Adult social care compliments and complaints annual report

1. Purpose of report
2. Background
3. What is a complaint
4. Who can make a complaint
5. The complaints procedure
6. Review of compliments received 2024/25
7. Review of complaints received 2024/25
8. Nature of complaints
9. Outcomes
10. Formal investigation
11. Mixed sector complaints
12. The Local Government Ombudsman
13. Local settlements and public reports
14. Timescale performance
15. Compensation payments
16. Methods of notifying complaints
17. Equality monitoring
18. Lessons learned
19. Service user satisfaction surveys
20. Developments and update - 2024/25
21. Guidance for dealing with unreasonable behaviour from service users
22. Protocol on complaints handing with commissioned service providers
23. Review of information literature for service users
24. Review of Adult Social Care Complaints 2024/2025.
25. Focus reports
26. Local Government and Social Care Ombudsman (LGSCO) and Housing Ombudsman Joint Complaint Handling Code Consultation
27. Other priorities to be taken into account during 2024/25
28. Conclusion
29. Appendices

Executive Summary

The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 combined the statutory complaints procedures for the NHS and Social Care under a single set of rules. This report, therefore, includes feedback in relation to Adult Social Care and Public Health.

Leeds City Council Adults and Health Directorate provides a range of services. Some services are provided by commissioned independent care providers in residential care, supported living and commissioned home and day care. This annual reporting, therefore, includes services provided by commissioned independent care providers.

This report provides information about compliments and complaints received during the twelve months between 1 April 2024 and 31 March 2025.

Adult Social Care and its Partners continue to face significant challenges and pressures. Despite financial constraints that necessitate tough decisions around service provision, people who use services expectations of what they can reasonably expect from the Adult Social Care remains very high. They feel empowered to hold the Council to account and to escalate their complaints to the Ombudsman as can be noted by the number of complaints and enquiries made to the Ombudsman.

Review of compliments and complaints provides an opportunity to assess some of the impact of the challenges and how staff have responded to some of the ongoing challenges.

In the reporting year 10,220 people received a service from Leeds City Council Adults and Health Directorate. When looking at a total number of complaints of 882, therefore, 8.6% of people who access services or someone acting on their behalf raised a complaint which is a an increase from the previous year when 582 complaints were received.

1166 compliments were received or 5% of people who access services or their representative raised a compliment about the service that they received, anincrease from the previous year when we received 984 compliments. It is pleasing to note the increase in the number of people talking positively to us about their adult social care service.

This report highlights how various services within the Adults and Health Directorate have performed in line with key principles outlined in the complaints regulations and provides information about the nature of complaints and compliments received. Appendix 7 has some examples of improvements made in response to the feedback and actions being taken to improve the quality of health and social care services across Leeds.

The focus for Leeds City Council Adults and Health has been to empower people to feedback about their adult social care service so that the feedback can be used to improve the quality of services provided. Adults and Health regards high numbers of complaints positively, as a positive indicator of care users and their family members speaking up when things are not right. The aim is to encourage more people to talk to us and to tell us what they think. We changed the language on complaints leaflets to ‘tell us what you think’ to encourage more people to tell us when things are not right so that we can act when we learn about problems.

The aim for the Complaints Team has been to try and maintain a good customer service by focussing on keeping people informed. An update on some of the initiatives is as follows:

The Complaints Team has continued its close working and sharing of intelligence with the Commissioning Teams. The aim of the closer working and regular meetings is to share business intelligence in order to support commissioned care providers to provide good quality services and attain good or outstanding Care Quality Commission ratings.

The Head of Complaints has continued to share key messages with Social Work teams by attending their management team meetings.

The Leeds city wide complaints group chaired by Healthwatch Leeds and made up of Leeds Teaching Hospitals NHS Trust, Leeds and York Partnership NHS Foundation Trust, Leeds Community Healthcare NHS Trust, NHS Leeds Integrated Care Board and Leeds City Council Adults and Health Complaints Teams have continued with their online meetings. The aim of the group is to improve care user and patient experience when things go wrong. The group share expertise, learning and good practice. They have all signed up to providing a ‘no wrong door’ so that wherever a complaint is raised it is the system and not the complainant that is responsible for routing it to the appropriate organisation to get it resolved.

The aim is to develop a system which draws together lessons learned from people’s experiences of health and social care across Leeds. Going forward, this should highlight more clearly the trends in city wide complaints and draw together lessons learned from the people’s experience of health and social care across Leeds.

At the heart of most failings are delays in service provision and poor communication with families and between professionals.

1,166 compliments were received compared to 984 received the previous year. The compliments received evidence how the Adults and Health Directorate is meeting the key qualities people expect from Health and Social Care Services i.e. being offered choice, being heard, being treated with dignity, respect and compassion.

882 complaints were recorded compared to 582 in the previous year, representing an increase of 300. The increase is pleasing to note because we want more people to speak up when things are not right so that they can be put right. The increase is most likely due to the usual practice by the Complaints Team and operational staff of reminding care users and their families on how they can provide us with feedback and also reminding commissioned care providers to share information about complaints relating to Leeds City Council Adult Social Care commissioned services.

The ongoing increase will, therefore, not necessarily be an indicative of a drop in the quality of service provided but rather staff efforts to empower people to speak up.

45 enquiries were made to the Local Government and Social Care Ombudsman compared with 29 the previous year. The Complaints Regulations requires the Council to inform people of their right to complain to the Ombudsman if, for whatever reason, they are unhappy with the way the Council has dealt with their complaint. The complaints leaflets and letters in response to complaints provides people with Ombudsman contact details. It is envisaged, therefore, that more care users will escalate their complaints to the Ombudsman because they would have liked a different outcome to their complaint.

A breakdown of the 45 enquiries is detailed in Appendix 5 of the Report. Of the 45 enquiries, 9 were referred back to the Council for local resolution; 16 were closed after initial enquiries; 16 of the 45 were investigated. Of the 16 investigated 1 was not upheld and 15 were upheld. That is a 94% uphold rate. Of the 94% uphold rate 20% had been upheld by the Adults and Health Directorate and a satisfactory remedy offered before the complaint reached the Ombudsman.

It is pleasing to note that despite the challenging year Adults and Health achieved a 100% compliance with the Ombudsman’s recommendations. This is when Adults and Health has satisfactorily implemented the Ombudsman’s recommendations within the timescale recommended by the Ombudsman.

Improvements in acknowledgement and resolving complaints within the timescale agreed with the complainants are continuing. 

Complaints data and analysis is used to commission improvement activities and training, where appropriate, and in informing individual Managers to take the initiative at service/team level or with individual staff members to address areas for development and manage local improvements. The complaints data has again led to a number of actions and areas for development as set out in Appendix 7 of this report. 

Judith Kasolo

Head of Complaints

1. Purpose of report

The purpose of the annual report is to review the operation of the complaints procedure over a twelve month period and to provide information about complaints themes, the compliments received and actions being taken to improve the quality of social care services.

This report provides information about compliments and complaints received during the twelve months between 1 April 2024 and 31 March 2025.

2. Background

Local authorities and the National Health Service are legally required to establish complaints procedures to deal with complaints about their health and social care functions. 

The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 applies to Adult Social Care. Similarly the NHS Bodies and Lo44cal Authorities (Partnership Arrangements, Care Trusts, Public Health and Local Healthwatch) Regulations 2012 applies to Public Health functions. 

3. What is a complaint

The Department of Health defines a complaint as:

‘An expression of dissatisfaction, however made, about the standard of service, actions or lack of action by the organisation, its own staff or those acting on its behalf, affecting an individual or group of individuals’

The Adults and Health Directorate uses this definition.

In addition, it is important to note that service users or their representatives generally view complaints in its everyday sense i.e. to mean any statement about a service or member of staff that has not met the standard that they can reasonably expect. An individual should not have to use the word ‘complaint’ for it to be treated as such.

