Summary: Mx Y complains about the Council’s response to a safeguarding referral it received about abuse by a care worker. We find the Council ended its safeguarding involvement prematurely. Although the Council later resumed its investigation, the earlier decision to close the enquiry caused avoidable distress. Mx Y also complains the care provider failed to deliver the agreed level of care to meet their assessed needs. We find fault because the provider did not consistently deliver the care hours the Council assessed as necessary. The Council will complete the remedial actions listed at the end of this statement.

The complaint

1. Mx Y complains the Council failed to properly investigate the safeguarding concerns raised about their former carer. Mx Y also says the Council failed to keep them updated during the safeguarding investigation and failed to seek their views.
2. Mx Y also complains the care provider, Domiciliary Care Experts (DCE), has not consistently delivered care and support in accordance with their assessed needs. In particular, Mx Y says the provider sometimes arranged evening care calls, which is against Mx Y’s preference. They also say the provider often fail to deliver the full care package as funded for 16 hours of support each week.

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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)

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How I considered this complaint

5. I considered evidence provided by Mx Y and the Council as well as relevant law, policy and guidance.
6. Mx Y 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

What should happen

7. 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. A council 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)
8. 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. The law and guidance do not set a fixed timescale for the completion of any enquiries.
9. The ‘Kent & Medway Safeguarding Adults Board’ (KMSAB) practice guidance makes clear that enquiries should progress at a pace proportionate to the level of risk, complexity, and multi‑agency involvement. Timescales should be monitored by the Safeguarding Adult Manager, taking account of factors such as police investigations, provider or people‑in‑positions‑of‑trust processes, and the adult’s wishes. The guidance recognises that enquiries may range from information gathering to prolonged multi‑agency activity.

What happened

Safeguarding

10. In April 2024, a care worker employed by the care provider commissioned to deliver Mx Y’s care moved into Mx Y’s property. This was shared accommodation with individual tenancy agreements issued by the property’s landlord.
11. The care provider became aware in July 2024 that the carer worker was living with Mx Y. Mx Y says the care provider took no action, despite their known vulnerabilities.
12. On 20 July 2024 the care provider emailed the care worker to say that they could continue to live with Mx Y if they were not also acting as their support worker.
13. Dissatisfied with the lack of action taken, a friend of Mx Y made a safeguarding referral to the Council in September 2024. A strategy discussion took place some days later. This covered the following key points:
• The Inquiry Officer (IO) will complete a home visit to Mx Y to assess the living circumstances. The visit may take place alongside the police.
• The IO to make enquiries with the landlord regarding the tenancy arrangements for the care worker.
• The IO to liaise both with the police and the Community Mental Health Team (CMHT) to establish what support, if any, Mx Y is receiving.
• The IO to gather the views and wishes of Mx Y.
• The IO to gather information from the carer provider about the care worker.
14. The Council completed a home visit on 12 September 2024. Mx Y said the matter was settled. Although the landlord had no grounds to evict the care worker, Mx Y received assurances the care worker had received a verbal warning about their behaviour. The care provider also said the care worker no longer worked for them. Mx Y has since expressed that they were unable to speak freely during this meeting as the care worker was present in the house at the time.
15. During the visit, the Council records Mx Y’s wish for the safeguarding matter to be closed. Another housemate told the Council the care worker was “manipulative” and expressed concerns that they were possessive towards Mx Y and the negative influence this had on Mx Y’s mental health.
16. The IO also discussed the concerns with the police who confirmed that Mx Y was spoken to and reported no criminal offences. The IO relayed this information to Mx Y who said they would contact the non-emergency police number to share further evidence to support their allegation. The IO also spoke with the care provider and recorded “… [Mx Y] has agreed to go with one of the carers to the police station to report it…. and will contact the agency when [they] are ready to visit the station for their support”.
17. Following this, Mx Y said they did not want the Council to continue with a safeguarding investigation. Mx Y said they did not want to move house due to the proximity of their support network. The Council formally ended its safeguarding investigation in October 2024.
18. In late December 2024, the Council received further concerns about the care worker’s behaviour in relation to alleged psychological abuse. Mx Y made several phone calls to the Council, who directed Mx Y to the police. Mx Y had expressed fear for their safety and decided to temporarily move to a family member’s home.
19. Around this time, the Council also received a referral from an NHS officer outlining their concerns about the care worker.
20. The care provider met with Mx Y to discuss their concerns. Mx Y expressed frustration about possible bias from the care provider, acting as employer. Mx Y also expressed concern about the care provider relaying information to the care worker and placing them at further risk.
21. In early January 2025 the care provider confirmed the police had taken statements regarding the allegations made. The care provider also took statements from relevant staff members and provided a summary of its investigation.
22. On 12 February 2025 the Council reviewed the evidence received as part of the safeguarding enquiries. It noted the following key points.
• Mx Y recently disclosed abuse by a former care worker and housemate. The abuse included verbal aggression, intimidation and sexually inappropriate comments. Mx Y has recently moved to a safe place whilst the case is investigated.
• The care worker moved out of the shared accommodation in early January.
• The police have stated, although unpleasant behaviour took place, no crimes were disclosed. The police confirmed their intention to file the case. The care provider was informed so that it could deal with the matter internally through disciplinary processes, as necessary.
• Mx Y has declined a secondary referral to support services because their previous GP referral was not successful.
23. The Council spoke with Mx Y to relay information from the police and to obtain their views and desired outcomes. Mx Y said they would like the care worker to lose their job.
24. The police formally concluded its investigation in June 2025 with no further action.
25. Following this, the Council arranged a multi-agency meeting, and concluded:
• The care provider has confirmed its policy says that staff members must not live with service users unless there is an agreement in place.
• Mx Y is now safe and is no longer at risk of harm. The care worker no longer lives with them and has no contact with Mx Y or other vulnerable people living in the property.
• The police have decided to take no further action.
• Mx Y has arranged to change their locks and had access to a doorbell camera.
• The Council recommends the safeguarding enquiry to be closed and any ongoing concerns to be addressed through case management with Mx Y’s allocated social worker.

