Summary: Mr B complained about how a Care Provider, Brooks Care and Nursing Services Ltd (commissioned by the Council) administered medication to his wife. We upheld the complaint, finding the Care Provider at fault for not giving medicine correctly, not sharing records with Mr B, poor customer service and not being candid with Mr B or the Council about its failings. We also found the Council at fault for carrying out an inadequate adult safeguarding investigation. These faults caused injustice as distress to Mr B and caused potential risk to his wife. The Council has accepted these findings and agreed a series of actions to remedy their injustice and improve its service to help prevent a repeat.

The complaint

1. Mr B complained on his own behalf, and that of his wife, Mrs B. His complaint concerned a Care Provider, Brooks Care and Nursing Services Ltd, commissioned to provide care to his wife by the Council. He complained:

• the Care Provider regularly overdosed Mrs B by giving doses of paracetamol too close together;
• the Care Provider failed to share all relevant medical administration records (MAR) charts, so he did not know the full extent of the overdosing; and
• the Council failed to undertake an effective investigation into these matters when he made it aware.

2. Mr B said as a result he experienced unnecessary upset worrying for Mrs B’s health. He feared she had experienced harm because of the overdosing.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
4. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. When we refer to ‘injustice’, we are considering whether any fault has had an adverse impact on the person making the complaint. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. 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(i), as amended)
7. Under our information sharing agreement, we will share our final decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

8. I considered evidence provided by Mr B and the Council as well as relevant law, policy and guidance.
9. I also gave Mr B, the Council and Care Provider a chance to comment on a draft version of this decision statement. I took account of any comments they made, or further evidence they provided, before finalising the content of this statement.

Back to top

What I found

Key legal and administrative considerations

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. Only the CQC, as the care regulator, can decide if a care provider meets the standards or is in breach of them. However, we consider the standards relevant to our investigations when deciding if a care provider was at fault. So, we take them into account and any accompanying guidance published by the CQC.
11. I consider the following fundamental standards relevant to this complaint:

• Regulation 12, which covers ‘safe care and treatment’. Providers must be able to show they have taken all reasonable steps to ensure the health and safety of those in their care and can manage risks arising while providing care.
• Regulation 16, covering the ‘receiving of and acting on complaints’. Providers must have effective and accessible procedures for identifying and responding to complaints.
• Regulation 17, which covers ‘good governance’. Providers must keep accurate, complete and detailed records about each person using their service.
• Regulation 20, which refers to the ‘duty of candour’. Providers must act in an open and transparent way with people who receive care and treatment.

12. The CQC also publishes specific advice on medicine administration in someone’s home. It says care providers should:

• keep a clear record of all support provided for each medicine. This should include who gave the medicine and whether the client took or declined it;
• agree with a family member if they may give medicine to the client instead at times;
• have a record of how often, and at what times, it should offer or give medicine;
• keep medicine administration records for “at least” eight years after the person’s care ended with the service.

13. Councils must make adult safeguarding enquiries if they think a person may be at risk of abuse or neglect and they have care and support needs meaning they cannot protect themselves. (Section 42, Care Act 2014)
14. The term ‘enquiries’ covers any action taken by a council in response to a concern about abuse or neglect. So, it can encompass anything from a conversation with the person who is the subject of the concern, to a more formal multi-agency discussion and plan of action. The council must decide whether it or another person or agency, should act to protect the person from abuse or neglect.

Chronology of key events

15. Mrs B is a disabled adult receiving care in her own home. Mr B has power of attorney, enabling him to make decisions on issues about her health and welfare. The Council contracts the Care Provider to deliver care to Mrs B. The Care Provider visits four times a day – at breakfast, lunch, teatime and night. Part of the care package requires the Care Provider to give medication to Mrs B.
16. Mrs B takes various medications for pain relief, including paracetamol. The Care Provider can give the paracetamol “as needed”. I assume that in line with standard NHS advice, Mrs B’s prescription advises she should not have more than four doses in 24 hours, and not more than one dose within four hours.
17. Towards the end of October 2024, Mr B contacted the Care Provider about two matters. One of these concerned paracetamol medication. Mr B had seen a MAR chart in use at the time. He noted from that Mrs B had received paracetamol at an interval of under four hours on 13, 21 and 23 October. He said he had spoken to care workers, who told him the Care Provider said it was fine to give the medication if three and a half hours had passed. He wanted to know if this was correct.
18. A few days later he also asked the Care Provider if it could also provide him copies of MAR charts “down the years”, so he could check if this had happened before.
19. On 31 October, the Care Provider replied to both matters raised by Mr B. Regarding medication, it said home care “was not an exact science”. This was because sometimes its care workers ran early or late for their appointments. After responding to Mr B on the other matter, it said that he may want to consider using a different provider.
20. On 1 November 2024, the Care Provider noted calling a GP and pharmacy. It said: “both confirmed that as long as adult is NOT regularly given this medication less than a four hour gap then there will be no ill effect”. Further, as Mrs B did not usually have more than three doses a day there was “even less risk of harm”.
21. It also made a note which recorded:

