Summary: Mrs W complains on behalf of her late father, Mr Y, about the standard of care and support he received whilst at Oakham Grange Residential Care Home. In particular, she says the home did not appropriately manage and administer Mr Y’s medication. The local safeguarding authority investigated the concerns and concluded with a finding of neglect and organisational abuse. It made a number of recommendations for service improvements. The care provider has agreed to apologise to Mrs W and make a symbolic payment in recognition of the uncertainty and distress caused by the failures.

The complaint

1. Mrs W complains about the care and support given to her father, Mr Y, whilst resident in Oakham Grange, which I will call ‘the home’. She says the home failed in its duty of care and was responsible for significant medication errors which placed Mr Y at risk of serious harm.
2. Mrs W also complains about the way the care home dealt with and responded to her complaints.

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The Ombudsman’s role and powers

3. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by their personal representative (if they have one), or someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
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) If an adult social care provider’s actions have caused 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)

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How I considered this complaint

6. During my investigation I discussed the complaint with Mrs W and considered the information she provided. This included complaint correspondence, the findings of the care home’s investigation and the safeguarding papers. Mrs W also provided some of the contemporaneous records such as Mr Y’s Medication Administration Record (MAR) showing the missed doses of medication.
7. Mrs W and the care provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Fundamental Standards of Care

9. 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. 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.
10. Regulation 12 sets out the requirement for care providers to deliver safe care and treatment. It says that medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe. Those administering medication must be suitably trained and competent and kept subject to review.
11. Regulation 16 sets out how care providers should deal with complaints about their service. It says providers must have effective systems to make sure that all complaints are investigated without delay. This includes:
• Undertaking a review to establish the level of investigation and immediate action required, including referral to appropriate authorities for investigation. This may include professional regulators or local authority safeguarding teams.
• Making sure appropriate investigations are carried out to identify what might have caused the complaint and the actions required to prevent similar complaints.
• When the complainant has identified themselves, investigating and responding to them and where relevant their family and carers without delay.

Summary of key events leading to the complaint

12. This section of the decision statement does not list every event which happened during the period complained about. Instead, it provides an overall summary of the key issues relevant to the complaint.
13. Mr Y and his wife, Mrs Y, moved to Oakham Grange (‘the home’) on 8 November 2022 as a short-term respite resident. One month later Mrs W complained to the home about several concerns which I will summarise below.
• On 12 November staff tried to give Mr Y his lunchtime medication twice. Mr Y noticed and declined the second dose.
• Mr Y told Mrs W On 6 December that care staff brought him five tablets the previous night, instead of four. Mr Y said he believed he received a double dose.
• Mrs W said Mr Y’s stoma bag is not routinely emptied and cleaned each morning.
14. On 18 January 2023 the care provider made a safeguarding referral. This said that Mr Y had missed doses of the medication used to treat the effects of Parkinson’s Disease. I will call this ‘Medication 1’.
15. The care provider said the error happened when Mr Y’s dosage increased from two to three a day. Although the change had been communicated to staff during handover and on the electronic system, an entry was mistakenly put onto the system to say the medication was ‘not required’.
16. The care provider issued a written response to Mrs W on 18 January.
• An incident in December which caused Mr Y distress was dealt with and the agency carers involved were advised not to return to the care home. Since then, the home has recruited more staff.
• Sometimes staff administer medication later than planned, but the time is not left uncorrected in the records. Staff scan the barcode on the resident’s medication and if they are trying to give medication without the correct time gap, the system will alarm.
• If the resident is new to the home, the barcodes may not be present, so it is the responsibility of the staff members to ensure they input the correct information on the device before administering the medication.
• In this case, the member of staff was removed from the position of team leader and is now a support worker.
• Emptying Mr Y’s stoma is a task is documented as being carried out every morning and as part of personal care.
• The care provider does not excuse the issues Mr Y has experienced and hopes to maintain a positive relationship with Mrs W.
17. Mrs W reviewed Mr Y’s MAR chart and identified significant medication errors and submitted her concerns in writing. On 6 February the home responded to say another tablet, ‘Medication 2’, “was initially stopped by ourselves as the label said for only 1 month and I am investigating the reason why the GP was not contacted at that point”.
18. On 7 February the care provider issued notice for Mr Y to end his respite placement and leave on 28 February. The letter said, “it would not be in the best interests of you as a family or us as care providers to allow this respite care contract to continue”. The letter went on to provide five reasons for the notice, one being that “we believe we have fallen short of delivering the care and support you expect”.
19. The care provider emailed Mr Y and Mrs W on 13 February in response to the concerns raised. In summary, the email said the following.
• The pharmacy was the root cause of some of the medication problems and because of this the home will be changing pharmacies.
• The complaint about missed doses of Medication 2 was investigated. This concluded that staff had followed instructions on the box “…which states take for one month and then stop”. Once aware that it needed to continue, the home spoke with the GP and obtained the medication the same day.
• Mr Y missed a single dose of Medication 1 on 24 December. The pharmacy changed the dosage instructions, but Mr Y noticed the error as he had capacity around health matters. The home has put measures in place to prevent future occurrences.
• There has been a variation in the dose of another medication given to Mr Y (for Calcium and Vitamin D3) due to a change in the dosage instructions made by the pharmacy. Mr Y noticed the error as he had capacity around health matters. The home has put measures in place to prevent future occurrences.
20. The care provider identified further medication errors on 18 February. Mr Y had not received Medication 1 since 14 February and therefore missed four days’ worth of tablets. The home said the error occurred due to confusing instructions on the pharmacy label which said to be administered “as required”.
21. On 22 February the Council met to discuss the safeguarding referral and decided to progress to enquiries. The issues were summarised as follows.
• Mr Y missed several doses of Medication 1 in February. The missed doses could result in the worsening of his symptoms. The care home consulted the GP who said, in their professional opinion, Mr Y was not harmed by the error.
• Mr Y missed Medication 1 for two days in December and January.
• The family reported that Mr Y missed doses of Medication 2 for 39 days.
• There is a lack of consistency with the administration of the Calcium and Vitamin D3 medication. This medication should not be given on Sundays. But on some Sundays, Mr Y received two doses, other weeks one dose and sometimes he received none.
• Previous attempts in January to improve the medication booking system were not sufficient because the errors continued throughout February.
22. The record of the meeting confirms, “a notification has now been submitted (28/02/23) with regards to [Mr Y’s Medication 2]”.
23. Mr Y moved to a different care home on 28 February. He was there for almost one month before he sadly died.
24. The Council held a safeguarding meeting on 25 April. During that meeting the Council considered comments from the GP, summarised as follows.
• The GP re-started Mr Y’s Medication 2 following the decision to “mistakenly” stop it by the home. The GP agreed to monitor Mr Y’s blood pressure. Five days after the appointment the specialist Parkinson’s team were contacted about Mr Y’s declining mobility.
• The GP could not comment on any potential effects from missed Medication 1 but said, “if there was any effect one would support that it would be a worsening of Parkinson’s symptoms”.
• The GP would not expect missed doses of the Calcium and Vitamin D3 to be detrimental to Mr Y’s health.
25. Following an inspection in April 2023, CQC gave an overall rating of ‘Inadequate’ and placed the home into ‘special measures’. Following a re-inspection in July 2023, CQC found the home had made some improvements which prompted a change in the overall rating to ‘Requires Improvement’.
26. Mrs W asked the home to undertake a second complaints investigation. The care provider declined due to the ongoing safeguarding enquiries. Mrs W raised her concerns with the Council, and it said:

“Whilst it may be the case that Oakham Grange acknowledge that the Formal Safeguarding Enquiry is a way of resolving a complaint or part of a complaint, it should not prevent Oakham Grange from logging your complaint and/or following up on actions regarding your complaint alongside or independent of the enquiry. They should log all requests for a complaint formally so that there is an audit trail”.

27. The care provider reviewed its position in September and accepted that the medication issues raised by Mrs W were dealt with as an enquiry, rather than a complaint. On 29 September the provider said, “we can only acknowledge that the general manager to whom the complaints were made failed to follow our complaint procedure”.
28. Following this, the care home agreed to review all correspondence and prepare a report with its responses for the complaints made. The provider issued a report on 12 December, the contents of which I will summarise below.
• At the time of the medication errors, the home’s electronic care planning systems were the subject of “national cybercrime”. This resulted in a sudden ending of the home’s care record system. Staff had to create and manage paper records for a period, which they had not received training for.
• Mr Y did not always receive the expected level of service. The provider failed to consistently apply its duty of care.
• There were care failings in medication administration and record keeping.
• The care provider did not always follow and implement its complaints policy in a timely way and investigations into some of the concerns were not always completed in a timely way.
• There is no evidence to show the home breached duty of candor.
• The home should internally investigate complaints in cases where no safeguarding enquiries have been confirmed.
• The care provider has learned lessons and made significant changes to management, administration and the delivery of care at the home.
• The care provider sincerely apologies for failing to consistently care for Mr Y in a way that was expected or appropriate. The team also apologises for the failure to consistently manage appropriate care records.
29. Mrs W expressed her dissatisfaction with the report because she said it did not deal with the specific complaints raised and contained factual inaccuracies. Mrs W asked the care provider to re-investigate, but it refused.
30. On 11 January 2024 the Council held a safeguarding case conference in relation to the referrals made about Mr Y’s medication. This concluded as follows:

“On the balance of probabilities, with the information gathered during the course of this enquiry, the allegation of neglect/act of omission and organisational abuse has been substantiated. The care home failed to ensure that [Mr Y] consistently received safe clinical care in line with his needs. The home’s failure to ensure medicines were managed/administered safely placed [Mr Y] at increased risk of harm. Following a number of issues in this area the home have taken the decision to only use qualified nurses to book in and manage medications. They have also employed three service managers, one for each unit to provide greater clinical oversight and direction. Where required, internal investigations, supervisions and retraining of staff have also been completed”.

