Date of decision: 23 March 2026
Summary
An older man receiving home care commissioned by the Council was left without reliable food, medication and scheduled visits, despite a clear care plan setting out his needs. His granddaughter raised repeated safeguarding concerns about neglect, but although the Council later fully substantiated these concerns, its care provider denied responsibility and produced an inaccurate complaint response.
What happened
The Council had commissioned Carepoint Services Limited to provide domiciliary care to an older man, Mr Y, in his own home, from early 2023 under a care plan setting out his needs, including food, medication and routine support.
In late 2023, his granddaughter, Mrs X, first raised concerns with the Council about the standard of care; the Council told her to raise those concerns directly with the care provider. From August 2024, Mrs X reported further worries that the care provider was not making sure Mr Y had food or his medication, indicating ongoing risks to his basic care and health.
Between September and December 2024, Mrs X and professionals raised six safeguarding concerns about Mr Y’s care, triggering the Council’s safeguarding duties. In response, the Council arranged for a different home care provider to start supporting Mr Y from January 2025, thereby ending Carepoint’s package but only after several months of concerns.
In February 2025, the Council asked Carepoint to complete a safeguarding report addressing the issues Mrs X had raised throughout the period of its involvement.
Carepoint sent its safeguarding report to the Council in March 2025, and the Council completed its own safeguarding investigation about a week later. The Council’s investigation found Carepoint was at fault and substantiated all of Mrs X’s concerns, recording multiple shortcomings including medication errors, neglectful behaviours, failure to report Mr Y’s deteriorating health, and non-compliance with protocols for reporting missed medication to the GP, as well as missed care visits.
The Council agreed to refund £500 of Mr Y’s care contributions to reflect the missed visits but signposted Mrs X to complain to the care provider directly about the wider issues and any compensation she sought for the family.
At the end of March 2025, Mrs X submitted a formal complaint to Carepoint, stating that the Council had substantiated neglect and explaining the upset and distress caused to Mr Y and his family; she asked the provider to pay compensation. Carepoint responded at the end of May 2025, claiming it had not been aware of the issues until the end of the care package and asserting it had dealt with matters when Mrs X raised them, while refusing any financial remedy on the basis that the Council had already refunded care charges.
Mrs X disagreed with this account and remained dissatisfied, feeling the provider had not accepted liability or acknowledged the neglect despite the Council’s safeguarding findings, so she brought the complaint to the Ombudsman asking the Council to ensure Carepoint accepted responsibility and compensated the family.
In response to the Ombudsman’s enquiries, the Council confirmed that Carepoint’s complaint response was not accurate because Mrs X had in fact raised concerns throughout the period of care, not only at the end. The Council also accepted that Carepoint’s response did not properly address Mrs X’s concerns and that it had itself not been sufficiently clear with the family that they could complain directly to the Council under its own complaint procedure, leaving them to spend significant time trying to resolve issues with the provider instead. The Ombudsman then considered the Council’s legal responsibility for services delivered on its behalf, its safeguarding findings, and how it and the provider dealt with the verified neglect and subsequent complaint handling.
What was found
The Ombudsman found that because the Council had commissioned Carepoint to deliver Mr Y’s domiciliary care, it remained legally responsible for failings in that service, in public law terms for failure to meet needs as planned for.
The Council’s safeguarding investigation had substantiated that Carepoint missed visits, made medication errors, failed to report concerns about Mr Y’s deteriorating health, and did not follow protocols for reporting missed medication, meaning Mr Y did not receive support in line with his care and support plan.
Although the Council recognised these failures and refunded £500 for missed visits, it did not ensure that its commissioned provider acknowledged the substantiated neglect, although it accepted that the provider’s complaint response to Mrs X was inaccurate and failed to address her concerns. Although the Council acknowledged the issues, the care provider did not. As the Council was responsible for the actions of the care provider, the Council did not take transparent responsibility for the safeguarding concerns. This was fault causing distress to Mrs X and her family.
By allowing the inaccurate provider response to stand the Council effectively failed to acknowledge the impact of the neglect on Mr Y and his family, causing avoidable distress and frustration for Mrs X.
There was also fault in complaint handling: the Council had directed Mrs X to complain to the provider rather than clearly offering its own complaint route, and the provider, bound by the Council’s complaint policy, took two months (a 24-working-day delay beyond the Council’s 18-day standard) to respond, further frustrating Mrs X.
Overall, the Ombudsman concluded that the services the Council commissioned fell below an acceptable standard, Mr Y’s needs were not met in line with his care plan, and Mrs X suffered significant distress and time and trouble, warranting an apology and financial remedy.
Within three months, the Council must also ensure Carepoint provides evidence of staff training and quality assurance work on medication administration, and that it delivers training and guidance to staff on the complaint policy and how to respond to complaints in a timely and accurate way, then provide the Ombudsman with evidence of compliance.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
Multiple safeguarding alerts between September and December, with replacement provision only from January – indicates that the man’s eligible needs for nutrition, medication support and routine care were not being met for months in circumstances where the Council knew, or should have known, that provision was not working. Under public law principles, once it became clear that the commissioned service was not reliably providing food and medication, the Council was required to take timely, effective action to secure alternative provision or interim safeguards, rather than merely investigating after the fact.
The Ombudsman records the change of provider as a remedial step but does not explicitly interrogate whether the delay in securing alternative care was itself a breach of the legal duty to ensure continuity of support in line with the plan, given the obvious risks to basic health and wellbeing. Community care case law on failure to implement care plans would support treating that delay as a substantive legal failing, not just service fault.
By framing the case almost entirely in safeguarding and complaint-handling terms, the Ombudsman does not challenge the Council’s apparent failure formally to revisit Mr Y’s eligible needs and outcomes at the point when multiple safeguarding alerts were raised. That omission risks normalising a practice where councils manage provider failure through safeguarding enquiries and partial refunds rather than through a structured return to the review-reassessment-care planning cycle required by the Care Act.
Public law principles around rational decision-making and taking relevant considerations into account would support an expectation that, once there were six safeguarding concerns about basic care, the Council should have reviewed whether the care plan still delivered the specified outcomes and whether the personal budget and commissioned support remained sufficient and appropriate. The report’s focus on refunding £500 for missed calls, and later paying the granddaughter £300 for distress, does not address that systemic duty.
The Ombudsman could have considered in more detail the Council’s handling of the safeguarding process once the concerns were raised not only by Mrs X but also by professionals in September to December 2024. The Care and Support Statutory Guidance sets out extensive guidance on safeguarding. For example, the guidance states that where safeguarding concerns arise from abuse or neglect, it is necessary to immediately consider what steps are needed to protect the adult, and stresses that the first priority should always be to ensure the safety and well-being of the adult. The Council does not appear to have followed these aspects of the guidance in this complaint
Also of relevance are the following statements contained in the Guidance:
‘Safeguarding is not a substitute for providers’ responsibilities to provide safe and high quality care and support;
Commissioners regularly assuring themselves of the safety and effectiveness of commissioned services
The Care Quality Commission assuring themselves of the safety and effectiveness of commissioned services’
In this complaint both the provider and the commissioners (the Council) failed to follow the requirements of the guidance.
Although the report does refer to the role of the CQC and sharing the report, doing so earlier on may have been an effective step for Mrs X to take, and would likely have caused concern to the provider if they were aware of it.
The Ombudsman’s analysis treats Mrs X solely as a complainant and witness to neglect, without asking whether the Council had any duties towards her as a carer once she emerged as the person providing necessary oversight to keep her grandfather safe.
This gap is not simply technical. Public law principles on involvement and participation stress that carers should be meaningfully involved in safeguarding, assessment and care planning, and that councils should recognise and support the burden that falls on relatives when commissioned services fail. On the facts described, Mrs X took on significant time, trouble and emotional labour trying to get basic care delivered, but the only remedy identified for her is an ex gratia payment for complaint-handling failures, not any consideration of whether she should have been offered a carers’ assessment or support in her own right. A specialist application of community care law would at least have flagged this as a potential missed opportunity, particularly where the granddaughter’s role was crucial to identifying and evidencing the neglect that the council ultimately substantiated.
The Ombudsman could also have considered whether there was any breach of the Health and Social Care (Regulated Activities) Regulations 2014. The requirements that care and treatment must be provided in a safe way, with proper and safe management of medicines, nutritional and hydration needs of service users must be met, service users must be protected from abuse and improper treatment, and providers receiving and acting on complaints, are of particular relevance.
A more rounded approach, grounded in community care law and public law principles, would treat the neglect findings and complaint failures as symptoms of deeper problems in how the council discharged its statutory functions, and would support stronger recommendations around timely replacement of failing services, automatic review of care plans after repeated safeguarding alerts, and explicit recognition and support for family members who are holding failing systems together.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Royal Borough of Greenwich (25 005 505) 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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