Delivery of care

26. In March 2025 Mx Y reported the care provider changed their rota for care calls without first informing them. Mx Y said one of the changes involved carers attending in the evening to assist with medication; something which Mx Y said they did not want or need.
27. The Council has provided evidence of support plans and reviews of Mx Y’s social care since 2023. All of these say that Mx Y needs 16 hours of support per week.
28. On 27 March 2025 the Council visited Mx Y to discuss their care needs and problems relating to their visits. Mx Y told the Council they wanted to have their weekly support delivered over three days: five hours for two days and six hours on the third day.
29. On 19 September 2025 the care provider emailed the Council to say that Mx Y would only allow one named person into their property. Mx Y says this was due to the significant trauma previously experienced and the subsequent loss of trust. The care provider said it had concerns that Mx Y’s preferred care worker was soon to be on leave and Mx Y would not allow any other care worker to support them. Mx Y said they would call the police if another care worker attended.
30. A review completed by the Council in September 2025 showed that Mx Y was receiving only 15 hours of support each week. This represented a weekly shortfall of one hour. Following this, the Council says it:
• Reviewed and amended the care pattern to ensure delivery in “usable blocks”.
• Raised concerns with the provider as part of the safeguarding enquiries and asked them to account for service delivery.
• Moved Mx Y to a Direct Payment (DP) arrangement, as per their preference, to enable Mx Y to secure reliable hours with a Personal Assistant of their choice.

Was there fault by the Council causing injustice to Mx Y?

