Summary: Mrs X complained on behalf of her late mother, Mrs Y, about the care she received from the Care Provider. We found it at fault for failing to provide Mrs Y with her prescribed medication and for poor record keeping. The Care Provider has apologised and issued a partial refund. It has also agreed to make a symbolic payment and review its procedures. Together, these actions are a suitable remedy.

The complaint

1. Mrs X complained on behalf of her late mother, Mrs Y, about the care she received from RKL Care Ltd (the Care Provider). She said Mrs Y was not given her prescribed medication which affected her health and wellbeing. She also complained that the Care Provider did not respond appropriately to her complaints or put suitable service improvements in place.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2) and 34C(2), as amended)

5. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

6. I considered evidence provided by Mrs X and the Care Provider as well as relevant law, policy and guidance.
7. Mrs X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Care Quality Commission (CQC)

9. The CQC is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

Fundamental Standards of Care

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
11. Providers must ensure they meet residents’ assessed care and support needs through the delivery of safe and appropriate care. This includes the proper and safe management of medicines, ensuring medicines are available when needed, stored securely, administered correctly, and accurately recorded. Providers should have suitable medicines policies and procedures, ensure staff administering medicines are appropriately trained and competent, maintain accurate and up-to-date medication records, and have effective systems in place to monitor and reduce medication-related risks.
12. Providers must also maintain accurate, complete and contemporaneous records about the care and treatment provided to residents. They should have effective systems to assess, monitor and improve the quality and safety of services, identify risks, and ensure lessons are learned when things go wrong. Good record keeping is an important part of demonstrating that appropriate care and treatment has been provided.

What happened

13. Mrs Y moved to a care home managed by the Care Provider in January 2025. Mrs Y’s family said that initially she seemed to settle into the home well.
14. In February 2025 family members visited Mrs Y at the home and found she was distressed and in pain. Family visited again the next day and, on finding Mrs Y was still distressed, raised concerns about staff not attending to residents’ needs in a timely way. They also discussed the option of moving Mrs Y back home.
15. Mrs Y moved home with family the following day. This was initially agreed for a one-week period. Whilst working with staff to collect her belongings, the family were told that Mrs Y had none of her prescribed medication available. Staff told Mrs X that Mrs Y had been without any medication for around one week.
16. Mrs X made a complaint to the Care Provider in mid-February 2025. She said that Mrs Y would not return to the care home and requested a full refund.
17. The Care Provider responded to Mrs X’s complaint in late February 2025. It said there were difficulties transferring Mrs Y to its GP surgery and therefore delays obtaining a repeat prescription for her. It said it also tried to get extra medication from the family, but was unable to do so as the family member who had access to the medication was away from home. It apologised and said it would review its procedures to prevent similar problems happening in future.
18. Mrs X escalated her complaint to stage two in March 2025. The Care Provider responded to Mrs X’s stage two complaint in April 2025. It reiterated its apology and plans to review its procedures, but refused to issue a refund.
19. Mrs X wrote again to the Care Provider in late April 2025. She repeated her concerns and asked for the fees to be refunded from the date that Mrs Y left the care home. Mrs X then chased the Care Provider for a response in May 2025 and said she would contact the CQC about her concerns.
20. The Care Provider responded to Mrs X in May 2025 and offered a symbolic payment of £500. It said it felt all points of Mrs X’s complaint had been dealt with. It also advised that it had discussed Mrs X’s concerns during a recent CQC inspection. It also said that it would not refund fees for care that was provided.
21. In July 2025 Mrs X complained again to the Care Provider and asked for a full refund, including for the fees paid for time after Mrs Y left the care home. Mrs Y unfortunately passed away in July 2025.
22. The Care Provider responded to Mrs X in August 2025 and agreed to waive its usual notice period and to refund fees paid from the date that Mrs Y left the care home. The Care Provider has confirmed that this refund was paid to the family in September 2025.

Analysis

23. The Care Provider acknowledged there were problems obtaining Mrs Y’s medication. It said there were difficulties transferring Mrs Y to the GP surgery and pharmacy it used, and this led to delays obtaining a repeat prescription. It also said there were communication problems about obtaining medication from family members.
24. Regardless of the reason for the delays, the Care Provider was responsible for ensuring appropriate arrangements were in place to meet Mrs Y’s assessed care needs. This included ensuring prescribed medication was available when needed. Mrs Y was without medication for around one week whilst living at the care home, which put her health at risk and caused distress. I therefore find fault by the Care Provider.
25. Mrs X also complained that the Care Provider did not take responsibility for what happened. I have considered the complaint correspondence provided by both parties. The Care Provider apologised for the medication problems and accepted its procedures should have been better. It also said it would review its medication processes and staff practices. I am therefore satisfied the Care Provider acknowledged failings in its service, although I understand Mrs X remains unhappy with its explanation of events.
26. The Care Provider also told Mrs X it had reviewed its medication procedures, staff training and care planning processes following the incident. These were appropriate actions to take following the medication failure and demonstrated the Care Provider recognised improvements were needed.
27. During this investigation I asked the Care Provider for copies of relevant records, including care planning documentation. The Care Provider was unable to provide some of these records and explained that it had changed electronic care planning systems and no longer had access to some historic information. Providers are required to keep accurate and complete records about the care they provide, including after someone stops using their service. The Care Provider's inability to produce important records more than a year after the events occurred is not consistent with good record keeping. This was fault which caused uncertainty to Mrs X about exactly what happened and limited my ability to establish exactly what action staff took when the medication issues arose.
28. Mrs X said the medication failure and insufficient response from the Care Provider caused the family to lose confidence in the care provided at the care home, and led to them bringing Mrs Y home. Mrs X and other family members then took on responsibility for caring for Mrs Y themselves, which was understandably distressing and placed them under additional pressure at an already difficult time.
29. I have considered Mrs X's concerns about the way the Care Provider handled her complaint. While I understand she was dissatisfied with the outcome, the evidence shows the Care Provider responded to the complaint, investigated the concerns raised, apologised for the medication problems and remained in correspondence with the family. I do not find fault in the way it handled the complaint itself.
30. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.
31. Following Mrs X's complaint, the Care Provider agreed to waive its notice period and refund the fees charged after Mrs Y left the care home. This was a significant financial remedy and appropriately recognised that Mrs Y did not receive care from the home after returning to live with her family.
32. However, I do not consider this remedy sufficient to acknowledge the avoidable distress caused to Mrs X and her family by the medication failures, nor the uncertainty arising from the Care Provider's poor record keeping. I therefore recommend a further symbolic payment to Mrs X.
33. I also note the Care Provider discussed these events with the CQC during a March 2025 inspection. The inspection identified concerns including medication management, record keeping, provider oversight and whether lessons were learned when things went wrong. While I have reached my findings independently, the concerns identified by the CQC are consistent with the faults I have found in this investigation.
34. Given the medication failure experienced by Mrs Y, and the Care Provider's inability to provide all relevant care records during my investigation, I am not satisfied there is sufficient evidence that the improvements referred to in its complaint responses have been fully implemented and embedded in practice. To remedy this, I recommend that the Care Provider either provide evidence of a recent review already undertaken or complete a review of its arrangements for medicines management and record keeping.

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Action

35. In recognition of the injustice caused, within one month, the Care Provider should:
• Apologise to Mrs X in accordance with our guidance on making an effective apology.
• Pay Mrs X £300 in acknowledgement of the distress caused.

36. In addition, within three months the Care Provider should:
• Review its arrangements for medicines management and record keeping, or provide evidence of a recent review already undertaken.
• The review should include consideration of how medication issues are escalated and monitored, how care records are retained and accessed, and how lessons learned from incidents are translated into service improvements.

37. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

38. I have completed my investigation and uphold Mrs X’s complaint. I have made recommendations to remedy injustice that the Care Provider has agreed to carry out.

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Investigator's decision on behalf of the Ombudsman