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Porthaven Care Homes No 2 Limited (17 008 532)

Category : Adult care services > Residential care

Decision : Not upheld

Decision date : 26 Mar 2018

The Ombudsman's final decision:

Summary: Mrs X complained about the respite care Mrs M received at her care home. She said that, as a result, she had no other choice but to immediately remove her mother. There was fault with regards to one of the concerns Mrs X raised. However, the Ombudsman did not agree with Mrs X that the care Mrs M had received warranted a (full) refund of her care home fees.

The complaint

  1. The complainant, whom I shall call Mrs X, complains on behalf of her mother in law, whom I shall call Mrs M. Mrs X complains that following several incidents of unsafe, inappropriate care and lack of care, the family had no other choice than to take Mrs M out of the care home. This was only four days into a three week stay. Mrs X therefore wants the home to reimburse Mrs M for the cost of the care, which they had to pay in advance.

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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 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 have received from Mrs X and the care provider. I also had a telephone interview with the care home manager. I shared a copy of my draft decision statement with both parties 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. In this case, the relevant Regulations are
    • Regulation 9 “Person-centred care”: This means the care a person receives must be appropriate and meet their needs. Care providers must, among others, carry out an assessment with the relevant person of their needs and design the care and treatment to achieving those. The assessments should be reviewed regularly and whenever needed throughout the person’s care and treatment.
    • Regulation 12 “Safe care and treatment”: This says, among others, that a care provider needs to have arrangements in place to respond appropriately and in good time to people’s changing needs. Furthermore, incidents must be reported appropriately, investigated and remedied to avoid a possible reoccurrence. The regulation also needs care providers to: administer medicines 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. Mrs M suffers from dementia. Her family arranged for her to go into Penhurst Gardens Care Home on Thursday 18 May 2017 for an initial two weeks period. The purpose of her stay was to provide her family with a break (respite) from caring and to see if her stay could become permanent if she settled.
  2. Mrs X told me that, before Mrs M went into the home, the family had a very lengthy discussion with the care home about her needs and medical conditions. They told the care home about her extensive medical regime, which included applying cream for her sore skin. The family also explained that Mrs M could become aggressive and unsettled due to her dementia. However, the home told her it had the expertise to deal with this. The family paid a fee of £1,568 a week in advance.
  3. The home completed its pre-admission assessment on 8 May 2017. It says: “When she does not want to do something, she will cry. Can lash out. Will easily get upset”.
  4. Mrs X told me that it quickly became clear to the family the home was not capable of providing the care Mrs M needed. She said that, as such, they were forced to remove Mrs X from the care home after only a few short days. The carers were lovely but unable to deal with her mother.

Issue 1: The way in which the care home handled Mrs’s arrival at the care home:

  1. Mrs X says:
    • It told the care home that her mother’s arrival at the home could be a very challenging situation, particularly once she would realise that she would be staying. As such, the care home assured the family that help would be on hand. Even so, there was no one to help them on arrival and the care home manager was nowhere to be seen.
    • However, once staff was aware of the situation, they rallied around to help Mrs M get in and settled.
    • The care home manager said the following day that he was unaware of Mrs M’s challenging behaviour and that she was being admitted yesterday.
  2. The care provider says:
    • Mrs M’s arrival was discussed within the home by all Heads of Departments in the week leading up to her admission. These discussions are documented in the minutes of five “Daily Morning Meetings” chaired by the care home manager.
    • The home also produced the following documents before her arrival: “Admission Form to ancillary staff”, which told all staff that Mrs M’s arrival would be at around 11am. It also completed the “New admission actions, for the nurses on duty” form, with information for the nurses who would be on duty.
    • The manager only told the family that “he was unaware of the full extent of which Mrs M’s behaviour could become challenging”. Following Mrs M’s first night at the home, he immediately suggested to organise a meeting with the family to document a more in-depth Behaviour Care Plan.


  1. The documents I have seen show that staff was aware and briefed about Mrs M’s arrival. In addition, Mrs X said staff quickly rallied around to help Mrs M get in and settled. It is not possible to conclude what the manager said the following day, as there are conflicting statements with regards to this.

Issue 2: The way in which staff handled Mrs M’s behaviour during the first night

  1. Mrs X says that, during her mother’s first night at the home, the staff were unable to settle her at night. In the end, the home asked Mrs M’s daughter who lives close-by (whom I shall call Mrs D) to help staff during this night with settling her. The night manager had told Mrs D that her mother was getting agitated and she was concerned about the other residents.
  2. In her letter of 31 May 2017, Mrs D said:
    • She did not mind the home called her in that night. When she arrived, she found her mother in a very agitated state. The night manager and nurses appeared unaware of her needs or what should be done to deal with Mrs M. Despite every single nurse and carer being wonderful and lovely, it was obvious they could not deal with Mrs M that night.
    • The night manager rightfully called emergency services and followed good practice. The home asked the emergency service if it would be OK to provide another 50mg of prescribed drugs to calm her. The emergency service said this was OK and advised the home to call the GP the next day.
  3. The care home said that:
        1. All its staff complete a thorough induction before starting work. This includes three courses on Dementia: “An Introduction”, “Understanding Behaviours”, and “Responding to Behaviours”.
        2. In addition, the care home’s dementia service is overseen by a Residential Care Manager who holds a 'Dementia Studies Foundations Degree'.
        3. Its pre-admission assessment says Mrs M shows challenging behaviour when she does not want to do something. She will cry, lash out and will easily get upset. This information was quite limited. If the family had provided more detailed information, the home could have immediately put appropriate systems in place at the point of admission, rather than retrospectively once the behaviours had presented.
        4. When Mrs M’s became challenging, staff completed an “Accident, Behaviour, Consequence” (ABC) form. The home used the information from this to update Mrs M’s “Behaviour Care Plan”. The following morning, the home asked a GP to visit Mrs M to review her medication, pain and behaviour. This meant that, one day after admission, the home had enough information to manage Mrs M’s behaviour appropriately. The ABC form clearly shows Mrs M’’s behaviour was managed successfully, once information from staff observations and Mrs D was passed onto staff in the home in the morning.
  4. A recent inspection report from CQC rated the service as good or better in all areas. It said people told them they were supported by skilled, knowledgeable staff that provided people with effective care. Records confirmed and staff told us they received training that was effective. This included health and safety, safeguarding, dementia, infection control, dignity, moving and handling and more.