If it is possible to resolve the matter immediately, there is no need to engage the complaints procedure.

4. Who can make a complaint

Anyone coming into contact with Leeds City Council can make a complaint. The Corporate Complaints Procedure provides a process for all service users to use. If the complaint is about Adult Social Care or Public Health functions, the statutory complaints procedure for Health and Social Care services must be used.

A person is eligible to make a complaint under the statutory complaints procedure where the Local Authority and the Health Service have a power or duty to provide or secure a service. This includes a service provided by an external provider acting on behalf of the Local Authority. In such cases care users or their representatives can either complain directly to the provider or to Leeds City Council, as commissioner of the service.

Commissioned providers are encouraged to attempt to resolve complaints at the first point of contact in line with good practice highlighted by the Local Government and Social Care Ombudsman. However, they are equally advised to direct care users or their representatives to commissioners of the service, where local resolution is not possible or appropriate, or where the complainant remains dissatisfied.

A complaint can be made by the representative of a care user who has been professionally defined (under the Mental Capacity Act 2005) as having no capacity to make decisions as long as the representative is seen to be acting in the best interests of that care user.

Anyone can complain who is affected (or likely to be affected) by the actions, decisions or omissions of the service that is subject to a complaint.

5. The complaints procedure

The complaints procedure is a two-stage complaints system, focusing on local resolution and, if unresolved, an investigation by the Ombudsman.

The aim of the Local Authority Social Services and the National Health Service complaints regulations is to make the whole experience of making a complaint simpler, more user-friendly and more responsive to people’s needs. The emphasis is to offer a more personal and flexible approach which is effective and robust. Complaints are risk assessed. The level of investigation needed is informed by the level of risk and complexity and the wishes of the complainant.

Complaints Officers contact the complainant to agree the complaint and sought outcome. They then determine the level of risk and complexity. Options include mediation, resolution by the Service Manager or an independent investigation.

Each complaint is treated according to its individual nature and the wishes of the complainant.

In the reporting year 10,220 people received a service from Adult Social Care. 

When looking at the total number of complaints of882,therefore, 8.6% of service users or someone acting on their behalf raised a complaint about a service that they received and 1166 or 11.4% of service users or their representative were happy with the service that they had received from adult social care or public health.

7. Review of complaints

Table 2 – Complaints received by service area

	2024/25		2023/24
Service area	Number of complaints	% of total complaints	Number of complaints	% of total complaints
Total	882	100.0%	582	100.0%
Independent Sector Care Homes	235	26.6%	71	12.2%
Blue Badge Applications	202	22.9%	74	12.7%
Area Social Work	114	12.9%	117	20.1%
Learning Disability Commissioned Services	76	8.6%	37	6.4%
Finance	75	8.5%	91	15.6%
Hospital Social Work	40	4.5%	41	7%
Learning Disability Social Work	32	3.6%	34	5.8%
Mental Health Social Work	22	2.5%	27	4.6%
Independent Sector Home Care	21	2.4%	38	6.5%
Equipment and Adaptations	18	2%	20	3.4%
Inhouse residential	13	1.5%	6	1%
Mental Health Accommodation and Day Services	11	1.2%	4	0.7%
Skills/Reablement	9	1%	10	1.7%
Commissioning Other	7	0.8%	-	-
Strategic Commissioning	3	0.3%	1	0.2%
Complaints	2	0.2%	1	0.2%
Mental Health Commissioned Services	1	0.1%	2	0.3%
Information Management Team	1	0.1%	-	-
Physical Impairment Commissioned Services	-	-	6	1%
Public Health	-	%	1	0.2%
Safeguarding	-	%	1	0.2%

7.1 The Adults and Health Directorate provides a range of services in a range of settings and where the Council commissions care from the independent sector, the Ombudsman is very clear that the Council remains accountable for the actions of the commissioned service provider. It is usually best to tell the care provider and give it chance to put things right. However, if the problem cannot be sorted out there and then and the person continues to be unhappy, they have a right to complain to the Council, as commissioner of the service. In these circumstances, care users or their representatives are advised to raise concerns with the Adults and Health Directorate Complaints Team. The Complaints Team recorded 882 complaints in this reporting year compared with 582 complaints the previous year. We encourage care users or their representatives to tell us what they think if for whatever reason they are unhappy with the service so that we can act when we learn about any problems. It is, therefore, pleasing to note the slight upward trend.

The monitoring and oversight of complaints made directly to commissioned service providers is in response to recommendations made by the Ombudsman in their Annual Review of Adult Social Care Reports. The Ombudsman continue to make it very clear that it will hold commissioners accountable for the commissioned service providers’ failings and further that it is the commissioner who will be held accountable to remedy any identified failings. In view of this, Adults and Health Directorate has a Complaints Information Sharing Protocol with its commissioned service providers in relation to any complaints and compliments relating to the Council’s Adults and Health commissioned services. This should provide the Council an opportunity to gain an overview of compliments and complaints of commissioned services.

8. Nature of Complaints

The most common category of complaints are as follows:

• 232 complaints challenging an assessment outcome
• 191 complaints about quality of service 
• 81 complaints about lack of Social Work support
• 58 complaints about being incorrectly charged
• 52 complaints about staff attitude or conduct

Challenging assessment outcome

Blue Badge

The majority of complaints about this issue were made by people whose application for a Blue Badge parking permit had been declined. Complaints were raised from people disputing that their blue badge disability parking permits had not been re-issued or their application had been declined following an assessment.

Area Social Work

Many complainants expressed concerns about not being adequately informed or involved in assessment reviews or changes to care packages. Several individuals reported not receiving timely notifications about reductions in care hours, changes to direct payments or the outcomes of reviews. There were also instances where family members felt excluded from important decisions or were not consulted as required. Some individuals with lifelong conditions described the process as overly bureaucratic, requiring them to repeatedly provide medical evidence despite no change in their circumstances. Complainants typically sought clearer communication, greater involvement in decision-making and timely responses to queries. There was a strong emphasis on the need for a more person-centred and responsive approach to social care assessments and support.

Finance

Complainants raised concerns about the council’s approach to assessing and recognising disability-related expenses. There were reports that certain expenses which contribute to individuals’ well-being and social inclusion were not adequately considered or justified when rejected. The lack of written explanations for these decisions was highlighted as a source of stress and frustration for care users and their families. Several cases described difficulties in communication, including not receiving important notifications about changes to financial support. There were concerns about the process and outcomes of financial assessments, including unexpected demands for repayment and lack of clarity about eligibility. Some complainants felt that their circumstances were not fully considered and that decisions were made without sufficient engagement or explanation. Complainants sought clearer guidance and more efficient and transparent processes. There was a strong emphasis on person-centred approaches that recognise the complexities of individual circumstances and minimise unnecessary stress.

Quality of Service

Commissioned Residential Care Homes

Many complaints relate to the standard of personal care provided to residents. Issues raised include inadequate support with hygiene, missed or inconsistent assistance with washing, dressing, toileting and concerns about residents’ dignity not being maintained. There were also reports of residents being left in soiled clothing, not being prompted to drink fluids and not having their personal preferences respected (e.g., clothing, room temperature, or privacy). A recurring theme is the quality of communication between care home staff, residents and their families. Some complainants described difficulties in obtaining information about care plans, changes to routines or incidents affecting their relatives. Delays in responding to queries, lack of notification about important events (such as hospital admissions) and insufficient involvement of families in decision-making were commonly reported. Concerns were frequently raised about staffing levels, staff training and the consistency of care provided. Some families reported that staff were not always available when needed, that there was a lack of continuity in carers or that staff did not appear to be adequately trained to meet residents’ needs. There were also reports of staff not following care plans and not using appropriate equipment. Several complaints focused on the physical environment of care homes, including cleanliness of rooms and communal areas, maintenance issues (such as lack of hot water or broken equipment), and the loss or misplacement of residents’ personal belongings. There were reports of missed medication, delays in responding to health concerns and inadequate support for residents with complex needs. Some complainants described incidents where residents’ health deteriorated due to lack of appropriate care or oversight, including issues with nutrition, hydration and pressure care. The emotional well-being of residents was also a concern, with some families noting a lack of meaningful activities or social engagement. 

Commissioned Learning Disability Services

Many complaints relate to difficulties in communication between service providers, care users and their families. Issues include unanswered calls, lack of timely updates, unclear or inconsistent information and delays in responding to queries or concerns. Some families reported feeling uninformed about important events, changes in care or incidents affecting their relatives. Concerns were raised about the standard of personal care provided, such as hygiene, cleanliness of living spaces and support with daily living tasks. Some complainants described instances were service users were left in soiled clothing, did not receive adequate support with washing or dressing or lived in unclean environments. There were also reports of missed meals, medication errors and lack of attention to individual needs and preferences. A recurring theme was the impact of staff shortages, high turnover, and the use of agency staff. Families and service users noted that frequent changes in staff affected the consistency and quality of care, with some expressing concerns about staff not being familiar with individual needs or support plans. There were also reports of insufficient management presence and lack of staff training in specific communication methods. Some complaints highlighted issues with support planning, including delays in reviews, lack of clarity about care plans and insufficient involvement of families in decision-making. There were also concerns about limited access to meaningful activities, community engagement and support for social inclusion. In some cases, service users were unable to participate in activities due to staffing or transport issues. Several cases referenced problems with the physical environment such as delays in repairs, poor maintenance and concerns about the suitability of accommodation. 

Area Social Work 

A significant number of complaints relate to the quality of communication between social workers, care users and their families. Issues raised include difficulties in reaching staff, lack of timely responses, and perceived insensitive conduct during interactions. Some complainants described feeling dismissed, misunderstood or unsupported and highlighted the impact of these experiences on their well-being and trust in the service. Concerns were raised about the processes for assessment and care planning, including confusion around direct payments, unclear roles and responsibilities and delays in arranging or reviewing support. Some individuals reported not being adequately involved in decisions about their care or not being informed about changes to their support packages. There were also instances where families felt that assessments did not fully consider the needs or circumstances of the person requiring support. Several complaints highlighted issues with the consistency and continuity of support, such as changes in social workers, delays in arranging equipment or services and lack of follow-up after initial contact. These issues sometimes resulted in unmet needs, increased anxiety or deterioration in health and well-being.

Lack of Social Work Support

Area Social Work

Many complainants described significant difficulties in contacting social workers, receiving timely responses or obtaining clear information about their cases. Some individuals reported not knowing who their social worker was, having only met them once or twice over several years or being unable to reach them by phone or email. Delays in returning calls, lack of follow-up and inconsistent communication were recurring issues. Concerns were raised about delays or gaps in needs assessments, care planning and reviews. Some care users felt that their needs were not fully understood or addressed, particularly in complex cases involving physical disabilities, mental health issues or safeguarding concerns. There were reports of cases being closed without adequate support in place or of assessments not leading to meaningful changes in care arrangements. Several complaints highlighted problems with continuity, such as frequent changes in social workers, lack of handover between staff or cases being discharged and then reopened without clear explanation. This lack of consistency often resulted in care users and their families feeling unsupported and having to repeat their circumstances multiple times. One care user complained that the delay led to their family having to borrow money to fund care.

Hospital Social Work 

Many complainants described difficulties in contacting social workers, receiving timely responses, obtaining clear information about care plans and support arrangements. Delays in communication, lack of follow-up and uncertainty about who was responsible for ongoing support were recurring issues. Concerns were raised about the adequacy and clarity of care planning, particularly around hospital discharge. Some families reported confusion over care packages, changes in care providers without notice and a lack of involvement in decision-making. In several cases individuals felt that care arrangements were rushed or not tailored to the needs of the person being discharged. Several complaints highlighted problems with continuity of care, such as changes in care agencies without proper handover or lack of coordination between hospital teams, social workers and care providers. This sometimes then resulted in gaps in support, missed visits or confusion about who was responsible for specific aspects of care. 

Mental Health Assessment and Care Management

Many complainants described difficulties in contacting social workers, receiving timely responses or obtaining clear information about care plans and support arrangements. Delays in communication, lack of follow-up and uncertainty about who was responsible for ongoing support were recurring issues. Concerns were raised about delays or gaps in needs assessments, care planning and reviews. Some care users felt that their needs were not fully understood or addressed, particularly in complex cases involving mental health crisis, safeguarding concerns or transitions between services. There were reports of cases being closed without adequate support in place or of assessments not leading to meaningful changes in care arrangements. Several complaints highlighted problems with continuity, such as frequent changes in social workers, lack of handover between staff or cases being discharged and then reopened without clear explanation. This lack of consistency often resulted in service users and their families feeling unsupported and having to repeat their circumstances multiple times.

Incorrectly Charged

Finance 

Many complainants reported being invoiced for services they did not receive or for incorrect amounts. Examples include charges for days when the service user was in hospital, on holiday, had cancelled their service in advance, billed for care not provided or for sessions missed due to illness. There were also instances of backdated bills, unclear adjustments and confusion over how charges were calculated. Several complaints highlighted a lack of communication about changes to billing systems or charging policies. Service users and their families described being unaware of new rules regarding cancellations, fixed charges or the need to pay for services not attended. Some expressed frustration that previous practices such as only paying for care received had changed without clear notice or explanation. A recurring theme was the difficulty in contacting the billing or finance teams to resolve queries or disputes. Many individuals described repeated unsuccessful attempts to reach staff by phone or email, long delays in receiving responses and a lack of clear information on invoices. This lack of accessible support often led to increased anxiety and distress, particularly for vulnerable service users and their families. 

Area Social Work

Several individuals reported being charged for services they believe were not agreed, not received or should have been exempt. Examples include, invoices for care received during periods when the care user was in hospital, bills for respite care were the complainant believed their contribution had already been paid or were Leeds City Council had not paid the provider as expected. A recurring theme was difficulty in contacting the relevant teams to resolve billing queries or disputes. Complainants described making multiple calls or requests for call-backs without receiving a response, and in some cases being promised follow-up that did not occur. This lack of communication contributed to confusion and distress, especially for those dealing with bereavement or complex care arrangements. 

Staff Attitude or conduct

Area Social Work

These complaints relate to the manner in which social workers communicate with care users, carers and families. Issues raised include perceived rudeness, abruptness, lack of empathy and unhelpful or dismissive responses. Some individuals described feeling spoken over, not listened to or treated without respect and sensitivity, especially during emotionally charged or complex situations. Concerns were raised about the approach taken by staff in situations involving mental health crisis, safeguarding and family disputes. Some complainants felt that social workers made assumptions, displayed bias or failed to consider the emotional impact of their words and actions.

Learning Disability Commissioned Services 

Several complaints relate to the manner in which staff interact with service users and their families. Issues raised include staff arriving late, using inappropriate language, raising their voices or displaying defensive or unprofessional behaviour during interactions. Some individuals described feeling spoken to disrespectfully, not listened to or judged about their home environment. Concerns were raised about staff not consistently following care plans or completing agreed tasks. There were also instances where staff behaviour was perceived as dismissive or unhelpful when feedback was provided. 

9. Outcome

The table below shows the outcome of complaints following an investigation. The three main categories for classifying the outcome of a complaint are “Upheld”, “Partly Upheld” and “Not Upheld”. Also included is a proportion that were “inconclusive” and those that were “Withdrawn”. It will be noted from the table that 74.4% of complaints were either upheld or partially upheld higher than the previous year when 68.4% of complaints were either fully or partially upheld. 

Outcome	2024/2025	%	2023/2024	%
Upheld	514	58.3%	309	53.1%
Not upheld	187	21.2%	114	29.6%
Partially upheld	142	16.1%	89	15.3%
Ongoing	15	1.7%	50	8.6%
Withdrawn	15	1.7%	16	2.7%
Inconclusive	9	1%	4	0.9%
Total	882	100%	582	100%

10. Formal investigation

As is standard practice, complaints requiring formal investigation are investigated by Investigating Officers who are independent of Leeds City Council. Independent investigation has proved effective in resolving complex complaints.

Appendix 7 of this report contains examples of action taken in response to investigation findings to improve the quality of services.

11. Mixed sector complaints

The Leeds Citywide Complaints group share expertise, learning and good practice. Leeds Healthwatch Chair the meetings of the Group.

The council recorded 9 mixed sector complaints in 2024 to 25. Disagreeing with assessment outcomes runs as a theme through the majority of mixed-sector complaints. 

Recurring themes includes:

• A disabled care user felt there was a lack of rehabilitation and equipment provided whilst in hospital and following discharge. 
• A relative was unhappy with the level of care received whilst in hospital and disagreed that the service user was fit for discharge. The relative felt staff from both Health and Adult Social care should have shown them more empathy. 
• A care user with mental health issues and Autism complained about a lack of support from workers which has caused a delay in assessment and services being put in place.
• A care user who has mental health issues felt not listened to when they raised concerns and disagreed with their plan for future support. 
• The family of a care user complained that due to the care user being self-funding they did not have the advantages of having support from workers and their experience which may have prevented the care user being able to remain in their own home for longer. 
• The family of a care user with mental health issues challenged the decision that the service user did not need to be held under a Section 117 of the Mental Health Act.
•  A relative challenged the decision that the care user was assessed as not requiring bedrails to be fitted following discharge and the care user subsequently fell out of bed. 
• The family of a care user raised concerns regarding the quality of care their relative received whilst in hospital and disagreed with the decision that they were fit for discharge. They also raised concern about staff being difficult to contact, rude and dismissive. 
• A relative of a care user raised concerns about the level of expertise of staff at a Recovery Hub and felt some of the care their relative received would be more appropriately be delivered in a hospital. 

Next Steps:

The group continues to work on developing a system which can draw together lessons learned from people’s experiences of health and social care across Leeds which should:

• Highlight more clearly the trends in city wide complaints and develop a process to draw together and share lessons learned from the people’s experience of health and social care across Leeds.
• To continue to challenge that learning is not done in ‘silos’. This means greater drawing out of actions and recommendations for improvement which relate to improving systems across Leeds. Whilst this happens already where individual cases are high profile it is not sufficiently consistent where system learning opportunities are present.

12. The Local Government and Social Care Ombudsman 

The Ombudsman has statutory powers to carry out joint investigations with the Parliamentary and Health Service Ombudsman (PHSO). They operate a joint team of both health and social care investigators and undertake a single investigation which as previously stated in the report provides a more effective way of ensuring that complaints are resolved and lessons learned.

The Ombudsman’s role in providing independent redress extends to all adult social care providers registered with the Care Quality Commission (CQC). This means that the Ombudsman investigates unresolved complaints about care arranged and funded by local authorities and from self-funders.

It is in everyone’s interest for complaints to be resolved by councils and care providers before people feel the need to escalate problems to the Ombudsman. The Ombudsman’s website provides practical advice and useful tools to help support good complaint handling. They offer training, guidance documents, templates and practical advice on how to run complaints systems and for independent care providers they provide template complaints procedures which can be adapted, response letters, checklists and posters.

In view of the fall in complaints received by the Ombudsman and the high uphold rate from independent care providers, they are calling for mandatory signposting to increase awareness of their role and outreach support for smaller providers, annual complaint reports from care providers to encourage transparency and clarity and consistency to service users with a new set of complaints standards across the sector.

Summary of Ombudsman Enquiries - 2024/2025 reporting year

The Council is required by Law to inform people of their right to complain to the Ombudsman if for whatever reason they are unhappy with the way the Council has dealt with their complaint. The Adults and Health Directorate complaints leaflets, therefore, provides people with the Ombudsman contact details and informs people of their right to escalate their complaint to the Ombudsman. In addition, complainants are provided with the Ombudsman contact details as part of the response letter to their complaint. 

In view of the above, it is envisaged that more care users will escalate their dissatisfaction to the Ombudsman either because they would have liked something more or a different outcome from the Council in response to their complaint.

In the reporting year, 45 complaints and enquiries in total were made to the Local Government and Social Care Ombudsman compared to 29 the previous year. 

The main measures the Ombudsman uses is the Uphold rate, compliance with its recommendations and satisfactory remedy provided by the Council before the complaint reaches the Ombudsman.

In terms of the causes of complaint, The Leeds City Council, Adults and Health position reflect the national picture, with Assessment and Care Planning, Charging, Residential Care, Safeguarding and Homecare being the main causes of complaints.

A total number of complaints and enquiries made to the Ombudsman was 45 compared with 29 the previous year. The total numbers include invalid/incomplete complaints and enquiries or from people who may not have initially contacted the council and, therefore, recorded as ‘premature’ and referred back to the Council. 

Below is the breakdown:

• 3 were invalid or incomplete
• 1 advice given
• 9 of the 45 were premature and referred to the council for investigation
• 16 of the 45 cases were closed after the Ombudsman made initial enquiries
• 1 of the ones investigated were not upheld
• 15 of the ones investigated were upheld
• The total uphold rate as reported in the Ombudsman’s report for Leeds Adults and Health was 94%
• Adults and Health achieved a 100% compliance rate with the Ombudsman’s recommendations
• Adults and Health achieved 20% upheld rate. This is where the local authority has offered a satisfactory remedy before the complaint reached the Ombudsman.

This evidences a resolution focused culture in complaints handling.

Total : 45

A breakdown of the Ombudsman enquiries and the findings are detailed in Appendix 5 of this report.

13. Local Settlements and Public Reports 

Where the Ombudsman finds fault - he may recommend a local settlement or issue a public report. There was no public report in this reporting period. 

14. Timescale Performance 

14.1 The statutory timescale for acknowledging complaints is 3 working days. In 2024/25 performance against this timescale was 97%. Good performance in acknowledging complaints within timescale has been maintained.

14.2 Whilst the statutory timescale for fully resolving a complaint is now up to six months based on level of risk and complexity, the service aims to provide an initial response to complaints risk assessed as low risk within 20 working days and 40 working days for complaints risk assessed as medium risk. This year performance against this timescale was 99% a slight increase from 96.3% the previous year.

15. Compensation Payments

Under Section 92 of the Local Government Act 2000, Local Authorities are empowered to remedy any injustice arising from a complaint. It is standard practice to consider small ex gratia payments by way of recompense for costs incurred or compensation for a distress caused as a result of a matter complained about. In some cases it may be appropriate to waive care fees. The Local Government and Social Care Ombudsman also has powers to direct the authority to remedy the complainant and to recommend the amount. 

16. Methods of notifying complaints

16.1 There is no requirement that a complaint must be written, although a person making a complaint is always encouraged to be as specific as possible. Consequently, complaints can be received via a number of different channels and the chosen channel of communication is recorded. Leaflets providing information on how service users or their representatives can send compliments and complaints are widely available across all service areas and the leaflet contains a simple form, which people can use.

16.2 This reporting year 29.8% of the complaints which the service received were made through a commissioned service provider or directly with an internal member of staff. This also includes complaints which were dealt with at a local level via the commissioned provider. This was a decrease from 37.5% from the previous year. 49.8% chose to make their complaints by e-mail. This was an increase compared to the previous year’s figure of 30.8%. There was a decrease in the numbers of people who made their complaints by telephone via the Contact Centre down to 11.9% from 20.4%. There was a decrease in people raising their complaint over the telephone from 3.6% to 5.6%. The numbers of people writing letters of complaint increased from 0.9% to 1.8%. The number of people making their complaint in person remained the same at 0%, however, some of these complaints may have been made in person via their commissioned care provider or internal staff member. Use of the complaints form included in our complaints leaflet reduced from 0.2% to 0.1%. There was a slight decrease in people using an advocate to make a complaint from 1.5% to 0.8%. The numbers of formal complaints submitted by Elected Members on behalf of constituents decreased from 2.6% to 0.5%. 0.6% of people submitted their complaints via the Patient Opinion / Care Opinion websites, down from 2.1% last year. 0.6% of complaints received were made to the Ombudsman. This was a decrease from 0.9% in the previous year. 0.2% complaints made were made to the Care Quality Commission (CQC). No complaints were received via the CQC in the previous year. 

16.3 Only 33.1% of complaints were made by service users themselves, which was an increase from last year’s figure of 20.8%. Of the people making complaints on service users’ behalf, 22.2% were from relatives which was a decrease from 27% followed by carers 23.7% down from 29.4%. Members of the public made up 10.4% of the complaints, a decrease from 11.4% other professional agencies 2.7% up from 1.7%, workers and other care providers 2.2%, advocates 1.4%, solicitors 0.3%, friends 1.1% and parents of working age adults 1.7%.

17. Equality Monitoring 

17.1 All complaints are subject to equality monitoring, which now includes all the equality characteristics protected through legislation (age, disability, gender, race, religion or belief, sexual orientation). Information is most frequently provided on ethnicity, gender and disability. No information has been provided about other characteristics. 75.3% of all complaints have ethnicity recorded, 96.6% have gender recorded,1 non-binary and 31.6% of complaints were from or on behalf of people with disabilities. 

Where complainants haven’t provided this information, the Complaints Team checks the social care record (CIS) and uses the information available there if it has been recorded. A breakdown of the equality related information provided by complainants is detailed in Appendix 6 of this report. 

18. Lessons Learned 

18.1 Where a complaint has been upheld, it is often the case that the manager undertaking the resolution of the complaint will make recommendations on how the service should be improved to avoid a similar situation arising for another service user. These actions will be brought to the attention of the complainant and there is a system in place for recording the action and the person with responsibility for implementing the action. Appendix 7 of this report contains some examples of the lessons learnt during the course of the reporting year and actions taken to improve the quality of service. 

19. Service user Satisfaction surveys

19.1 The Complaints Team sends a satisfaction questionnaire to all complainants after they have received a response to their complaint. The purpose of the questionnaire is to seek complainants’ views on how easy they found it to complain and how satisfied they are with key aspects of the process and outcome. The return rate in this reporting period was 1.7% of the satisfaction questionnaires which were returned. 72.7% were either very satisfied or quite satisfied with the response to their complaint. Complainants commented that it was easy to complain or their complaints were passed on to the Complaints Team by another department. The main reservations complainants had about completing the satisfaction questionnaire was that ‘they were not sure it would do any good”. The Complaints Team are looking into how the satisfaction questionnaire return rate can be improved. 

20. Developments/updates - 2024/2025

Although still below the pre-pandemic figures, it is pleasing to note that in the 2024/2025 reporting year, the numbers of compliments and complaints have continued to increase. The number of compliments increased from 984 to 1166 and the number of complaints increased from 520 the previous year to 882. The Complaints Team continue to deal with increasingly more complex complaints and the challenge of operational managers who act as investigating officers having to support front line service delivery. This particularly can affect timescale performance in resolution of complaints. Commissioning Officers too have been supporting front line commissioned service providers so they too have had challenges in trying to resolve and/or investigate complaints within the agreed timescale. Finance Officers too have been involved in providing support payments to commissioned care providers hence challenges in trying to maintain good performance in resolving complaints.

The focus for the Complaints Team has been to maintain good customer service by focussing on good communication by keeping complainants informed of any progress.

21. Guidance for dealing with unreasonable behaviour from care users 

Occasionally the behaviour or actions of some service users or their representatives has made it very difficult for staff to deal with them. In a small number of cases the actions of individuals become unreasonable and can be considered to be unacceptable because they involve abuse of staff and has a huge impact on Council resources.

In view of this, Adults and Health Directorate has Guidance for staff to guide them when dealing with care users whose behaviour is unacceptable or unreasonable and with action that can be taken.

22. Protocol on Complaints Handling with commissioned service providers

The Local Government and Social Care Ombudsman has made it clear that where a Council commissions care from the independent sector, that the Council remains accountable for the actions of the provider it has commissioned. In view of this, Leeds City Council, Adults and Health Directorate has a protocol with its commissioned service providers.

The purpose of the protocol is to provide a framework for collaboration in handling complaints and ensuring regular communication in relation to commissioned services between Leeds City Council, Adults and Health Directorate and its commissioned service providers. This should also allow the Council to gain an overview of service user feedback in relation to commissioned services as well as provide an opportunity to collate information to ensure that learning points arising from compliments and complaints are used to inform contract monitoring and/or used to improve services and inform commissioning activities.

The protocol is also extended to Spot Providers. The Complaints and Commissioning Teams continue to remind providers to share information as requested in the protocol.

Providers are reminded to feedback on how the Protocol can be improved. The Council will update the Protocol as we learn from both care user or their families’ feedback and staff. Providers are reminded to ensure that responses to complaints are thorough and for them to ensure that responses are quality assured by their line Managers before sharing the response with the council's Complaints and Commissioning Teams. 

23. Review of information literature for service users

23.1 Monitoring and review of information for service users or their representatives in order to try and ensure that the Complaints Procedure is accessible is one of ongoing monitoring, development and review. 

23.2 There is the Easy Read Complaints Leaflet.

23.3 Deaf people using British Sign Language can contact the Complaints Team using mobile telephone number 07800005460.

24. Review of Adult Social Care Complaints 2024/2025

The Ombudsman published its Annual Review of Adult Social Care complaints in September 2025.

It will be noted from the report that the Ombudsman saw an increase of 8% in complaints received compared to the previous year and an uphold rate of 79% of complaints investigated including a significant 28% increase in complaints about charging for care services. In Leeds we saw an increase of 275% in complaints about charging for care services from 4 to 15 in the reporting year.

The Ombudsman is also concerned about the consistently few complaints received from private (self) funders than they would expect given their share in the market (estimated at 23% of all care users) yet the number of complaints they receive from this group remains disproportionately low. Although there are likely to be a range of reasons for the decrease in numbers, the Ombudsman believes that a lack of proper signposting to their services plays a role.

The Ombudsman also states that whilst it understands that there are challenges within the adult social care sector, they are clear that Councils and Care Providers must prioritise care for the most vulnerable and focus on getting the basics right wherever possible. It urges …”all councils and care providers to prioritise clear, timely and compassionate communication, ensuring people are informed, consulted and empowered……”

25. Focus reports

The Ombudsman offer practical guidance documents, tools and training to support care providers and local authorities with good complaints handling. Focus reports and Good Practice Guidance documents have included:

“People not structures – Putting People at the heart of integrated care” – published July 2024: This was a report produced by the Local Government and Social Care Ombudsman with the Parliamentary and Health Service Ombudsman.

Integrated Care Systems (ICS) are made up of representatives from local authority social services and NHS partnerships that work together to support the needs of people in their areas. The report said ICS are not doing enough to put the vulnerable people they support at the heart of what they do.

The report detailed some of the things that can and do go wrong when people are not prioritised and when services do not work together effectively. 

It recommended for integrated care systems to agree a ‘person first approach’ where Councils and Health Services work together to look at how a person’s needs can be met as first priority. It also suggested that Councils and Health Services agree standard frameworks for effective communication focused on ensuring professionals on the frontline interact effectively and record all discussions and decisions. 

