Summary: Mrs D complains on behalf of Mrs E that HC-One Oval Homes did not provide the residential care Mrs E paid for. Mrs D says Mrs E’s care home neglected her and gave her an insulin overdose. The Ombudsman has found HC-One Oval Homes at fault. HC-One Oval Homes has agreed to reimburse Mrs E half her care home fees, give staff training and develop an action plan to ensure policies are put into practice.

The complaint

1. Mrs D complained on behalf of Mrs E that HC-One Oval did not provide the residential care Mrs E paid for. Mrs D complained the care home:
• gave Mrs E an insulin overdose;
• administered non-prescribed medication;
• neglected Mrs E;
• lost Mrs E’s personal belongings; and
• did not communicate well with Mrs E’s family.

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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 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)
3. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. (section 26A or 34C, Local Government Act 1974)
4. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
5. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
6. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. I considered:
• Mrs E’s complaint and information Mrs D provided;
• documents supplied by the HC-One Oval;
• relevant legislation and guidelines; and
• HC-One Oval policies and procedures.
• Ms D and the Council reviewed a confidential draft of this decision and comments received were considered before the decision was finalised.

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What I found

National legislation and guidance

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. These include:
• Regulation 12 is safe care and treatment. Staff responsible for the management and administration of medication must be suitably trained and competent and this should be kept under review.
• Regulation 13 is safeguarding service users from abuse and improper treatment. Care and treatment must be planned and delivered in a way that enable’s all a person’s needs to be met. This includes making sure that enough time is allocated to allow staff to provide care and treatment in accordance with the person’s assessed need and preferences.
• Regulation 17 is good governance. Records relating to the care and treatment of each person using the service must be kept and be fit for purpose.
• Regulation 18 is staffing. Providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements.

Care Quality Commission (CQC)

10. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.

HC-One Oval policy and procedures

11. HC-One Oval’s diabetes procedure says each resident’s risk of hypoglycaemia should be assessed and documented in their care plan, including a recommended blood glucose range to lessen the risk of developing hypos.
12. The procedure says if a resident’s blood sugar is below 4mmol/Ls staff should treat the resident for hypoglycaemia. After treatment has been given, staff must recheck the resident’s blood glucose after 10 – 15 minutes and given another hypoglycemia treatment if the resident’s blood sugar remains below 4mmol/Ls. The procedure tells staff to call for paramedic assistance if a resident’s blood sugar remains below 4mmol/Ls for over a 45-minute period.
13. Each resident with diabetes should have an individualised diabetes care plan which includes:
• Type of diabetes Resident has, e.g. Type 1 or Type 2 diabetes.
• Blood glucose target levels if colleagues are checking Resident’s blood glucose levels.
• Whether Residents are at risk of hypoglycaemia (low blood glucose) or not.
• If risk of hypoglycaemia is identified, the Resident’s preferred hypo treatment and amount to be given should be recorded in their care plan. All colleagues must be aware of this information.
14. The choice of hypo treatment for each resident should be documented in their care plan and medical case notes and colleagues should be aware of this.
15. HC-One Oval’s blood sugar monitoring process states if a repeat reading confirms the resident’s blood sugar levels are outside the acceptable limits (4-7 mmol/L), staff must check the resident’s other vital signs and inform their line manager and the resident’s G.P.

What happened

16. This chronology includes key events in this case and does not cover everything that happened.
17. Mrs E moved into Hornchurch care home, which is owned by HC-One Oval, in June 2018. A preadmission assessment was completed by the home. The assessment was that Mrs E needed 24-hour nursing care and had band 3 needs. Band 3 needs are those that require nursing rather than residential care. The home admitted Mrs E to a floor for residents with either nursing or residential care needs.
18. The care home completed a management of diabetes plan for Mrs E at the end of July 2018; over a month after Mrs E had moved in. The plan said staff should not give Mrs E insulin when her blood sugar was below 4mmol/L and that her acceptable range was between 5 and 7 mmol/Ls. However, Mrs E’s doctor said this was recorded without consulting her and that she considered anything below 5 mmol/Ls as low. The hypo and hyper glycaemia warning signs sections of the care plan were not completed by the home.
19. In August 2018, at 5pm a staff member gave Mrs E insulin despite having low blood sugar (3.9mmol/L). The insulin was administered by a nurse from a different floor as there was no nurse assigned to Mrs E’s floor; a staff interview suggested this was not unusual. The nurse told staff to give Mrs E a sugary drink and a snack.
20. The member of staff in charge of Mrs E’s floor said she had attended diabetes training “many moons ago”. The nurse who gave the insulin said she had diabetes training, “a long-time ago”.
21. Mrs E’s blood sugar level was then not checked for over 5 hours until the next shift started. When Mrs E’s blood sugar was checked by staff at 10.30pm, it was 2.8mmol/Ls. Staff gave Mrs E sandwiches, a cup of tea and non-prescribed medication. Staff did not record that non-prescribed medication had been administered.
22. Mrs E’s blood sugar was taken again at 12.30am; it was 3.3mmol/L. Staff gave Mrs E a banana and a cup of tea. Staff did not check Mrs E’s blood sugar levels again until 8.25am. Medical advice was not sought until the morning. Staff contacted Mrs E’s doctor who told them to monitor her for hyper/ hypoglycaemia.
23. The following day, the care home called an ambulance because of concerns about Mrs E’s blood sugar levels. The paramedics took Mrs E to hospital and she was discharged the same day. The care home made a safeguarding referral about the insulin overdose. The Council asked the care home to conduct an internal investigation.
24. Just over two weeks after the incident, Mrs E was admitted to hospital for a month because of her erratic blood sugar levels.
25. Mrs E was ready for discharge in October 2018. Mrs D says the social worker told her Mrs E could not return to the care home because there were no beds available. Mrs D contacted the home. The home said it told Mrs D that Mrs E could return. However, Mrs E was discharged to a different home.
26. An internal investigation was undertaken following the incident. The investigation finished in October 2018 and found:
• Staff ratio should be one nurse and four care assistants per floor. On the day of the incident there was no nurse on Mrs E’s floor.
• Failure to contact emergency services for advice put Mrs E’s life at risk.
• The deputy manager did not have knowledge of diabetes.
• Mrs E’s management of diabetes care plan was incomplete.
• Staff gave Mrs E Medication that was not prescribed.
• Accurate records were not kept.

