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Porthaven Care Homes No 2 Limited (20 002 698)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 23 Mar 2021

The Ombudsman's final decision:

Summary: Mr X complained the Care Provider, Porthaven Care Homes, failed to ensure his mother, Mrs Y, was given her medication for several days which he says led to her being hospitalised. Mr X also complained the Care Provider failed to keep accurate care records. He said this caused him and Mrs Y significant distress and upset. The Care Provider was at fault when it failed to follow its complaints process, did not stock Mrs Y’s medication for several days and kept records which were unclear and contradictory. The Care Provider should address this by apologising to Mr X and reminding its staff of the importance of following its complaints process and keeping accurate records.

The complaint

  1. Mr X complained:
      1. the Care Provider did not give his mother, Mrs Y medication for several days and this led to her being hospitalised.
      2. Mr X also complained the Care Provider terminated Mrs Y’s care contract without explaining why or formally serving notice.
  2. Mr X said this situation caused him and Mrs Y significant distress and upset.

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What I have investigated

  1. I have investigated Mr X‘s complaint 1a). I have not investigated his complaint 1b) for the reasons explained at paragraph 38.

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The Ombudsman’s role and powers

  1. 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)
  2. 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)
  3. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
  4. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
  5. 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

  1. I contacted Mr X and discussed his view on the complaint.
  2. I considered the Care Provider’s submission which included, Mrs Y’s care records and complaint correspondence shared between Mr X and the Care Provider.
  3. I have written to Mr X and the Care Provider. I considered their comments before making a final decision.

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What I found


  1. 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.
  2. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out the standards registered care providers must achieve when providing care services. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
  3. Regulation 9 requires care providers to make sure that each service user receives appropriate person-centred care and treatment that is based on an assessment of their needs and preferences. Care providers must work in partnership with the service user, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves.
  4. Regulation 17 requires care providers to maintain accurate, complete, and detailed records in respect of each person using the service.
  5. Regulation 19 says care providers must have an effective system in place for identifying, receiving, handling and responding appropriately to complaints and comments made by service users, or persons acting on their behalf.

Care Provider’s Complaints Procedure

  1. The Care Provider has a three stage complaints procedure:
    • Stage 1: the home manager should acknowledge the complaint within 48 hours and provide a written response within 20 working days.
    • Stage 2: the regional director will respond to the complaint within 20 working days.
    • Stage 3: if the matter is not resolved after Stage 2, the operations director or chief executive will respond to the complaint in writing within 20 working days.

What happened


  1. Mrs Y is elderly, suffers from dementia and requires daily doses of multiple medications. She stayed in the Care Provider’s nursing home for several years until 2019.
  2. On 25 April 2019 Mrs X was admitted to hospital because she was behaving aggressively and exhibiting erratic behaviour.
  3. The Care Providers medical records kept between 20 April 2019 and 24 April 2019 showed:
    • 20 April - the care provider attempted to mix Mrs X’s medications in her food but Mrs X refused to eat.
    • 23 April - Mrs X refused to take her medication.
    • 24 April - Mrs X again refused to take her medication after both the care provider and Mr Y attempted to give it to her.
  4. One of Mrs X’s medications was also listed as out of stock between 21 and 24 April 2019.
  5. Mr X says the Care Provider did not formally serve notice and verbally told him Mrs Y would not be welcome back to the care home.

Mr X’s complaint

  1. Mr X applied for health funding to assist with Mrs Y’s care costs in June 2020 and requested a copy of her care records from the Care Provider.
  2. After reviewing the records, Mr X complained to the Care Provider in July 2020.
  3. Mr X said:
    • the Care Provider failed to give Mrs X one of her medications for five days prior to her being hospitalised
    • care records for 20 April 2019 recorded one of Mrs X’s medications as out of stock. However, a carer left a note on the same day and time stating they had attempted to covertly give Mrs X the medication.
    • the Care Provider received a prescription for one of Mrs X’s medications for one week, but the medication chart showed the Care Provider administered the medication for two weeks.
  4. Mr X said the Care Provider’s failure to administer Mrs X’s medication for several days was the reason she had to go to the hospital. Mr X told the Care Provider he remained unhappy Mrs Y had been asked to leave the care home and said he had never received written notice of termination of the contract.
  5. The Care Provider responded to Mr X in July 2020 and said it would not address the complaint because it was vexatious. The Care Provider said it had previously addressed the issues Mr X had raised and too much time had passed for it to investigate the complaint.
  6. Mr X referred the matter to the Ombudsman. As part of our enquiries, we asked the Care Provider to provide evidence it had previously investigated Mr X’s concerns about Mrs Y’s medication. The Care Provider did not provide this information.


  1. Mr X is unhappy the Care Provider did not give Mrs Y her medication for several days prior to her hospitalisation. The regulations require the Care Provider to take the wishes of the service user into account when managing their care. Mrs Y refused medication for three days during the period Mr X has complained about.
    I cannot hold the Care Provider responsible for this. There is no fault in the Care Provider’s actions.
  2. Mr X complained the Care Provider’s medical records showed it did not have one of Mrs Y’s medications in stock for most of the period leading up to her hospitalisation. It is the Care Provider’s responsibility to ensure service users receive person centered care. The evidence shows the Care Provider was unable to offer Mrs Y one of her medications for several days. This is fault. I am unable to determine the impact of this to Mrs Y as I cannot know whether Mrs Y would have taken the medication had she been offered it.
  3. Mr X has complained about discrepancies in the Care Provider’s records. The Care Provider is required to keep clear and detailed records. To date, the Care Provider has not provided an explanation for the contradiction shown on the medical records on 20 April or clarified the medicine prescription issue Mr X has highlighted. Having reviewed the records, I agree that the records are unclear. This is fault and leaves Mr Y with a sense of uncertainty over what medication Mrs Y received.
  4. The Care Provider refused to address Mr X’s complaint because it said had already dealt with the concerns he raised, and the complaint was out of time.
    The Care Provider’s complaint process requires it to investigate a complaint brought to its attention. It does not state there is a time limit for which matters it will agree to investigate. Mr X brought the complaint to the Care Provider as soon as he became aware of the issue. I have not seen evidence the Care Provider has previously investigated this specific complaint. I therefore consider the Care Provider should have followed its complaints process. Its failure to do so is fault. Mr X has had to spend time referring the complaint to the Ombudsman because of the Care Provider’s refusal.

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Recommended actions

  1. Within one month of the date of the final decision, the Care Provider should apologise to Mr X in recognition of the frustration he experienced due to its actions.
  2. Within two months of the date of the final decision, the Care Provider should remind its staff of the importance of following the correct complaints process.
  3. Within two months of the date of the final decision, the Care Provider should remind staff of the importance of completing clear, detailed medication records.
  4. It should provide us with evidence to show it has done this.

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Final decision

  1. The Care Provider was at fault when it failed to keep accurate records and did not follow its own complaints process. I have therefore completed the investigation.

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Parts of the complaint that I did not investigate

  1. I have not investigated Mr X’s complaint 1b). This complaint point relates to events which took place more than 12 months ago. It was open to Mr X to bring this matter to our attention at the time and there are no good reasons why I should exercise my discretion and investigate it now.

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Investigator's decision on behalf of the Ombudsman

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