  1. The family had explained that Mrs M could become aggressive and unsettled due to her dementia. In addition, it is common for a change of environment to be very unsettling for elderly people, particularly for those with dementia. Staff had also not yet been able to gain first-hand experience in dealing with Mrs M’s specific circumstances, or establishing what strategies would be particularly successful in dealing with Mrs M’s specific situation. This made the first night very challenging for staff.
  2. The care home acted correctly by putting measures in place to capture the learning to avoid and better manage future situations. The care home used the learning from the first night and the further information provided by Mrs D and the GP to update Mrs M’s “Behaviour Care Plan”. This enabled the home to deal with Mrs M’s complex behaviour more effectively and efficiently. There were no such further incidents.
  3. This was in line with regulations 9 and 12.

Issue 3: Staff gave Mrs M a second dose of Lorazepam on 20 May 2017

  1. Mrs X told me her mother received a second dose of medication on 20 May for her agitation, even though she should only receive one dose a day if needed. This did not give her confidence the home was properly managing Mrs M’s medication, and she believed this may happen again.
  2. The care home said that:
    • One of Mrs M’s daughters took her out of the home on Sunday afternoon. The daughter had asked the nurse to give Mrs M her daily medication for agitation, before they left for the day. The home had warned the family in advance that taking Mrs M home during her trial period could have a negative impact on her settling, and could lead to more confusion and distress.
    • On Mrs M’s return to the home, she became very agitated, verbally aggressive and she hit out at her daughter. Mrs M’s daughter asked the same nurse to administer a second dose to calm her down. Mrs M’s daughter knew that her mother had already received her daily dose earlier that day [Mrs X says it was she who returned her mother in law that day and she did not ask for a dose to be given].
    • When the care home manager carried out a medication audit the following day, he found out that the nurse had given an additional dose. The manager called the GP who said that it was OK. Staff also informed the family and alerted the Council of this incident. The home immediately shared the learning of the incident with staff members and the nursing team.
    • Following its investigation, the care home concluded the nurse had failed to follow the correct protocol. If the nurse believed a second dose was needed, she should have first asked the on-call duty doctor prior to administering the additional dose. The manager subsequently discussed this with the nurse.
    • The Council’s safeguarding investigation concluded it was an isolated error where no harm had occurred and appropriate actions was taken. It also said that no further incidents around the safe management of medication had been identified since the error in question.
  3. A recent inspection report from CQC found that people's medicines were managed safely and people's medicine administration records (MAR) contained necessary information. Medicines were managed and administered by trained staff.


  1. The nurse failed to follow the correct procedure before administering a second dose. This was not in line with regulation 12.
  2. However, once the care home manager became aware of the incident, the home took the correct steps, including reporting and investigating it. It also discussed the incident with the nurse involved to ensure it would not happen again. This was in line with regulation 12. The Council’s safeguarding investigation concluded it was an isolated error where no harm had occurred and the care home had taken the appropriate actions as a result.

Issue 4: The care home failed to apply cream on one occasion

  1. Mrs M had cream for her legs (dry skin), that had to be applied daily. However, Mrs X says that when she visited her mother on 20 May 2017 around lunch time, she had not yet received her cream. Even so, a staff member told her the home had already applied the cream.
  2. Staff recorded they applied Mrs M’s cream on the following dates and times:
        1. 19 May: 09:10 and 19:45
        2. 20 May: 16:45 and 18:45
        3. 21 May: 08:20
        4. 22 May: 07:00.
  3. The care home told me it is not uncommon for individuals suffering with dementia to refuse intervention at points during the day. Normal practice is to adhere to the individual's wishes and re-approach at a later time. This technique generally proves successful and the individual will consent to care.
  4. The Daily Hygiene Sheet states Mrs M refused personal care in the morning of 20 May. This meant staff were unable to provide cream at that time. When Mrs M returned from her day out, staff applied her daily cream.
  5. Assessment
  6. Mrs M’s cream for dry skin had to be applied daily and the care home records show that staff followed this. This was in line with regulation 12.
  7. I did not investigate the allegation that a staff member lied to Mrs M as it is unlikely I would have been able to obtain sufficient evidence to come to a view on this.

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Final decision

  1. I would have only considered recommending a full refund for the days Mrs M was no longer in the home, if the care she received was so poor that there was no other option to ensure her safety than by removing her immediately. However, I did not find evidence of substandard care, other than the fault identified in paragraph 25. This did not require a remedy.
  2. I have completed my investigation, because I am satisfied with the actions taken by the care provider.
  3. Under the terms of our Memorandum of Understanding with the Care Quality Commission, I will send it a copy of my final decision statement.

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Investigator's decision on behalf of the Ombudsman

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