An independent provider in the East Staffordshire area

4. Mrs K complains about the care and treatment her father, Mr K, received from the NH between the end of June and the end of July 2024.

5. Mrs K complains the NH: • prescribed the incorrect dose of Parkinson’s Disease medication on four occasions • provided her father with food that did not comply with a level five or six Speech and Language Therapy (SALT) diet and left him unsupervised while eating • left her father in his chair without a sensor mat, and the alarm unplugged when he was at high risk of falls • had only one member of staff qualified to change her father’s catheter.

6. Parkinson’s is a progressive neurological condition. Its core symptoms include a tremor (shaking), rigidity (muscle stiffness), and slowness of movement.

7. A SALT diet is a guide to make eating and drinking safe for someone with swallowing difficulties. It changes the texture of food and the thickness of liquids, so they are easier to chew, control in the mouth, and swallow without choking

8. Mrs K says: • these errors caused his symptoms to worsen, leaving him very unwell with severe tremors, which in turn made him unable to take subsequent doses, further impacting his condition • her father did not receive adequate food intake and was put at risk of chocking • this led to a near miss, as he was found wondering around in his room unsupervised • her father experienced frequent blockages and infections, which caused him extreme pain and to become unwell and confused.

9. Mrs K is seeking an apology and service improvements.

10. Mr K was a very unwell gentleman with complex needs associated with advanced Parkinson’s Disease. Mr K moved into the NH at the end of June 2024 to receive care and support for his condition.

11. At the end of July, due to a deterioration in Mr K’s condition, he was admitted to hospital.

12. Mr K sadly passed away in mid-August at hospital.

Incorrectly prescribed medication

16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the NH has done enough to address the impact of these events.

17. Mrs K says the NH prescribed the incorrect dose of Parkinson’s Disease medication for her father, Mr K, on four occasions during his stay.

18. Mrs K says these errors caused a worsening of Mr K’s Parkinson’s symptoms, which left him very unwell with severe tremors. She says this, in turn, made him unable to take subsequent doses of medication, which further impacted his condition.

19.  Section 4.14 and 4.15 of the NMC’s Standards of proficiency for registered nursing says nurses must: • understand the principles of safe and effective administration of medication in line with local and national policies • demonstrate proficiency and accuracy when calculating dosages of prescribed medicines • recognise the effects of medications, identify potential issues (e.g., allergies, side effects, adverse reactions, or prescribing errors), and respond appropriately.

20. Section 5.5, 8.1, 8.5, and 8.6 of the NMC Code outlines nurses must: • share information with patients and families in a sensitive and understandable way • collaborate with colleagues to safeguard the safety of patients, refer matters when necessary, and share information to manage risks.

21. Regulation 20 of the CQC’s Duty of Candour requires organisations providing care to act openly and transparently with patients and their families when things go wrong.

22. Our Complaint Standards explain that organisations must acknowledge when things go wrong, explain what happened, apologise, take appropriate action to remedy any harm caused, and show what lessons have been learned to prevent similar mistakes.

23. The NH response acknowledged there were two transcription errors with Mr K’s Parkinson’s medication at the end of June, two days after his admission, rather than the four claimed. It said the errors were quickly identified, escalated to the Parkinson’s nurse and addressed the same day, as it gave Mr K additional timed doses to ensure he received his full daily medication.

24. The NH explained it logged the incident as part of its safeguarding process and informed both Mr K and Mrs K of the errors, explained what had happened, and apologised. Is said that Mr K was closely monitored during and after the incident. It said he showed no signs of deterioration or side effects, and his condition remained stable as he continued to receive his prescribed medication.

25. To prevent similar issues, the NH said it had reviewed and improved its medication processes and provided extra staff training.

26. From the records and safeguarding referral, we can see the NH identified and responded to two prescribing errors at the end of June. Mr K initially received a shortfall of medication during that day. This was quickly identified and rectified with additional timed doses.

27. The NH’s actions to identify, escalate and correct the error align with NMC’s Standards of Proficiency. This requires healthcare staff to ensure safe and effective medication administration, take prompt action to address and rectify prescribing errors, and implement risk management procedures to minimise harm.

28. The information shows the NH logged the incident appropriately and reported it via local safeguarding pathways. In compliance with Regulation 20 of the CQC Duty of Candour, the NH informed Mr K and Mrs K of the error, apologised, and outlined the steps being taken to prevent recurrence.

29. We reviewed Mr K’s care records and found no indication that he became very unwell or was unable to take subsequent doses of his medication. The records show that Mr K continued to take his medication as prescribed and consumed his meals after the incident.

30. The Extended Care Plan for Mr K also noted the progression of his Parkinson’s Disease prior to his admission to the NH. It stated he was experiencing ‘more bad days than good’ in terms of his mobility, which aligns with the natural progression of his condition.

31. Our clinical adviser reviewed the records and explained they could see two transcription errors had occurred. They explained as the NH had administered additional medication on the same day and closely monitoring Mr K, it ensured he received his full daily dosage and reduced any potential risks.

32. The advisor found no evidence of severe deterioration or side effects following the errors, as Mr K remained clinically stable in the days following the incident.

33. We understand how distressing this situation must have been for Mrs K, particularly as it involved her father’s health. We also understand her concerns about the potential impact of the errors and why this matter is so important to her.

34. Having read the NH’s responses and reviewed the information, our view is that while it appears the NH did initially make transcriptions errors, it quickly recognised and took prompt and appropriate action to address these, ensured Mr K received the correct dosage of medication, and reported the incident as required. It also took responsibility and informed both Mr K and Mrs K of the errors, and apologised.

