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Lincolnshire County Council (18 019 814)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 06 Sep 2019

The Ombudsman's final decision:

Summary: Mrs X complained the Council’s commissioned care provider stopped her mother’s, Mrs Y’s medication and lied about how this occurred. When Mrs X complained it gave Mrs Y notice causing them distress and anxiety and they had to find an alternative care home at short notice. The care provider was at fault for stopping medication without checking with a GP. This did not cause significant harm to Mrs Y but caused some confusion. The care provider was entitled to give notice to Mrs Y. The care provider has already amended its medication procedures. The Council has agreed to apologise to Mrs X for the confusion caused.

The complaint

  1. Mrs X complains on behalf of her mother, Mrs Y, about the care provider, Mayfield Residential Home. The care was arranged and funded by the Council. She complains the care provider wrongly stopped her mother’s medication and lied when questioned about how this occurred. When Mrs X complained about this, the care provider gave Mrs Y notice to leave the care home causing them distress and anxiety and they had to find an alternative care home at short notice. In addition, it affected Mrs Y financially as she had to pay for two care homes for part of the notice period.

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The Ombudsman’s role and powers

  1. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  2. 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, section 25(7), as amended). As the care provider is acting on behalf of the Council, the complaint is registered against the Council.
  3. If we are satisfied with a council’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 supplied by Mrs X including records of a telephone conversation with her. I have considered the Council’s response to my enquiries.
  2. I gave Mrs X and the Council the opportunity to comment on a draft of this decision.
  3. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

  1. On 7 February 2019 Mrs Y went to hospital for a planned operation. The care home sent Mrs Y’s MAR (medication administration records) sheets and her current medication with her to the hospital. The hospital noted that zopiclone (a sleeping pill) which was on Mrs Y’s pre-admission records was no longer on the medication charts. Mrs X phoned the care home as it appeared they had not got all the MAR sheets. The care home took an additional MAR sheet to the hospital. This showed it had stopped administering zopiclone to Mrs Y. Mrs X also said the care home had not provided sufficient other medication for the duration of the hospital stay. Mrs X says she phoned the care provider to complain about the issues. During the discussion Mrs X says the care home manager gave verbal notice to Mrs X terminating Mrs Y’s placement. This was followed by written 28 days’ notice terminating the placement dated 8 February 2019.
  2. Mrs X called the Council with her concerns about the medication and the Council raised a safeguarding concern. The Council called the care home who confirmed it had given Mrs Y notice. The records noted Mrs Y could return to the care home from hospital in the short term. Mrs X emailed the Council and queried whether this was possible given the safeguarding concern The Council confirmed Mrs Y could return to the care home if she wanted to. It said it could look to have a meeting to see if it could resolve the issues. It also gave Mrs X details of other care homes with vacancies.
  3. The hospital discharged Mr Y to an alternative care home on 12 February 2019. On 15 February 2019 Mrs X cleared Mrs Y’s belongings from the care home. It refunded the care home fees paid from this date to the end of the month.
  4. Mrs X emailed a complaint to the care provider on 15 February. The care provider responded on 14 March. It said it had supplied only three days of medication when Mrs Y went to hospital as it was awaiting a delivery. It said it had explained this to Mrs X’s sister when she collected Mrs Y from the care home, for the hospital stay.
  5. It said it had stopped the zopiclone as Mrs X had instructed it to do so on 27 January with effect from 4 February in discussion with the care home manager. It acknowledged it should have verified the instruction to stop the zopiclone with the GP. It said the MAR sheets supplied to the hospital were up to date. It had not included MAR sheets for medication no longer taken. Going forward it said it would only action medication changes if it had specific GP instructions to do so. It acknowledged a medication was added to Mrs Y’s MAR sheet in error which was crossed out and noted onto the correct resident’s MAR sheet at the time.
  6. In the complaint response the care provider said it considered some of the comments made by Mrs X during the telephone call to the care home on 7 February were derogatory to staff, management and the home and that Mrs X had said she was not happy with the home and staff. It said the manager regretted becoming irritated but decided in the circumstances the care home’s ability to continue to meet Mrs Y’s needs was compromised and the care provider concurred with this view. In the light of the breakdown in trust it considered it had no choice but to give one month’s notice to terminate the tenancy.
  7. The Council carried out a safeguarding enquiry. It visited the care home on 18 February, spoke with staff and looked at the care home’s records. The care home manager said they had stopped the zopiclone following a conversation with Mrs X when she said it was to stop from 4 February. Mrs X denies this conversation or ever stating the medication should stop. Mrs X says she emailed eth manager in
  8. As part of the investigation the Council looked at the GP records. It found no evidence the GP had instructed the zopiclone should be stopped. The GP had prescribed a further 28 days of the drug on 28 January but the care home had no record of this. The Council queried why zopiclone did not stop after 4 weeks but continued until 4 February. The care home said it was told to do this by the family. The care home recorded it had contacted the GP on 7 February who said they had sent a repeat prescription but would reassess the medication on Mrs Y’s hospital discharge. The Council found a transcribing error recording medication prescribed for another resident on Mrs Y’s MAR sheet. It was clearly recorded on the sheet this was an error and the care home had amended the records at the time.
  9. The Council found the care home had sent the up to date records to the hospital with Mrs Y. It had not included MAR sheets for stopped medication as the hospital requested records of current medication. However, it had stopped zopiclone without checking this with the GP. Mrs Y did not receive the zopiclone for two days but there was no evidence this caused her any harm. It concluded the care home should not have stopped administering the medication without authorisation from the GP. It was satisfied the care home had taken action to minimise the risk of this happening again.


