Summary: Ms X complained about poor care in a care home including about a failure to ensure she had all her medicines and a failure to apply a device to reduce swelling after surgery. We upheld the complaint. The Care Provider will apologise and make a symbolic payment to reflect the avoidable distress and confusion.

The complaint

1. Ms X complained about care in one of the Care Provider’s care homes, Carpathia Grange. She complained:
1. Staff did not ensure all her prescribed medicines were available for her
2. Care staff did not use a cryo cuff on her wound (a device to reduce swelling)
3. Care staff failed to dry her properly before dressing her
4. Staff did not know how to put on her compression stockings
5. Food and drink were poor quality and presented poorly
6. The room was dark, dull and poorly furnished and there was no means to elevate her leg or chair for a visitor
2. Ms X said this caused avoidable distress.

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The Ombudsman’s role and powers

3. We make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
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 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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

8. I investigated complaints (a) to (d). I did not investigate the other complaints because the injustice to Ms X is insignificant in the context of a week’s stay for respite care.

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How I considered this complaint

9. I considered evidence provided by Ms X and the Care Provider as well as relevant law, policy and guidance.
10. Ms X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
12. Regulation 12 of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by:
• working with health professionals to ensure the health and welfare of residents.
• assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks. Where equipment or medicines are supplied the care provider should ensure there are sufficient supplies to meet needs and medicines are managed safely.

What happened

13. Ms X went into the Care Home at the end of June 2024 for a week of respite care after a hip operation.
14. The hospital discharge summary said ‘keep dressing dry and intact until removal of staples…. Keep Ted stockings until back to full mobility…. for removal of clips [staples] and physio in two weeks.’ The summary listed two types of painkiller, but not the indigestion medicine.
15. The discharge paperwork I have been provided with does not say anything about a cryo cuff. Ms X told us that she had worn the cuff in hospital four times a day and she was told by the hospital to tell care home staff about it.
16. A separate list of Ms X’s regular medicines that I have been provided with didn’t list the painkiller (paracetamol) or indigestion medicines. The Care Provider’s complaint response (see later), however, did refer to a third document (a letter) listing the indigestion tablet as a regular medicine.
17. The daily records say a member of staff called Ms X’s daughter on two occasions and asked the daughter to bring in some painkillers (paracetamol) and indigestion tablets for Ms X.
18. Midway through her stay, Ms X asked staff if she could take her medicine independently. This was agreed following an assessment of her abilities.
19. There is one note of staff assisting Ms X to put on compression stockings after showering and drying. There is no record of Ms X raising any concerns about this at the time.
20. Staff records show the team leader discussed and reflected on the medicine incidents. The Care Provider also completed a staff bulletin summarising what had gone wrong and saying in future staff needed to check all available documentation as well as discuss it with the resident to make sure all a person’s medicines were available at the home.
21. Ms X complained to the Care Provider about the maters she has raised with us. The Care Provider’s final complaint response said:
• The indigestion medicine was not on the hospital discharge summary as one of her regular medicines and none came with her. However, another letter listed it and so the team leader asked her daughter to bring some in as well as some pain relief as this was running low. There had been a meeting with the team leader about the second letter and learning from this incident had been shared with the team. In future all paperwork would be checked and queried to make sure all medication was available. The Care Provider was sorry for the distress
• The discharge summary said the cuff was to be used after the dressing and staples were removed. The dressing and staples were in place during her stay and so staff were correct not to apply the cuff
• She had discussed self-medicating (taking her own medicine) with the team leader and this was agreed.
• There was no record of her raising concerns about being dressed while wet or about how staff helped her with compression stockings.

Findings

Staff did not ensure all prescribed medicines were available

22. I uphold this complaint. Staff should have cross-referenced all available written information and checked with Ms X (who was later assessed as capable of managing her medicines and so could likely have given a full account of her current prescription) to ensure there was a complete list of her current medicines and these were all available for the period of Ms X’s stay. The failure to do this was not in line with Regulation 12 which was fault causing avoidable distress.
23. The Care Provider accepted fault and has taken some appropriate action through informal staff training which will minimise the risk of recurrence.

Care staff did not use a cryo cuff on the wound

24. The complaint response said the discharge summary says the cryop cuff was to be used after removal of the staples. This is incorrect. It says nothing about the cuff. Giving incorrect information is fault causing avoidable confusion. I would expect care staff to have called the hospital to find out how and when to use the cryo cuff. This was poor communication and liaison with a health provider which as not in line with Regulation 12 and was fault causing avoidable distress.

Care staff failed to dry her properly before dressing her and staff did not know how to put on her compression stockings

25. There is no written record of any concern about either of these issues. We make findings on a balance of probability. The absence of a contemporaneous record means there is not enough evidence of fault.

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Agreed Action

26. The Care Provider has apologised and evidenced action it has already taken to minimise the risk of recurrence. This is a partial remedy. Within one month of my final decision, the Care Provider has agreed to:
• a further written apology reflecting my findings We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• a symbolic payment of £100 to Ms X to reflect her avoidable distress and confusion.
27. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

28. I find fault causing injustice. I have recommended an apology and payment to remedy the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman