Summary: Mr X complained about the care provided to his late mother, Mrs Y, by care providers on the Council’s behalf. Mr X also complained the Council failed to act on his reports and safeguarding concerns. Mr X was unhappy with the Council’s communication. The Council was at fault for two missed visits to his mother and a carer falling asleep during a shift. The Council was also at fault for its communication with Mr X. This caused Mr X uncertainty and frustration. The Council was not at fault for how it investigated his complaint or in its actions regarding the safeguarding concerns. The Council has agreed to apologise to Mr X and has offered to make him a payment.

The complaint

1. Mr X complained on behalf of his late mother, Mrs Y, who had dementia and has since died. Mr X said the Council did not provide Mrs Y with satisfactory care through two care providers, Provider A and Provider C. Mr X said the Council also failed to properly respond to his reports about errors in care provision and failed to act on safeguarding concerns. Mr X said the Council also made inappropriate remarks to him about how he was spending Mrs Y’s money and it did not investigate his complaint properly.
2. Mr X said this affected his health, concentration at work and sleep, as he felt he had to check the cameras at his mother’s home because of a lack of trust in the care provider. Mr X also said the Council’s mishandling of his complaint caused him stress. Mr X would like the Council to arrange for his complaint to be correctly and independently investigated.

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The Ombudsman’s role and powers

3. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
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). We also consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended).
5. Part 3 and Part 3A of the Local Government Act 1974 give 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 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act).
6. 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).
7. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974).
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

9. 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).
10. Mr X had concerns over the care provided to Mrs Y by Provider A between July 2023 and February 2024. Mr X complained to the Ombudsman in July 2025. Part of Mr X’s complaint is late. Mr X could have complained to us sooner about the care provided by Provider A. I have decided to investigate events between July 2024 and July 2025.

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How I considered this complaint

11. I considered evidence provided by Mr X, the Council and the Council’s website, as well as relevant law, policy and guidance.
12. Mr X 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

The Law

Adult social care and safeguarding

13. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include that providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences (regulation 9).
14. 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).

Adult Social Care complaints

15. Councils should have clear procedures to deal with social care complaints. Regulations and guidance say they should investigate and resolve complaints quickly and efficiently. A single stage procedure should be enough. The council should include in its complaint response:

• how it considered the complaint;
• the conclusions reached about the complaint, including any required remedy; and
• whether it is satisfied all necessary action has been or will be taken by the organisations involved; and
• details of the complainant’s right to complain to the Local Government and Social Care Ombudsman.
  (Local Authority Social Services and National Health Service Complaints (England) Regulations 2009).

16. The Council’s adult social care services complaints policy on its website said the service involved will normally investigate the complaint. The website said if the complainant is not happy with the response then they can complain to the Ombudsman.

Background

17. The Council secured Provider A to provide care to Mrs Y in her home in July 2023. Mr X had concerns over the care provided by Provider A, so the Council changed the care provider to Provider B from April 2024.
18. The Council arranged Mrs Y’s care, which she paid for in full.

