Summary: Mrs X complained on behalf of her mother Mrs Y that the Care Provider failed to administer medication, maintain basic levels of hygiene, provide adequate general care given her visual impairment, and did not tell the truth when she raised concerns. We find the Care Provider at fault for failing to administer medication, maintain cleanliness and provide person-centred care which cause significant distress. It should apologise, reimburse some of the care fees and make service improvements to remedy the injustice.

The complaint

1. Mrs X complains on behalf of her mother Mrs Y about the care she received from Avery Homes (Nelson) Ltd when she stayed at Avalon Court Care Home between 16 May and 3 June 2025. In particular she complains the Care Provider failed to:
1. Administer prescribed medication.
2. Maintain basic levels of hygiene and infection control.
3. Provide adequate general care given Mrs Y’s visual impairment.
4. Properly respond to her concerns when it intentionally falsified records and made dishonest statements.
2. Mrs X said the Care Provider’s actions caused her mother and their family significant distress during her stay, and resulted in her requiring emergency medical treatment at a hospital.
3. Mrs X would like the Care Provider to put systems in place to prevent the same thing happening to anyone else, take disciplinary action against the staff involved, refund the care costs, and pay expenses associated with the hospitalisation.

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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 an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
5. 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.
6. 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)
7. When we find fault, we can recommend remedies for significant personal injustice, or to prevent future injustice, caused by that fault. We look at organisational fault, not individual professional competence. Decisions about individual’s fitness to practise or work are for the organisations concerned, and for professional regulators, not the Ombudsman. (Local Government Act 1974, s26(1) and s26A(1) as amended)
8. 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)
9. We normally expect someone to notify the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)

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How I considered this complaint

10. I considered evidence provided by Mrs X and the Care Provider as well as relevant law, policy and guidance.
11. Mrs X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
12. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Legal framework

Role of the CQC and the fundamental standards of care

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.
14. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards. The fundamental standards include:

• Person-centred care
• Safety
• Premises and equipment

What happened

15. This is a summary of key events. It is not a detailed chronology of everything that happened. I have included more detail where necessary in the analysis section.
16. Mrs Y is elderly and is registered blind. She moved from a nursing home into Avalon Court Care Home (the care home) in May 2025. The care home is operated by Avery Homes (Nelson) Ltd (the Care Provider).
17. The Care Provider carried out a pre-admission assessment of Mrs Y in early May before the move. It received information about Mrs Y’s medical history and prescribed medications from the nursing home the day before Mrs Y moved in. The medical history form included two inhalers, and a medicine in tablet form that should be taken once a day
18. When Mrs Y moved into the care home the staff started keeping records of the care provided to Mrs Y. These included medication administration record sheets also known as MARS.
19. On 21 May Mrs Y was registered with the GP surgery allocated to the care home.
20. On 24 May the care records showed Mrs Y’s family visited. It recorded the family raised concerns about Mrs Y’s room being untidy.
21. On 25 and 26 May the care records show Mrs Y’s family raised concerns she did not have her inhaler. A staff member checked her records and said no inhaler was part of her medications. The MARS shows there is no record of the inhalers.
22. Mrs Y stayed overnight with a family member on 27 May.
23. Mrs Y’s family said they saw poor standards of hygiene and cleanliness in Mrs Y’s room when they returned the following day. They took photos of the issues. They complained to the Care Provider by email. It replied and apologised. They had a meeting about the issues and Mrs Y’s family also raised concerns she did not have her inhalers.
24. Mrs Y’s family and the Care Provider wrote to one another following the meeting. The Care Provider said Mrs Y would be on the ward round the following week to see a doctor about organising an inhaler. The Care Provider completed a doctor ward list form that recorded “Wheezy chest Coughing Request inhaler”.
25. On 28 May Mrs Y’s family said they spoke to a member of staff about Mrs Y only having three tablets left of the medicine in tablet form she was supposed to take once a day.
26. The MARS shows the Care Provider ran out of that medicine from 1 June.
27. On 1 June the Care Provider sent an email to its allocated GP urgently requesting medication for Mrs Y. The request included the medicine it had run out of.
28. On 3 June Mrs X said Mrs Y told her family she had not had that medicine for more than a week. Mrs Y’s family emailed the Care Provider and asked if she had been receiving that medicine. The email also described concerns that Mrs Y was anxious about her wheezing.
29. Later in the evening on 3 June the care records show Mrs Y had shortness of breath and persistent coughing and requested her inhaler. Staff decided to contact 111. An operator did a telephone assessment and dispatched an ambulance.
30. Paramedics arrived, reported her heart rate was showing some variation, and decided to take her to hospital for further assessment and monitoring.
31. Mrs Y’s family decided she would not move back to the care home due to their previous concerns and her admission to hospital. They went to the care home on 4 June, asked to see Mrs Y’s medication records and to speak to a senior member of staff. They said a senior member of staff initially agreed to speak to them but then left without telling them.
32. Mrs Y’s family formally complained to the Care Provider in mid-June. They complained of failings in three areas: administration of prescribed medication, basic levels of hygiene and infection control, and general care of Mrs Y given her visual impairment.
33. The Care Provider responded to the complaint about a week later. It accepted some errors. It said it was conducting an internal investigation into aspects of Mrs Y’s admission process, acknowledged the distress caused by the hygiene issues identified on 18 May, and acknowledged some parts of the complaint about the care provided to Mrs Y. It did not agree with all of Mrs X’s complaint.
34. Mrs X was not satisfied with the Care Provider’s response or accuracy of its account of some of the events. She escalated the complaint and subsequently complained to us.

Analysis

35. The amount of information provided by Mrs X and the Care Provider was considerable. In this decision, I have not referred to every element of that information, but I have not ignored its significance.
36. As a publicly funded body we must be careful how we use our resources. We conduct proportionate investigations; completing them when we consider we have enough evidence to make a sound decision. This means we do not try to answer every single question a complainant may have about what the organisation did.
37. I have therefore concentrated my investigation on those claims of fault which have potential to have caused significant injustice.
38. I address each part of the complaint in turn below:

a) Administration of prescribed medication.

39. Mrs X complained about the Care Provider’s records of different medications. I have investigated two types of prescribed medication that she said were linked to Mrs Y’s admission to hospital. This is because I have decided they have the potential to have caused significant injustice. These are the inhalers for wheeziness, and a medicine in tablet form that should be taken once a day.
40. The medical summary document Mrs Y’s previous nursing home sent the Care Provider on 15 May showed she was prescribed the inhalers. It showed they had been issued recently.
41. Based on the records I find the Care Provider failed to record Mrs Y’s prescribed inhalers on its system. There is not enough evidence to find, even on the balance of probabilities, whether the actual inhalers were received by the care home. However, the Care Provider’s failure to record them meant it failed to identify their absence or know to order more. This was fault.
42. I therefore find the Care Provider failed to supply and administer the inhalers at any point during her stay including when she had difficulty breathing immediately before she was admitted to hospital. This was fault.
43. I also find the Care Provider ran out of tablets of the other medicine from 1 June. It therefore failed to administer this prescribed medicine for the first three days in June, including the day she was admitted to hospital. This was fault.
44. It is relevant the general NHS website says it is important that people do not stop taking that medicine suddenly, or without talking to their doctor first.
45. These failings occurred despite the Care Provider having the opportunity to request the medicines from 21 May. This is when Mrs Y was registered with the GP surgery allocated to the care home.
46. I find the Care Provider’s faults caused significant injustice to Mrs Y and Mrs X in the form of distress and uncertainty.
47. Mrs X said the Care Provider’s failure to administer the medicines caused Mrs Y’s hospitalisation. I have decided I cannot say, even on balance, that the failings are linked to Mrs Y being admitted to hospital. However, I find the distress arising from the uncertainty on this point caused an injustice to Mrs Y and Mrs X.
48. CQC guidance on the fundamental standard of care regarding safety says medicines must be supplied in sufficient quantities, and administered appropriately, to make sure people are safe. I find the Care Provider potentially breached this fundamental standard of care.

b) Levels of hygiene and infection control.

49. Based on the evidence I have seen I find, on the balance of probabilities, the Care Provider failed to meet acceptable standards of hygiene and cleanliness around 28 May when it left incontinence waste on the floor, urine in Mrs Y’s commode, dirty surfaces, and dirty glasses with stale drinks overnight. I also find, on balance, the commode was not appropriately cleaned or sterilised by the care home staff when the matter was highlighted to them. This was fault.
50. I find the Care Provider’s faults caused significant injustice to Mrs Y and Mrs X in the form of distress.
51. I have decided there is not enough evidence to find, even on balance, whether the same fault occurred at other times during Mrs Y’s stay at the care home.
52. CQC guidance on the fundamental standard of care regarding premises and equipment says premises must be kept clean and domestic and clinical waste must be managed in line with current legislation and guidance. I find the Care Provider potentially breached this fundamental standard of care.

c) Provision of adequate general care and care of a sensory deprived person.

53. Mrs Y has very low vision and is registered blind. Mrs X complained the care home staff failed to provide adequate standards of care given her visual impairment. Examples included:

• Staff did not announce themselves when they entered Mrs Y’s room which caused her to jump.
• Badges provided by the family that explained Mrs Y was visually impaired were removed and lost.
• Decaffeinated tea was not made easily available in line with her requests.
• Staff failed to provide an easily accessible hand towel despite agreeing to do so.
• She could not read the daily activities sheet and staff declined to tell her what the activities were. This meant she missed activities and felt left out.
• Staff did not stay with her when she took her medication and family members found tablets on the floor on two occasions despite raising concerns after the first occasion.

54. There is no documentary evidence regarding these matters. I have considered the weight of the evidence in Mrs X’s accounts of what happened. I have also considered the Care Provider’s complaint responses that refute some but not all of the accounts. I have decided, on the balance of probabilities, the examples provided by Mrs X happened as described.
55. Taking all aspects of this part of Mrs X’s complaint as a whole, I find the Care Provider at fault for not providing an adequate general standard of care for Mrs Y given her visual impairment. This caused injustice to Mrs Y in the form of distress and frustration.
56. CQC guidance on the fundamental standard of care regarding person-centred care says providers must do everything reasonably practicable to make sure that people who use the service receive care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be. I find the Care Provider potentially breached this fundamental standard of care.

d) Responses to concerns, intentional falsification of records and dishonest statements.

57. Mrs X said some of the Care Provider’s records were intentionally falsified. She also said some of the care staff’s statements, and the Care Provider’s complaint responses, were intentionally dishonest.
58. I have considered the records and statements. I note there are examples of inaccurate records and statements that are inconsistent with documentary evidence. These include records that Mrs Y had a visit with her family on 3 June when she did not, and a member of staff telling Mrs X only one day of medicine had been missed when it was actually three days.
59. CQC guidance on the fundamental standard of care regarding good governance says providers must securely maintain accurate, complete and detailed records. I find the Care Provider potentially breached this fundamental standard of care.
60. However, based on the evidence I have seen, I do not find intentional falsification or dishonesty. This is because I have decided the inaccurate records or statements could have been due to unintentional mistakes. For this reason I do not find the Care Provider at fault for this part of the complaint.

Injustice and recommended remedy

61. For the reasons explained above, I find the Care Provider’s actions caused injustice as follows:

• Deprived Mrs Y of access to prescribed inhalers.
• Mrs Y did not receive a prescribed daily medicine from 1 June.
• Poor levels of cleanliness and hygiene around 28 May.
• Inadequate general standard of care given Mrs Y’s visual impairment.

62. I have considered our guidance on remedies. I have decided the total injustice should be remedied by the Care Provider reimbursing Mrs Y’s care fees from 1 June onwards.
63. I have decided the injustice was significant enough to warrant the reimbursement of care fees for this period because it was when the Care Provider failed to administer her daily medicine, and includes the distress caused by its failure to administer her prescribed inhaler before she was taken to hospital.
64. I have also decided to recommend the Care Provider apologise, and make service improvements to prevent future injustice identified in part a) of the complaint from happening to others. This should be an organisation led improvement plan.

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Action

65. Within four weeks of the final decision the Care Provider should:
1. Apologise to Mrs Y and Mrs X for the injustice caused. 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.
2. Reimburse Mrs Y’s care fees charged for the period from 1 June onwards.
66. Within eight weeks the Care Provider should:
1. Conduct an organisation-led improvement plan to identify the issues that led to its failure to record the inhalers listed on the medical history document it received on 15 May, and running out of the medication from 1 June. The improvement plan should identify the issues that led to the fault, and put in place steps to prevent recurrence.
67. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

68. I have completed my investigation and uphold parts a). b) and c) of Mrs X’s complaint for the reasons in the analysis sections. I have made recommendations to remedy injustice the Care Provider has not yet agreed to carry out.

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Investigator's decision on behalf of the Ombudsman