Summary: Ms B complains about the standard of care her father received while resident at a care home (“the Home”). Ms B says staff did not properly manage medications, complete detailed care plans or provide adequate personal care, among other concerns. The Ombudsman finds fault with the Home’s care of Mr Y, including medication management, care planning, personal care and record keeping.

The complaint

1. The complainant, who I refer to as Ms B, complains about the care her father (“Mr Y”) received while resident at the Home. I have separated Ms B’s concerns into the following heads of complaint:
• Medication management
• Delay in transfer between floors
• Care plans
• Standard of personal care
• Unsupervised visits with Mr Y
• Unprofessional attitude towards private carers
• Observations on the day Mr Y passed away
• Delay in refunding fees
• Collection Mr Y’s property

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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 injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. We may investigate complaints from the person affected by the complaint issues, or from someone they authorise in writing to act for them. If the person affected cannot give their authority, we may investigate a complaint from a person we consider to be a suitable representative. (section 26A or 34C, Local Government Act 1974)
5. If we are satisfied with an organisation’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 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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How I considered this complaint

7. I considered the information Ms B provided and spoke to her about the complaint, the made enquiries of the Home. I sent a copy of my draft decision to Ms B and the Home for their comments before making a final decision.

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What I found

Law, Guidance and Local Policies

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
10. The fundamental standards include:
• Regulation 9: Person-centred care. The guidance says, ‘providers must do everything practical to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be’.
• Regulation 12: Safe care and treatment. The Guidance says, ‘Staff must follow policies and procedures about managing medicines’. It also says, ‘Medicines must be administered accurately, in accordance with any prescriber instructions and at suitable times to make sure that people who use the service are not placed at risk’.
• Regulation 17: Good governance. The guidance says, ‘Records relating to the care and treatment of each person using the service must be kept and be fit for purpose. Fit for purpose means they must:

Be complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable. This includes results of diagnostic tests, correspondence and changes to care plans following medical advice.

Include an accurate record of all decisions taken in relation to care and treatment and make reference to discussions with people who use the service, their carers and those lawfully acting on their behalf.’

11. The Care Home Regulations 2001 sets out a schedule of records care homes must retain for at least three years. This includes records of medication administration, care plans and assessments and other care records.
12. The CQC has guidance on ‘When required medicines in adult social care’. It says, ‘A person-centred care plan should contain enough information to support staff to administer when required medications… The care plan should include:
• Details about what condition the medicine is prescribed for
• Does instructions. This includes the maximum amount to take in a day and minimum interval between doses. Where a variable dose is prescribed there should be clear directions as to what dose should be given.
• Signs or symptoms to look out for and when to offer the medicine. Include if the person can ask for the medicine or if they need prompting or observing for signs of need. For example, non-verbal cues.
• The plan should include appropriate alternative support. It should also include interventions to use before medicines.
• Where more than one when required medicine is available for the same condition, it should state how and in what order they will be administered.
• When to review the medicine and how long the person should expect to take it. For example, what to do if the medicine is taken regularly or not used for a long period of time.
• When to check with the prescriber if there is any confusion about which medicines or doses to give.

For medicines used to manage a person’s behaviour staff should know how to support a person in a different way before using a medicine. For example, changes to the person’s environment. This information should be accessible to staff at the time of medicines administration.

Care plans should detail how the medicines will be offered to the person when they are experiencing the symptoms. For care homes this should, not be limited to medicines rounds or times printed on MARs.

When PRN medicines are administered the record should include:

• the reasons for giving the when required medicine
• how much has been given
• the time of administration for time sensitive medicines
• the outcome and whether the medicine was effective’
8. The Home has provided its Medication Administration Policy dated December 2019. The policy has a section on PRN medications, which says, ‘To ensure the medication is given as intended, a specific care plan for administration must be recorded in the care plan, and ideally kept with the MAR charts. This should state clearly what the medication is for and the circumstances in which it should be given.’

