Summary: Mr X complains on behalf of the late Mr Y that the Care Provider did not restart Mr Y’s prescription after he moved from another nursing home. Mr X says Mr Y did not receive all his prescribed medications during his stay with the Care Provider. Mr X says this has caused him uncertainty about the care provided to Mr Y. We find no fault in how the care home administered Mr Y’s medication, but some fault caused by delays in replying to Mr X. The Care Provider has already apologised for this fault. It has agreed to remind its staff to adhere to its complaints policy.

The complaint

1. Mr X complains on behalf of his late father, Mr Y that Camelot Care (Plymouth) Limited), (the Care Provider), did not restart Mr Y’s prescription and repeat medications after he moved from another nursing home.
2. Mr X says Mr Y did not receive all his prescribed medications during his stay, and this has caused him uncertainty about the care provided to Mr Y.

Back to top

The Ombudsman’s role and powers

3. 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 or others. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
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. 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)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

7. I read Mr X’s complaint and considered the information he provided.
8. I made enquiries to the Care Provider and considered the information it provided.
9. Mr X and the Care Provider had the opportunity to comment on a draft of this decision. I have considered their comments before making a final decision.

Back to top

What I found

Legislation and guidance

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve.

• Regulation 12 of the Act says care providers must provide care and treatment in a safe way for service users. This includes assessing risks, mitigating them as far as reasonably practicable and ensuring persons providing care or treatment have the necessary qualifications, skills, knowledge and experience. This section also says that where a service provider supplies medicines, it should make sure there is enough medication to meet the needs of the service user.
• Regulation 17 of the Act says accurate, complete and contemporaneous records about the care and treatment provided to each person using the service must be kept.

Care Quality Commission (CQC)

11. 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.

Medical Administration Records

12. Medical Administration Records (MAR) are formal records of administration of medicine within a care setting. They can be used as evidence in investigations and/or court cases.

The care provider’s policy

13. The Care Provider’s policy at the time of Mr Y’s stay refers to “medication reconciliation”. It says, “it is the duty of anyone prescribing to ensure that medications are correctly reconciled for each service user who is admitted to our home”.
14. The policy also says “the prescription chart should be completed appropriately and clearly” after administering medication to the service user.
15. In May 2019, the Care Provider replaced this policy with separate policy documents.

The Care Provider’s complaints policy

16. The Care Provider’s complaints policy says that when a written complaint is received, an investigation may be carried out by the care home. The policy says the Care Provider should “be prepared to respond to the complainant in writing or at a meeting within 7 days”.
17. The policy says it will tell the complainant if the complaint cannot be resolved within seven days and will provide a written response within 28 days.

What happened

18. Mr Y was diagnosed with dementia and took several different prescribed medications for his health issues.
19. On 21 January 2019, Mr Y transferred from the care home in which he had been living, Care Home A, to the Care Provider’s home, Care Home B. At about the same time, the Care Provider applied to register Mr Y at a new doctor’s surgery.
20. On 4 February 2019, Mr Y was admitted to hospital after his health worsened. Mr Y remained in hospital and did not return to Care Home B.

Mr X’s complaint

21. Mr X says a doctor at the hospital told him Mr Y’s General Practitioner (GP) had stopped his prescriptions on 28 January 2019.
22. In July 2019, Mr X wrote to the Care Provider. He asked why Mr Y’s medication had stopped and why the family was not consulted. In September 2019, Mr X wrote to Mr Y’s GP to ask the same questions.
23. In January 2020, a third-party organisation acting on behalf of Mr Y’s GP responded to Mr X. It said the electronic notes for Mr Y showed his medication stopped when he moved to his new GP. The third-party organisation said this is normal practice when closing a patient’s record. It said the Care Provider should have requested repeat medications when it registered him with the new GP. It said it had not received a request for Mr Y’s medication, and that from the information available, it appeared Mr Y’s medication was stopped in error.
24. In March 2020, the Care Provider replied to Mr X and apologised for the delay in replying. It said Care Home B received Mr Y’s medication and a full list of his medicines when he transferred from Care Home A. It said its records showed all Mr Y’s medications continued from the date he moved in to Care Home B until the date he was admitted to hospital. The Care Provider said its computer records also showed it gave Mr Y his medication.
25. Mr X remained unhappy with the Care Provider’s response and brought his complaint to the Ombudsman.

Administration of medicine to Mr Y

26. Mr X says doctors at the hospital told him Mr Y’s medication was stopped. However, the Care Provider says it continued to administer Mr Y’s medication as required.
27. I have reviewed the Care Provider’s medication administration records (MAR). As previously stated, these records may be used as evidence in investigations and/or court cases. The MARs are the primary record of the medication given to Mr Y. These show the Care Provider continued to give the prescribed medication to Mr Y, from the date of his transfer to Care Home B to the date he was admitted to hospital.
28. I have also compared the MARs from Care Home A with those from Care Home B. The Care Provider’s MARs show that Care Home B administered the same medication as Care Home A, as instructed in Mr Y’s prescription.
29. The letter sent on behalf of Mr Y’s GP says its notes show Mr Y’s medications were stopped. Mr X also says this is what the hospital told him. However, the letter says this is normal practice when a patient’s record is closed. This explains why a GP who stops acting as a patient’s doctor may also stop prescribing medication to that patient. I acknowledge the letter raises questions about whether Mr Y’s medication continued, but I do not consider this is evidence the Care Provider stopped giving Mr Y his medication.
30. The MARs show the different types and quantities of Mr Y’s medication received by Care Home B when Mr Y was transferred to its care. The Care Provider says it did not request a repeat prescription when it registered Mr Y at the GP because it received enough medication when he moved into its care home. The Care Provider says it would have ordered more medication about a week before the existing supply ran out and was due to request a prescription on the day Mr Y went to hospital. It says it did not make this request because the hospital admitted Mr Y.
31. The quantities of the medication listed on the MARs support this explanation. The doctor’s letter also explains why it may have appeared Mr Y’s medication had stopped.
32. I have seen no evidence the Care Provider decided that Mr Y’s medication should be stopped, and I have seen no evidence it failed to restart or provide all prescribed medication to Mr Y. The Care Provider’s MARs and explanation of its actions are also in line with relevant legislation and its own policy at the time.

Was there fault by the Care Provider?

33. Because the evidence shows Care Home B continued to give Mr Y his medication as prescribed, I have found no fault by the Care Provider in this matter.
34. However, there is evidence of delay by the Care Provider in replying to Mr X’s complaint, as it took almost eight months to respond. This is much longer than the 28 days specified in its complaints policy. I consider this delay constitutes fault by the Care Provider.
35. Having identified fault, I must consider if this caused a significant injustice to Mr X and/or Mr Y.
36. The fault identified did not affect the care provided to Mr Y. For this reason, I consider it did not cause an injustice to Mr Y.
37. The injustice to Mr X is the uncertainty he felt about the care provided to Mr Y. Primarily, this was caused by the information given to Mr X by third party healthcare providers. However, the Care Provider took eight months to reply to Mr X’s concerns and I consider this delay added to Mr X’s uncertainty.
38. I acknowledge the Care Provider has already apologised to Mr X. It is positive the Care Provider identified and acknowledged the delay it incurred.

Agreed action

39. The Care Provider has agreed to remind its care home managers and/or complaints handlers to adhere to the timeframes within its complaints policy. The Care Provider is required to provide us with evidence it has taken this action within two weeks of the final decision.

Back to top

Final decision

40. I have found no fault in how the care home administered Mr Y’s medication, but some fault caused by delays in replying to Mr X. I have therefore concluded my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman