Summary: There was fault in the Home’s administration of medication and its communication. The Home has agreed to apologise and pay a symbolic sum to reflect the distress its actions caused.

The complaint

1. Ms B complains on behalf of her father, Mr C, who does not have the mental capacity to make the complaint. The complaint relates to Darwin Court care home in Lichfield.
2. She says there was poor communication between the Home and the family and professionals and there were repeated errors in the administration of medication.

Back to top

The Ombudsman’s role and powers

3. 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. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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)

Back to top

How I considered this complaint

6. I have discussed the complaint with Ms B and I have considered the evidence that she and the Home have provided and the relevant law, guidance and policies. I have also considered the council’s safeguarding enquiry.

Back to top

What I found

Law, guidance and policies

Care Quality Commission

7. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, breaches of fundamental care standards and prosecute offences.
8. 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.
9. The standards include:
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).

Background

10. Mr C moved into the Home in August 2021. He has a diagnosis of Alzheimer’s disease.
11. Mr C’s care plan said Mr C was unable to take his medications so all medications should be administered to him. The plan said the family wanted to be involved with the care planning and wanted the Home to discuss any changes in the care plan with them.

Complaint – February 2022

12. Ms B made a formal complaint to the Home on 20 February 2022. Ms B said:
• The family had not been able to see Mr C or communicate with him and had raised concerns about his care. To remedy this, the Home agreed on 25 November 2021 that it would provide fortnightly video calls with the family to update them on Mr C’s progress, but the Home failed to organise the calls.
• The Home had also agreed to update Mrs C with brief conversations with staff when she visited but failed to do so. This did not happen and instead Mrs C was met with hostile language from administrative staff.
• The family found out on 20 February 2022 that there were changes in Mr C’s behaviour on 18 January 2022 which led to a change in his medication. The family was not informed of this.
• Mr C had a seizure on 18 February 2022, but the Home failed to inform the family.
13. The Home said:
• The Home upheld the complaint that it failed to provide the video calls. It said that this was due to the staff who had been informed of this request being off sick or moved to another part of the Home.
• It upheld the complaint that the Home failed to inform the family of the seizure at the time it happened, but said this was the fault of agency staff. It had reminded staff of the importance of keeping residents’ families informed.
• The Home said that medication to prevent blood clots (medication 1) had been stopped but this happened later, after the seizure. The Home apologised for the miscommunication as this may have led to the family believing that the change in medication 1 led to the seizure which was not the case.

Complaint – March 2022

14. Ms B said:
• The Home had not informed her that medication 1 the family had been stopped. The GP informed her of this. She had also been informed that the medication had been stopped because the Home had not requested the required blood tests to renew the prescription.
15. The Home said:
• The GP practice called that week (second week of March 2022) to enquire about the blood tests. The Home told the GP practice that Mr C had heightened anxiety so it would not have been possible to take his blood. The Home asked the GP practice to send a phlebotomist from their surgery to see whether they would be successful.

Safeguarding enquiry – March 2022

16. Ms B raised a safeguarding concern about her complaint to the council in February 2022.
17. The council’s enquiry obtained further information regarding the medication.
18. The Home told the social worker that the family was informed (incorrectly) that medication 1 was stopped in January 2022 and therefore the family may have thought that this contributed to the seizure on 18 February 2022. However, the Home said medication 1 was stopped on 23 February 2022 because the pharmacy’s stocks were low. The pharmacy received further stock on 25 February 2022 and the medication was restarted. Mr C should have received two doses of medication 1 per day so Mr C missed five doses of medication 1 in total.
19. The social worker informed the GP of what the Home had told her about the medication. The GP said there had been no change in the prescription of medication 1. But yearly blood tests were needed to determine the dosage of the drug. The GP asked the Home to carry out the blood tests in October 2021 and January 2022 but the Home failed to do so. This led to the drug prescription being stopped on 15 February 2022 but it was restarted on 23 February 2022.
20. This should not have meant that Mr C was out of medication as he was issued enough medication 1 on 17 January 2022 to last until 23 February 2022. However, the pharmacy had run out of medication 1 on 23 February 2022. The GP said the Home could have notified the GP practice that it did not receive medication 1 on 23 February 2022 or it could have requested that the prescription was issued to a different pharmacy, but did not do this.
21. The GP said there was a meeting on 14 March 2022 where it was suggested that the GP practice ask an advanced nurse practitioner to administer the blood test and the GP practice made that request. The nurse visited Mr C on 18 March 2022 to administer the blood test.
22. The council said the safeguarding concern had been substantiated.
23. The council made the following recommendations and said the Home should:
• Update the care plan regularly.
• Improve communication with the family and relevant professionals.
• Provide further staff training on record keeping and communication with family and professionals.
• Ensure the GP was informed if the Home was unable to obtain blood samples.

Complaint – May 2022

24. Ms B said: (I have not repeated the complaints which were addressed in the previous complaint correspondence):
• In November 2021 she and her brother found a pill on Mr C’s bed.
• On 26 April 2022 the Home failed to order and administer Mr C’s medication for 5 days.
• The Home always seemed to blame someone else for its failures in its previous complaint correspondence and did not seem to accept responsibility.
• Mr C ate the cutlery free dining option but had been observed to be given low quality food.
25. The Home said:
• In response to the tablet that was found on Mr C’s bed, the Home said it was unable to establish who administered the tablet or when it happened. The Home had recirculated its medication policy to staff to reinforce the process.
• In April 2022, Mr C was not given medication 1 and medication 2 (for bone health) for four days and medication 3 (antipsychotic drug) for three days. That was the fault of agency staff not ordering the medication.
• It apologised for the quality of the cutlery free option that was served on the day Ms B attended.
26. The Home had made improvements to ensure the errors of medication did not occur again:
• Any time the pharmacy sent sheets over to query missing medication, these sheets would be dealt with by the Home’s manager and deputy manager to oversee the matter.
• The pharmacy would contact the Home if a sheet was not returned within 24 hours.
• The agencies would discuss the issues raised with their staff and confirm to the Home’s management that they had done so.
• Supervision would be given to staff who manage medication at the Home regarding ordering and following up missing items and the standards they were expected to adhere to.
27. The Home had made the following improvements to the food options:
• A new Head Chef was in post and he was proposing changes to the menu. He was willing to meet with Ms B to discuss Mr C’s likes and dislikes and the options available to him.
• Head Of Culinary had been asked to attend to oversee the menu.

Analysis

Medication

28. There were faults in the administration and renewal of the prescription of the medication. The faults were:
• A tablet was found in Mr C’s bed in November 2021. The Home explained that this was a one-off incident and the cause of this is unknown.
• Mr C was not given medication 1 from 23 February 20 to 25 February 2022. This was caused by the pharmacy being out of stock. However, the Home could have obtained the medication from another pharmacy or could have alerted the GP but did not do so.
• The GP practice asked the Home to administer a blood test in October 2021 and January 2022 to enable the GP practice to renew the prescription of medication 1. The Home failed to do this. The Home said it could not administer the blood test because of Mr C’s anxiety. The failure to administer the blood test was not fault in itself, but the Home did not take any further action, for example let the GP practice know that it could not administer the blood test and that it needed assistance. The failure to escalate the matter was fault.
• The Home failed to administer three different medications in April 2022 because it had failed to order the medications.

Communication / care

29. There was also fault in the Home’s communications.
30. The Home agreed to improve its communication with the family on 25 November 2021 and said it would set up calls on a fortnightly basis but then failed to do so. This was fault. There were also times when the Home did not update Mrs C as agreed.
31. This occurred during the COVID-19 pandemic and the Home had to restrict visits because of outbreaks of COVID. I appreciate that this meant that the staff at the Home would be under additional pressures. However, it also meant that Mr C’s family were not able to visit him. They were concerned about Mr C and wanted to be involved with his care planning. Therefore it was even more important that the Home adhered to its plan to have fortnightly meetings with the family.
32. The Home also failed to inform the family that Mr C had a seizure on 18 February 2022.
33. I also note that, although the Home upheld most of the complaints in the correspondence, it then also seemed to distance itself from the issues by referring to staff absences or agency staff’s failings. This meant that Mr C’s family felt that the Home was not accepting responsibility for the issues. Mr C’s family expected the best care for Mr C. If there were failures, then the Home was ultimately responsible. The Home should have made that clearer in its complaints correspondence.
34. The Home has upheld the complaint about the quality of the cutlery free option observed by Ms B.

Injustice

35. I have considered the injustice suffered by Mr C. Medication 1 lowered the risk of blood clots and medication 3 was an anti-psychotic medication so the failure to administer the medications meant Mr C was at greater risk of these conditions. However, there is no evidence Mr C suffered any actual medical harm.
36. Ms B and Mr C’s other family members suffered an injustice as they were not kept informed about Mr C’s progress and care plan. They were concerned about the repeated failures in the medication and the risks this posed to Mr C. They felt that, even though they raised the issues over time, nothing was done to change things.
37. I recommend the Home should apologise to Ms B, acknowledging the fault. In cases such as this one, where no direct financial loss has occurred, we can recommend a small symbolic payment to acknowledge the distress they have been put through. This is normally a moderate sum between £100 to £300.

Back to top

Agreed action

38. The council and the Home have already made relevant recommendations of service improvements as a result of the upheld complaints. I therefore do not recommend any further service improvements.
39. The CQC is the regulator of care home and is well placed to address any service improvements. Under our information sharing agreement, we will share this decision with the Care Quality Commission.
40. The Home has agreed the following actions within one month of the final decision. The Home will:
• Write to Ms B to apologise and to acknowledge the fault.
• Pay Ms B £200 as a symbolic amount for the distress caused by the distress.
41. The Home should provide us with evidence that it has complied with the above actions.

Back to top

Final decision

42. I have completed my investigation and have found that the Home’s actions have caused an injustice. The Home has agreed the remedy to address the injustice.

Back to top

Investigator's decision on behalf of the Ombudsman