Background

14. Mr Y had dementia and was a resident at the Home from mid-January to end of March 2020, when he passed away. Prior to his admission Y had received care at home from domestic care support workers, privately arranged by Ms B. When he was admitted to the Home Ms B arranged for his existing carers to attend the Home on occasions each week to help with personal care, while Mr Y settled in. Ms B says going into a care home was distressing for Mr Y and the carers were familiar to him so would help him transition.
15. Mr Y was prescribed Risperidone PRN for occasions when Mr Y was agitated. The MAR chart for January 2022 says, ‘take half a tablet twice a day when necessary’. Risperidone is a medication used to treat schizophrenia and bi-polar disorder.
16. Ms B says that two days after Mr Y’s admission to the Home, a senior carer told her Mr Y had refused to put his pyjamas on the previous evening. Therefore, staff would administer Risperidone to Mr Y at 17:00 every day. Ms B challenged this as she said staff should use other techniques, such as talking and distraction tactics, and only administer Risperidone if necessary.
17. Ms B was concerned that staff were overmedicating Mr Y and that Risperidone was not suitable. She contacted Mr Y’s GP who agreed, 11 days after Mr Y’s admission, to discontinue the medication. A note on Mr Y’s MAR chart said, ‘this medication is not to be offered/given to Mr Y until GP advises otherwise’.
18. The MAR chart shows Risperidone was administered on the following occasions (Day 1 is the day Ms B says staff advised her they would administer every day at 17:00):
• Day 1 – 17:00
• Day 2 – 13:00
• Day 3 – 17:00
• Day 4 – 13:00 and 17:00
• Day 5 – 17:00
• Day 6 – 17:00
• Day 7 – None
• Day 8 – 17:00
• Day 9 – 13:00
• Day 10 – Discontinued
19. The Home put in place care plans for Mr Y in each of his main areas of need. I can see the original care plans are dated January 2020. The latest review of each was in early March 2020.
20. In late January 2020 Ms B says one of the private carers telephoned her to say that a visitor had attended the Home and spoken to Mr Y. The carer asked the visitor who they were and they said they had been referred by Mr Y’s GP to ask him questions about an emergency health care plan. The carer said the Home’s receptionists did not know who the visitor was and no member of staff was present during the meeting. Ms B contacted the community nursing team who confirmed a community nurse had visited.
21. Ms B asked the Home for records of the visit and said it should report this as a safeguarding incident. The Home could not provide any records of the visitor signing in but decided it was not an incident that should be reported to safeguarding. Ms B says a similar incident happened in March 2020, where an NHS worker visited Mr Y without any evidence of signing in or being accompanied by a member of staff.
22. The Home placed Mr Y on its second floor. Ms B says she raised concerns about this with the Home during the first week. She says the initial information provided to her suggested the Home would keep residents with dementia on the ground floor. She says Mr Y would become confused and agitated, trying to access the lift. Ms B says that in early February 2020 the Home told her it would move all dementia residents to the ground floor. However, this was delayed and did not happen until early March 2020. The Home apologised for the delay and said it was not clear why the delay occurred.
23. Over the course of the two months Mr Y was at the Home, Ms B says the privately arranged carers raised numerous concerns with her about the level of personal care Mr Y received. These concerns included finding staff had not properly dressed Mr Y, that he was unshaven and unkempt and that on at least two occasions he was left in soiled bedding. Ms B also says the attitude of certain members of staff at the Home towards the private carers was unprofessional. She says one member of staff was rude and hostile towards the carers being there.
24. Mr Y passed away in late March 2020. Ms B says that when she attended the Home, a staff member told her they had completed observations of Mr Y that night every two hours. However, she says the Home then told the police that staff had conducted observations every hour.
25. Shortly after Mr Y passed away, his next instalment of fees was paid by direct debit before Ms B had a chance to cancel this. Ms B therefore asked the Home to refund the fees. It agreed to do so in early April 2020. However, Ms B says she did not receive the refund until late June 2020, despite chasing.
26. Ms B says she visited the Home again to collect Mr Y’s belongings around five weeks after he passed away, due to ongoing restrictions caused by coronavirus. She says his laundry still had vomit and bodily fluids on it and had been sitting in a black bag for those five weeks.
27. Ms B requested Mr Y’s care records from the Home. She says there was a delay in receiving these and when she did the records were not complete. After receiving and reviewing the records, Ms B made a formal complaint in March 2021. The complaint included issues set out at Paragraph 1 of this statement.
28. The Home sent Ms B a complaint response in April 2021. Ms B was not satisfied the response and raised further concerns. The Home provided a further complaint response dated November 2021.

Findings

Medication management

29. I find fault in the Home’s management of Mr Y’s Risperidone.
30. As outlined at Paragraphs 12 to 13, both the CQC guidance and the Home’s policy are clear there should be a specific care plan for each PRN medication. That care plan should provide clear details for staff around how and when to give the medication. There is no evidence the Home had a care plan of this nature for Mr Y’s Risperidone. There is no evidence staff were provided with any guidance on when it was appropriate to administer the medication. This is fault.
31. Ms B says staff told her they would administer Risperidone at 17:00 every night as Mr Y would get agitated around that time. The Home’s complaint response says the records show Mr Y would become unsettled from around teatime and walk around, trying to leave. The medication would have been given to allow time for this to get into his system and reduce the risk of further incidents. This response supports that staff did take the approach of administering Risperidone regularly at a certain time, in anticipation that he would become agitated. This is clear fault. It is equivalent to staff themselves prescribing Mr Y with a regular dose of a strong, serious medication, to treat anticipated symptoms of agitation, rather than following a clear plan to determine whether on each separate occasion it was appropriate to give the medication when he became agitated, after other techniques had not been effective.
32. The MAR charts show staff administered Risperidone at 17:00 on six days out of nine. Therefore, staff did not administer it every day at that time, but on the majority of days. There is no record on any of those occasions about why staff gave the medication, or whether it was effective. The CQC guidance is clear there should be such records every time staff administer the medication. The lack of record keeping in this instance is fault.
33. I note the Home’s complaint response also appears to suggest staff administered Risperidone to Mr Y in March 2020, in the week before his passing. I asked the Home to provide the MAR charts for March 2020, but it says it does not have these. It said it had no information about whether staff administered the Risperidone in March 2020 or whether it had permission from the GP to continue this. The Home has not provided any records of communication between the Home and the GP as requested and says it has no more information it can send.
34. With the lack of records it is impossible to know for certain whether the Home administered Risperidone to Mr Y in March 2020. However, the complaint response suggests that did happen. There is no evidence to indicate the GP gave permission to continue administration of this medication, that was suspended two months earlier. If this did happen, without authorisation from the GP, there was serious fault in staff administering a medication that was essentially no longer prescribed.
35. Overall there is significant fault in the Home’s management of Mr Y’s Risperidone. There was no care plan or guidance for staff to follow, no records of why staff gave it on each occasion, and evidence staff administered regular doses to Mr Y at a set time to prevent the possibility of agitation, without any consultation with his GP. It is not within the scope of my role to say what impact this had on Mr Y from a health point of view. However, it creates significant uncertainty about the impact this might have had on Mr Y, which causes considerable distress to Ms B.
36. I also read through the Home’s latest full CQC inspection report, dated April 2021. It said, ‘Medication management was unsafe. Some people’s medicines were not given safely in accordance with the manufacturer’s instructions. Staff lacked clear guidance on how to administer people’s ‘as and when’ required medicines.’ This suggests the fault I have found was not isolated to Mr Y. There were likely systemic issues with the management of PRN medications within the Home.

Delay in transfer between floors

37. The Home’s complaint response accepts there was a delay in moving Mr Y to the ground floor. It is not clear why there was a delay. I asked the Home to provide any correspondence or care records showing its communication with Ms B on this point but have not received any records. I also asked the Home to clarify how and when it made the decision to move Mr Y and any reasons for any delays. The Home said it cannot comment. I therefore cannot make a proper assessment of whether there were any justifiable reasons for the delay.
38. On balance I find fault. There is evidence Ms B raised concerns about the impact of Mr Y being on a floor that had a lift. The Home appears to have accepted this and agreed to move Mr Y. However, there were delays of at least month in it doing so, with no explanations as to why that was. This caused distress to Ms B about whether Mr Y was left in a situation that was causing him frustration and anxiety.

Care plans

39. I asked the Home to provide all versions of the care plans it had for Mr Y. The Home provided the latest updated version, but not the version it put in place when Mr Y first entered the Home. The Home said it did not have any further records. However, it previously sent the original copies to Ms B and she provided these to me.
40. I reviewed the original care plan for ‘personal, oral and footcare’. The care plan was generalised and did not appear person centred. It did not seem to outline any needs that were specific to Mr Y. For example, it said ‘Nurse to be aware of drug interaction with the health of teeth and gums’. It did not say whether any of the medications Mr Y received were specifically relevant. It also said ‘Mr Y requires assistance from 1 member of staff to maintain level of personal care’ and ‘staff to offer assistance when required’. Again, the plan did not outline anything specific to Mr Y, such as whether he needed assistance with shaving or getting into the shower.
41. The plan did not say anything about the fact Ms B had arranged for private carers to attend the Home. I note in the Home’s complaint response, when responding to Ms B’s concerns about personal care, it asks why the private carers were employed if not to provide personal care. If the private carers were responsible for personal care and carried this out instead of staff from the Home, I would have expected this to be clearly recorded in the care plan, including how often they came in and which tasks they would complete.
42. Another example is the ‘nutrition and hydration’ care plan. It says, ‘Mr Y’s likes and dislikes to be incorporated into menu planning’. It does not say anything about his specific dietary needs or preferences. The later care plan does provide more detail but, as far as I can see, was only reviewed and updated two months later in March 2020.
43. Again, there was no individualised care plan for the management of Mr Y’s PRN medication.
44. It is consistent throughout all the original care plans that most of the information could likely have applied to almost every resident in the Home. The updated care plans are more detailed, but the recorded review date is March 2020 and I cannot see any evidence of reviews taking place before then.
45. Mrs B also raises concerns that information about Mr Y in the care plans, such as his height and age were incorrect.
46. The Home’s response says care plans develop over time. This is true but the Home should have person centred, individualised care plans in place from the outset, based on a full initial assessment of needs. Reviews then take place to consider what is working well or not and adapt to any changes in needs.
47. I find fault in how the Home completed the original care plans as the plans were not person centred and did not contain information specific to Mr Y, such as his preferences, the involvement of his privately arranged carers and information about his PRN medication.

Standard of personal care

48. I asked the Home for the full daily progress notes for the two months Mr Y was a resident at the Home. The Home said it did not have these records. It did, however, provide these to Ms B previously and I was able to obtain the notes from her.
49. Ms B’s main concerns about personal care were that staff did not ensure Mr Y was properly dressed or shaven. She also mentions two occasion that the private carers reported that Home staff had left Mr Y in soiled bedding.
50. I have already found fault in the lack of information in Mr Y’s care plans. For instance, the personal care plan had nothing about shaving, or how often Mr Y should be shaved. That feeds into my findings in this section.
51. I have reviewed the daily records and made a note of every time there is a record about what personal care staff provided. I can only see a record of personal care having been provided on 23 out the 72 days Mr Y was at the Home. Therefore, on more than two thirds of the days he was living at the Home, there is no record of staff having provided personal care. It is impossible to know whether staff really did not assist with personal care on all those occasions. It may be more likely that staff did not record their intervention. However, record keeping is a basic principle of providing care. The absence of clear care plans and daily records, combined with the concerns raised by the private carers and Ms B, creates significant uncertainty about whether staff properly managed Mr Y’s personal care.
52. The overall standard of record keeping in the daily progress notes was poor. I could regularly see days where no records were made whatsoever for entire shifts or even over multiple shifts. This is fault.