31. The Council made several recommendations for the care provider’s management.
• Medication to be booked in by appropriately qualified staff in a timely way.
• Staff to seek prescriptions in a timely way to allow for dispensing.
• Address any prescription or medication issues in a timely way.
• Notify the pharmacy in a timely way of any concerns or issues.
• Ensure appropriate and timely monitoring is in place to respond to errors.
• Notify the software company of any issues with the electronic system to ensure they are resolved in a timely way.
• Staff to receive appropriate training for the clinical areas they work within.
• Internal processes (such a HR, disciplinary and re-training) to be identified and completed in a timely way to address risk.
• Ensure robust care planning for residents’ changing needs. Review and amend these accordingly.
• Care plans and risk assessments to be shared with all staff at the care home. Ensure they are followed and implemented and any breaches to be recorded and appropriate action taken.
• Undertake thorough handovers to ensure staff can fulfil their roles in a safe and timely way. Handover books to be used for recording salient issues.
• Deliver staff training for the electronic systems.
• Management of supervision and clinical supervision for the nursing team to continue at regular intervals with appropriate recording.
• Ensure that residents and/or family receive information about any incidents, including medication errors, in a timely way.
32. The care provider says it has implemented the above recommendations.

Was there fault causing injustice in the care provider’s actions?

33. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment.
34. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.
35. A decision about what a suitable remedy should be for a complaint is one for us to decide. Each case is considered on its own merits. Our Guidance on Remedies sets out the general principles that investigators should apply when deciding what recommendations to make.
36. In our view, and based on the evidence we have seen, we find fault with the care provider. As there has been a thorough safeguarding investigation of the issues complained about, it has not been necessary for us to review the contemporaneous records because the concerns have already been substantiated. We therefore find fault for the following reasons.
• The home made significant errors with three types of Mr Y’s medications. Some of those errors were over a prolonged period of 39 days and were not an isolated incident. The risk caused by this error has been acknowledged by the local safeguarding authority who recorded a finding of neglect, acts of omission and organisational abuse.
• The home initially blamed the pharmacy for a labelling error. The safeguarding investigation concluded “there is nothing on the script [prescription] to confirm either ‘one month’ or ‘one month and stop’ as asserted by Oakham Grange in their reports/responses later to family on this matter”.
• When the initial confusion arose amongst staff at the home, the care provider did not seek clarity from any family members, the pharmacist or medical professionals about the dosage instructions. To the contrary, the care provider only identified the true extent of the Medication 2 error after Mrs W reviewed the MAR charts and submitted her comments.
• The care provider failed to consider and respond to Mrs W’s complaint in accordance with its complaints policy. Some of the complaints raised by Mrs W were wrongly logged by the manager as enquiries. Furthermore, it failed to investigate whether staff were appropriately cleaning Mr Y’s stoma bag each morning. The complaint response also omitted Mrs W’s complaint about a statement made by the home that Mr Y insisted that Mrs Y was hoisted to a bed rather than a chair.
37. The fault identified caused Mr Y significant injustice. Although we cannot make causal links about the effects of any missed medication, the GP did note there may have been a worsening of Mr Y’s symptoms. With that said, the records do not show that Mr Y was the subject of any medical examinations at the time to check whether the medication errors had contributed to his decline.
38. 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. In our view, we cannot say – on the balance of probabilities – that Mr Y’s declining health was solely and directly caused by the missed medication. We do however accept that the uncertainty from this has been a significant cause of avoidable distress for Mrs W which the care provider has agreed to acknowledge with an apology and a symbolic payment.
39. We have also considered whether to recommend any service improvements for this case. The Council has already made wide-ranging recommendations to ensure the improvement of the care delivery, especially around the administration of medication. These recommendations are thorough and proportionate to the fault and so it would not be appropriate for the Ombudsman to recommend any further improvements. However, we will seek evidence that those improvements have been implemented.

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Agreed action

40. Within four weeks of our final decision, the care provider has agreed to:
• Issue an apology letter to Mrs W for the medication errors and the effect on Mr Y. 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.
• Make a symbolic payment of £700 to Mrs W. This is in recognition of the avoidable distress and uncertainty caused by the care provider’s actions. This is in accordance with the range suggested in the Ombudsman’s Guidance on Remedies
• I have not recommended any service improvements for the reasons explained in paragraph 39 of this statement. However, the care provider will provide evidence to the Ombudsman to show the recommendations made during the safeguarding investigation have been implemented or are in the process of being implemented.

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Final decision

41. I have completed my investigation with a finding of fault causing injustice for the reasons explained in this statement. The actions listed in the section above will provide an appropriate remedy for the injustice caused by fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman