Summary: The Care Provider failed to administer medication and record interventions properly. This potentially had serious health implications for Mrs D. The Care Provider has agreed to make procedural changes and a payment to Mrs D for uncertainty caused by its actions.

The complaint

1. For anonymity I have referred to the complainant as Ms C, and her mother, Mrs D. Ms C complains on behalf of her mother about residential care services provided at Ashley Court, owned by Regal Care Trading Limited, the “Care Provider”.
2. Ms C complains the care provided to her mother was inadequate and caused a deterioration in Mrs D’s health. Ms C says the Care Provider failed to:-
1. provide a handrail by the toilet;
2. administer medication properly;
3. act following a fall;
4. obtain appropriate eye care;
5. keep her mother’s room temperate and free from intrusion from other residents.
3. Ms C also complains the Care Provider inappropriately restricted her visits to the care home. Ms C says the Care Provider’s failures caused her mother’s health condition to deteriorate and resulted in a hospital admission. Ms C feels that because of these failures the Care Provider should reimburse all her mother’s care fees.

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The Ombudsman’s role and powers

4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. 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)
7. 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. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (Local Government Act 1974, section 26A or 34C as amended)

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How I considered this complaint

8. I spoke with Ms C and considered written information she provided. I made enquiries of the Care Provider which involved asking for documentary information and asking questions about the care provided. I considered:
• daily care records;
• photographs provided by both Ms C and the Care Provider;
• Medical Administration Records (MAR);
• risk assessments and care plans;
• hospital discharge notes;
• 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), the regulator of care services has issued guidance on how to meet the fundamental standards below which care must never fall. I considered the fundamental standards when deciding about fault.
9. During the investigation, for clarification, I also spoke to the Care Provider.
10. Ms C and the Care Provider had an opportunity to comment on my draft decision. I considered the comments made before reaching a final decision.

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What I found

Background information

11. Mrs D entered the care home following a stay in hospital. Mrs D needed help with personal care tasks. While at the care home Mrs D could make her own decisions about day to day activities.

What should have happened

12. Regulation 9 – “Person-centred care” This regulation says care providers must make sure each person receives appropriate care which is based on an assessment of their needs and preferences. Care providers must act within the law and within the requirements of the Mental Capacity Act 2005.
13. Regulation 12 – “Safe care and treatment”. This Regulation aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment. Guidance says providers must do what is reasonably practicable to mitigate risks. The guidance related to this regulation says, “people’s medicines must be available in the necessary quantities at all times to prevent the risks associated with medicines that are not administered as prescribed…”
14. The guidance also says policies and procedures should be in line with current legislation and guidance and address, supply and ordering, administration and recording.
15. Regulation 17 – “Good governance”. This regulation requires providers to have systems and procedures in place to meet other regulatory requirements. Systems and procedures should assess, monitor and mitigate any risks relating to the health, safety and welfare of people using services. Providers must also maintain accurate, complete and detailed records for each person using the service.

What happened, and did the actions of the Care Provider cause an injustice?

16. For ease I have separated out the complaints providing accounts from both Ms C and the Care Provider; and whether I consider the actions of the Care Provider have affected Mrs D, Ms C, or both.

Issues related to Mrs D’s room

17. Ms C complains the temperature of the room was hot and stuffy. The Care Provider says each room has a thermostatically controlled radiator and window openings to manage individual room temperatures. There is a care record to show the Care Provider acted when Mrs D told staff she was hot by opening a window.
18. Mrs D could say when she felt too hot or too cold. Carers or family could change the temperature in the room, I therefore do not consider the Care Provider’s actions caused Mrs D an injustice.
19. Ms C complains the Care Provider failed to change the carpet as it had promised. The Care Provider says the work was scheduled over the next few months and it had explained this to the family. I do not intend to investigate this further as it concerns a conversation(s) where there is no independent witness on which to make a finding.
20. Ms C complains that when visiting she had to lock her mother’s room to prevent other residents entering Mrs D’s room. While I understand this is frustrating, due to the nature of the other residents’ needs it would be difficult for the care home to ensure the privacy of individuals without the need for locking the door.
21. Ms C complains the Care Provider failed to provide handrails in her mother’s en-suite. The Care Provider is at fault for failing to properly risk assess Mrs D’s use of the en-suite toilet at the beginning of her stay. After Ms C asked for hand rails the Care Provider assessed Mrs D as needing a raised toilet seat. The Care Provider says a few days after, it provided Mrs D with a raised toilet seat with a surrounding frame to help Mrs D manoeuvre within the en-suite. Ms C disputes this and says one was never provided.
22. Both the Care Provider and Ms C have provided pictures of the bathroom, each supporting the presence/absence of the raised toilet seat. There is no recording by the Care Provider about when it installed the raised toilet seat. This is a potential breach of regulation 17. Without an independent account I am unable to say how long Mrs D was without the aid, or whether she received it. There was however a period when Mrs D did not have a raised toilet seat. This would have made using the toilet difficult.

Issues related to Ms D’s care

23. Ms C says the Care Provider failed to get eye care for Mrs D. The Care Provider says an optician visited Mrs D and prescribed glasses. It has provided an email from the optician to show this took place and that Mrs D left the care home before the glasses could be delivered. In response to a draft of this statement Ms C says the Care Provider should have told her when the appointment was so that she could have been with her mother. This was not part of the original complaint but in any event, I am unable to say the Care Provider’s actions caused Ms C or Mrs D significant injustice.
24. The Care Provider has provided an explanation for the failure to apply cream on Mrs D on one occasion. This was due to concern about how to administer the medication. The Care Provider sought clarity the next day. While it is unfortunate Mrs D did not have medication applied on this occasion, the potential risk to misapplying the medication outweighed the effects of Mrs D missing one application. However, the Care Provider failed to document its actions, this is a potential breach of regulation 17.
25. The Care Provider accepts and apologises for failing to administer medication properly. It says this was because the GP failed to list additional prescribed medication from hospital on the repeat prescription. It does however accept that it should have checked the medication when delivered.
26. The error concerns two medicines, Lansoprazole and Prednisolone. On 20 March 2019 Mrs D was diagnosed with a skin disorder which results in blistering of the skin. The GP prescribed 20mg of Prednisolone. The instructions said the Care Provider should reduce the dosage by 5mg after the first four to six weeks.
27. The MAR sheet which is difficult to read says, 20mg one tablet a day, then “one daily dosage reduced to 5mg from 5th”. The MAR sheet has an arrow under 6th April which suggests that Mrs D’s dosage was reduced on that day. Mrs D went into hospital on 13 April, the hospital discharge record states the cause as a urinary tract infection. The discharge note says Mrs D should receive 15mg of Prednisolone. The next MAR is on 17 April. This records Mrs D receiving Prednisolone for the next nine days. This is at odds with the amount of medication which the MAR says it had remaining which suggests it could only have administered medication for five additional days.
28. During the same period, the Care Provider administered Lansoprazole for five days after which the Care Provider says it no longer had any tablets. There are no records of the care home administering either medicine from 25 April to the date Mrs D left the care home on 6 May.
29. On 24 April the care home contacted the GP as Mrs D’s skin condition had deteriorated. The GP took photos and advised that he would contact the dermatologist.
30. The Care Provider’s recording is inadequate, and exacerbated by the loss of MAR sheets from 26 April. These are potential breaches of regulations 12 and 17.
31. I have seen photographs both from Ms C and the Care Provider and the skin condition Mrs D had was widespread on her body and looks incredibly painful. It is unclear whether the Care Provider reduced the medication to 5mg or it was a recording error and it reduced the medication by 5mg to 15mg. It appears the medication was one 20mg tablet so it is unclear how carers could administer 5mg.
32. As a result of the poor recording Mrs D and Ms C have uncertainty about what doses, if any, were given to Mrs D and how this may have affected her skin condition.
33. I am however unable to say any potential medication errors resulted in Mrs D’s admission to hospital. This is because the hospital records the reason for admission was a urinary tract infection.
34. Mrs D told care staff she had a fall. The care plan and risk assessment identifies that Mrs D is at risk from falling but does not say how carers should manage the risk. Mrs D had a mat sensor. Carers recorded on some nights the mat sensor was plugged in and working. However, on the night Mrs D says she fell there is no record of carers testing the mat. The Care Provider says it checked Mrs D and found her without injury and took no further action. However, when Mrs D told Ms C about the fall, she said she was in pain in her chest and had a lump on her head. The Care Provider says Ms C did not share this information at the time.
35. I consider the Care Provider should have considered the incident more carefully either by completing an incident report or through daily recording. I consider the failure to do so was not in line with regulation 9 and 12.
36. The Care Provider suggests Mrs D could not have fallen as she could not have lifted herself up. However, Mrs D independently told both a carer and later her daughter that she had fallen and hurt herself. In these circumstances I consider the record should have included that Mrs D had an unwitnessed fall but on examination there were no signs of injury. It should have checked and recorded whether the matt sensor was on and working, and monitored Mrs D more closely.
37. The following night carers responded to the mat sensor going off. The records say Mrs D was unsteady on her feet and coming out in a rash. She went into hospital. It is difficult to say now whether but for the faults identified above the Care Provider would have identified a need for medical attention earlier. Mrs D and Ms C however have the uncertainty that the Care Provider could have taken further action at the time.

Issues related to Ms C

38. Ms C says the Care Provider asked her to stop visiting her mother. The Care Provider says that it was difficult to provide care to Mrs D as Ms C was there for long periods of time with the room door locked. It says this prevented staff from building up a relationship with Mrs D and that it never stopped Ms C from visiting.
39. It does not appear that Ms C reduced her visits to Mrs D or complained to the Care Provider at the time. Although Ms C would have been upset at the time, I am unable to say the Care Provider’s actions caused her significant injustice.

Agreed action

40. I have found the actions of the Care Provider have caused Mrs D and Ms C injustice. In response to Ms C’s original complaint the Care Provider waived the month’s notice period, which amounts to £3200, and offered to reimburse Mrs D a £500 arrangement fee.
41. The Care Provider has had team meetings, staff training and is looking to digitalise its MAR sheets, so they are legible and to reduce mistakes. The Care Provider has also reminded staff about checking when medication is undelivered and not assume, they have been stopped.
42. The actions of the Care Provider in learning from the complaint, taking preventative action, and offering a remedy to Mrs D are welcomed.
43. In addition I consider the following actions are appropriate to acknowledge the impact on Mrs D and Ms C, and to prevent future problems:-
1. apologise to Mrs D and Ms C for the further failures I have identified;
2. pay £300 to Ms C for the anxiety and frustration caused and the time and effort in pursuing the complaint;
3. in addition to the refund of £500 arrangement fees, pay Mrs D £1000 for the uncertainty caused by the Care Provider’s failure to properly record interventions and medication administration. In particular the skin condition which was widespread and would have been incredibly painful and uncomfortable;
4. remind staff about the importance of recording key information within daily records, MAR, care plans and risk assessments;
5. remind staff about how to record risk assessments to ensure they include the steps carers need to take to minimize the risk identified;
6. remind staff of the importance of residents being able to make and contribute to decisions about their care;
7. review internal policies for the safe administration of medication and ensure that medication administrators are aware of what action to take. If necessary, provide additional training.
44. The Care Provider should complete actions (a)-(c) with a month of the final decision and (d) to (g) within three months of the final decision.

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Final decision

45. I have found the actions of the Care Provider have caused injustice to both Mrs D and Ms C. I consider the agreed actions are appropriate to remedy the complaint and have completed my investigation on this basis.
46. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), I will share this decision with CQC.

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Investigator's decision on behalf of the Ombudsman