Safeguarding

31. Although the second safeguarding enquiry was lengthy, the records show the Council’s actions were influenced by ongoing and unresolved issues with the care provider. In these circumstances, the duration of the enquiry was broadly in line with the Council’s published guidance and is not procedural fault.
32. While there were periods when communication could have been clearer, including an explanation of safeguarding processes, the IO’s role, or how Mx Y would be involved, the Council did maintain regular contact with Mx Y and sought their views at key points during the enquiry.
33. However, in response to our enquiries, the Council has acknowledged that its handling of the initial safeguarding concerns raised in September 2024 was not sufficiently robust. Although Mx Y asked for the safeguarding investigation to end, the Council should have used its professional curiosity to balance this request against the information it held from others about potential coercion and manipulation, rather than treating Mx Y’s wishes as final.
34. This is because Section 42 of the Care Act 2014 places a duty on councils to make safeguarding enquiries where they have reasonable cause to suspect an adult with care and support needs is at risk of abuse or neglect and unable to protect themselves. This duty is triggered by the level of risk and does not depend on the adult’s consent.
35. The Council accepts the first enquiry should have gone further to ensure the alleged perpetrator was no longer employed by the care provider and posed no ongoing risk. The Council should have also ensured that this was properly communicated to Mx Y. The Council acknowledged that better oversight at that stage could have provided greater reassurance to Mx Y. I agree that there was fault in how the Council handled this matter in September 2024 which caused avoidable distress to Mx Y, which the Council will provide a symbolic remedy for.

Delivery of care

36. Mx Y had preferences for care to be delivered at certain times and by a single named worker. While the Council and care provider should take preferences into account where possible, they do not amount to assessed care needs. The Council and provider were therefore not required to guarantee they would always be met unless this had been agreed and recorded as a reasonable adjustment under the Equality Act. There is no evidence Mx Y or their representative requested such an adjustment during the period I have considered. I therefore do not find fault where the Council or care provider could not accommodate these preferences on every occasion.
37. With that said, the Council acknowledged that Mx Y was consistently assessed as needing 16 hours of support per week, but the commissioned care package was often delivered over three five hour visits, amounting to 15 hours. The Council accepted that this represented a shortfall of one hour against Mx Y’s assessed needs and that the provider did not correct this.
38. However, the Council explained that, in practice, the delivery of care was often flexible rather than fixed, with hours being moved or reduced in response to crises, Mx Y’s preferences, and staffing problems. It said that the most significant factor affecting delivery was Mx Y’s preference for receiving care only from a single named worker, which meant the provider was unable to deliver the full rota at times when that worker was unavailable.
39. The Council maintains that, once the shortfall was identified, it acted through care reviews, raising concerns with the provider as part of safeguarding enquiries, and, with their consent, moving Mx Y to a direct payment arrangement. This resolved the issue by giving Mx Y control over their package of care and support.
40. While the Council states the shortfall was usually only one hour per week, the rotas provided by Mx Y show that delivery was significantly below this level. Recorded weekly provision ranged from as little as three hours to a maximum of 15 hours, with most weeks falling well short of the hours Mx Y needed. The shortfalls were persistent and continued over an extended period.
41. It is important to note that Mx Y’s preferences limited the amount of care the provider could deliver when the chosen care worker was unavailable. While the Council later identified the issue and took steps to address it, including engagement with the provider and moving Mx Y to a direct payment arrangement, it did not maintain sufficient oversight to ensure the commissioned care was delivered as agreed. This is fault, as the Council is responsible for securing the assessed level of care and support. The fault caused avoidable distress to Mx Y which the Council will provide a symbolic remedy for.

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Action

42. Within four weeks of our final decision, the Council has agreed to:
• Apologise to Mx Y for the fault we had identified, including the premature closure of the safeguarding investigation in October 2024, clarity of communication and the failure to ensure the delivery of the full hours needed to meet Mx Y’s assessed needs. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council will consider this guidance in making the apology.
• Make a symbolic payment of £500 to Mx Y in acknowledgment of the distress caused by fault. I recognise Mx Y experienced significant distress during this period. However, I can only attribute part of that distress to the identified faults.
43. Within twelve weeks of our final decision, the Council will also:
• Provide evidence to show it has reviewed its monitoring arrangements for commissioned care packages to ensure that under delivery, especially when persistent or prolonged, is identified and escalated promptly. This should include trigger points for a review where care is consistently delivered below what the person is assessed as needing to meet their eligible care and support needs.
44. The Council will provide us with evidence it has complied with the above actions.

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Decision

45. I find fault causing injustice. The Council will complete the actions listed in the section above to remedy the injustice caused by fault.

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Investigator's decision on behalf of the Ombudsman