannot see it told Miss X it would not take any further action.
14. Mr Y was admitted to hospital in January 2025 and did not return to the care home where Miss X works.
15. The Council contacted Miss X in early March 2025 to find out what action the home had taken to safeguard following the incident which took place in November 2024.
16. Miss X raised a complaint with the Council in early March 2025 and said it had failed to act on referrals made to it.
17. The Council made enquiries about the November incident and referral in mid-March 2025. The Police confirmed in early April 2025 that there had been a delay in interviewing Mr Y.
18. The Council closed the safeguarding referral about the November incident in early April as Mr Y had moved out of the area.
19. The Council issued a response to Miss X’s complaint and said it completed enquiries into the November incident and a protection plan was put in place which should have been implemented by the care home.

Analysis

20. Miss X made several safeguarding referrals to the Council. The Council has assessed each of the referrals and decided what action, if any, it needed to take.
21. The Council initially acted on each referral Miss X has sent to it. However, it has not always kept Miss X updated with the outcome of the referrals.
22. The Council has acknowledged it had not updated Miss X about the referral she made in late December 2024. This is fault and would have caused Miss X frustration.
23. The notes from the safeguarding meeting in early December 2024 regarding the November referral say the Council would communicate with the care home, police and another Council. I have not been able to see that the Council took any action between the meeting in early December 2024 and March 2025 when the Council contacted Miss X. This is fault and would have caused Miss X frustration.

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Action

24. Within four weeks of a final decision, the Council should:

• Write to Miss X and apologise for the frustration caused by the faults identified. 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.
• Remind staff of the importance of keeping relevant parties updated with the outcome of any safeguarding referrals.

25. The Council should provide us with evidence it has complied with the above actions.

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Decision

26. I find fault causing injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman