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Rushcliffe Care Ltd (21 002 808)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 13 Dec 2021

The Ombudsman's final decision:

Summary: Mrs X complains about the failure of a care home to administer her mother’s medication correctly. There was fault which warrants a remedy.

The complaint

  1. Mrs X complains that Thornham Grove Residential Home failed to correctly administer her mother’s medication, causing detriment to her mother and upset and distress to her family.

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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 an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
  3. 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

  1. I spoke to Mrs X and considered the information she provided. I asked the Care Provider for information and I considered what it provided in response to the complaint.
  2. Mrs X and the Care Provider had an opportunity to comment on my draft decision. I considered the comments received before making a final decision.

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What I found

CQC Standards & Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

  1. CQC Standards include good governance. Regulation 17(2)(b) relates to record keeping. It states social care providers must maintain secure, accurate and up to date records about the care of service users. This includes accurate records about medicines each person should receive and what has been administered.
  2. CQC Standards include a duty of candour. Regulation 20 sets out this duty. It explains that registered persons must act in an open and transparent way.
  3. CQC Standards regarding safe care and treatment. This is Regulation 12. It requires, amongst other things that a care provider ensures the proper and safe management of medicines. To achieve this staff must follow policies and procedures about management of medicines.
  4. Section 1.71 of the National Institute for Health and Care Excellence (NICE) guidance on managing medicines in care homes states the care home manager or the person responsible for a resident’s transfer into a care home should coordinate the accurate listing of all the resident’s medicines (medicines reconciliation). They should ensure that the resident and/or a member of their family, a pharmacist and any other relevant health or social care professionals are involved in medicines reconciliation.

PRN medications given “as required”

  1. The CQC state that care plans should contain enough information to support care workers to correctly administer ‘as required’ medication. 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. Care plans should record when to check with the prescriber if there is any confusion about which medicines or doses to give.
  2. For PRN medications, care plans should also record the reason for giving PRN medication, how much was given, the time and whether the medication was effective.

What happened


  1. Mrs X complains about the care given to her mother (referred to in this statement as Mrs Y). The complaint concerns issues with Mrs Y’s medication and specifically a failure to administer Pyridostigmine correctly.
  2. Mrs Y moved into Thornham Grove Residential Home in August 2020. Mrs X sent us a copy of a drugs list that she provided to the care home at the outset. This showed there was a need for Mrs Y to receive one 60mg tablet of Pyridostigmine at Breakfast, one at Lunch and one at Tea time. The care home told us that Mrs Y’s prescription for Pyridostigmine when she moved into the home stated “half to one tablet up to three times daily as directed”.
  3. Mrs X’s care plan noted that Mrs Y’s mobility was variable. It stated she was sometimes able to mobilise using a walking frame with a member of staff supporting her. However, she had a medical condition that affected the muscles in her legs. She sometimes needed support to mobilise. The care plan stated Mrs X should be encouraged to walk as much as possible to help maintain her independence. It noted Mrs Y had initially been reluctant to do exercises recommended by her doctor, but as of January 2021 she had restarted these.
  4. In June 2020 Mrs Y had been in hospital and the care provider sent us the discharge information from that hospital stay. The discharge information recorded the medication Mrs Y needed to take upon discharge. This included the need to take one 60mg Pyridostigmine tablet three times a day (morning, lunchtime and evening).
  5. The care home’s Medication Administration Record (MAR) charts show that from admission in August 2020 until 7 December 2020 Mrs X was only being given one tablet of Pyridostigmine every morning.
  6. On 7 December, in preparation for a medical appointment, Mrs X asked for a list of her mother’s medication. A care worker emailed a list of Mrs X’s medication back to her in response. The care worker emailed back stating what the MAR charts showed; Mrs Y was being given one 60mg tablet of Pyridostigmine every morning.
  7. Mrs X explained she was having difficulty getting through to Mrs Y’s GP to verify things but she asked the care worker to double check, because Pyridostigmine should be given three times a day. The care worker responded saying “what we are administering mum at present is Pyridostigmine Bromide 60mg tablets and the direction to give this on the medication box states “Take one full tablet three times a day”.
  8. On 8 December the MAR chart was changed to ‘take one tablet three times a day’. On the chart “one” was crossed out by hand and replaced by ‘half’. This particular chart for Pyridostigmine recorded the period 8 December to 27 December. It is unclear when the change from one to half was made. That is not documented.
  9. From December 2020 visiting was limited because the care home was locked down due to a COVID-19 outbreak at the home. This prevented ‘in-person’ visits by friends and relatives.
  10. On 28 December 2020 the MAR chart changed again. The care home could not explain why the dosage changed on this date. The new MAR chart stated “Take half every morning”. The MAR charts record this dosage then being administered up to and including 9 February 2021.
  11. A fresh MAR chart recorded another change on 9 February. It recorded the dosage being changed to ‘Half a tablet 3 times a day as prescribed by your doctor’. This began on 9 February 2021. So, the record of administering of this medication is duplicated for 9 February. It is unclear if Mrs Y received the Pyridostigmine recorded on both charts on 9 February.
  12. The care provider’s records show that the change on 9 February was as a result of GP advice.

Mrs X’s complaint

  1. Mrs X complained in February 2021 about the care home’s failings. This prompted an investigation and safeguarding report.
  2. From 10 February 2021 an MAR chart recorded that the dosage of Pyridostigmine should be ‘One tablet three times a day’. This is the correct dose. The chart notes this was as instructed by Mrs Y’s GP on 10 February via a fresh prescription.
  3. The care home accepted Mrs Y had been given an incorrect dose of Pyridostigmine between August 2020 and February 2021.
  4. The care home’s investigation accepted that, regardless of any misleading instructions, the MAR chart did not reflect the prescription instructions. So, it was no mitigation for the error. It found that care home staff failed to do due diligence and there had been a failure to follow the medication policies and procedures.
  5. The care home stated all staff had been re-assessed against medication competency and it’s disciplinary procedures had been followed. A medication audit had taken place and all staff had been spoken to about the lessons learned from this case.
  6. The care home apologised to Mrs Y and the family for the distress and upset caused. The home stated Mrs Y’s GP stated as a result of the reduced medication she would have been weaker in her lower limbs but she should not have any other adverse reactions. The care home stated it had taken steps to prevent a reoccurrence of the error it had made.
  7. In response Mrs X noted that the family had been very upset and they were not satisfied the matter had been fully resolved. They noted their mother paid for her care and the care provider had failed to meet her needs. Mrs Y subsequently moved to another care home.

What should have happened

  1. When Mrs Y first became a resident at Thornham Grove her medication was incorrectly written up on the home’s MAR charts. What was written on the chart did not match either what the prescription said, or what Mrs X and the hospital discharge information set out. There is no record of the care home staff having consulted Mrs Y’s GP about the apparent ambiguity in her Pyridostigmine prescription when she first became a resident.
  2. Even if the care home considered Pyridostigmine was a PRN drug, it still had insufficient information about how often, and in what circumstances it should have been administered and what results to expect. These details should be part of the care plan for PRN drugs.
  3. The dosage should have been clarified at the outset. The failure to do so was fault. I found that insufficient care was taken to ensure these important records were correct.
  4. In December when Mrs X questioned the dosage of Pyridostigmine, a care worker misled her. When Mrs X asked the care worker to double check the dose, it seems likely, on balance, the care worker knew the dosage had been wrong up to that point. I say this because the care worker told Mrs X what the correct dosage was on the box in December. But, the care provider’s records clearly show this had not been what Mrs Y had been given. Rather than explain to Mrs X what had happened in an open and transparent way and report the issue as a safeguarding and practice issue, the only action taken was to change the dosage the next day. This too is fault. The CQC standards set out a duty of candour.
  5. Although the instructions on the box in December seemed clear, the dosage was still incorrect after the change the care worker made from 8 December. There is no evidence anyone at the care home contacted Mrs Y’s GP to check the dosage in December. It is difficult to understand why the issue was not resolved when Mrs X queried it. It was a missed opportunity to rectify the matter.
  6. To make the situation worse, the care provider made another change to Mrs X’s dosage in late December. This was to an even lower dose than the care provider had administered between August 2020 and December 2020. The care provider cannot explain why. This is very poor practice and there is no record of the care provider speaking to Mrs X or Mrs Y’s GP before making this change.
  7. The error was only rectified in February 2021, following discussion with Mrs Y’s GP. This meant the incorrect dose of Pyridostigmine had been given from August 2020 to February 2021.
  8. I note the care provider accepts it did not properly deal with Mrs Y’s medication, the apology it provided and the actions it has taken to learn from the failings and address issues with its staff in this case. It provided us with evidence of staff reassessments.


  1. Mrs X and her sisters were understandably upset and distressed by the failure by the care home to correctly administer Mrs Y’s medication, for misleading Mrs X and for the missed opportunity to rectify the error in December 2020.
  2. Mrs Y received an incorrect dose of medication aimed at stabilising a condition which affects her muscles to maintain her mobility. Mrs X explained that Mrs Y’s mobility reduced while at Thornham Grove. I cannot determine if the reduced medication was the cause. However, the medication error persisted over a significant period of 6 months. It may well have contributed to this. Mrs Y is left with the uncertainty of how much the lack medication affected her health.

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Agreed action

  1. Within four weeks of my final decision the care provider should:
    • pay Mrs Y £1000 to recognise the uncertainty and distress about how much the lack of correct medication affected her health and mobility.
    • Pay Mrs X and her two sisters £250 each to recognise the distress they were caused by the failure to properly meet Mrs Y’s needs.

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Final decision

  1. There is fault that has caused injustice. As my recommendations were accepted by the care provider and Mrs X I have now completed my investigation and close my file.

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Investigator's decision on behalf of the Ombudsman

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