Date of decision: 27 August 2025
Summary:
A man complained that a home care agency commissioned by Essex County Council repeatedly gave his disabled wife paracetamol doses less than four hours apart, withheld medication records, and misled him about its actions. The investigation found both the provider and the Council at fault for unsafe medication administration, missing records, and poor safeguarding.
What happened:
Mrs B, a disabled adult, received four daily care visits from Brooks Care and Nursing Services Ltd, a company commissioned by Essex County Council. Her husband, who held a welfare power of attorney, noticed in October 2024 that carers had given her paracetamol less than four hours apart on several days. When he questioned this, the Care Provider’s manager said home care was “not an exact science” and later told him that three-and-a-half-hour gaps were acceptable. Still dissatisfied, he asked for copies of medicine administration records (MAR charts) for previous months.
On 1 November 2024, the Care Provider said a GP and pharmacist had confirmed minor timing variations would not harm Mrs B. Further, as Mrs B did not usually have more than three doses a day there was “even less risk of harm”.
It told care staff to avoid giving doses less than four hours apart but downplayed the risk.
Mr B continued requesting MAR charts and raised more dosage errors in November, one less than two hours apart. He was concerned about this because Mrs B’s body weight was very low.
The provider refused detailed explanations, dismissed concerns, saying that twice a day or the family taking that aspect of the care over would be a solution; and told him to communicate only through the social worker because the company was not willing to continue ‘the conversation’.
By late November, Mr B had contacted the Care Quality Commission (CQC), triggering a safeguarding enquiry through the Council (because CQC does not DO the investigation itself).
In December, Mrs B’s GP independently warned the Care Provider that the medication timings risked unsafe care. The Council’s safeguarding lead asked Mrs B’s social worker to investigate, but she relied mainly on the provider’s account, which under-reported errors. The Care Provider supplied partial MAR charts, missing August and December records, claiming earlier files were archived. On 23 December 2024, the Council closed its enquiry, concluding there had been “no errors” and “no ill effect.”
In January 2025, after reviewing the available charts himself, Mr B identified at least 11 occasions of sub‑four‑hour doses, including four less than two hours apart. He raised this with the Council, but its senior social worker responded defensively, suggesting he change providers and criticising his contact with the CQC. Mr B then complained formally.
The Council’s internal review in February 2025 upheld only part of the complaint, acknowledging some missing records but maintaining no harm occurred. When the Ombudsman investigated, it found at least 16 documented dosing errors between March and November 2024, with intervals as short as 41 minutes. The Care Provider’s notes omitted key incidents, and its correspondence with Mr B showed dismissive and misleading conduct. Its offer to restrict paracetamol to two fixed times daily also ignored the “as needed” prescription requirement.
The Ombudsman found the Council failed properly to analyse medication records, did not cross‑check with the GP, failed to challenge missing or falsified records, and communicated poorly with Mr B. It did not inform him of safeguarding findings and ignored his subsequent attempts to clarify matters.
What was found:
The Ombudsman found fault by both the Care Provider and the Essex County Council. The Provider would likely be found to have been in breach of duties under Regulations 12, 16, 17, and 20 of the Health and Social Care Act 2008.
- Regulation 12 covers ‘safe care and treatment’. Providers must be able to show they have taken all reasonable steps to ensure the health and safety of those in their care and can manage risks arising while providing care.
- Regulation 16 covers ‘receiving of and acting on complaints’. Providers must have effective and accessible procedures for identifying and responding to complaints.
- Regulation 17 covers ‘good governance’. Providers must keep accurate, complete and detailed records about each person using their service.
- Regulation 20 refers to the ‘duty of candour’. Providers must act in an open and transparent way with people who receive care and treatment.
The Care Quality Commission also publishes specific advice on medicine administration in someone’s home. It says care providers should:
- keep a clear record of all support provided for each medicine. This should include who gave the medicine and whether the client took or declined it;
- agree with a family member if they may give medicine to the client instead at times;
- have a record of how often, and at what times, it should offer or give medicine;
- keep medicine administration records for “at least” eight years after the person’s care ended with the service. Archiving records was not an excuse as any company should be able to recover records from its archives.
A proposal to offer the medication at breakfast and tea, meant there could be no prospect of her having two doses within four hours. But it also meant Mrs B might have to wait several hours longer than necessary for the medication, when in pain.
The Council was separately at fault for flawed safeguarding under the Care Act 2014, poor oversight of a commissioned provider, and dismissive communication. These failings caused distress, frustration, and uncertainty about possible harm to Mrs B.
The Council:
- failed to press the Care Provider on what it told the GP. Did it make them aware of the true number, frequency and nature of the incidents where it gave paracetamol less than four hours apart;
- did not check what instructions the Provider gave its care workers on time intervals between paracetamol doses (given Mr B’s original suggestion set out in paragraph 17 which he repeated subsequently);
- did not check why, if as claimed, the Provider spoke to care workers on 21 October, just two days later, it again gave doses less than four hours apart;
- did not pursue the large gaps in record keeping;
- did not speak to Mrs B’s GP.
It then overlooked repeated efforts by Mr B to point out the number of incidents its social worker should have known about. The email sent to Mr B by the senior social worker in reply to one of his, on 10 January 2025, was wrong in content and tone.
It showed no regard for Mr B’s understandable concerns. It failed to engage with his reasonable questions and comments. It offered no reflection on the Care Provider’s engagement with the issue at the crux of his concerns. It suggested unhappiness Mr B had alerted the regulator to his concerns and suggested Mr B should seek a different provider. This was inappropriate as there was nothing petty or unreasonably persistent in Mr B’s contacts. A Council should not encourage users of services to seek a different provider because they seek to raise a legitimate concern.
The Council and Provider each apologised and agreed to pay £300 to Mrs B and £300 to Mr B for distress, plus £150 for Mr B’s time, trouble, and poor communication.
The Council also agreed to locate missing MAR charts, review medication procedures, and improve staff handling of complaints and safeguarding enquiries to ensure evidence‑based investigations and proper signposting to complaint routes. The report was shared with the CQC by the Ombudsman.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
Community care law emphasises that safeguarding enquiries under section 42 of the Care Act must be proportionate, evidence-based and fair, but also inquisitorial and not reliant solely on a Provider’s account, for obvious reasons.
In this case, proper accountability would require independent verification of any alleged error, consultation with health professionals, and inclusion of the family’s evidence before closure. The Council’s reliance on incomplete MAR charts and dismissive closure breached the requirement to make – or to cause to be made – whatever enquiries should have been regarded as necessary to decide if action was needed to prevent neglect. In public law terms, the Council failed in its duty to equip itself with sufficient information to discharge the evaluative and decision-making tasks.
In community care law, a safeguarding enquiry is not merely a paper exercise. The lead agency must evidence its fact-finding, disclose relevant information to the complainant unless restricted by law, and record how it evaluated disputed accounts. The Ombudsman’s report could have more clearly identified the clear procedural fault in terms of public law principles, which is to take account of all relevant considerations.
Similarly, the Council’s response to Mr B disregarded guidance that adult safeguarding must “make safeguarding personal” — by consulting and feeding back to service users and their representatives.
The Care Act consolidated the legal principle that if a council uses a contractor to deliver the services, it cannot thereby get out of the public law responsibility to meet the needs adequately, and is thus responsible for the failings of a commissioned provider, whom it should be scrutinising not the least because of the s5 duty regarding the promotion of quality in the market. It remains the legal decision-maker with ultimate accountability for safety and compliance, even where providers are independent, and even if a decision-making function has actually been formally delegated (which can be done for care planning, albeit not for safeguarding functions).
A safeguarding response that compounds distress, or fails to support a carer’s reasonable safeguarding alert, offends the duty to promote wellbeing of carers as well as service users.
Finally, public law principles in community care law require a fair, transparent, and non‑defensive investigation process. The record here shows the council closing its safeguarding enquiry without independent scrutiny or timely communication. The Ombudsman could have stressed that the omission of MAR charts and absence of a valid capacity or best‑interests record could render a safeguarding decision inadequate and provide grounds for judicial review, and not merely an LGSCO’s investigation.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Essex County Council (24 018 068) report. If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
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