Summary: We find no fault in the way the Council carried out a safeguarding enquiry, but its communication regarding the police involvement could have been clearer.

The complaint

1. Mr B complains on behalf of his adult daughter, Ms C, who lacks the mental capacity to make the complaint. He says the Council has not carried out a proper safeguarding enquiry after safeguarding concerns were raised in November and December 2024.

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The Ombudsman’s role and powers

2. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We 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)
3. We cannot investigate a complaint about the start of court action or what happened in court. (Local Government Act 1974, Schedule 5/5A, paragraph 1/3, 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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What I have and have not investigated

5. Ms C’s care package is funded by the Integrative Care Board (ICB) so the care package is NHS funded. The actions of NHS agencies are investigated by the Parliamentary and Health Service Ombudsman (PHSO) and are outside of the LGSCO’s jurisdiction.
6. Therefore, I have not investigated the following:
• The actions of the ICB.
• Whether the ICB’s care plan meets Ms C’s needs.
• The actions of the care agencies funded by the ICB.
7. Also, there is a dispute between Ms C’s family and the ICB about Ms C’s care plan and the matter has been referred to the Court of Protection (CoP) so the CoP is making decisions about Ms C’s care plan. The Ombudsman cannot investigate the start of court action or what happened in court.

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How I considered this complaint

8. I have discussed the complaint with Mr B and I have considered the evidence he and the Council have provided as well as relevant law, policy and guidance.
9. Mr B 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

Law, guidance and policies

Care Act 2014

10. The Care Act 2014 and the Care and Support Statutory Guidance 2014 set out the Council’s duties towards adults who require care and support. The Council also has its own policies.

Safeguarding duty

11. Section 42 of the Care Act 2014 says that, if a local authority has reasonable cause to suspect that 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.
12. 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.
13. The CASS Guidance says:
• Although the local authority is the lead agency for making enquiries, it may require others to undertake them. 
• Where a crime is suspected and referred to the police, then the police must lead the criminal investigations, with the local authority’s support where appropriate, for example by providing information and assistance.
14. The Council’s safeguarding policy says:
• The enquiry lead will decide who is the most relevant person or agency to carry out an enquiry; with the police always leading criminal investigations.
• The need for police involvement is the person’s decision unless they lack capacity or there is a risk to others.

Carer’s assessment

15. The CASS Guidance sets out a council’s duty to carry out a carer’s assessment (Section 10 of the Care Act 2014):
• ‘Where an individual provides or intends to provide care for another adult and it appears that the carer may have any level of needs for support, local authorities must carry out a carer’s assessment. Where an adult provides care under contract (for example, for employment) or as part of voluntary work, they should not normally be regarded as a carer, and so the local authority would not be required to carry out the assessment.’

What happened

16. Ms C is an adult woman who has a learning disability and autism. She lives at home with her parents, Mr and Mrs B. She also had a care package funded by the ICB and provided by a care agency, Agency 1.
17. Organisation 1 is a third-party organisation for individuals who receive a personal health budget or direct payments for adult social care. They support in the recruitment and management of care providers and managing financial budgets.
18. Concerns had been raised about Agency 1 so the plan was for Agency 2 to take over from Agency 1. Organisation 1 was supporting Agency 2 in shadowing Agency 1 so that it could learn how to support Ms C and then take over.
19. In November 2024, Organisation 1 said Agency 2 was ready to take over the care package as it had been shadowing Agency 1 for 3 weeks.
20. Ms C’s sister, Ms D, sent an email to Organisation 1 on 5 November 2024. She said:
• The family had raised concerns about Agency 2 which had not been addressed. The concerns were that staff were sleeping and praying on duty during shifts.
• Agency 2 did not have any better specialist training than Agency 1. Agency 2 did not have a person-centred approach. The family was not convinced that Agency 2 was ready to take over the care package.
21. Organisation 1 responded to Ms D’s email on the same day and said:
• Agency 2 had been shadowing Agency 1 and all was going well. Organisation 1 had only received positive feedback and there had been no incident reports regarding Ms C displaying issues.
• The recordings and feedback were that Ms C responded positively to Agency 2’s staff and staff were confident they could provide care to Ms C.
• Agency 2’s staff had received the appropriate training to provide care to Ms C and this had been checked by Organisation 1.
• In response to the allegations of staff sleeping and praying during shifts, Organisation 1 said it had no evidence of this and the staff of the other agency had not reported any concerns or issues.
22. The family then refused access to Agency 2 and Organisation 1 made a safeguarding referral to the Council on 7 November 2024.
23. The Council held a safeguarding strategy meeting on 2 December 2024. Organisation 1, representatives of the ICB and Ms D attended the meeting. Ms D explained that the family had raised concerns about Agency 2 with Organisation 1 and said staff had slept and prayed while on shift and staff had looked at social media videos during a shift. Ms D said there had been no response from Organisation 1 so this was why the family had taken the action it had.
24. Organisation 1 said it had addressed all the concerns the family had raised about Agency 2 except for the social media videos issue which was a new allegation.
25. Ms D said the family found it overwhelming to have four staff members in the house (two from Agency 1 and two from Agency 2) and said it would be better if Agency 2 shadowed the family, rather than Agency 1. This was agreed as a way forward. Following this meeting, the family allowed access to Agency 2.
26. A second strategy meeting was held on 6 December 2024. Ms D said an incident had happened on 4 December 2024. She said Mrs B had taken Ms C to the shops and had told staff from agencies 1 and 2 to stay behind. A care worker of Agency 1 had entered the shop and this distressed Ms C who then threw herself on the floor.
27. Mr B arrived during the incident and said that staff had ‘pinned [Ms C] to the corner, restricting her movement. He also alleged that one of the staff members was dragging [Ms C] in and out of the house.’
28. The following actions were agreed at the meeting:
• The family would support Ms C and staff would shadow the family.
• A personal assistant who had known Ms C for years would continue to provide support until the plans were finalised.
• The CQC had been notified of the incident.
• The police had been notified and were involved.
• A further strategy meeting was to be held on 9 December.
29. The meeting was held on 9 December 2024. Ms D said that the family was still not satisfied with the care agencies but it was up to the ICB to agree a change. Nobody from the ICB attended the strategy meeting so it was agreed to hold a further meeting on 10 December 2024.
30. At the meeting on 10 December 2024 the following was noted:
• The attendants were informed that Agency 2 was no longer willing to shadow the family.
• The ICB representative explained that, as decisions regarding Ms C’s care package were decided by the CoP, the ICB had to seek legal advice before it could take any action.
• The police had been provided with a link to the CCTV recordings of the incident.
• Ms D said the family could continue to provide support and asked whether the personal assistant could provide more shifts.
• It was decided that the matter could not be progressed until the ICB had obtained legal advice.
31. At the strategy meeting on 20 January 2025, the attendants were informed that the ICB and the family were still waiting for a CoP hearing date. The family agreed to continue to provide support. The police had closed the matter and would not take any further action in relation to the incident on 5 December 2024.
32. There was a strategy meeting on 13 March 2025 but, as the CoP date had still not been set, the position remained as before.
33. A new agency, Agency 3, started to provide care in July 2025 and Ms D confirmed on 24 July 2025 that this was working well. The Council advised Ms D that it would close the safeguarding enquiry and Ms D agreed with this decision.
34. A hearing was held at the CoP on 5 September 2025 where it was agreed, among other things, that Agency 3 would continue to provide the care.

Mr B’s complaint to the Council and the Council’s response

35. Mr B complained to the Council in October 2025. The complaint was sent as a stage 2 escalation of a previous complaint (date not known ) which the Council responded to in November 2024. However, the October 2025 complaint related to the ICB’s decision to withdraw funding support from agencies 1 and 2 in December 2024 and to the Council’s safeguarding enquiry which was started in December 2024. Therefore, it appears the Council treated it as a new complaint.
36. Mr B said:
• The removal of the ICB’s commissioned care on 5 December 2024 left Ms C without professional support and the family at risk of a breakdown. The ICB did not provide alternative care which meant the family had to provide the care.
• The Council had not met its statutory duty under Section 42 to carry out a safeguarding enquiry. The Council had not carried out a safeguarding enquiry, risk assessment or a carer’s assessment.
37. The Council responded on 24 December 2025 and said:
• It received two safeguarding referrals, the referral dated 7 November 2024 against the family for not allowing Agency 2 access and the later referral in December from the family against Agency 2, in particular the incident on 4 December 2024.
• It set out the various safeguarding meetings that were held (as set out above) between December 2024 and March 2025.
• It explained that the family had been consulted throughout and agreed to continue to provide support at each meeting while the ICB tried to find a new agency. The matter was further complicated by the ongoing involvement of the CoP which had to approve the care plan.
• A police referral was made regarding the 4 December 2024 incident and the police confirmed on 20 January 2025 that no action was to be taken in relation to this incident.
• The ICB found Agency 3 to provide care to Ms C and Agency 3 was commissioned in June 2025. Ms D confirmed in July 2025 that this new agency was working well. Therefore, the Council decided to close the enquiry and this was agreed with the family.
• The safeguarding concerns raised had been addressed appropriately. Ms C had been safe in her family’s care during this time and the family had been involved in the decision making throughout.
• The family had not requested a carer’s assessment during any of the meetings and so therefore this was not considered as part of the safeguarding process. If the family wanted a carer’s assessment now, it should let the Council know. The Council included the contact details of the Carers Assessment Assessors which the family could contact to obtain a carer’s assessment.

Further information

38. Mr B took his complaint to the Ombudsman in February 2026. He said that the family had made allegations against Agency 3 and a new safeguarding enquiry had been started relating to those allegations. Mr B said that this reinforced his concern that the Council should not have closed the first safeguarding enquiry. He was of the view that the Council had not demonstrated that it was ‘holding the ICB to account for failures to act in my daughter’s best interests.’
39. The Council told me, in its response to the Ombudsman’s enquiries that it had not yet carried out a carer’s assessment. Mr B has informed me that the Council carried out a carer’s assessment of him in April 2026.

Analysis

40. I have set out the limitations of this investigation in paragraphs 5 to 7. I am not investigating the ICB’s actions nor the ICB’s care plan for Ms C as we cannot investigate NHS agencies, and, in any event the CoP makes decisions on Ms C’s care plan. The Ombudsman also does not carry out safeguarding enquiries. That is the Council’s role.
41. I have therefore explained to Mr B that my investigation into his complaint is very limited and only relates to whether the Council met its duty to carry out a safeguarding enquiry.
42. I note the following:
• The Council considered the Section 42 threshold and agreed to carry out enquiries relating to two referrals which were treated as a joint enquiry.
• The Council held multiple meetings to discuss the plans.
• The Council involved the family as much as possible in those meetings, in line with its duty to keep the person at the centre of the enquiry. There was a slight limitation to this as the first enquiry related to an allegation against the family.
• The Council addressed any risk to Ms C. The first risk related to the family’s refusal to allow access to Agency 2 which was resolved by the family’s agreement to resume working with Agency 2. The second risk related to the family’s allegations against Agency 2. Agency 2 refused to work with the family so there was no further risk and the family agreed to provide the care while a new agency was found.
• During the enquiry, the family did not raise any issues that it was struggling to provide care or that this could cause a safeguarding concern to Ms C.
43. I note that the Council did not carry out its own investigation into the incident on 4 December 2024 as the matter had been referred to the police. I find no fault in relation to this approach as this is in line with the CASS Guidance and the Council’s own safeguarding policy.
44. However, this could have been better explained to the family. It appears to me that the family thought that the police and the Council would be investigating the same incident which was not the case. A council does not normally investigate an incident when the police is involved as a council’s investigation could hinder the police’s work, particularly from an evidential point of view. This should have been explained to the family in the strategy meetings.
45. The Council should also have explained that its position was that, if the police found no evidence of a crime, then the Council would not carry out its own investigation.
46. However, overall I find no fault in the Council’s safeguarding enquiry. The enquiry addressed the concerns raised and the enquiry was closed when a new agency was found to provide support to Ms C. Mr B is of the view that the Council should have continued to be involved and have an oversight of Ms C’s care plan, but that was not the Council’s role and not its duty under Section 42. The fact that a further safeguarding enquiry was later started in relation to Agency 3 after the family made allegations against Agency 3 did not change that.
47. In terms of the carer’s assessment, I am working on the assumption that the ICB did not pay the family for the care they provided as the duties of the Council towards paid carers are different (see paragraph 15).
48. The Care Act and the CASS Guidance say that councils have a duty to carry out a carer’s assessment when ‘it appears that the carer may have any level of needs for support’. This normally transpires when a social worker is carrying out an assessment of a person’s needs or if the family carer tells the social worker that they need support or asks for an assessment.
49. The situation with Ms C was unusual as the Council did not carry out the assessment of Ms C’s needs nor did it write her care plan. That was the ICB’s role. Also, during the safeguarding meetings, the family raised no concerns about its continued provision of support. The family said they could continue to support.
50. Therefore I cannot say whether the duty had arisen as it is not clear to me whether the Council had been made aware that the family carers had support needs in their own right. However, it may have been good practice, for the Council to have raised the option of a carer’s assessment during the safeguarding meetings.

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Decision

51. I have completed my investigation and have not found fault by the Council.

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Investigator's decision on behalf of the Ombudsman