Unsupervised visits with Mr Y

53. Ms B originally complained about the incident of January 2020. During the course of my investigation, she also raised the incident of March 2020. However, this means the Home’s complaint response only referred to the first visit. In that response, it says members of staff will always be present in meetings between residents and external visitors. However, it does not say whether a member of staff was present at the community nurse visit in January 2020.
54. The Home’s policy on visitors says everyone who arrives at the Home must report to reception and sign in. It does not say whether a member of staff should be present when professional visitors meet with residents.
55. The Home says it cannot locate any signing in sheets or other records of the community nurse visiting Mr Y. The visit is also not recorded in the daily progress notes. Therefore, there is no evidence members of staff were present during the visit or that any of the management or care staff were even aware the visitor was in the Home and meeting with Mr Y.
56. There is fault in how the Home followed its procedures. This is because there is no record of the visitor having signed in. It is clear from the Home’s response that it accepts a member of staff should be present during such visits. The absence of any evidence this happened is also fault.
57. I also cannot say for certain whether the Home should have reported this incident to the local authority safeguarding team. I have looked through the local authority’s safeguarding criteria and, in cases where there is a one-off incident involving risk management, and no actual harm occurs, it is likely it would treat the incident as a low-level concern. Such concerns may or may not need to be reported. Therefore, there is an element of judgement on the Home’s part.
58. In this case I cannot see evidence of significant harm to Mr Y from the incident, although Ms B says the visit was distressing to him. The Home may have been able to justify not reporting the incident to safeguarding, had it properly investigated, identified what happened, and ensured systems were in place to prevent it happening again. My concern is that I cannot see any evidence the Home properly investigated this incident. It could not find the records so simply said it could not comment and that normally a member of staff would be present. It made no efforts to understand why there were no records, why no member of staff was present in this instance or whether the Home’s systems were fit for purpose. Therefore, I also find fault in how the Home investigated Ms B’s concerns. I note Ms B reports that a similar incident occurred again, and again there are no records of that visit.
59. The injustice to Ms B from these incidents is distress and uncertainty about whether the Home had adequate security systems in place to ensure Mr Y’s safety.

Unprofessional attitude towards private carers

60. Ms B raises concerns that carers were unprofessional towards the privately employed carers and questioned why they were at the Home. I have not made a finding of fault on this point. I cannot make any judgement on the things staff may have said or their tone. I can only investigate whether the Home properly accounted for the carers’ role in Mr Y’s care. I have made findings on this in respect of the Home’s personal care plan not including the role of the private carers.

Observations on the day Mr Y passed away

61. Ms B says the Home gave inconsistent and misleading information to her and the police about the observations staff conducted on the day her father passed away. Ms B says that when she attended the Home a senior carer told her staff had checked her father every two hours. However, she says the Home then told police they had checked Mr Y every hour. She says the Home did not explain this inconsistency.
62. In January 2020 none of Mr Y’s care plans stated how often staff should carry out checks during the night. The Home reviewed Mr Y’s ‘communication care plan’ in March 2020. That updated version says, ‘staff are to check hourly whilst in bed’.
63. I have looked through the daily records from January to March 2020. Throughout that period there are records of two hourly checks during the night shift. That continues up until, and on, the day Mr Y passed away.
64. The Home has provided intermittent copies of observation records. There are dates that are missing. In particular, the Home has provided the observation records for the day before Mr Y passed away. It has not provided records for the evening or following morning. Mr Y passed away during that early morning.
65. The observation records for all dates show hourly checks. So, these appear inconsistent with the daily records. It is not clear why staff recorded two hourly checks in the daily records, alongside one hourly checks on the observation notes. Again, the record keeping in general raises concerns and uncertainty about what level of care staff were providing to Mr Y, and whether it reflected what was in his care plan.
66. I also have no evidence that, during the morning Mr Y passed away, and the night before, staff completed one hourly observations, as required in his care plan. The complete absence of the observation charts for this period, but records of two hourly observations in the daily records, combined with the carer’s comments to Ms B, create further uncertainty about whether the Home’s records accurately reflected the care Mr Y received.
67. I cannot comment on what information the Home gave to the police. I also cannot say what, if any, impact it would have had if staff did not complete observations as required. However, the standard of record keeping around observations, particularly on this date, cause significant uncertainty and distress to Ms B.

Delay in refunding fees

68. Ms B says the Home delayed in refunding fees of nearly £5,000, following her father's death. The refund was for fees paid up front for care. The Home agreed the refund at the start April 2020 but did not pay this until the end of June 2020, almost three months later.
69. The Home has accepted there was a delay and apologised for this. I find the delay in refunding the fees was fault. On its own, I would not find this caused a significant injustice as Ms B did receive the refund. However, in the context of the significant fault I have found elsewhere, I am of the view the delay added to the distress already caused to Ms B.

Collection Mr Y’s property

70. The Home’s complaint response accepts it was not acceptable for staff to return Mr Y’s belongings in the state they were in. It said it will ensure all items are checked in future. I find this was fault, which again added to the distress caused by the significant fault found elsewhere.

Consideration of remedy

71. I have found fault on the following points:
• Management of Mr Y’s PRN risperidone
• The delay in transferring Mr Y to a different floor
• Care plans were not individualised, or person centred for up to the first seven weeks Mr Y was in the Home
• Inconsistent and absent records of staff providing personal care
• The absence of records around visits to Mr Y by external professionals and a failure to investigate Ms B’s concerns
• Inconsistent and absent records of observations, in particular on the morning that, and night before, Mr Y passed away
• Delay in refunding fees and returning personal belongings in an unacceptable state
72. There is significant fault throughout several areas of care. The fault identified around medication management is of particular concern, as is the level of record keeping. I note the Home has been unable to produce many of the relevant records and the daily records were often not completed.
73. While I cannot make any findings about what impact the fault might have had on Mr Y’s health, it causes considerable injustice to Ms B in terms of distress and uncertainty about the care Mr Y received while at the Home. Based on the number of areas in which I have found fault and the significance of those issues, I recommend the Home pay Ms B £1,500 to recognise the distress caused.
74. I note the CQC found ongoing issues with a lack of care plans for PRN medications. The CCQ is the most appropriate body to address improvements in overall standards of care and may review the introduction of care plans in future inspections. The Home has provided evidence of a recent audit in June 2022 by the local Clinical Commissioning Group, which rated the Home as good in respect of medication management. It said PRN protocols in the Home were detailed and person centred. This suggests improvement in this area since the last CQC visit. The CQC is the body responsible for inspecting and addressing wider issues with care in care homes. It will conduct further inspections of the Home in future which may look again at medication management. Therefore, I have not made any service improvement recommendations in relation to medication management.
75. I have also not made service improvement recommendations relating to record keeping. This is because the recent CCG report did not note significant problems with record keeping. The Home has outlined that it has made improvements in the two years since Mr Y was a resident at the Home. This includes introducing a Quality Team, which reviews and improves policies and arranges staff training. Again, the CQC is the organisation best positioned to review the Home’s safety and care quality in any future inspections.
76. The Home has also provided details of changes it has made to its visitor arrangements and provided a copy of its visitors’ policy. It has introduced and electronic sign in system which retains a permanent record of visitors and the resident they meet. This addresses the recommendations I would have made around visitation going forward.

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Agreed action

77. The Home has agreed to, within a month of this decision:
• Apologise to Ms B for the fault identified
• Pay Ms B £1,500 to recognise the distress caused

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Investigator's decision on behalf of the Ombudsman