The investigation recommended staff training, supervision and disciplinary action. It also recommended the home put in place robust diabetes care plans for residents and ensured the staffing level/ skill mix was adhered to.

27. The safeguarding enquiry undertaken by the Council substantiated the allegations of neglect and acts of omission. It found:
• The home failed to provide enough staff.
• Mrs E’s sugar level was not checked regularly even though it was unusually low.
• The risk assessment for hypoglycaemia was not followed.
• Medication was given to Mrs E that was not prescribed.

The enquiry recommended the home reviewed its staffing levels, properly trained its staff, kept good communication with families, made referrals to other services/ professionals and watched resident’s weight.

28. In December 2019, HC-One Oval wrote to Mrs D. It accepted responsibility for:
• Mrs B being given an unnecessary dose of insulin and medication which had not been prescribed;
• a suitable care plan not being in place; and
• not seeking advice on how best to support Mrs E.

Mrs D was offered a full refund of the nursing part of Mrs E’s fees and money to replace items that were lost during Mrs E’s stay; in total £2,500 was offered.

29. In January 2019, HC-One Oval wrote to Mrs D and acknowledged:
• A serious incident had occurred;
• the service Mrs E received did not always optimise her well-being, respect and dignity;
• it failed the family with regards best practice communication; and
• Mrs E’s items had been lost.

The home told the family staff had been disciplined, a new module on diabetes for care and nursing staff had been introduced and it would revise its complaints procedure. The care home increased its offer to Mrs D to £4,000.

30. In April 2019, HC-One Oval paid Mrs D £4,000 as a gesture to reflect it had heard her frustrations and concerns and regretted missing the opportunity to resolve the matters more swiftly.
31. HC-One Oval provided the training records for its staff for May 2019. Of twenty staff, eight nurses’ and one senior care assistant’s medical competency assessment training was out-of-date.

Analysis

32. Mrs E moved into the home in June 2018, but her management of diabetes plan was not finished until the end of July 2018. Given the importance of this plan, the home should have completed it as soon as Mrs E moved into the home; not doing so was fault.
33. Staff at the home did not follow Mrs E’s management of diabetes plan and gave her insulin despite her blood sugar level being below 4mmol/L; this was fault. If staff had followed the procedure, Mrs E would not have been given insulin and would have been treated for hypoglycaemia instead.
34. Mrs E’s blood sugar levels were below 4mmol/Ls for over 45 minutes, in these circumstances the procedure says paramedics should have been called. Instead, Mrs E was given medication by staff she had not been prescribed; this was fault. Staff did not record that Mrs E was given this non-prescribed medication; again, this was fault.
35. Once insulin had been administered, Mrs E’s should have been checked 10-15 minutes later. However, staff left Mrs E for 5 hours without checking her; this was fault.
36. Mrs E’s blood sugar levels were found to be below 4mmol/Ls again 2 hours later at 10.30pm. Staff gave Mrs E treatment for hypoglycaemia but did not check her again for 8 hours. Not checking Mrs E’s blood sugar was fault.
37. A blood sugar level below 4mmol/L should have promoted staff to tell their line manager and the resident’s doctor. Mrs E’s doctor was not told until the following morning; this was fault.
38. When the incident happened there should have been one nurse and four care assistants assigned to Mrs E’s floor. However, there was no nurse. A nurse assigned to a different floor gave Mrs E’s insulin. Not having the required staffing levels was fault. Neither the nurse who gave the insulin nor the senior care assistant who signed it off had up-to-date diabetes training; this was also fault. This fault should have been remedied following the care home and the Council’s investigations, however, in May 2019 almost half of the care home’s staff needed medical competency assessment training; failure to comply with the investigations recommendations was fault.
39. The home stayed in contact with Mrs E’s family when she was in hospital and during the investigation. However, HC-One Oval gave the family timescales to complete its internal investigation it did not meet and promised information it did not provide; this was fault.
40. These findings are corroborated by HC-One Oval’s internal investigation and the Council’s safeguarding investigation.
41. I do not have enough evidence to make a finding on the loss of a cabinet from Mrs E’s room. However, the home has accepted that some of Mrs E’s personal items were lost.
42. Mrs E was not given the correct standard of care when she was a resident at Hornchurch care home. HC-One Oval potentially breached the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in particular regulations 12, 13, 17 and 18; see paragraph 11.
43. The faults identified put Mrs E’s health at risk and caused considerable stress for her family.

Agreed action

44. Within one month of the final decision, HC-One Oval will:
• refund half Mrs E’s residential home fees minus the money already paid to the family.
45. Within three months of the final decision, HC-One Oval will:
• ensure all staff members have completed medical competency assessment and diabetes training; and
• create an action plan to ensure policies and procedures about diabetes, medication administration, staffing levels and care planning are put in to practice.
46. HC-One Oval should provide the Ombudsman with evidence that the above recommendations have been completed.

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Final decision

47. I have completed my investigation and uphold Mrs E’s complaint. Mrs E has been caused an injustice by the actions of HC-One Oval. HC-One Oval has agreed to take action to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman