The Local Government Ombudsman (LGO) has issued an Adverse Findings Notice against a Leamington Spa care home after it refused to improve its policies following an independent investigation.

A man complained to the LGO about a number of administrative aspects of his mother’s care while she was living at the Albemarle Rest Home in Kenilworth Road in the town.  He said a ‘Do Not Attempt Resuscitation’ (DNAR) order was not passed on when his mother was taken to hospital. He also complained the home did not have sound checking procedures to ensure she received certain medication, and had not notified him when she refused it. He was concerned that the hospital would not be aware of his mother’s expressed wishes about resuscitation if an emergency situation had occurred. He also lost the opportunity to discuss with his mother the implications of refusing to take certain medication. The man was otherwise happy with the general level of care his mother received.

Following the investigation, the LGO made a number of recommendations to improve the care home’s policies and procedures.  The care home has refused to comply with these recommendations.

Dr Jane Martin, Local Government Ombudsman, said:

“The recommendations I have made are pragmatic, sensible and proportionate, and will assist the care home in providing higher standards.

“I am disappointed that the care home has refused to improve its policies and procedures for the benefit of residents and staff.

“I now urge Albemarle Rest Home to rethink its position and agree to implement the procedural changes I have highlighted.”

The LGO recommended that the care home ensure it has DNAR decisions clearly recorded on people’s files, and that this form accompanies people when they transfer to another care service. If another agency refuses to take the form, a clear record should be made of this.

The home should also develop a clear procedure for monitoring the administration of medication and ordering repeat prescriptions. It should ensure checks are in place to reduce the risk of human error to a minimum and learning takes place when a mistake does occur.

The care home should also look at its complaint-handling process to ensure it takes a more objective approach to investigating complaints.

As Social Care Ombudsman, the LGO investigates complaints about all registered adult care services, regardless of whether that care is provided by a council or paid for privately. An Adverse Findings Notice is the final stage of an investigation into a privately-run care home and is issued where the provider has failed to comply with recommendations.   It is rare that such a step is required, with only two such notices issued across the whole of England in 2015-2016.

Details of the investigation have been passed on to health and care regulator, the Care Quality Commission (CQC).

Article date: 28 April 2016