• that Mrs B had not received more than four doses of paracetamol in 12 hours. It said this “confirms what we were told by the pharmacy and GP that there would be no ill effect”;
• it had spoken to care workers on 21 October and advised them not to give doses of paracetamol less than four hours apart;
• it had changed practice to record paracetamol on a ‘regular’ MAR chart in the future and that it would only give the medication twice daily during the breakfast and teatime visits.

22. On the same day Mr B wrote back to the Care Provider. He was unhappy with its reply to his concern. He noted it had not commented on the question he asked, wanting to know what instructions it gave to its care workers. He said that if care workers arrived less than four hours after a previous visit, they could ask him to give paracetamol to Mrs B.
23. Over the next two weeks Mr B sent brief messages, asking again about seeing MAR charts. Then in mid-November he highlighted another incident on 11 November, where care workers recorded giving Mrs B paracetamol less than two hours apart. He expressed concern noting Mrs B has a very low body weight. He copied this email to the Council.
24. The Care Provider replied on 15 November. It said on four occasions between 30 May and 30 September it had given paracetamol at intervals of around three hours and forty minutes. It said the record on 11 November was wrong. It advised Mr B of the conversation it had with the GP on 1 November. It concluded by saying it “would not get in an argument” with Mr B. It said: “we can either change the paracetamol to a regular chart two times daily OR we stop giving the paracetamol completely and family can take this over, please let me know which option would suit you and [Mrs B]”.
25. Mr B replied saying there were two occasions when the Care Provider recorded giving Mrs B paracetamol less than two hours apart (on 21 October and 11 November). He asked if the Care Provider had checked if this was safe. He said he only wanted Mrs B to receive medication in line with her prescription. He also asked again about seeing the MAR charts.
26. The Care Provider sent a brief reply saying in future it would offer Mrs B paracetamol at the morning and teatime visits only.
27. When Mr B tried to question this, the Care Provider told him to “go through [Mrs B’s] social worker” as it “was not continuing with this conversation”. Mr B went on to send an email direct to the social worker asking if he could obtain the MAR charts.
28. On 28 November the Council opened a safeguarding enquiry. It is not clear from the record why it did so. But on its ‘safeguarding alert’ form, there are emails from the CQC, which Mr B had contacted directly. I assumed therefore the CQC contacted the Council and asked it to consider Mr B’s concern.
29. On 13 December, Mrs B’s GP sent an email to the Care Provider, expressing concern at what Mr B had told them about paracetamol administration. They said it “raised potential safety issues regarding medication and adherence to prescription guidelines”.
30. On 16 December, the Council completed its initial assessment of the safeguarding alert. It decided to step up the status of the referral to a “safeguarding concern”. It asked Mrs B’s social worker to investigate.
31. Over the next week, the social worker spoke to the Care Provider which said it had carried out its own safeguarding investigation into Mr B’s concerns. The social worker recorded the Care Provider telling her that it had twice given paracetamol to Mrs B at less than four hours apart. And that it had spoken to two GPs who did not express any concern.
32. Around the same time, the Care Provider sent Mr B MAR charts for the period April to November 2024. However, there was no record for August, nor the period 1 to 18 November. It said it had archived records for January to March meaning they were unavailable. Mr B queried this and alerted the Council to his concerns.
33. On 20 December 2024 the Care Provider completed a document entitled “internal investigation timeline”. This identified it telling care workers not to give paracetamol less than four hours apart on 1 November. And it had sent a ‘follow up’ message to care workers on 20 December to reiterate this advice.
34. On 23 December 2024 the Council closed the safeguarding concern. It noted the Care Provider now only offered paracetamol to Mrs B at the breakfast and teatime visits. It said it need take no further action as Mrs B had suffered “no ill effect” from how the Provider gave her medication. It said there were “no errors to answer”.
35. On 6 January Mr B contacted the social worker directly. Having now reviewed the MAR charts he had identified 11 occasions where the Provider gave doses of paracetamol less than four hours apart. On four occasions (6 April, 7 April, 22 April and 21 October) the doses were less than two hours apart (in one case just 41 minutes apart). Mr B also noted crossings out and overwriting of the MAR chart in April 2024. And he pointed out he did not have MAR charts for all of 2024 (see paragraph 32).
36. On 10 January a senior social worker replied to Mr B (Mrs B’s social worker being off work). They said: “we offered you the option to change providers and receive direct payments, but you declined”. The senior social worker said he would advise Mrs B’s social worker “to request a change of provider. Over the past four months, we have observed a breakdown in the relationship with the care agency. [We have] offered two options that can meet her needs, but you declined”. The email also defended the Care Provider not providing more MAR charts and suggested disapproval Mr B had copied the CQC into some of his emails.
37. Mr B sent further emails on 10 and 17 January setting out dissatisfaction with this reply. He said it was not helpful to suggest changing providers and that Mrs B did not want this. He said when he spoke to Mrs B’s GP, they suggested Mrs B could suffer physical harm from overdosing.
38. On 21 January 2025, Mr B then made his complaint to us. We asked the Council to investigate it first and it replied to him in February. The Council summarised its safeguarding enquiries and defended the outcome it had reached. It said it had asked that in future the Care Provider give copies of the MAR charts to Mrs B. And that it upheld the complaint, because the Care Provider had not provided all historic records.
39. In March 2025, Mr B resubmitted his complaint to this office. He provided an updated analysis of the MAR charts he had seen. He identified 16 incidents where Mrs B received paracetamol less than four hours apart (sometimes more than one incident in the same day). The gaps between doses ranged between 41 minutes and three hours fifty minutes. There were four or possibly five occasions when the time between doses was two hours or less (the chart being only partly legible).
40. We asked the Council to obtain more records from the Care Provider. In reply it sent us a MAR chart for March 2024 also. This contained one entry where Mrs B received paracetamol less than fours apart. The Council told us the Care Provider had given “all the information they have on their records and are not able to guarantee they can locate all of the MAR charts”. The Council said it had “challenged this and asked them to provide their written policy on how they report incidences of missing information including informing CQC if charts are missing.”
41. In response to my draft findings the Council also said that it had also begun a second safeguarding investigation at the end of May 2025. This was considering concerns about the Care Provider’s medicine administration and record keeping.

My findings

42. I started my analysis by noting Mr B’s underlying concern, at the beginning of events, was that his wife may suffer harm from receiving medication not in accord with her prescription. This was after he identified three occasions in a short time where this happened (or the Care Provider recorded it happening). I considered this a reasonable concern anyone might have for their spouse.
43. It was also reasonable for Mr B to question what advice the Care Provider gave to its care workers on giving paracetamol. He asked this because he said care workers reported the Care Provider encouraging them giving paracetamol at a gap of three and a half hours apart. He wanted to know if this was correct.
44. The Care Provider’s response to this contact was poor. I recognised Mr B’s email contained mention of another matter. But its reply simply did not address these two key points made by Mr B. Worse, its content could only add to his concern. This was because the Care Provider appeared indifferent towards the timing of medication, when it said care workers could sometimes run early or late to their appointments. The Care Provider implied it did not matter therefore if Mrs B’s medication ran early or late as a result.
45. Unsurprisingly therefore, Mr B chose to pursue his concern. Reasonably, he also wanted to see earlier MAR charts, to check how often the Care Provider had given medication earlier than prescribed. He then became aware of another incident in November, where the Provider recorded a dosage time of under two hours. This could only add to his concern.
46. In its reply of 15 November, the Care Provider said the 11 November record was wrong. But it provided no explanation for why or how any mistake in recording happened. It said that four times since May, it had given Mrs B paracetamol at less than four hours interval. But it counted neither the October incidents which gave rise to Mr B's first contact, nor the April incidents which appear most serious given their frequency and short gaps between doses. So, the Care Provider under-reported how often it had given Mrs B paracetamol at under four hours. Nor did it advise Mr B if a lack of records hampered its research. The Care Provider had a duty of candour. I cannot see how its actions here were compatible with that. So, I had to record it at fault.
47. Further it still did not answer Mr B’s reasonable question about what advice it gave its care workers on when to administer the medication. Nor respond to his suggestion that it could liaise with him, so he would offer Mrs B paracetamol later, if care workers visited twice within a four-hour window. Nor did it answer his request for disclosure of MAR charts. Instead, its reply sought to dismiss his concerns and inappropriately, given this list of omissions, close down his enquiry.
48. I considered it was also fault the Care Provider went on to propose giving Mrs B paracetamol in a way that was incompatible with her prescription. A proposal to offer the medication at breakfast and tea, meant there could be no prospect of her having two doses within four hours. But it also meant Mrs B may have to wait several hours longer than necessary for the medication, when in pain. This proposal therefore defeated the point of an “as needed” medication, because Mrs B would not always receive her medication when needed.
49. Reasonably therefore Mr B continued in pursuit of his enquiry and it is disappointing to read how dismissive the Care Provider continued to be of his concerns. I recognised there were some underlying tensions present. I kept the chronology above focused on the issue at the crux of this complaint. But I saw that correspondence from both sides covered another matter and sometimes Mr B referred to an earlier complaint. Sometimes he also made derogatory comments about the Care Provider that went beyond the issue at hand. I made no finding on any other matter where Mr B had contact with the Care Provider. But I assumed the previous contacts had impacted on the tone of communications from both sides.
50. But whatever the reason, nothing could excuse the poor customer service Mr B received from the Care Provider discussed in paragraphs 44 to 49. Even if it thought it had done all it could to address his concerns, it should have signposted Mr B to the Council’s complaint procedure. This suggested a possible failing by the Care Provider to meet the relevant fundamental standard on complaint handling. Its poor customer service to Mr B resulted in another finding of fault.
51. I also found the Council’s response disappointing, when it had the opportunity to investigate Mr B’s concerns following the safeguarding referral. The first point I noted here is that if the Council recorded its conversation with the Care Provider accurately, the Care Provider was again not candid. Clearly there were more than two instances where Mr B reported concerns about paracetamol dosage and that was before he had seen most of the MAR charts. The Care Provider also knew itself of more than two incidents. And there was no record of the Care Provider speaking to “two GPs”. Nor did the Provider appear to have told the Council about the concerns raised directly with it by Mrs B’s GP after the safeguarding investigation began.
52. These omissions from the Care Provider hampered the safeguarding enquiries. But the Council also made errors of its own. It undertook no analysis of the MAR charts for itself, which would have identified far more examples of doses of paracetamol at less than four hours, as Mr B told it had occurred. Had it done so, then for the months of March to November (excluding August where the Care Provider failed to provide a MAR chart) it would have found 18 such incidents. Those comprised the 16 identified by Mr B, plus one in March and one on 11 November. While sometimes the doses were at nearly four hours, I highlighted above that in at least four cases the doses were at two hours or less. The Council did not identify that information.
53. The Council also:

