Summary: Mrs X complains about the care provided by the Council to her father, Mr Y, when he was at a care home. She considers the failings contributed to a decline in his health and the need to return to hospital. We will not investigate this complaint. This is because the failings have already been accepted and action taken to remedy the injustice.

The complaint

1. Mrs X complains about the care provided to her father, Mr Y, while he was resident at a Nursing Home (the Home). Cambridgeshire County Council (the Council) arranged and funded the placement. Mrs X’s complaint includes that the Home:
• did not use correct manual handling to help Mr Y move around; and
• gave Mr Y an overdose of his medication.
2. Mrs X says the failings led to Mr Y suffering avoidable pain and the stress of needing to go back into hospital. Mrs X says she also experienced significant distress and a loss of confidence in care homes.
3. Mrs X says she wants improvements made with medication checking, extra training on manual handling, and for the Home to accept responsibility and accountability for the failings.

Back to top

The Ombudsman’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse effect on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start an investigation if we decide the tests set out in our Assessment Code are not met. (Local Government Act 1974, section 24A(6), as amended)

Back to top

How I considered this complaint

5. I considered information provided by the complainant, the Council and the Home. This included relevant sections of Mr Y’s care notes.
6. I considered the Ombudsman’s Assessment Code.
7. Mrs X had an opportunity to comment on my draft decision and I considered her comments before making a final decision.

Back to top

My assessment

Brief background

8. The Council arranged a place for Mr Y at the Home following a hospital admission in early 2024. He was at the Home just over two weeks. When Mr Y had been at the home for just over a week, staff gave him the wrong amount of medication. The Home referred to safeguarding and sought medical advice. The medical advice confirmed the medication given was not over safe limits. The Home monitored Mr Y and amended the medication in line with the medical advice.
9. Following this, Mrs X raised concerns about the way staff were helping Mr Y to move around. She saw staff supporting Mr Y by holding onto his clothing and said this had caused pressure sores.
10. Mr Y’s health declined and he returned to hospital. He moved to a different Care Home when he left hospital.
11. Mrs X complained to the Home about the care it had provided to Mr Y.

My assessment

12. The Home has accepted there was an error with giving Mr Y his medication. When this happened, the care records show the Home sought medical advice. A doctor took details of the type and amount of medication Mr Y had taken. After consulting with another doctor, they advised the Home the amount given was within a range where Mr Y was not at risk of overdosing. The doctor advised the Home to monitor Mr Y and amend the medication to the prescribed level.
13. The care records show the Home took appropriate action by seeking medical advice and monitoring Mr Y. Staff recorded Mr Y showed no adverse effects from the extra medication. The Home also reported this incident to the council’s safeguarding team. They advised no further action was needed. The way the Home acted when it realised its error was good practice. It was open and transparent and took action to keep Mr Y safe.
14. Records show Mr Y’s health was stable immediately after the medication error. His health declined the following week. The care records note nursing staff felt this may be due to an infection. Given the timings and medical advice that was provided, I consider we are unlikely to be able to link Mr Y’s decline to the medication error.
15. The Home also accepted there were manual handling issues when staff were helping Mr Y to move around. Staff had held Mr Y’s clothing when supporting him. This is evidence of fault and it appears to have caused Mr Y a pressure injury. When Mrs X raised this with the Home the records show it acted quickly to address this. It discussed this with the staff members, made a referral to physiotherapy and agreed to use a hoist to help mobilise Mr Y. The Home also contacted the GP to get cream for the pressure injury. The records note staff discussed this with Mr Y’s daughter.

Back to top

Final decision

16. We should not investigate this complaint. This is because the Home, on behalf of the Council, has accepted fault and taken reasonable actions to address this. We are unlikely to achieve more by investigating.

Back to top

Investigator's decision on behalf of the Ombudsman