Summary: The actions of the care provider did not cause injustice to Ms X.

The complaint

1. Ms X (as I shall call the complainant) complains about her care and treatment in the care home after her discharge from hospital. She complains about incorrect room allocation, a door which was difficult to open, a failure by the care provider to organise necessary tests and being offered the wrong dosage of warfarin on two occasions. She also complains about a lack of hot water.

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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)

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How I considered this complaint

3. I considered all the information provided by Ms X and by the care provider. Both parties had an opportunity to comment on a draft of this statement before I reached a final decision.

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What I found

Relevant law and guidance

4. 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.
5. Regulation 12 says care providers must ensure the proper and safe management of medicines.

What happened

6. Ms X was admitted to hospital for planned heart surgery. She was advised to find a convalescent placement for two weeks post-discharge. A friend (Ms A) found Broad Oak care home and liaised with the manager about Ms X’s needs. The care home records show the lead nurse advised Ms A that the hospital would have to arrange necessary post-operative INR tests as the home could not do so. The records also show the manager advised Ms X’s GP would have to be told she was out of his area for two weeks and send the care home a summary of Ms X’s care. Ms A says the day nurse said that two blood tests a week would not be a problem: she says the nurse told her that a phlebotomist would attend if the nurses at the home could not take the bloods.
7. Ms X says she understood she would be admitted to a particular room (Ms A had shown her photographs) with an air mattress. However when she arrived at the home on 25 February she says she was initially shown to another room, as staff told her there was a problem with the light fitting in her preferred room. She said she understood from what they said it was a simple broken bulb. The new room did not have an air mattress.
8. The care provider says there was no clinical reason for Ms X to sleep on an air mattress: Ms X says this was her preference, however, and her understanding of what would be provided. The care provider says Ms X insisted on the original room although there was a concern about a leak in the ceiling (the ‘problem with the light fitting’ as Ms X had been told). The maintenance staff could not then access the room on the following day to repair the leak as the room was occupied.
9. On Wednesday 27 February Ms X went to open her room door but found it very stiff. She says she thought she pulled a muscle in the attempt but then became concerned in case she had damaged the site of her recent surgery. The following day the pain had not lessened. The care staff arranged for a GP consultation. Ms X was taken to hospital on 01 March to have the area checked and was reassured no damage had been done. The care provider says all the doors are fire doors and this was no different, although Ms X says she did not have difficulty with any other doors.
10. Ms X says as there was no hot water in her first choice of room she had to move into the neighbouring room and shower in a dusty bathroom. She says the water was “lukewarm at best” the following day.
11. The care provider has provided details of its attempts to arrange the INR testing which Ms X required to inform the warfarin dosage. The care provider asked for the hospital to arrange the referral but it did not do so. The temporary GP service could not do so until 48 hours after Ms X’s temporary registration. Ms X says she was concerned to find out that the home had not arranged the appropriate blood tests when she had been assured it would not be problematic. She points out that a delay in the arrival of her records at the GP’s should not have caused a problem in the second week of her stay.
12. Ms X attended an INR test on 28 February. The care home’s records show repeated phone calls to the INR clinic but without response. The GP advised to continue with the same dosage of warfarin.
13. Ms X says on 28 February an agency nurse offered her the incorrect dose of warfarin - 9mg instead of 2mg. Ms X refused the dosage and the correct dosage was given instead. Notes of the home manager’s meeting with Ms A on 01 March record that Ms A told the manager about the incident. The notes go on, ‘I informed (Ms A) that I would investigate the incident and that I was concerned that (Ms X) had not communicated this to me when I saw her this morning.’ The care provider has provided copies of the MAR chart for the period of Ms X’s stay which shows she was given the correct dosage of warfarin at all times. Ms X points out she was only given the correct dosage because she personally noticed the incorrect dosage on offer.
14. The care home manager also wrote to Ms A about the warfarin dosage. She said she had raised the matter with the nursing agency and asked that any agency nurse sent to the home completed practical training in safe administration of medication.
15. Ms X left the care home three days before her planned date.
16. Ms X complained to the care provider on 8 March. She said because of the problems she had experienced she requested a reduction in her fees.
17. The care provider responded to the complaint on 4 April. In respect of the wrong dosage of warfarin being offered, the manager said there was a record that the nurse on duty ‘had a dialogue’ with Ms X as Ms X had been admitted with a range of warfarin strengths. She said the charts showed the correct dosage had been given on every occasion. She provided more explanation for the other points Ms X raised but reiterated that the care home could not arrange the INR testing, that there was no clinical reason for Ms X to have an air mattress, and that the waiting time for the ambulance was not within the care home’s power to change.
18. Ms X remained dissatisfied and complained to the Ombudsman. She said the care provider had not delivered the service which was promised to her and should reimburse some charges.

Analysis

19. The care provider took action to investigate the medication ‘near-miss’ and asked the agency to take steps to avoid a recurrence. In any event, through her own diligence, Ms X was not caused any harm and the correct medication was administered throughout her stay.
20. The care provider acknowledged it could have notified earlier that Ms X’s chosen room was unexpectedly not available for her but the change in room was an inconvenience rather than an injustice. Ms X experienced difficulty in opening the room door, which caused her some pain, but a hospital check showed no harm had been caused.
21. It was not the fault of the care provider that the two INR tests were not able to be arranged within a week, as there was a delay in the medical records being available. The records show efforts made by the care home to organise blood tests in the second week.

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Final decision

22. My decision is that no significant injustice was caused to Ms X by the actions of the care provider.

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Investigator's decision on behalf of the Ombudsman