  1. The care provider says Mrs X told it to stop the zopiclone. Mrs X denies having this conversation or ever stating this. I cannot resolve this difference or establish exactly how this misunderstanding took place. However, the care provider was at fault for stopping Mrs Y’s medication without verifying this with the GP. This caused some confusion at the hospital.
  2. The Council investigated this issue under its safeguarding procedures and there is no evidence of fault in the way it did this. The aim of safeguarding is to stop harm or the risk of harm. The safeguarding investigation found no evidence the omission of the medication caused Mrs Y harm. Following the investigation, the care provider has put procedures in place to ensure, in future, medication changes are verified with a GP.
  3. The care provider accepts there was a transcribing error as it wrongly recorded another person’s medication on Mrs Y’s MAR sheet. This was amended straight away. The safeguarding investigation found no evidence any resident received the wrong medication because of this so no injustice was caused to Mrs Y or to any other resident.
  4. I do not know exactly what was discussed between Mrs X and the care home when Mrs X phoned it on 7 February to complain about the stopped medication. It is apparent the conversation between the care home manager and Mrs X was heated and difficult. I am concerned the care provider’s decision to give notice to Mrs Y was a knee-jerk reaction following this difficult conversation. However, the care provider considered there was a breakdown in trust between the family and care provider. In such circumstances it was entitled to give 28 days’ notice to Mrs Y in line with the contract and so I cannot say this is fault.
  5. It was open to Mrs Y to return to the care home during the notice period. The records show the Council offered to try and arrange a meeting with the care home to see if the issues could be resolved. This was appropriate in the circumstances. I cannot now know whether the care provider would have agreed to this or what impact this would have had but in any case, Mrs X did not take up this offer. Mrs Y moved into an alternative care home and the care provider refunded the fees paid after the date her room was cleared.

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Agreed action

  1. The Council has agreed to apologise to Mrs X for the confusion caused by the care provider stopping Mrs Y’s medication without verifying this with the GP. It should do this within one month of the date of this decision.

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Final decision

  1. I have completed my investigation. There was fault causing injustice for which the Council has agreed a remedy.

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Investigator's decision on behalf of the Ombudsman

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