26. Local Government and Social Care Ombudsman (LGSCO) and Housing Ombudsman Joint Complaint Handling Code Consultation

The Code will provide a single standard for complaint handling in local councils in England for complaints not already subject to statutory processes. The aim of the Complaints Handling Code is to provide more certainty for people on how their complaints should be handled and give Councils a better understanding of what good practice looks like, to resolve complaints promptly and to use the data and learning from complaints to drive service improvements.

There will be a launch of the Complaint Handling Code in London on 26 March 2026. The event is an opportunity for the Ombudsman to share their experience of developing the Code as well as the experience of councils who have been piloting the Code. The event will mark the start of the Code being applied in the Ombudsman’s casework. 

27. Other priorities to be taken into account during 2025 onwards include 

• To continue to contribute to Leeds achieving the aims in the Council Plan by making sure we are working to make sure we are best serving our residents within the resources available
•  Continuing to contribute to achieving organisational effectiveness by doing things better so that we can deliver excellent services
• To develop our approach to Artificial Intelligence and explore its potential to help us in our work to improve our service and efficiency
• Continuing to contribute to gathering intelligence and sharing this widely so that lessons learnt from compliments and complaints can inform service improvements.
• Continuing to contribute to support the Council to achieve its Best City Ambition, one which recognises the strengths and opportunities which the Council has within these difficult times, to be a place that prioritises people, partners and businesses working together as Team Leeds.
• Continuing to contribute to the Best Council ambition to be efficient, enterprising and a healthy organisation and meeting this by ensuring that staff are effective and have the right knowledge and skills to continue to improve complaints handling.
• Continuing to contribute to the Council Climate strategy by adopting practice which contributes to addressing this emergency.
• Continuing to contribute to the Council achieving its vision of a more enterprising Council, working with partners and businesses who are more civic and a more engaged public.
• Via the compliments received continuing to evidence how the Adults and Health Directorate is meeting the key qualities and priorities that people expect of keeping people safe from harm, people feeling safe and people living with dignity and staying independent for as long as possible. The Complaints Service is another useful tool for indicating where services may need adjusting and/or where they are not working well.
• Continuing to work closely with operational and support services’ teams, sharing lessons learned from service user feedback to inform commissioning activities and service improvements.
• Continuing with the Complaints training via virtual classroom on the statutory complaints procedure, incorporating learning from service user feedback.
• Continuing to provide briefings to voluntary sector organisations so that they understand the health and social care complaints procedure so that they can effectively support people who may wish to access the complaints process.
• We will continue to push forward a learning culture throughout the organisation. We will continue to do this by ensuring learning is followed up by simple action plans with the Heads of Service at the time the complaint is closed. Learning which has a wider impact will be shared widely with the relevant teams/partners.
• We will continue to monitor and evaluate information to ensure that the complaints procedure is accessible to all service user groups.
• Continuing to promote the complaints service across all Adults and Health operational teams by attending their management team meetings to share key messages, the national picture and the impact this will have on their practice.
• A new member of staff has been recruited to the Billing

28. Conclusion

Despite financial constraints faced by the Council that necessitate tough decisions around service provision, care users’ expectations of what they can reasonably expect from the Council remains very high. Care users feel empowered to hold the Council to account and to escalate their complaints to the Ombudsman as can be noted by the number of complaints made to the Ombudsman.

When a Council commissions another organisation to provide services on its behalf the Ombudsman holds the Council responsible for those services and for the actions of the organisation providing them. So, although they may find fault with the actions of the commissioned care provider, the recommendations to remedy any injustice is made to the Council. In view of this, the impact of commissioned services’ failings has potential reputational and financial risks for the Council as well as increasing pressure on both the Council’s Commissioning and Complaints Teams in terms of volume, complexity and the need to ensure that the quality of complaints handling within commissioned care services is good in addition to continuing to strengthen our systems with commissioned care providers.

Review of compliments and complaints has provided an opportunity to assess Adults and Health Directorate’s performance against the key qualities that people expect from health and social care services.

It can be noted from the compliments recorded in the annual report that despite the challenges overall health and social care and its commissioned care providers has continued to respond well to some of the ongoing challenges. 

At a time of such pressure, it is now more important than ever to listen to public concerns in the form of complaints as they provide free market research and intelligence to spot problems that can lead to responsive, engaged and improved services. As can be evidenced in appendix 7, the complaints informed service improvements. Some complaints data and analysis informed individual Managers to take the initiative at service/team level or with individual staff members to address areas for development and local improvements.

Complaints are a crucial early warning sign when something has gone wrong and the person complaining could be without a crucial service at a critical time. Our strategy, therefore, is to continue to encourage as many people as possible to provide us with this feedback so that issues can be resolved early and for these to drive service improvements.

The focus for the Complaints Team is to continue to ensure that we communicate clearly with complainants and keep them informed of progress.

As in previous years, it is important that the Council takes even greater measures to evidence that lessons learned from complaints are used to improve and maintain the quality of the services it provides and commissions. Complaints continue to be a complex and difficult service area with potential for both reputational and financial risks for the council. 

If you would like to comment on this report, or to receive it in large print, Braille or other format, please contact: complaints.socs@leeds.gov.uk

Complaints Service, Leeds City Council, Adult Social Care, PO Box 848, Leeds LS1 9PQ

Telephone: (0113) 2224405. 

Email: Judith.kasolo@leeds.gov.uk

Complaints Team Members include:

Judith Kasolo, Head of Complaints

Dominic Wyatt, Complaints Manager

Tina Price, Senior Complaints Officer 

Sarah Jones, Complaints Officer and

Ayesha Iqbal, Complaints Co-ordinator

Appendices

Appendix 1 - Compliments received by service area

Service area	2024/25	%	2023/24	%
Independent Sector Care Homes	678	58.1%	271	27.5%
Area Social Work	106	9.1%	61	6.2%
Learning Disability Social Work	62	5.3%	44	4.5%
Learning Disability Housing and Day Services	59	5.1%	75	7.6%
In-house Older People Residential and Day Services	57	4.9%	120	12.2%
Skills/Reablement	53	4.5%	87	8.8%
Resources and Strategy	47	4%	52	5.3%
Equipment and Adaptations	23	2%	10	1%
Blue Badge	17	1.5%	8	0.8%
Strategic Commissioning	16	1.4%	10	1%
Independent Sector Home Care	13	1.1%	11	1.1%
Mental Health Social Work	12	1%	13	1.3%
Hospital Social Work	10	0.9%	7	0.7%
In-house Mental Health Residential and Day Services	9	0.8%	85	8.6%
Independent Sector commissioned (working age adults, mental health and physical impairment)	1	0.1%	20	2%
Commissioned service	1	0.1%	5	0.5%
EDT	1	0.1%	1	0.1%
Care Brokerage	1	0.1%	-	-
Physical Disability Residential and Day Services	-	-	92	9.3%
Leeds Shared Lives	-	-	12	1.2%
Total	1166	100%	984	100%

Appendix 2 - Complaints by service area

	2024/25		2023/24
Total	882	100.0%	582	100.0%
Independent Sector Care Homes	235	26.6%	71	12.2%
Blue Badge Applications	202	22.9%	74	12.7%
Area Social Work	114	12.9%	117	20.1%
Learning Disability Commissioned Services	76	8.6%	37	6.4%
Finance	75	8.5%	91	15.6%
Hospital Social Work	40	4.5%	41	7%
Learning Disability Social Work	32	3.6%	34	5.8%
Mental Health Social Work	22	2.5%	27	4.6%
Independent Sector Home Care	21	2.4%	38	6.5%
Equipment and Adaptations	18	2%	20	3.4%
Inhouse residential care	13	1.5%	6	1%
Mental Health Accommodation and Day Services	11	1.2%	4	0.7%
Skills / Reablement	9	1%	10	1.7%
Commissioning Other	7	0.8%	-	-
Strategic Commissioning	3	0.3%	1	0.2%
Complaints	2	0.2%	1	0.2%
Mental Health Commissioned Services	1	0.1%	2	0.3%
Information Management Team	1	0.1%	-	-
Physical Impairment Commissioned Services	-	-	6	1%
Public Health	-	%	1	0.2%
Safeguarding	-	%	1	0.2%

Appendix 3 - Complaints how received

How received	2024/25	%	2023/24	%
Email	439	49.8%	179	30.8%
Via a Worker/commissioned provider	263	29.8%	218	37.5%
Corporate call centre	105	11.9%	119	20.4%
Telephone	32	3.6%	19	3.3%
Letter	16	1.8%	5	0.9%
Via an Advocate	7	0.8%	9	1.5%
Patient Opinion	5	0.6%	12	2.1%
Via the Ombudsman	5	0.6%	5	0.9%
Via an elected member	4	0.5%	15	2.6%
Healthwatch	3	0.3%	-	-
CQC	2	0.2%	-	-
Form	1	0.1%	1	0.3%
Total	882	100%	582	100%

Complaints - received from

Complainant - how involved	2024/25	2023/24
Service User	292	121
Carer	209	171
Relative	196	157
Member of Public	92	65
Other Agency	24	10
Worker/commissioned provider	19	19
Parent	15	6
Advocate	12	13
Friend	10	6
Elected Member	5	6
Other	5	1
Solicitor	3	7

Appendix 4 - Timescale performance

Acknowledged within	Responded within
% within 3 days	% after 3 days	% within 20 days	% after 20 days
Resources	98.6%	1.4%	100%
Social Work and Social Care Provision	98.1%	1.9%	98%
Strategic Commissioning	84.6%	15.4%	100%
Public Health	-	-	-
Total	96.7%	3.3%	99%

Appendix 5 - breakdown of Ombudsman complaints and enquiries received between 1 April 2024 and 31 March 2025

Complaints and enquiries	Total
Assessment and Care Planning	9
Charging	15
Safeguarding	6
Transport (including blue badges)	3
Direct Payments	0
Disabled Facilities Grants	1
Residential Care	5
Home Care	3
Supported Living	0
Other	7

Outcome	Total
Invalid or Incomplete	3
Advice given	1
Referred back for local resolution	9
Closed after initial enquiries	16
Not Upheld	1
Upheld	15

Appendix 6 - Complainants by ethnicity provided by complainants

Ethnicity	2024/2025 Number	%	2023/24 Number	%
White British	534	60.5%	386	66.3%
Not known	218	24.7%	145	24.9%
Refused Information	46	5.2%	3	0.5%
Asian Other	24	2.7%	8	1.4%
Pakistani	15	1.7%	4	0.7%
White Other	14	1.6%	7	1.2%
Indian	8	0.9%	1	0.2%
Black Other	6	0.7%	13	2.2%
White Irish	3	0.3%	3	0.5%
White and Black Caribbean	3	0.3%	2	0.3%
Black African	3	0.3%	-	-
Mixed Other	3	0.3%	-	-
Black Caribbean	2	0.2%	1	0.2%
Any other ethnic group	1	0.1%	4	0.7%
White and Asian	1	0.1%	1	0.2%
Arab	1	0.1%	-	-
White and Black African	-	-	3	0.5%
Chinese	-	-	1	0.2%
Total	882	100%	582	100.0%

Complainants by gender

Gender	2024/25 Number	%	2023/24 Number	%
Female (including Trans)	511	57.9%	338	58.1%
Male (including Trans)	317	35.9%	229	39.3%
Not known	30	3.4%	6	1%
Joint (married / partnership)	23	2.6%	7	1.2%
Non-Binary	1	0.1%	2	0.3%
Total	882	100.0%	582	100.0%

Complainants by disability provided by the complaints

Disability	2024/25 Number	%	2023/24 Number	%
Disabled	279	31.6%	164	28.2%
Not known	491	55.7%	374	64.3%
Non-disabled	112	12.7%	44	7.6%
Total	882	100.0%	582	100.0%

Appendix 7 – Learning from Complaints

A number of service improvements have been made in response to customer feedback. Key themes of service improvements have included the training and performance management of staff, review of processes and policies and the revision of communication. Some examples can be found in the table below 2024 to 2025.

Independent Sector Supported Living

A service user expressed dissatisfaction with a new resident who had moved into the supported living and was demonstrating disruptive behaviour and distressing the existing residents.

Lessons learned:

• Ensure that more time is spent learning about a new person before they move in.
• There are also regular reviews held to ensure all actions are completed
• Revisited support and risk plans. Planned activities to build relationships.
• More robust transition planning with planned activities and overnight stays. Planned time with each person for regular debrief.

A parent complained that a service user was distressed and a lack of information given when the service user visited the complainant.

• Staff to look out for possible 'warning' signs in the service user’s behaviour. Additional coaching on reporting and recording was required for the staff member; the team would benefit from additional coaching.

Finance

A service user complained about lack of flexibility with the new billing process as they do not always attend their service. They also complained about not being notified of the changes in the billing system.

Lessons learned:

• Not informing people about this change is not in line with Leeds City Council values of being Open and Honest. We have listed to your comments, once a decision has been made about the invoice cancellations and amendments policy we have asked for this to communicated clearly and in detail so that people understand the charging process.

A family member complained that they had received a backdated bill with no explanation of what the charges were for. They have attempted to call to query this but have been unable to get through to a member of staff.

Lessons learned:

• A new member of staff has been recruited to the Billing Team.
• A new phone system with call monitoring, queuing and call back functions has been put in place.
• Charges will be based in the amount of service a person receives rather than a fixed amount of planned service, this make invoice more accurate.
• Backdated charges will include a description of the charges on an invoice and where a backdate is for more than 12 week.
• A letter explaining how the charging process is administrated will be sent with a person’s first invoice.
• Changes to the financial assessment letter to include information specific to a person’s invoices/charging.

A complainant who usually receives monthly invoices received ten in one month.

Lessons learned:

• A separate Adult Social Care Billing e-mail address is now used to help prioritise and report instances where new billing records have errors which require prompt correction, to enable authorisation. This will avoid the reliance on a single officer having to deal with the request and mean that Managers can regularly check and review that the billing queries are being resolved in a timely manner. Continuous daily reviews are now carried out by our Sundry Income billing team to identify any Adult Social Care billing record that has been awaiting authorisation for more than 7 days, which will then be chased up again by e-mail to our Adult Social Care billing team. Any billing queries still not resolved after a second e-mail will be referred to the Adult Social Care Billing Manager to resolve.

The relative of a service user was notified when they passed away.

Lessons learned:

• The Deputy and Estates team have been through a significant and challenging transformation over last 2 years. As part of this, a new client management system was introduced, the team structure has changed, and new staff have been recruited. The new system that was introduced has built-in workflow processes that help staff to monitor tasks and has clearer financial information, therefore instances such as this should be dealt with more thoroughly in the future.
• The care home will now record family member’s contact details during the pre-admission stage.

Assessment and Care Planning – Area social work

A service user on an out of area placement was unhappy in their current placement and requested to move.

Lessons learned:

• The importance of offering face to face visits, regardless of distance and not making assumptions was highlighted with the team.

The parent of a service user with complex needs as not invited to a review and the service user’s care package was subsequently reduced without consulting the complainant.

Lessons learned:

• Social Workers were reminded of their responsibility to ensure reviews are completed with the involvement of the person, any representative/s and current support provider, and all views are heard to complete a fair and balanced review of care and support arrangements.

The parent of a service user complained they were not advised that they would need to contribute towards the cost of the care. Following the realisation of this they cancelled the service.

Lessons learned:

• The Social Work Teams are regularly reminded that they must discuss the finance assessment process with clients and advise people that they may have a contribution to make towards their services and that they need to ensure that finance booklets are provided, and people are sent a copy of their assessment and support plans as common practice.
• This care was discussed with the team and the personal impact this has had upon the service user.

A vulnerable service user who is self-funding. As they are self-funding they were unable to have a needs assessment and their case was closed. Due to the service user’s mental health issues they are unable to arrange care themselves, so no care is in place.

Lessons learned:

• Learning was shared about the importance of explaining the assessment process and charging policy at the first opportunity and clearly documenting this within the assessment. This will be monitored and reviewed. The importance of timely communication and responding to people within appropriate time frames wherever possible was discussed.
• Learning around the case closure process was taken on board and shared with the team to ensure cases are not closed prematurely, where there is still outstanding support needs.

Reablement/Skils

The family of a service user complained that they felt the service was free for 6 weeks, they received nothing in writing. They supplied financial information for a financial assessment, but it was not explained to them how charges would work.

Lessons learned:

• To avoid a repeat of this incident the service proposed to undertake wider training with the Social Work teams to ensure that everyone is aware that, people will be charged for the Reablement service at the point when their ongoing needs have been identified.

Disability services

A service user complained that equipment was delivered without any notice and was not taken upstairs.

Lessons learned:

• When the delivery drivers call to arrange a collection of equipment that is no longer required and the phone number goes to voice mail, the driver will inform the client what date and time they are calling, and for the client not to worry if they are not in, as a card will be left for them to call and rearrange the collection.

Commissioned Residential Care

The family of a service user complained that an item of the service user’s jewellery was not returned to them following the death of the service user.

Lessons learned:

• The residential care home’s policy has now changed in relation to inventory management and photographs of valuables are now also retained within the safe. The home has amended their inventory template.

The family of a service user raised concerns regarding the lack of physiotherapy following discharge to the home from hospital and the appropriate equipment not being in place.

Lessons learned:

• Any equipment required but not in service is to be ordered. This has been cascaded to the nursing team, Occupational Therapists, Physical Therapists and all other external parties involved. Care being provided in a rehabilitation setting will be provided in line of the individuals needs including risk assessments and care planning. This will be liaised with all multi-disciplinary teams and the residents and relatives personally. Care provided will be person-centered.

The family of a service user expressed concerns when they arrived to escort their relative to an appointment which had been cancelled by the residential care home without notifying the family.

Lessons learned:

• Staff will ensure that they involve appropriate representative who have a Lasting Power of Attorney on relevant decisions, including care plans, finances, changes in care needs or treatment required. This is to be clearly documented on PCS that contact/involvement has been completed effectively. Policies and procedures such as flash meetings, resident of the day already in place and to be adhered to by the home manager and staff in the homes. This was discussed in the next Manager’s meeting.

Mental Health Care Management

A relative of a service user questioned why they were not notified that the service user had been held under a section of the Mental Health Act as they are the Nearest Relative.

Lessons learned:

• It has been highlighted as part of this learning the need for workers to recognise and value those involved in a caring role whilst balancing the need to protect an individual’s right to confidentiality and the importance of carers being given relevant
• information about the support available to them.
• The team manager in her role as AMHP professional Lead for Leeds City Council delivered additional training on the processes involved in delegation and revocation of the Nearest relative function for all AMHP’s in the service. There has been specific training provided to the Emergency Duty Team with respect to the role of Nearest Relative and dealing with requests made in relation to the Mental Health Act from a Nearest Relative out of hours.

Recovery Hubs

Concerns were raised by a relative of a service user when they found the service user in soiled clothes. They also raised concerns regarding food and fluid intake.

Lessons learned:

• Additional training with the nurse lead around catheter care support was undertaken, this was also a theme of an upcoming ‘learning corner’. Training was delivered across the entire staff team about appropriate interactions. This was also followed up with a letter to remind staff of this.
• Discussions were held with our Safeguarding and Risk Manager who supported staff with a reflection of any learning that was implemented to the team this was also supported by the Principal Service Manager for the beds as is protocol for the services when there are concerns raised about the service provided to any individual. All staff reflected on what can be done better around communication.

A family member raised a complaint regarding staff being on their phones and the service user being left in their room despite the care plan stating that they should have a daily walk.

Lessons learned:

• The Registered Manager and Principal Service Manager increased the observations of staff practices and discussions in staff supervisions will reinforce the need to ensure staff remain engaged and attentive. However, it was acknowledged there was a lack of documentation detailing substantial practice outside of the Physiotherapy and Occupational Therapy. sessions. Simple tasks such as walking to the dining room for meals can positively impact recovery, and staff will promote this more routinely.

Independent Sector – Home Care

A relative of a service user challenged the care hours that were delivered and felt they had been overcharged, the carers were often late and had not read the care plan so felt care was not being delivered.

Lessons learned:

• Service User’ schedules, requirements and expectations will be regularly reviewed.
• communication practices and case management at the branch. Were reviewed
• The branch will ensure that clear communication is established with all service users regarding their specific call times prior to the commencement of care, as well as outlining the expectations of care.
• All care staff were reminded to thoroughly read the care plan and digital activities available on the digital app prior to commencing care for each service user.
• Senior Managers will examine and determine the branch's ongoing staffing needs based on factors such as service demand, caseloads, staff turnover rates, and any upcoming changes or expansions in services. This will provide the required understanding to maintain a safe staffing level for the service and support consistency of care.

A complaint was received regarding carers arriving late but signing in that they were at the service user’s property.

Lessons learned:

• The traffic conditions in the service user’s area played a significant role in delaying the carers’ arrival. The home care provider has proactively increased staff levels within the area and hired more locally based carers to mitigate any such delays.
• The policy with supervisory staff to ensure immediate communication in any future occurrences has been reinforced.
• To maintain transparency, the app functionality by enabling geolocation tracking has been enhanced. This requires carers to be within a 50-meter radius of the client's property before they can log in, ensuring that all recorded entries are accurate and verifiable.
• All carers are trained to assess and handle these risks appropriately, and they have completed necessary competencies regarding medication administration in compliance with regulations.
• To ensure these standards are upheld, we have followed up with the carers involved to reinforce their understanding of the clinical implications of their schedules, and additional training was scheduled, and provided retrospectively to those involved, to further strengthen their competencies.
• More regular reviews of the service users was initiated.

Hospital Social Work

A relative raised a complaint regarding a vulnerable couple who both had care needs and wanted to be discharged to a dual placement but they were assessed separately, and one party was denied funding.

Lessons learned:

• Clear and concise information to be shared with family and clients to ensure that realistic expectations are set about the possibility of funding for 24 hour placements
• To ensure clear communication between the service user, family, Health colleagues and social care colleagues to ensure the correct outcome is attained and to minimise any distress

A relative of a service user complains that they were advised that the service would be free for 4 weeks following discharge to allow for assessment.

• Social Workers will give out discharge summary letters to all service users and or their families on discharge, Social Workers to be more clear, compassionate and considerate in their discussions with families at these very stressful difficult times.

Learning Disability Care Management

The parent of a service user complained about the lack of communication between workers.

Lessons learned:

• Changes have been implemented to the Duty system. Cases on the Duty handover will now be discussed on a weekly basis, rather than relying upon Duty workers to decide when something needs manager attention.
• North Duty Team will from now on, people living out of area who are in need of a review will be allocated a Care Manager so that people receive a better service. Duty meetings have been updated to not only discuss new referrals, but ongoing progress on current referrals so that I have greater oversight of the work duty.

Independent Sector

A service user complained that the carer did not attend to put them to bed and when they pressed their pendant this was initially ignored.

Lessons learned:

• Supervisions were carried out with the members of staff involved
• Competency checks were carried out
• The service user was shown the correct procedure of alerting staff using their pendant
• Concerns raised about care professional’s attitudes were discussed in the next Team Meeting.

A service user was sent a booklet through the post with inadequate postage so they had to pay the additional postage for the booklet to be delivered.

Lessons learned:

• It was shared with my colleagues the importance of weighing envelopes prior to them being posted to avod any further or future repeat of this mistake. The incident was also addressed by the contractor.