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APS Care Ltd (16 015 689)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 29 Mar 2018

The Ombudsman's final decision:

Summary: Mrs C complained to us the care home where her husband had stayed for a period of respite care, had failed to provide him with the medication he needed. The Ombudsman found fault with the way in which the care home managed Mr C’s medications and how it investigated Mrs C’s complaint. The care provider has agreed to provide a written apology to Mrs C and pay an amount of £1,600.

The complaint

  1. The complainant, whom I shall call Mrs C, complained on behalf of herself and her (late) husband, whom I shall call Mr C. Mrs C complained the care home failed to provide her husband with the medication he needed, when he stayed at the home for a period of respite care between 15 and 28 July 2016.

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The Ombudsman’s role and powers

  1. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
  2. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
  3. If we are satisfied with a care provider’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)

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How I considered this complaint

  1. I have considered the information I received from Mrs C and the care provider. I shared a copy of my draft decision statement with Mrs C and the care provider and considered any comments I received, before I made my final decision.

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What I found

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards, below which care must never fall.
  2. When investigating complaints about standards of care in a care or nursing home, the Ombudsman considers these Regulations and whether the fundamental standards set out in CQC guidance have been met. If they have not, she considers whether any identified faults have resulted in an injustice.
  3. The relevant Regulations are “Safe care and treatment”, which deals with the proper and safe management of medicines. It states, among others, that: “Medicines must be administered accurately, in accordance with any prescriber instructions and at suitable times to make sure that people who use the service are not placed at risk”.

What happened?

  1. Mr C went into the care home on 15 July 2018 for a period of respite care. Mrs C spent £1,600 for his stay.
  2. Mrs C told me that, after her husband returned home on 28 July 2016, she found out the care home had not given him all the medication he needed:
    • The Medication Administration Record (MAR sheet) stated her husband should receive his water tablets at 8am and 12am. ‘Water tablets’ help the body to get rid of extra water. Although Mr C had received his morning-time water tablets, staff failed to give his lunch-time water tablets on 9 out of 13 occasions. This was despite the fact Mrs C had stressed the importance of her husband receiving these. The lack of tablets resulted in a built up of fluids, for which he was admitted to hospital on 1 August 2016. He died in hospital two weeks later due to hospital acquired pneumonia.
    • Mr C had not received his epilepsy medication on six days.
    • Mr C had only received his Senna tablets (to treat constipation) and a laxative drink on five days.
  3. Neither the care home manager, nor the staff members responsible for administering Mr C’s medication at the time, were still working at the care home when I investigated this complaint. However, the care provider sent a copy of three statements that the care provider had obtained from the staff members in September 2016. According to the statements, Mr C had not received his lunch time tablets, because he often had his morning tablet very late.
  4. There is nothing in the records to substantiate the above statement. There is no evidence that shows Mr C received his morning tablets late, or explained why this would have been the case. If the above statement was correct, staff should have discussed with the care home manager and Mrs C what it should do to ensure Mr C would receive all water tablets. This never happened.
  5. The new care home manager told me:
    • Staff should have considered offering the lunch medication later in the afternoon, especially as it was happening regularly.
    • He has been unable to find evidence that the staff / management carried out regular basic audits at the time, to identify if staff were administering Mr C’s medication according to his prescriptions.
  6. The Care Quality Commission (CQC) concluded in November 2016, following an inspection, that medicines at the care home were not always managed or administered in a safe way. A report from June 2017 reported there were still concerns with regards to some aspects of the care home’s medication management, supervision and recording.
  7. The care home manager has told me he has since introduced daily, weekly and monthly medication audits by the care home’s management team.
  8. Mrs C made a complaint about the above in September 2016:
    • The care home’s complaints procedure states it would provide a full response within 28 days. However, Mrs C did not receive a response. As a result, Mrs C referred her complaint to the Ombudsman, who contacted the care provider.
    • There had been a change of care home manager, since Mr C had stayed at the care home. The new manager acknowledged in March 2017 that Mrs C’s complaint had not been properly dealt with. The manager promised to look through Mr C’s files to determine what happened and put actions in place to avoid a reoccurrence. The manager wrote to Mrs C two weeks later. In the letter, the manager said she was appalled at how Mr C was treated during his stay at the home. The manager explained she was unable to provide a response to Mrs C’s questions, because she was not in post at the time of the events. The manager did not provide an apology within the letter.
    • Mrs C told the care provider she was unhappy with the response and that she had not received an apology or a financial remedy. The Ombudsman asked the care provider to consider these issues. The provider sent a response to Mrs C on 20 June 2017. However, it again failed to provide any details about the (lack of) care her husband had received. It only mentioned some action the care provider would carry out to try and prevent a reoccurrence of the events. The care provider said it would not be able to offer any compensation, because: it was not possible to conclude that Mr C’s care contributed to his hospital admission (three days after he left the care home) where he subsequently passed away. Again, Mrs C did not receive an actual apology for the shortcomings in Mr C’s care, within the letter.
  9. Since then, a new care home manager has been appointed. The manager reviewed the way in which the care home responded to Mrs C’s complaint. The manager said:
    • He could not explain why the previous manager failed to provide an apology within its response, even though she had identified short comings in Mr C’s care.
    • The managerial turnovers at the home resulted in significant delays in dealing with Mrs C’s complaint.
    • He would like to offer apology to Mrs C for: the experience she has had; both at the time when her husband was unwell, for the oversight in terms of the medication being omitted and for the subsequent delay in terms of response by my predecessors.
  10. The care provider told me that Mrs C received an apology over the phone.


  1. The care provider failed to ensure that Mr C received the medication he needed. This was fault and not in line with the regulations for safe care and treatment. On the balance of probabilities, this resulted in Mr C’s hospital admission on 1 August 2017, due to a built up of fluids. There is insufficient information to conclude how the care home’s medication errors happened. However, the regular audits introduced by the home since the above events, should enable it to pick up any medication errors more quickly now.
  2. It is not for the Ombudsman to come to a view whether any fault by the care home resulted in Mr C’s death in hospital from hospital acquired pneumonia. However, I do acknowledge that Mr C’s hospital admission has caused her distress. There should therefore be a financial remedy for the lack of care Mr C received with regards to his medication and the distress this caused Mrs C.
  3. There was also fault by the care provider in the way it dealt with Mrs C’s complaint, as it did not investigate it thoroughly enough. Even though the complaint response letters concluded there had been failings in the care, they failed to include an apology. However, the care provider has since told me it did provide an apology over the phone. However, Mrs C denies this.

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Agreed action

  1. I recommended the care provider should, within four weeks of my decision:
    • Write to Mrs C and provide an apology for each of the faults identified above and the distress they have caused her.
    • Pay Mrs C £1,600.

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Final decision

  1. For reasons explained above, I have upheld Mrs C’s complaint. There was fault by the care provider which caused an injustice. I am satisfied with the actions the care provider has agreed to take, and I have therefore completed my investigation.
  2. Under the terms of our Memorandum of Understanding with the Care Quality Commission, I will send it a copy of my final decision statement.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman

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