• failed to press the Care Provider on what it told the GP. Did it make them aware of the true number, frequency and nature of the incidents where it gave paracetamol less than four hours apart;
• did not check what instructions the Provider gave its care workers on time intervals between paracetamol doses (given Mr B’s original suggestion set out in paragraph 17 which he repeated subsequently);
• did not check why, if as claimed, the Provider spoke to care workers on 21 October, just two days later, it again gave doses less than four hours apart;
• did not pursue the large gaps in record keeping;
• did not speak to Mrs B’s GP.

54. Without that information I had to find fault in the safeguarding investigation. It was hard to see how the Council could have come to the view the Care Provider made “no errors” even on the evidence it had. But it surely would not have said this had it made the enquiries it should have.
55. I also questioned the finding Mrs B came to no harm or suffered no exposure to a risk of harm. I considered there was enough evidence of irregularity in the dosing of paracetamol to question if Mrs B received safe care and treatment in line with the fundamental standards.
56. I also found fault in the Council’s communications with Mr B after the safeguarding investigation concluded. First, I found no evidence it communicated the findings with him, a matter of courtesy and good practice.
57. Second, it then overlooked repeated efforts by Mr B to point out the number of incidents its social worker should have known about. In particular his email of 6 January 2025.
58. The email sent to Mr B by the senior social worker in reply, on 10 January 2025, was wrong in content and tone. It showed no regard for Mr B’s understandable concerns. It failed to engage with his reasonable questions and comments. It offered no reflection on the Care Provider’s engagement with the issue at the crux of his concerns. It suggested unhappiness Mr B had alerted the regulator to his concerns and suggested Mr B should seek a different provider. This was inappropriate as there was nothing petty or unreasonably persistent in Mr B’s contacts. The Council should not encourage users of services to seek a different provider because they seek to raise a legitimate concern.
59. I also found that after 10 January, Mr B made clear to the Council he did not consider it had not responded properly to his concerns. The Council should have treated his emails as a complaint, or else signposted him to its complaint procedure. Not doing so, was also a fault.
60. The Council’s later complaint response recognised a problem with the Care Provider’s record keeping. However, even here it did not offer a fully satisfactory resolution. I welcome that it sought to ensure Mr B could access MAR charts moving forward, but did not address the omissions in the Care Provider’s records.
61. This led me to make a final finding of fault, with the Care Provider’s record keeping. It is not our role to obtain records for complainants, who have an alternative route of redress for this (via the Information Commissioner’s Office). But it is our role to address poor record keeping practice and to seek record sharing where appropriate, as part of a remedy to a complaint. I found both considerations relevant here.
62. It was unacceptable the Care Provider had not produced records of MAR charts for Mrs B for January, February, August and December 2024. In response to the draft decision the Council said it was exploring these omissions but was unsure if the records still existed. But clearly the Care Provider should have access to those records and for earlier years. Archiving records was not an excuse as it could recover records from its archives. Its failure to provide records suggested the Care Provider was not meeting another of the fundamental standards.
63. Finally, I welcomed the Council advising it had opened another safeguarding investigation. Its response to the draft decision indicated it accepted all of my concerns set out above with both the Care Provider’s response to Mr B’s concerns and its initial safeguarding investigation.

Injustice

64. In paragraphs 46, 48, 50, 54, 56, 57, 59 and 61 I summarised where I found fault by the Care Provider or Council. I went on to consider the consequence of these faults.
65. On the issue at the crux of the complaint, I could not say that Mrs B suffered harm from the irregularities in paracetamol medication. But I could not find she was not at risk of harm. That there has been no satisfactory investigation to explore this risk created uncertainty, something we consider a form of distress. That was an injustice to both her and Mr B.
66. In addition, the poor communications and failure to provide records, caused Mr B avoidable frustration and distress. He also experienced unnecessary time and trouble in making his complaint.

Back to top

Agreed Action

67. The Council has accepted the findings set out above. To remedy the injustice caused to Mr and Mrs B it has agreed that within 20 working days of this decision, it will:
1. provide its own apology and arrange for Mr B to receive an apology from the Care Provider, accepting the findings of this investigation. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. Both organisations will consider this guidance in making the apology recommended;
2. arrange for Mrs B to receive a symbolic payment of £250 in recognition of the distress arising from the failings of the Care Provider and Council in medication administration and the investigation of the same;
3. arrange for Mr B to receive a symbolic payment of £250 in recognition of the distress arising from the failings of the Care Provider and Council in medication administration and the investigation of the same;
4. arrange for Mr B to receive a further symbolic payment of £150 in recognition of the distress and unnecessary time and trouble, caused by the poor communications and complaint handling of the Care Provider and Council;
5. arrange, if possible, for Mr B to receive MAR charts showing paracetamol medication given to Mrs B for the months January, February, August, November (full month) and December 2024. In the event the Council’s safeguarding investigation has not located these records it will explain to him the enquiries it has made and if it intends to continue the pursuit of those records;
6. confirm that its ongoing safeguarding investigation will cover:
1. the instructions and guidance given to care workers by the Care Provider on administering paracetamol;
2. establishing the number of incidents of doses given to Mrs B at less than four hours apart for any time it has records;
3. establishing any risk of, or actual harm, resulting from doses given at under four hour intervals to Mrs B, including those at two hours apart or less;
4. gathering Mr B’s views, if it has not already done so;
7. review with the Care Provider the current arrangements for Mrs B’s paracetamol, in consultation with her GP if necessary. It should seek a way to make the medication available consistent with the prescription if this still requires it to be offered “as needed”;
8. commit that it will share the outcome of the investigation at f) with Mr B once complete. It will also share it with its contract monitoring team to explore if there are any wider issues with the management of medication by the Care Provider which might impact on other users of the service.
68. The recommendation at 67e) above will not prevent Mr B from making a request also to the Care Provider for copies of earlier MAR charts. I would expect the Care Provider to understand the need for it to have kept those records and to share them to anyone lawfully entitled to see them on request.
69. In terms of wider service improvements, I welcomed the Council’s comment it had challenged the Care Provider on its record retention and that its safeguarding investigation was considering that. In addition, the Council has agreed that within two months of this decision it will:
1. gain assurance the Care Provider has a satisfactory complaint procedure in place consistent with its contract expectations and that it knows to signpost those dissatisfied with its service to that procedure;
2. issue a reminder to social work staff that they should signpost users of services dissatisfied with a Care Provider to complaint procedures if unable to resolve their issue. They should not suggest they seek a different care provider as an alternative to pursuing a complaint;
3. issue a reminder to social work staff undertaking safeguarding enquiries, that their investigation must properly explore and reflect the concerns raised and reach evidence based conclusions.
70. The Council will provide us with evidence to show it has complied with the above actions.

Back to top

Decision

71. For reasons set out above I upheld this complaint finding fault by the Council caused injustice to Mr and Mrs B. The Council accepted these findings and agreed to take action that I considered would remedy that injustice and help prevent a repeat of the fault. So, I could complete my investigation satisfied with its response.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman