Summary: Mr X complains on behalf of his wife, Mrs Y, that Oldbury Grange Nursing Home failed to administer four of five prescribed medications, between 12 and 16 May 2025. Mr X also says the provider failed to administer a prescribed supplement between 4 and 5 June 2025. Mr X says this has caused Mrs Y to miss medication and has caused the family distress. We have found fault in the care providers actions for failing to ensure medication was available and for failing to advise Mr X when it was not. The care provider has agreed to complete a service improvement.

The complaint

1. Mr X complains on behalf of his wife, Mrs Y, that Oldbury Grange Nursing Home, Welford Healthcare MC Ltd (the care provider) failed to administer four of five prescribed medications. Resulting in Mrs Y missing a total of 13 consecutive doses of medication between 12 and 16 May 2025. Mr X also says the provider failed to administer a prescribed supplement between 4 and 5 June 2025.
2. Mr X says this has caused Mrs Y to miss medication and has caused the family distress.

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The Ombudsman’s role and powers

3. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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 normally name care homes and other care 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) 
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(1), as amended)
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC). 

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How I considered this complaint

9. I considered evidence provided by Mr X and the care provider as well as relevant law, policy and guidance.
10. Mr X and the care provider were invited to comment on my draft decision. I have considered any comments before making a final decision.

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What I found

11. 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.
12. Regulation 12 requires providers to take all reasonable steps to ensure the health, safety, and welfare of service users. This involves assessing risks, maintaining safe premises and equipment, safe medicine management, and proper infection control to prevent avoidable harm.

What happened

13. The care provider ordered the medication Mrs Y needed in April 2025 as part of a monthly order.
14. The care provider noticed Mrs Y did not have the medication she needed on 12 May 2025 when it came to administer it. The care provider contacted the GP to request this urgently. The care provider received Mrs Y’s medication two days later.
15. Mr X reviewed documentation detailing the care his wife, Mrs Y, was receiving from the care provider in June 2025. Mr X discovered that Mrs Y had missed medication between 12 and 16 May 2025.
16. Mr X raised a complaint with the care provider in late June 2025. Mr X said Mrs Y had missed 13 doses of medication between 12 and 16 May 2025 and missed a supplement between 4 and 5 June 2025.
17. The care provider logged and investigated the complaint the following day. The notes from the investigation concluded that the care provider did not administer certain medication on those dates. This was due to medication not being in stock. The investigation also noted it had not followed it’s procedure relating to this. The care provider made a referral to the CQC.
18. The care provider responded to Mr X’s complaint in early July and said medications were on a monthly prescription and it routinely requested medication three weeks in advance. On this occasion there were delays from the GP which resulted in the care provider not receiving medication. The care provider said once it established it had not received the medication an urgent request was sent to the GP. The care provider said the delay was not acceptable. It said it had put a process in place to ensure a nurse verified medication was in stock before it is needed. The care provider also said Mrs Y had expressed a preference for milkshakes rather than the supplement.

Analysis

19. I have seen the care provider ordered the medication Mrs Y needed in advance but it did not receive this. While I accept the care provider had ordered the medication, I cannot see that it checked it had received it. This is fault.
20. Once the care provider had established the medication was not available, I cannot see it informed Mr X of this. Mrs Y’s care plan says her family should be kept up to date and I cannot see the care provider did so in this instance. This is fault and has caused Mr X distress.
21. The care provider accepts the medication Mrs Y needed was not available. It has apologised to Mr X for this and apologised for the distress he was caused by not telling him at the time. This is a suitable remedy for the injustice caused to Mr X.
22. A doctor has confirmed that Mrs Y was not put at risk by missing the medication and the care provider made a referral to the CQC regarding the incident.
23. I can see the care provider has taken action to put updated procedures in place to ensure this does not happen again.

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Action

24. Within four weeks of a final decision, the care provider should:

• In writing, remind staff of the importance of keeping families up to date with relevant information in line with individuals care plans.

25. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

26. I find fault causing injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman