Summary: Mrs X complained the council did not safeguard her relative, Mr Y. She also complained the Council did not respond to her complaint. Mrs X said this distressed her and Mr Y was left in an unsafe situation, resulting in harm and hospital admission. There was fault in the way the Council did not consider safeguarding reports and did not respond to Mrs X’s complaint. This frustrated Mrs X and caused her uncertainty. The Council agreed to apologise and make a financial payment.

The complaint

1. Mrs X complained the council did not safeguard her relative, Mr Y. She also complained the Council did not respond to her complaint. Mrs X said this distressed her and Mr Y was left in an unsafe situation, resulting in harm and hospital admission.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with a Council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
5. 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)

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How I considered this complaint

6. I read Mrs X’s complaint and spoke to her about it on the phone.
7. I considered evidence provided by Mrs X and the Council as well as relevant law, policy 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

Background information

9. 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)
10. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
11. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.
12. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan. The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.
13. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.
14. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
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 complaint policy says it will acknowledge the complaint within three working days, discuss the complaint and agree how to deal with it, set out a timescale and keep the complainant updated on progress.
17. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

What happened

18. This is a summary of events, outlining key facts and does not cover everything that has occurred in this case.
19. Mr Y had a package of care to support him to remain living independently at home. Mrs X contacted the Council in January 2025. She told the Council Mr Y was not coping at home.
20. The Council reviewed the support plan at the start of February 2025. It increased Mr Y’s package of care to four calls per day.
21. Mrs X continued to raise concerns throughout February and March 2025.
22. At the start of March 2025, a neighbour found Mr Y outside looking for a pet who had died some time ago. Mr Y was admitted to hospital but released shortly after. Mrs X asked the Council for a residential placement because Mr Y was a severe safeguarding risk.
23. A neighbour found Mr Y outside in the night looking for his pet again at the end of March 2025. Mr Y suffered injuries requiring medical attention and was admitted to hospital.
24. Mrs X complained the following day. She complained she asked the Council for help given the risks and Mr Y needing 24-hour support, but the Council had not safeguarded Mr Y.
25. The Council responded three days later saying it would not accept the complaint at this time given the safeguarding concerns. The response said it would pass the matter to its safeguarding department.
26. The hospital completed a mental capacity assessment and decided Mr Y lacked capacity. Mrs X supported Mr Y to move to a residential care home.
27. Mrs X chased the Council at the start of April 2025. The Council noted Mr Y was now in hospital, so it was not a safeguarding matter. It noted if Mrs X had concerns, she should raise them with the hospital. I have seen no evidence it communicated this decision to Mrs X.
28. Mr Y’s family arranged for him to move to a care home. Mr Y moved in April 2025.
29. Mrs X was not satisfied with the Council’s response and has asked the Ombudsman to investigate. Mrs X would like the Council to acknowledge its mistake.
30. In response to my enquiries the Council stated it considered the incident reported by Mrs X and the carers at the end of March 2025 but decided it had not met the threshold for safeguarding action and Mr Y was cared for in hospital. It accepted it did not communicate this decision to Mrs X.

My findings

Safeguarding

31. The Ombudsman is not an appeal body, and it is not our role to decide whether neglect or abuse has taken place, this is the Council’s responsibility. We do not take a second look at a decision to decide if it was wrong. We investigate the processes a council followed in making its safeguarding enquiries, to assess whether it made its decision properly. Our role is to consider whether the Council followed the Care and Support Statutory Guidance process and considered all relevant information to reach its view.
32. Mrs X raised concerns in January 2025. The Council considered the concerns, reviewed Mr Y’s support plan and increased the number of care visits per day. The Council considered the situation and acted appropriately to the concerns raised. The Council was not at fault.
33. In response to my enquiries, the Council said it considered the concerns after the complaint about the incident at the end of March 2025. It accepted it had not followed up on the concerns, given a clear rationale or recorded a decision. The Council apologised for this and detailed the service improvements it made. The Council accepts it did not respond properly after the incident at the end of March 2025. The Ombudsman expects a council to effectively communicate with people accessing its services. It did not. This is fault frustrating Mrs X.
34. Mrs X raised concerns throughout February and March 2025 and asked for a residential placement. The Ombudsman expects a council to consider the concerns and document its decision making. The Council has not provided any assessment or decision making for these concerns. The Council’s failure to properly consider Mrs X’s February and March 2025 concerns, is fault. I cannot say, even on the balance of probabilities, what the Council may have decided had it considered this properly, investigated and documented its decision making. However, there remains uncertainty for Mrs X about how things may have been different.

Complaint handling

35. When the Council received Mrs X’s March 2025 complaint, it considered the issues raised as a safeguarding concern. The Council told Mrs X it would not accept the complaint and would consider the safeguarding matter. I have found fault, above, with the lack of communication relating to safeguarding.
36. However, while Mrs X’s complaint was about the incident, it was also about Council “negligence” because she told the Council Mr Y was not safe at home before the incident and it had not acted. This is a complaint about the Council actions before the incident, so separable from the incident. The Council did not respond to this complaint. This is fault, frustrating Mrs X.

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Action

37. To remedy the outstanding injustice caused to Mrs X by the fault I have identified, the Council agreed to take the following action within 4 weeks of my final decision:
• Apologise to Mrs X for the distress, frustration and uncertainty the Council fault caused. 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.
• Pay Mrs X £300 to recognise the distress, frustration and uncertainty caused by the Council fault.
38. The Council should provide us with evidence it has complied with the above actions.

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Decision

39. I have completed my investigation. I have found fault by the Council, which caused injustice to Mrs X.

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Investigator's decision on behalf of the Ombudsman