Summary: Mrs X complained that Monarch Healthcare Limited failed to keep her mother, Mrs Y safe during her stay at Clifton Manor Residential Home in November 2021. The care home was not at fault for Mrs Y’s fall. However, the failure to return the unused milkshakes amounts to fault. This fault has caused an injustice for which the care home has agreed to apologise and reimburse Mrs X.

The complaint

1. The complainant, whom I shall refer to as Mrs X complained that Monarch Healthcare Limited failed to keep her mother, Mrs Y safe during her stay at Clifton Manor Residential Home in November 2021. In particular she complains Monarch Healthcare Limited:

• Failed to prevent Mrs Y from falling;
• Failed to properly manage Mrs Y’s medication; and
• Failed to assist Mrs Y to dress in her own new clothes, instead dressing her in someone else’s old clothes.

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The Ombudsman’s role and powers

2. 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 an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. 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

4. As part of the investigation, I have:
• considered the complaint and the documents provided by Mrs X;
• made enquiries of the Care Provider and considered the comments and documents the Care Provider provided;
• discussed the issues with Mrs X;
• 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

5. In November 2021 Mrs Y went to Clifton Manor Residential Home for six weeks respite care. Mrs X is unhappy that when they arrived at the care home they had to wait outside in the cold and could not enter until Mrs Y had taken a COVID test. Mrs X states that although the test did not work, Mrs Y was then allowed into the home. She states she stressed to the care home staff the need to ensure Mrs Y took her medication.
6. The documentation shows Mrs Y was unsettled during her first few days at the care home and was not sleeping. In the following days she was seen by a GP who advised the care home to monitor Mrs Y’s weight and fluid intake, and by a mental health nurse who reviewed Mrs Y’s medication and mood.
7. In the early hours of 30 November 2021 Mrs Y was admitted to hospital having had seizures and fallen out of a chair. The care home’s incident report states Mrs Y was unresponsive with her eyes open and would not answer or speak. Mrs Y then began to have a seizure which resulted in her falling forward and banging her head. A carer immediately called 999. The report states Mrs Y had a second seizure after the paramedics had arrived and was then taken to hospital.
8. Mrs X states a doctor at the hospital told her the seizures were due to a lack of her medication diazepam. She states Mrs Y’s forehead was swollen and black and blue, her nose was broken and both her eyes were black. Mrs Y also had cuts on her nose and face.
9. Mrs X made a safeguarding referral to the local authority. She questioned why the care home had allowed Mrs Y to fall for a second time; why the care home had not administered medication for her infection; and why Mrs Y was not dressed for bed and was wearing socks that did not belong to her.
10. This investigation concluded in December 2021 having found no causes of concern. It noted:
• Mrs Y fell out of her chair during the first seizure but did not fall during the second seizure.
• Symptoms of an infection became evident the morning of 29 November 2021 and a GP prescribed antibiotics that afternoon. The pharmacy did not deliver the medication that afternoon, this was likely to be due to it receiving the prescription later in the day.
• Care home staff assisted Mrs Y into a night shirt on the evening of 29 November 2021 but she was reluctant to take off her leggings. Mrs Y was wearing another resident’s socks due to an error by the laundry staff.
11. In January 2022 Mrs X made a formal complaint to the care home about the care Mrs Y had received. She again questioned why Mrs Y had been allowed to fall twice when a member of staff was with her, and why she was dressed in someone else’s old clothes. Mrs X stated Mrs Y moved to the care home with two sacks full of new clothes. The clothes had not been hung up but were still in the sacks in Mrs Y’s room. Mrs X also complained she taken Mrs Y 43 milkshakes but when she collected Mrs Y’s possessions the care home only returned a few and suggested Mrs Y had drank the rest.
12. Mrs X was unhappy the care home was administering Mrs Y’s medication on an as needed basis when Mrs Y would be unable to inform carers that she needed medication. She also asserted the care home had delayed in collecting Mrs Y’s medication for an infection.
13. The Care Home responded to Mrs X’s complaint in February 2022. It noted that the COVID-19 restrictions in place in November 2021 meant it could not allow anyone to wait in its reception area without a negative lateral flow test and the use of personal protective equipment. The care home had suggested Mrs Y wait in the car and it had previously advised Mrs X they would not be allowed into the main area of the home.
14. In relation to Mrs X’s medication, the care home noted the mental health team had prescribed Mrs Y diazepam medication before her admission to the home. It was prescribed as 2mg for agitation/ anxiety up to four times a day, as needed. The care home stated it administered diazepam on three occasions while Mrs Y was in its care. It stated it had a legal duty to administer medication as prescribed by the prescriber.
15. The care home also noted the mental health team reviewed Mrs Y’s medication twice whilst she was at the care home and diazepam was kept as a PRN (as needed) prescription.
16. The care home confirmed that Mrs Y had fallen from the chair to the floor on 30 November 2021 and there was no second fall. It stated Mrs Y was sitting in the lounge with a member of staff when she became unwell and began to have a seizure, falling forward onto the floor. The care home stated it could not have anticipated the fall and the staff member did begin to reach for Mrs Y but was unable to stop the fall.
17. In addition the care home stated it had frequently offered Mrs Y the milkshakes Mrs X had provided, but these were thrown away once open if Mrs Y did not drink them. It noted that whilst in its care Mrs X began eating small meals and snacks and had gained weight.
18. As Mrs Y had presented as confused, the care home had obtained a urine sample on 29 November 2021 and the GP had prescribed antibiotics. This prescription was sent to the home’s dedicated pharmacy for distribution.
19. In relation to Mrs X’s concerns about the clothes Mrs Y’s was wearing, the care home confirmed there were at that time three residents with the same initials as Mrs Y. The laundry team had placed another resident’s clothing in Mrs Y’s wardrobe. It apologised for this error and confirmed it had raised this with the laundry staff.
20. Mrs X was not satisfied with the care home’s response. She also raised concerns about the care home’s invoice of £2875 for Mrs Y’s care. The invoice specified a weekly rate of £875 which Mrs X disputed. She referred to correspondence showing the care home had agreed to charge the local authority rate of £578.50 per week for the six week respite period. This would increase to £875 for any additional weeks after the respite period.
21. The care home confirmed in March 2022 that it had invoiced Mrs Y at an incorrect rate and would issue an amended invoice. It apologised for any distress and inconvenience caused. Mrs X paid these fees in early June 2022.
22. In response to my enquiries the care home states Mrs Y’s clothing was hung up in her wardrobe and accessible to be worn. It states that due to a strict COVID-19 risk assessment in place during Mrs Y’s stay at the home family members made use of the visiting room and did not access residents’ bedrooms. The care home states that when Mrs Y’s family came to collect her belongings, staff placed Mrs Y’s clothing into bags to give back to her family. It states Mrs Y’s family emptied the bags in the car park and left some items they said did not belong to Mrs Y. The family then returned within a short period as they realised the clothes were Mrs Y’s.
23. The care home states that due to the confusion around Mrs Y’s clothing and the family’s actions, some of her milkshakes were left in the kitchen area and not returned to the family. It states it is happy to reimburse the cost of the milk shakes and apologise for this oversight.

Analysis

24. There is no evidence that Mrs Y fell twice on 30 November 2021. The documentation is clear that Mrs Y fell from a chair to the floor during the first seizure and that during the second seizure the paramedics placed her on the floor for her safety. Nor is there any evidence the care home staff could have prevented Mrs Y from falling out of the chair during the first seizure. The records suggest there was no warning prior to the seizure and Mrs Y fell too quickly for staff to prevent it.
25. Mrs X asserts the seizures were caused by the care home’s failure to administer diazepam regularly. She states Mrs Y had taken diazepam for around 55 years and it was dangerous for her to stop taking it. Unlike some of Mrs Y’s other medication which were prescribed to be taken daily, diazepam was prescribed to be taken as required. The care home’s records show it administered diazepam three times during Mrs Y’s stay, on 8, 10 and 28 November 2021 as Mrs Y was agitated and unsettled. We would expect the care home to administer all medications as prescribed and in the case of diazepam only as required.
26. It is unfortunate that Mrs Y did not receive her medication for the infection on 29 November 2021, but this was not due to fault by the care home. The care home has arrangements in place for with a pharmacy to deliver all prescriptions. Mrs X asserts Mrs Y could have had the medication sooner if the care home had used a different pharmacy closer to the care home. The arrangements for the delivery of prescriptions is a matter for the care home. There is no guarantee another pharmacy would have been able to deliver the medication sooner.
27. The care home has explained why Mrs Y was wearing another resident’s clothes on 30 November 2021 and has apologised for this. It has also addressed this with its laundry team to ensure all residents’ clothing is checked before being returned to their rooms. I consider this to be an appropriate response.
28. There are differing views on whether Mrs Y’s clothing was available for her to wear while at the care home. Mrs X complains Mrs Y’s new clothing was unworn and left in bags in her room throughout her stay. While the care home states her clothing was hung up in her wardrobe and then placed in bags to return to the family following Mrs Y’s admission to hospital. I am unable to resolve this issue by further investigation.
29. Mrs X is also unhappy the care home was unable to account for a number of the milkshakes she had taken to the home for Mrs Y. She states she delivered 43 milkshakes on 28 November 2021 and only half a dozen or so were returned following Mrs Y’s admission to hospital. Mrs X disputes Mrs Y could have drunk the rest over the course of one day. The care homes daily records show that Mrs X drank or was offered milkshakes during her stay at the care home, but it is unlikely she would have consumed over 35 milkshakes in just over 24 hours.
30. It is unclear why in response to Mrs X’s complaint the care home did not acknowledge that some milkshakes had not been returned due to the confusion and disagreement regarding Mrs Y’s clothing when her family were collecting her belongings.
31. The failure to account for the milkshakes is fault. The care home has confirmed it will apologise to Mrs X and reimburse her the cost of the milkshake.

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Agreed action

32. The care home has agreed to apologise to Mrs X for the failure to return the unused milkshakes and reimburse the cost of these milkshakes.
33. The care home should take this action within one month of the final decision on this complaint.

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Final decision

34. The care home was not at fault for Mrs Y’s fall. However, the failure to return the unused milkshakes amounts to fault. This fault has caused an injustice for which the care home should apologise and reimburse Mrs X.

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Investigator's decision on behalf of the Ombudsman