What happened

19. Provider B provided care to Mrs Y in her home from April 2024 during the day and at night. In March 2025, the Council decided Mrs Y’s waking night visits should change to sleeping nights. Provider B told the Council it disagreed with the Council’s recommendation to change the type of night visit, and it would not provide sleeping night visits. The Council told Mr X it had found another provider, Provider C, who could provide the sleeping night visits. The Council and Mr X agreed that Provider B would continue to provide Mrs Y’s care during the day, and Provider C would provide care at night starting in late March 2025.
20. Provider B later told the Council it could not continue providing care to Mrs Y during the day. The Council secured another provider, Provider D, to provide Mrs Y’s care during the day from April 2025. The Council and Mr X agreed that Provider C would continue to provide the sleeping night visits.
21. On 22 April 2025, Mr X told the Council the carers from Provider C had not shown up for the night visit on 21 April 2025. Mr X told the Council that Mrs Y did not come to any harm, but he would like to raise the missed visit as a safeguarding concern.
22. The Council asked Provider C about this, and the Provider said it thought the arrangement was only for two weeks and had ended. The Council told Provider C it said it would review the arrangement after two weeks but did not say the contract would end. Provider C said it could restart the overnight visits that night, but the visits would have to be waking night shifts rather than sleeping night shifts.
23. The Council told Mr X it had agreed to two weeks of waking night shifts while it reviewed Mrs Y’s care. The Council said it could not agree to permanent waking night shifts as it had decided Mrs Y did not need them.
24. In May 2025, Mr X told the Council he had seen carers asleep on camera during waking night shifts. The Council carried out enquiries with Provider C about this. Provider C asked the Council to provide Mr X’s footage, and the Council said it would speak to Mr X to get his permission to do so.
25. In late May 2025, the Council and Mr X discussed his safeguarding concern about the missed night visit from 22 April 2025. The Council said it would close the safeguarding concern as no harm had come to Mrs Y, but he could complain if he wanted to. A few days later, Mr X told the Council that Provider C had missed another night care visit to Mrs Y.
26. On 2 June 2025, Provider C told the Council Mr X had reported another incident where a different carer was asleep during the night visit. Mr X had reported the matter to Provider C after seeing the carer asleep on camera. Provider C visited the carer at Mrs Y’s home, and the carer said they had accidentally fallen asleep. The Council and Provider C agreed to raise this as a safeguarding concern. Provider C gave notice to the Council to end the care package. Provider C told the Council that communication and trust with Mr X had broken down, and it could no longer meet Mrs Y’s needs.
27. Mr X complained to the Council and said he wanted the provider changed immediately. Mr X also complained the Council had not acted on his concerns and complaints and said it had not planned for the end of the two-week period where Provider C was providing overnight care for Mrs Y. Mr X also said the Council had made an inappropriate comment to him about his spending decisions for Mrs Y.
28. The Council responded to Mr X’s complaint in July 2025. It said Provider C had apologised and partially refunded Mr X for the carer sleeping on 2 June 2025. The Council said the other video clips were less clear. The Council accepted that Provider C missed two visits to Mrs Y on 21 April 2025 and 26 May 2025, the second of which was due to an issue with its electronic monitoring system. The Council also accepted it had given Mr X a dismissive response on one occasion when he had raised concerns and it had also made an inappropriate comment about his spending decisions.
29. In the Council’s complaint response, the Council agreed to take action to prevent a recurrence of the fault. It said it would refer Provider C to its quality assurance team to review the Provider’s new monitoring system. The Council also said it would remind staff to communicate in a respectful and appropriate manner and would share learning about safeguarding and meeting attendance with relevant teams.
30. The Council and Mr X met to discuss Provider C and Mr X said he had seen carers sleeping on night shifts 11 times. The social worker told Mr X they had asked for the budget to pay for waking night visits, but this was turned down. The Council apologised for the gap in provision after the two-week night care period and said it would review its processes. The Council closed the safeguarding concern regarding a second missed night visit as there had been no harm to Mrs Y and it had taken action to keep her safe in future.
31. Provider C told the Council it had watched some of Mr X’s camera recordings where he said the carers had been asleep. Provider C said it was unclear if the carers were sleeping or not. A couple of weeks later, Provider C gave notice it would stop night visits from 25 June 2025. Around this time, Mr X said he was looking to find a care home for Mrs Y to move into.
32. The Council also said that Provider C had not followed its own policies and procedures after a carer admitted falling asleep on 2 June 2025. Provider C should have sent the carer home but instead allowed them to finish their shift. On 10 July 2025, Mr X told the Council Mrs Y was in hospital and would be going into residential care from there.
33. Around this time, the Council told Mr X it had seen evidence that carers from Provider C were sleeping on night shifts. The Council said it would ask Provider C to charge for sleeping rather than waking night shifts between 24 April 2025 and when Mrs Y went into hospital. Provider C agreed this and said it would refund the difference in night care costs between 23 April 2025 and 18 July 2025.
34. Mr X remained unhappy and complained to the Ombudsman. Mr X said the Council told him his complaint would be investigated independently, but the Council then investigated the matter itself. Mr X said the Council’s investigation was not independent or factually correct.
35. In early August 2025, Mrs Y was discharged from hospital and she moved into a care home.

My findings

36. Provider C failed to provide person centred care when it missed visits and staff fell asleep while providing waking night care. There is no evidence of harm to Mrs Y. However, this was fault and was not in line with the fundamental standards of care.
37. The Council accepted that Provider C missed two night care visits to Mrs Y in April and May 2025. This was fault. It caused Mr X uncertainty about the reliability of care in place for Mrs Y. There was no evidence of harm to Mrs Y because of the fault.
38. The Council accepted that a carer fell asleep during a waking night shift on at least one occasion. Provider C also did not follow its own policies and procedures by letting the carer finish their shift. This was fault. It caused Mr X frustration and uncertainty about the care Provider C was delivering to Mrs Y. The Provider provided a partial refund for the difference in night care costs between 23 April 2025 and 18 July 2025. I consider this to be a suitable financial remedy for the injustice caused. The Council also acted by referring Provider C to its quality assurance team for these incidents. There was no evidence of harm to Mrs Y because of the fault.
39. The Council accepted it had given Mr X a dismissive response and made an inappropriate comment about his spending decisions. This was fault and caused Mr X frustration.
40. The law says the Council must make enquiries if it thinks a person is at risk of abuse or neglect. The Council made enquiries for each of the safeguarding concerns Mr X raised, including speaking with Mr X and the Provider. Our role is not to ask whether an organisation could have done things better, or whether we agree or disagree with what it did. Instead, we look at whether there was fault in how it made its decisions. If we decide there was no fault in how it did so, we cannot ask whether it should have made a particular decision or say it should have reached a different outcome. I have considered the steps the Council took to investigate the safeguarding issues, and the information it took account of when doing so. There is no evidence of fault in how it considered and responded to the safeguarding concerns.
41. Mr X complained the Council investigated his complaint itself rather than it being investigated independently. The statutory adult social care complaints process does not state that councils have to arrange for an independent investigation. The Council completed its investigation in with the guidance. The Council was not at fault.

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Action

42. When a council commissions or arranges for another organisation to provide services, we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of the care provider and make the following recommendations to the Council.
43. Within one month of the final decision, the Council has agreed to apologise to Mr X for the frustration and uncertainty caused by the two missed visits and the carer falling asleep during a waking night shift. The Council has also agreed to apologise for the frustration caused by its dismissive response and comment about Mr X’s spending decisions. 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.
44. The Council has also offered to pay Mr X £150 to acknowledge the frustration and uncertainty he experienced.
45. Within one month of the final decision, the Council has agreed to provide us with evidence it completed the actions set out in its complaint response, including that it:
1. Referred Provider C to its quality assurance team and the quality assurance team acted on this;
2. Issued a reminder to staff to communicate in a respectful and appropriate manner.
3. Shared learning about safeguarding communication and meeting attendance with relevant teams.
46. The Council should provide us with evidence it has complied with the above actions.

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Decision

47. I find fault causing injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman