The Local Government and Social Care Ombudsman has issued a stark reminder that local authorities remain responsible for safeguarding oversight, even where care is delivered by commissioned providers.
The decision follows an investigation into serious failings involving a Portsmouth woman's care, including allegations of missed visits, falsified records and the provision of dog food instead of a meal. The case will be of particular interest to local authorities, commissioners, safeguarding leads and care providers considering the extent of their respective responsibilities where safeguarding concerns arise.
Case summary
The Ombudsman's investigation concerned the care provided to an elderly woman living in extra care housing. Concerns were raised regarding a range of issues, including missed care calls, failures to follow her care plan, poor quality food provision and serious shortcomings in record keeping. One incident involved the woman being provided with microwaved dog food, which was recorded in care notes as a lamb dinner.
Alongside concerns about the quality of care itself, the Ombudsman examined the handling of the subsequent safeguarding process. The local authority opened a safeguarding inquiry in April 2024 but did not conclude it until October 2024, considerably exceeding its own target timescales. The Ombudsman also found that the council had relied too heavily on the provider's internal investigation and had failed to apply sufficient independent scrutiny to the issues raised.
The case also highlighted concerns regarding staff awareness of important clinical information. The woman's DNAR form had reportedly been found stored in a cupboard and was not known to care staff responsible for delivering her care.
Key lessons for commissioners and providers
The most significant aspect of the decision is the Ombudsman's reminder that commissioning care does not transfer safeguarding responsibility.
Whilst providers are responsible for delivering safe and effective care, local authorities retain their statutory safeguarding duties under the Care Act 2014. Those duties include ensuring that concerns are properly investigated and that appropriate oversight is maintained where serious allegations arise.
The Ombudsman was particularly critical of the council's reliance on the provider's own investigation. Although internal investigations will often form part of the overall safeguarding response, the decision emphasises that councils must remain satisfied that inquiries are robust, objective and sufficiently independent, particularly where allegations concern systemic failings or organisational culture.
The decision highlights the close relationship between safeguarding oversight and contract management.
Commissioners will often receive assurance from providers regarding service quality, governance arrangements and incident management. However, where safeguarding concerns are identified, particularly concerns suggesting potential neglect, abuse or widespread practice issues, authorities should actively consider whether additional scrutiny is required.
The findings are also likely to prompt renewed focus on:
provider governance and management oversight;
accuracy of care records;
escalation and reporting processes;
staff understanding of care plans and key legal documents; and
the effectiveness of quality assurance processes within commissioned services.
For providers, the decision illustrates how individual care failures can quickly expose wider governance weaknesses.
The Ombudsman identified concerns extending beyond the immediate incidents themselves, including record keeping, staff knowledge, supervision and management oversight. The case demonstrates the importance of ensuring staff understand care plans, recognise critical documents such as DNAR notices and appropriately escalate concerns where issues arise.
Providers should also be aware that safeguarding investigations will increasingly look beyond isolated incidents and consider whether organisational systems could identify and address risks at an earlier stage.
The findings are particularly relevant at a time when many authorities are managing increasing levels of commissioned care and significant financial pressures. The decision demonstrates that resource constraints will not excuse delays in safeguarding inquiries or a failure to maintain sufficient oversight of providers.
Comment
The facts of this case are unusual, but the Ombudsman's central message is straightforward: local authorities remain accountable for safeguarding, regardless of who delivers the care. Where serious concerns arise, councils must be able to demonstrate timely inquiries, appropriate challenge of providers and adequate independent oversight.
Although the decision arises from adult social care, the principles have much wider application and will resonate across health and care commissioning. It underlines the continuing expectation that public bodies maintain effective oversight of outsourced services, particularly where vulnerable individuals may be exposed to neglect or abuse.
How we can help
To find out more about our social care work and how we can support you with safeguarding investigations, please contact Isobel Matthews.
Our content explained
Every piece of content we create is correct on the date it’s published but please don’t rely on it as legal advice. If you’d like to speak to us about your own legal requirements, please contact one of our expert lawyers.