Summary: Mrs X complained about the quality of care provided to her mother, Ms Y, by The Orders of St John Care Trust when she resided in Goodson Lodge Care Centre. We found the Care Provider’s actions did not cause injustice to Ms Y.

The complaint

1. Mrs X complains about care her mother Ms Y received when residing in Goodson Lodge Care Centre (the Care Home). She says the Care Home:
• had inadequate blood testing processes in place to deal with insulin-dependent diabetic residents such as Ms Y;
• failed to provide adequate diabetes care to Ms Y in March 2025;
• had staff that did not know how to recognise and deal with Ms Y’s hypoglycaemic incident;
• delayed in sourcing prescribed cream to treat the Ms Y’s bed sores;
• needed to be chased by her to get Ms Y’s basic needs met.
2. Mrs X said the Care Provider’s failings resulted in Ms Y receiving inadequate care in the lead up to her death. Mrs X’s emotional health and wellbeing also suffered greatly.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
6. The law says we cannot normally investigate a complaint unless we are satisfied the organisation knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the organisation of the complaint and give it an opportunity to investigate and reply. (Local Government Act 1974, section 26(5), section 34(B)6)
7. 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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What I have and have not investigated

8. I have not investigated anything that happened after mid-May 2025, as this is when the Care Provider sent its stage two response to Mrs X’s complaint. As explained in paragraph six of this decision we should allow care providers to respond to any issues first before we start investigating them.

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How I considered this complaint

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

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What I found

Legislative and administrative framework

Fundamental standards of care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) issued guidance (the Guidance) in March 2015 on how to meet the fundamental standards.
12. The fundamental standards are the standards below which the care must never fall. Everybody has the right to expect the following standards:
1. Person-centered care – you must have care or treatment that is tailored to you and meets your needs and preferences;
2. Dignity and respect – you must always be treated with dignity and respect while you are receiving care and treatment. This includes making sure you have privacy when you need and want it.
3. Safety – you must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Providers must assess the risks to your health and safety during any care or treatment and make sure their staff have the qualifications, competence, skills and experience to keep you safe.
4. Safeguarding from abuse – you must not suffer any form of abuse or improper treatment while receiving care. This includes neglect and degrading treatment.
5. Food and drink – you must have enough to eat and drink to keep you in good health while you receive care and treatment.
6. Premises and equipment – the places where you receive care and treatment and the equipment used in it must be clean, suitable and looked after properly.
7. Good governance – the provider of your care must have plans that ensure they can meet fundamental standards. They must have effective governance and systems to check on the quality and safety of care. These must help the service improve and reduce any risks to your health, safety and welfare. The records kept for you should be accurate, complete and contemporaneous.
8. Staffing - The provider of your care must have enough suitably qualified, competent and experienced staff to make sure they can meet these standards. Their staff must be given the support, training and supervision they need to help them do their job.
13. Risk assessments relating to the health, safety and welfare of people using services must be completed and reviewed regularly by people with the qualifications, skills, competence and experience to do so. Risk assessments should include plans for managing risks. Providers should use risk assessments to make required adjustments.

What happened

14. The Care Home offers residential and respite care.
15. Ms Y was diabetic. In September 2024 she stayed in the Care Home for two weeks. She was very happy with her stay. Mrs X had no concerns about care provided by the Care Home to her mother.
16. Ms Y’s health was deteriorating throughout winter 2024/2025. A few times she received hospital treatment. At the end of February 2025, following her stay in hospital, Ms Y was admitted to the Care Home on a residential basis.
17. A day before her admission the Care Home completed a telephone pre-admission assessment with Mrs X. Mrs X held a Lasting Power of Attorney for Ms Y. There were no concerns about Ms Y’s mental capacity to make decisions. Mrs X told the Care Home that Ms Y was diabetic and took insulin. The Care Home staff explained that district nurses would support Ms Y with administering insulin and monitoring blood sugar levels.
18. At the beginning of March 2025 the Care Home carried out a review of Ms Y’s care plan. It was noted that district nurses administered insulin to her daily to manage her diabetes. Staff were to be aware of the need to maintain Ms Y’s sugar intake. The Care Home completed a “Living with Diabetes plan” for Ms Y.
19. On 10 March 2025 in the morning a visiting district nurse noted her concerns about Ms Y. In view of her low sugar levels the nurse said she would consult with the Care Home doctor (the GP). She also told the Care Home staff not to give Ms Y one of her medications. The following day the GP confirmed Ms Y should not continue with this medication.
20. In the early afternoon of 10 March 2025 the GP visited Ms Y. The GP noted Ms Y’s poor state of health and prescribed medication to be given if Ms Y needed them at the end of her life. The GP contacted Mrs X to discuss the deterioration in Ms Y’s health.
21. In the afternoon Mrs X found Ms Y lying down on the floor in her room. She called the Care Home staff to assist her. A district nurse found Ms Y’s blood sugar levels were extremely low. After consultation with the district nurse team the GP decided to stop insulin treatment for Ms Y.
22. Later this day and at night the Care Home staff and district nurses continued to regularly monitor Ms Y.
23. On 14 March 2025 the Care Home noted the risk of Ms Y developing pressure ulcers. Ms Y was sleeping on the specialist mattress and was repositioned every four hours at night.
24. A few days later the Care Home ordered a cream from the pharmacy to treat Ms Y’s bed sores. After a few further days the Care Home corresponded with the pharmacy about some complications with obtaining what Ms Y needed.
25. At the end of March 2025, during the next care plan review, it was noted that the GP decided to stop administering insulin to Ms Y. District nurses would monitor Ms Y’s blood sugar levels once a day. The same regime was confirmed during a review a month later.
26. In the second week of April 2025 The Orders of St John Care Trust (the Care Provider) responded to Mrs X’s complaint, partially upholding it. It said it would:
• carry out a comprehensive review of Ms Y’s care plan to ensure her basic needs were met promptly and effectively;
• carry out discussions with the District Nurse team to enhance monitoring and support for residents with diabetes;
• review staff training to enhance their knowledge about diabetes.
27. Mrs X remained unhappy about her mother’s care in the Care Home. At the end of second week of April 2025, she said, her mother did not receive one of the medications she needed.
28. The Care Provider responded at stage two in mid-May 2025. It explained the member of the Care Home’s staff had missed giving Ms Y medication on one occasion as they wrongly understood this was prescribed for when required. This member of staff apologised to Mrs X, received sanction for the error and would be undertaking some re-training. The Care Provider did not accept the extent of failings suggested by Mrs X in her complaint. It emphasised how well Ms Y settled into the Care Home and that she was visited daily by district nurses who monitored her blood sugar levels with the GP’s oversight. The Care Provider offered to undertake a complete review of Ms Y’s care and offered Mrs X a specific member of the Care Home staff as a single point of contact.
29. At the very end of May 2025 Ms Y had another fall. She died a few days later in the Care Home.

Analysis

30. In the Care Home, which is residential rather than a nursing home, medical needs of its residents are primarily met by the District Nurses team who work with the doctor (the GP).
31. The Care Provider holds “Diabetes Care Management Requirements” which provides care homes’ staff with the standards of care and processes required to manage the treatment of residents’ type 1 and type 2 diabetes. It states that only registered nurses shall carry out blood glucose monitoring. The frequency of monitoring shall be documented in the resident’s Core Care Plan – Living with Diabetes. The document contains also required treatment for hypoglycaemia and hyperglycaemia.
32. Before offering a place to Ms Y, the Care Home carried out her pre-admission assessment. In this document Ms Y’s medical and care needs were described and the Care Home explained how it was proposing to meet them.
33. I found the Care Provider was transparent in the way it proposed to meet Ms Y’s care and medical needs. The Care Home:
• assessed Ms Y’s needs before offering her a place in the Care Home and explained what care she could expect;
• prepared for Ms Y an individual plan of managing her diabetes and followed it;
• district nurses visited Ms Y daily to monitor her blood sugar levels and consulted the GP with any concerns;
• Ms Y’s care plan was regularly reviewed;
• the GP had an oversight of Ms Y’s medical care and was amending Ms Y’s medication, when needed.
34. When Mrs X raised her concerns about the management of Ms Y’s diabetes, the Care Provider decided to take some actions listed in paragraph 26 of this decision. This is what we would expect.
35. On a few occasions the Care Home failed to provide the high standard of care to Ms Y. These incidents included:
• delay in getting a cream to prevent bed sores for Ms Y by a few days. Part of the delay was caused by the circumstances outside the Care Home’s control.
• on one occasion missing one of Ms Y’s medication.
36. Once aware of these incidents the Care Provider took action to remedy the situation, as pointed out in paragraph 28 of this decision. This is what we would expect as part of good governance.
37. Despite the individual incidents, overall the Care Home provided acceptable care to Ms Y. When things went wrong the Care Provider identified correct actions to prevent similar incidents.

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Decision

38. I find no fault.

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Investigator's decision on behalf of the Ombudsman