Summary: Ms X complained about the standard of care provided to her late relative, Mrs Y, by the Care Provider where she lived. We found the actions of the Care Provider caused avoidable injustice to both Mrs Y and Ms X. To remedy this injustice, the Care Provider has agreed to apologise to Ms X.

The complaint

1. Ms X complains about the standard of care provided to her late relative, Mrs Y, at Cliveden Manor Care Home (the home) towards the end of her life. Specifically, she complains:

• required medications were not received at the home in a timely manner;
• required medications were not administered in a timely manner;
• monitoring checks on Mrs Y were not as frequent as they should have been; and
• record keeping and communication was not as good as it should have been.

2. Ms X also complains that Avery Healthcare (the Provider) took too long to respond to her initial complaint.
3. Ms X says this caused her avoidable distress and frustration and meant Mrs Y was not delivered the standard of care she should have been.

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The Ombudsman’s role and powers

4. 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)
5. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

7. 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)
8. When considering complaints, 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.
9. 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 the CQC.
10. 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)

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How I considered this complaint

11. I have considered all the information Ms X provided. I have also asked the Provider questions and requested information, and in turn have considered the Provider’s response.
12. Ms X and the Provider had the opportunity to comment on my draft decision. I have taken any comments received into consideration before reaching my final decision.

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What I found

Relevant law and guidance

13. The CQC is the statutory regulator of care services. It keeps a register of care providers that 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.

Fundamental standards of care

14. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The CQC has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:
• person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences.
• safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety.
• complaints (Regulation 16): The provider must have a system in place to handle and respond to complaints;
• good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user; and
• staffing (Regulation 18): Providers must deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure that they can meet people's care and treatment needs.

Controlled drugs

15. The Controlled Drugs (supervision and management for use) Regulations 2013 sets out the procedures for how controlled drugs should be handled, stored and administered.

What happened

16. I have set out below a summary of the key events. This is not meant to show everything that happened.
17. Ms X’s relative, Mrs Y, had lived at the home for several years before she died in November 2024. Mrs Y suffered from numerous age-related health conditions and was a self-funded resident there.

September 2024 onwards

18. In mid-September 2024, the home moved Mrs Y into its residential dementia unit as her condition progressed.
19. On 29 September, Mrs Y’s GP saw her and prescribed medication for an infection. The home received this on the same day and began to administer it as prescribed until the course of tablets finished on 5 October.
20. On 30 September, the home called the county’s out of hours triage service (the triage service) as Mrs Y was in pain and her normal pain relief was not having the required effect. The triage service advised a triage GP would call back to discuss Mrs Y’s case, but there are no records to show when this happened.
21. As a result of the initial triage call on 30 September, pain relief medication (medication A) was at some point prescribed.
22. On the morning of 2 October, the home realised medication A had been added to Mrs Y’s medication list but had not yet arrived from the pharmacy. It then chased this and medication A arrived later in the day. Medication A was first administered at 11pm on 2 October. Records show it was administered three times on 3 October and on several occasions over the next 7 days, as required.
23. On the morning of 8 October, the home called the triage service as it was concerned Mrs Y was hallucinating and had not opened her bowels for several days. The triage GP called back that evening and prescribed a laxative (medication B) for Mrs Y. The home received this on 10 October and administered it that evening, as per the prescription. Medication B was administered each evening over the coming weeks.
24. On 10 October and during a weekly visit to the home, Mrs Y’s regular GP prescribed liquid painkiller (medication C) due to her increased difficulties in swallowing the tablet form which she normally did. The home administered tablet painkillers to Mrs Y until the afternoon of 11 October and then medication C from the evening of 11 October onwards, when it had arrived on site.
25. On 17 October, a locum GP visited the home. The home and GP discussed that Mrs Y was moving towards the end-of-life stage and there was a need for anticipatory medications related to this. The home was asked to discuss this with Mrs Y’s regular GP when they returned to the surgery on 21 October.
26. On 18 October, the home noted Mrs Y was no longer able to use the call bell due to a further deterioration in her condition. The care plan in place at this time said she was due to be checked on every four hours during the night and every two hours during the day.
27. The home contacted Mrs Y’s GP surgery on 21 October regarding the anticipatory medications and again on 22 October but was unable to speak to a GP. The GP prescribed the medications on 22 October and discussed this with the family on 23 October.
28. Mrs Y’s GP placed her on an end-of-life pathway on 23 October. One of the anticipatory medications prescribed was morphine (medication D). The home changed from delivering dementia residential care to delivering dementia nursing care to Mrs Y on the same day.
29. From 25 October, the home was scheduled to check on Mrs Y a minimum of every 30-60 minutes.
30. Anticipatory medications arrived at the home on 25 October, but medication D was not received. The home queried this with the pharmacy. The pharmacy advised that the strength of the prescribed medication was not the same as that commonly held by most pharmacies. The home requested this item be returned to the central prescription system which meant it could then be filled by a different pharmacy. The family then assisted and collected Medication D late on the morning of 26 October.
31. Medication D arrived at the home and was first administered on the afternoon of 26 October. More of the medication arrived the next day.
32. On 27 October, the home agreed with the family that it would now check on Mrs Y every 15 minutes and inform the nurse if she was distressed.
33. Ms X made a detailed complaint to the Provider on 31 October before Mrs Y died at the beginning of November.
34. The Provider completed a detailed response to Ms X on 25 November. It said that:
• all communications should be documented to ensure queries were followed up in a timely manner and this had not happened with some of the communications in Mrs Y’s case;
• stocks of ‘homely remedies’ such as laxatives and liquid painkillers were available in the home and could have been administered to Mrs Y when prescribed items of the same were delayed;
• the home should have been more responsive to chasing up prescribed medications when they had not been delivered as expected; and
• paper records should be kept when its electronic care recording system was not working, but this had not happened in Mrs Y’s case.
35. In mid-January 2025, Ms X emailed the Provider to say she had not yet received her complaint response from it. The Provider sent a copy of November 2024’s response.
36. In mid-March and unhappy with its response, Ms X escalated her complaint with the Provider.
37. At the end of March, the Provider sent its final complaint response. It set out the actions it had taken based on its ‘lessons learnt’ detailed in its stage one complaint response. It said it had:
• reviewed and strengthened systems for following up prescriptions and ensuring clarity around GP consultations;
• improved documentation and shift-to-shift communication, particularly during end-of-life care;
• put in place escalation protocols for pharmacy and triage delays, supported by additional training;
• ensured all learning has been embedded and reviewed through its quality and governance framework.
38. It said these improvements aimed to prevent similar delays from occurring and to ensure residents and families continue to receive the high standard of care it expected across all of its homes.
39. The Provider’s response signposted Ms X to the Ombudsman, after which she brought her complaint to us.

Analysis

Background information

40. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment.
41. However, if we consider the person who has complained to us has been adversely affected by the impact of that poor care on their relative, we may make a recommendation to remedy their own distress.

Timeliness of medications being received

42. The Provider’s complaint response to Ms X says medications should have been delivered within 24 hours of being prescribed. The Provider normally uses a local pharmacy to fill its prescriptions.

Medication A

43. It is unclear exactly when medication A (pain relief) was prescribed for Mrs Y.
44. The Provider, in response to Ms X’s complaints, confirmed the triage GP did not call back on 30 September, but that there were also no records of any GP call being received on 1 October, despite the medication being prescribed. The Provider’s complaint response said all communications must be documented to ensure queries are followed up. It also said that if it had been documented the triage GP had been in touch about prescribing medication A, the home could have chased this when it did not arrive. Instead, it was chased on 2 October when the home later realised it had been prescribed but had not yet arrived.
45. Whilst its later than expected delivery was not the fault of the home, I agree the home should have documented it was being prescribed which would have meant an earlier chase to the pharmacy. The actions of the home were not in line with Regulations 9 and 12 and therefore caused an injustice to Mrs Y which cannot now be remedied. This also caused an injustice to Ms X of the avoidable distress of knowing the medication was not administered to her relative as quickly as it could have been. I have made a recommendation below to remedy this injustice.

Medication B

46. The triage GP agreed to prescribe medication B on the evening of 8 October. It is unclear when the prescription was sent to the pharmacy to be filled. However, the medication was received in the home on 10 October and administered that evening as directed. On the balance of probabilities, I am satisfied there was no injustice to Mrs Y in the timing of the home receiving medication B and it being administered.

Medication C

47. On 10 October, Mrs Y’s regular GP prescribed medication C which was a liquid. Mrs Y continued to receive the tablet form of this until the liquid form arrived at the home on the evening of 11 October. Medication C was first administered later that evening. It continued to be regularly administered, as prescribed, over the next few weeks.
48. This timeline contradicts the Provider’s complaint response to Ms X which said the medication had not arrived and had to be chased. I am satisfied, however, that evidence shows Mrs Y received the medication in a timely manner as soon as it had been received in the home and which was the day after it was prescribed. Whilst I note Mrs Y had difficulty in swallowing tablets by this time, records show she was still receiving pain relief via this method. I am therefore satisfied there was no injustice to Mrs Y here.

Anticipatory medications

49. Anticipatory medications were prescribed at some point on 22 October, meaning they should have been at the home by late 23 October. There is no evidence the home chased the whereabouts of the anticipatory medications when they were not received in the usual timescale.
50. Three of the four prescribed medications arrived on 25 October but medication D was not sent.
51. In response to Ms X’s complaint about the delayed arrival of medication D, the Provider said the home had acknowledged it should have been more proactive chasing up anticipatory medications. It said if this had been done, it would have been aware of the issue with medication D and that in all probability would have meant it was in the home before 26 October.
52. Medication D was administered to Mrs Y as soon as it was on site, Ms X says that by this time however, Mrs Y had been in severe pain for over an hour and her normal pain relief medication was not having any effect.
53. I agree with the Provider’s assessment. On the balance of probabilities, I am satisfied it is more likely than not the required medication would have arrived earlier if the home had been more proactive. It would then have been on site well before Mrs Y required it, which is in line with the Provider’s end of life care policy, to ensure there is no delay in responding to a symptom in the last hours or days of life.
54. I note the medication was administered as soon as it arrived. However, I am satisfied the delayed arrival was not in line with Regulations 9 and 12 and caused an injustice to Mrs Y which cannot now be remedied. I am also satisfied the delayed arrival caused avoidable distress to Ms X. I have made a recommendation below to remedy this injustice.

Medications being administered in a timely manner

55. When Mrs Y became distressed and in pain on the morning of 27 October, Ms X was unhappy because the required staff were not immediately available to administer medication D to Mrs Y. She was also unhappy that a second dose could not be immediately administered when the first dose did not seem to take effect.
56. I acknowledge the distress it caused the family to see Mrs Y in pain. However, because medication D was a controlled medication, this required both the home’s registered nurse and a second trained member of staff to administer it.
57. Medication D was administered to Mrs Y 25 minutes after the family first pressed her call bell for attention. I am satisfied the home’s procedures were in line with its policy for the administration of controlled drugs. The policy is written based on relevant government regulations. I am satisfied there is no fault on the home’s part here.
58. Ms X was unhappy that there were not additional, trained staff to administer controlled medications when the nurse on duty and the second member of staff were busy administering to someone else. She was also unhappy that the home did not have rapid access to an experienced doctor who could attend the site and adjust medication as needed and that the home used the triage service which took time to get through to on the telephone.
59. In its complaint response to Ms X, the Provider explained the triage system is used by all care homes in the county. It explained it was unable to administer more of medication D before two hours had passed without the consent of a GP. It also explained the triage service took an extended time to get through to and by the time the triage GP had called back, the two-hour window had passed and Mrs Y had already received a second dose of medication D.
60. I acknowledge Ms X’s stance on this, but a difference of opinion is not evidence of fault. The home uses the triage service it is required to and cannot administer medication more frequently than prescribed without the consent of a GP. The home cannot be held responsible for the response time of the triage service or the time it takes for a triage GP to call back to discuss an individual case. I am satisfied the home took proportionate action to try and progress the situation and do not find fault in its actions.
61. I have also reviewed the medicine records for how much of medication D was in the home - both the higher initial strength and a later prescribed lower strength. In response to my draft decision, Ms X said there was only enough medication as the family queried stock levels and chased this with the home. Regardless of how more medication came to be in the home, I am satisfied that at no time did the home run out of medication D and therefore there was no injustice to Mrs Y.
62. The Provider considers it is proportionate to have one registered nurse on shift to work with a second member of staff to administer any controlled medications. I am satisfied this is a decision for the home to make and that the home was staffed as intended on the day in question. On this basis, I do not find fault in its actions.

Monitoring checks on Mrs Y

63. The home recorded that Mrs Y was no longer able to use her call bell on 18 October 2024.
64. As part of my enquiries, I asked the home what protocol was in place when someone becomes unable to use a call bell. The Provider sent me a copy of its call bell policy. This states that if someone is unable to use a call bell, an additional care plan and risk assessment must be completed.
65. The home already had a safety care plan in place for Mrs Y, with a lowered bed and crash mats on either side being part of this. Mrs Y’s care plan was reviewed on 18 October. This shows she was due to be checked on at four-hourly intervals during the night and two-hourly intervals during the daytime.
66. I have viewed Mrs Y’s care records. From 18 October until she was placed on the end-of-life pathway on 23 October, evidence shows Mrs Y had contact with staff more frequently than her care plan stated. This included things such as emotional wellbeing checks, administration of medicines, meal times, and general checks. On this basis, I am satisfied there was no injustice to Mrs Y during this time in terms of monitoring and checks made, when compared to the plan in place.
67. When Mrs Y was placed on the end-of-life pathway, care records show she was due to receive checks every 30 minutes from the early hours of 25 October onwards. The Provider’s response to me said her checks were increased to every 30-60 minutes. I have viewed the records. The overwhelming majority of visits to Mrs Y were carried out between 30- and 60-minute intervals until she moved to 15-minute checks on the afternoon of 27 October. Regardless of whether this should have been every 30 minutes or between 30 and 60 minutes, it is clear regular checks were carried out on Mrs Y during this time. I am satisfied, that on the balance of probabilities it is more likely than not she did not suffer an injustice in terms of monitoring during this period. Missing records during the morning of 27 October are discussed below.
68. I have viewed the records from the afternoon of 27 October until Mrs Y’s death. Evidence shows she was frequently checked multiple times an hour, often with many more checks than the four per hour which were scheduled. On this basis, I am satisfied there was no injustice to Mrs Y.
69. I acknowledge this was a very upsetting time for Ms X and the wider family. In her complaints to the Provider, Ms X stated she believed a resident on the end-of-life care pathway should routinely be monitored every 15 minutes. She also stated that Mrs Y’s signs of pain were very short lived and required someone to be in the room to notice them. However, Mrs Y’s provision was not one-to-one.
70. The Provider’s response to my enquiries stated there was no specific amount of checks someone on end-of-life care should receive and this is based on the needs of the specific resident. I am satisfied this is a reasonable stance for the home and the Provider to take and that it increased checks as it felt was required and as Mrs Y came closer to death. I therefore consider there was no injustice to Mrs Y.

Record keeping and communication

71. In response to Ms X’s complaints, the Provider confirmed that its electronic record keeping system was not working on the morning of 27 October. The home should have used paper records during this time for the information to later be uploaded to the electronic logs. The Provider confirmed this did not happen. Not keeping accurate records was fault and was not in line with Regulation 17. However, the Provider has confirmed that CCTV showed checks were carried out on Mrs Y every 15 minutes during this time. Regular checks were also confirmed by Ms X in her comments on my draft decision. On this basis, I am satisfied Mrs Y was checked every 15 minutes and the lack of accurate paper or electronic recording during this time did not cause her an injustice.
72. In response to Ms X’s complaint to it, the Provider said there were several lessons to be learned, these are set out at paragraph 37.
73. The Provider acknowledged that record keeping and communication had not always been what they should have. I agree. In line with CQC Regulations 9 and 12, the Provider’s actions caused an injustice to Mrs Y that cannot now be remedied. I have made a recommendation below to remedy the avoidable distress caused to Ms X.
74. In response to my enquiries, the Provider sent evidence of the actions it had taken to address identified shortcomings as per its responses to Ms X. These show ‘lessons learnt’ had been discussed with staff at the home and procedures changed as appropriate. On this basis, I do not intend to make any service improvement recommendations related to this complaint.

Complaint handling

75. Ms X has provided evidence of the stage one complaint response being sent in November 2024 but then recalled straight away.
76. In response to my enquiries, the Provider said it had initially sent the response in an incorrect format so had recalled this and immediately resent this in the correct format.
77. The Provider has sent me evidence of the complaint response being sent to various other parties that day, but not evidence of it being re-sent to Ms X. A copy was then sent to Ms X when she chased this in January 2025.
78. On the balance of probabilities and with a lack of evidence to the contrary, I am satisfied it is more likely than not the Provider did not re-send the complaint response as intended in November 2024. This caused avoidable distress and frustration to Ms X. I have made a recommendation below to remedy this injustice.

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Agreed action

79. To remedy the injustice I have identified, the Provider has agreed to apologise to Ms X within four weeks of the date of my final decision.
80. The apology written should be in line with the Ombudsman’s guidance on remedies on making an effective apology.
81. The Provider should send us evidence it has complied with the above actions.

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Final decision

82. I have completed my investigation. I uphold this complaint because the Provider’s actions caused injustice to Ms X and Mrs Y.

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Investigator's decision on behalf of the Ombudsman