Date of decision:
21 October 2025
Summary
A daughter complained that Leicestershire CC did not make sure her mother received proper and safe home care from a Council-arranged care provider called Care at Home. She raised concerns about missed medication, lack of food nutrition, poor record keeping and unsafe personal care. The Council mishandled safeguarding concerns and delayed reassessing the care needs although problems had become clear.
What happened
Mrs Y received a care package at home arranged in late August 2023 by the Council and delivered by a commissioned care provider. Her care plan included personal care, medication, meals, drinks, household tasks and keeping her safe. In September 2023, Mrs Y fell from bed and the ambulance staff made a safeguarding referral to the Council citing the family’s concerns that the care provider was not completing tasks such as giving prescribed medication. However, the Council closed the safeguarding on the basis of there only having been a one-off instance of missed medication and that the visit had been delayed that morning because of an emergency with another client.
In October 2023, Mrs Y fell again and cut her leg and again in early November; the staff left her to wait for the ambulance on her own.
Mrs Y’s daughter, Mrs X, was concerned that care workers were not following the care plan, for example allowing clutter to build to a dangerous extent around the bed and leaving an extension lead on a hot radiator and sending two male staff when it was known that it should be one of each gender.
In December when Mrs Y fell from the bed again, the ambulance staff made another safeguarding referral to the Council, saying that Mrs Y’s bed had been raised as high as it could go and the brakes had not been applied.
In January 2024, although the Council acknowledged that longer visits might be needed to ensure that Mrs Y had encouragement to eat, and it agreed to reassess Mrs Y’s needs, the reassessment was not started before Mrs Y required re-admission into hospital.
Mrs X was further concerned that care staff were lying about the time spent in the house and what had or had not been done; they had also allowed Mrs Y’s hair to become matted and sores had developed in her groin.
Mrs X repeatedly asked care workers to obtain a stool sample as requested by the GP, but this did not happen. This caused Mrs Y to be diagnosed later with a bacterial infection.
In February 2024, further missed medication was reported and the Council found one morning when staff were late and recorded an inappropriate comment in the records.
Although the staff member had been disciplined, still no reassessment was carried out.
Mrs Y was again admitted to hospital with a serious pressure sore in mid-February 2024 and later died.
According to the detailed care notes, care workers often arrived late in the morning and missed one of the 4 visits finishing early in the evening, yet claimed full visit durations. There were three consecutive missed medication administrations and further missed offers of washes, such that it was not offered daily, evidence that food was sometimes declined and that the woman had been forgetting to take medication left out for her. Safeguarding referrals were made following several falls, but the Council had closed or delayed action on them.
What was found
The Ombudsman found that the Council failed to ensure the care provider followed the required regulations, including consistently providing support as outlined in care plan, poor record-keeping, missed medication, incomplete personal care, unsafe practices, inadequate responses after falls, and ensuring timely visits.
The Council also failed to consider all presented concerns before closing the referrals or delayed taking necessary action, such as performing reassessment of Mrs Y’s urgent needs.
These faults caused Mrs Y and Mrs X to suffer significant frustration, distress and uncertainty.
The Council needed to apologise and pay a remedy of £300.
Moreover, the Council was required to take steps to prevent similar situations in future cases, such as providing sufficient training to adult safeguarding staff, considering all relevant facts before deciding on action, and ensuring accurate visit and care records by providers.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
This Ombudsman highlights numerous breaches of the legal framework, under the Care Act and in light of public law principles. When failures in safeguarding, reassessment, or care record keeping occur, it is not really sufficient to apologise or pay compensation. Councils thus called out, need to review their compliance with statutory obligations because if urgent concerns about harm are raised, it is not lawful to await routine re-assessment.
Authorities must respond immediately to any safeguarding referral, as confirmed by statutory guidance.
It is basic public law that all relevant facts and concerns be thoroughly considered before a decision and in the context of safeguarding, this really matters, because a decision may well be one that involves closing the referral or taking no further action. The Council was found at fault here, because it closed the September 2023 referral based on only the care provider’s explanation, failing to consider other serious issues raised, such as the frequent lateness and failure to keep Mrs Y clean. This left Mrs Y unprotected and frustrated.
In this case, the care provider was at fault for having incomplete records and for staff failing to keep accurate records of arrivals and departures. Missed medication, rushed visits and poor record-keeping are serious failures and can place vulnerable people at risk. Therefore, councils remain responsible for these failures if commissioning them, and it was itself told to ask the care provider to provide guidance or staff training on the importance of keeping accurate records of care provided.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Leicestershire County Council (24 016 108)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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