35. The NH also outlined that it had learned from the incidents and had taken appropriate steps to improve medication administration processes to prevent similar mistakes in future. This included a review of its internal processes to prevent transcription errors, further staff training, and the reinforcement of existing procedures for addressing such errors promptly. These actions align with the standards set out by the NMC, CQC, and our Complaint Standards.

36. Considering this, we believe the NH has done enough to address the impact of the medication incident and put things right. As such, we will take no further action regarding this part of Mrs K’s complaint.

37. We hope our explanation gives Mrs K some reassurance that the NH has learned from the incident, taken steps to improve its processes, and taken her concerns seriously to prevent similar errors in the future.

Provided inappropriate food and left her father unsupervised

38. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have found no indications that something has gone wrong.

39. Mrs K says the NH provided her father, with food that did not comply with the level five or six SALT diet he required. She also says her father was left unsupervised while eating, which she believes led to insufficient food intake and placed him at risk of choking.

40. The Care Quality Commission (CQC) highlights that choking is a serious and potentially fatal risk that can often be avoided when appropriate care is in place. For people with dysphagia (swallowing difficulties), clear and detailed care plans must explain how food and drink should be prepared and how care staff should support the individual.

41. The Royal College of Physicians advises that nursing homes should ensure sufficient staff are available, particularly at mealtimes, to help individuals who need extra time or assistance to eat and drink safely.

42. Section 3.5 and 5.3 of the NMC Standards of proficiency for registered nurses explains nurses must: • assess and process all relevant information to create person-centred, evidence-based care plans tailored to an individual’s needs • assist individuals with eating and drinking, using appropriate aids to meet nutritional and hydration needs safely.

43. The NH response explained that Mr K was placed on a level six soft and bite-sized diet that was adapted to his Parkinson’s-related needs and dietary preferences. Meals such as lightly toasted brown bread (no crusts) with butter and jam were agreed upon with Mr K’s family and documented in his care plan. The NH explained that his care plan also included a food chart and specific guidance, which were shared with all staff responsible for his care.

44. The NH said it found no evidence that Mr K had been left unsupervised during meals in any way that placed him at risk of choking or aspiration. It said staff prepared and served his meals in line with his assessed dietary needs and provided appropriate supervision and support during mealtimes.

45. From Mr K’s care records, we can see that a detailed nutritional and hydration care plan was in place. This included information on Mr K’s dietary preferences (for example no seafood), a recommendation for a level six soft and bite-sized diet, the equipment needed to assist with safe eating and drinking, and instructions on correct positioning to reduce any risk of choking, which included supervision during meals.

46. Food charts and nursing records confirm staff monitored Mr K’s food and fluid intake regularly. The information also shows that staff encouraged and supported Mr K to eat and drink during mealtimes, as he was dependant on them for assistance.

47. Mr K’s dietary needs were also reviewed by SALT in late July 2024, who updated his diet to a level five minced and moist consistency and level one thickened fluids. These updates were implemented as part of his care plan.

48. Our adviser reviewed the available information and gave their view that the NH had an appropriate, person-centred nutritional care plan in place for Mr K, aligned with his assessed dietary requirements and preferences (for example, dislikes such as seafood). The care plan provided clear guidance to ensure Mr K received suitable food and fluids while minimising his choking risk.

49. Our adviser noted that Mr K’s food charts and care records suggest that staff adhered to the care plan by providing appropriate supervision and assistance during meals. They noted that there was no evidence to suggest Mr K was given food or drink inconsistent with his dietary requirements, or that he was left unsupervised during meals.

50. We recognise how concerned and upset Mrs K must have been to believe her father may have been placed at risk of choking and that his dietary needs may not have been met. Ensuring proper nutrition, hydration, and safety for individuals with dysphagia is critically important, and we understand why this matter is important to her.

51. The information shows the NH followed documented guidance to manage Mr K’s nutritional and hydration needs appropriately. The care plan, developed with input from SALT, outlined his dietary requirements, required level of supervision, and necessary support, all of which the NH implemented. Staff also monitored and recorded his food and fluid intake regularly, ensuring his needs were met.

52. There is no evidence to suggest Mr K was left unsupervised during meals, provided with unsuitable food or drink, or that his safety was compromised. The NH took reasonable measures to minimise his choking risk, in line with relevant standards, including the NMC's Standards of Proficiency for Registered Nurses and the CQC’s guidance on choking risks.

53. Based on the available evidence, our view is that the NH appropriately managed Mr K’s dietary needs and safety. We do not consider further action necessary regarding this aspect of Mrs K’s complaint.

54. We hope this explanation reassures Mrs K that her father’s dietary needs were well-managed by the NH and that measures in place ensured his safety.

Left at risk of falls

55. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have found no indications that something has gone wrong.

56. Mrs K says the NH left her father seated without a sensor mat and with the alarm unplugged, even though he was at high risk of falls. She says that he was found wondering in his room unsupervised, which she described as a near miss.

57. Mr K had advanced Parkinson’s disease, which significantly increased his mobility challenges and risk of falling. This is consistent with guidance in the Parkinson’s booklet.

58. NICE guidance on the interventions to reduce the risk of falls advises, people aged 50 to 64 with one or more risk factors of falls, as well as everyone aged 65 or over, should have personalised care plans that address their specific fall-related risks. Comprehensive falls management is essential to reduce the likelihood of falling.

59. The NH response explained that Mr K’s care plan required the use of sensor mats while he was seated or in bed. It said that these mats were always in place and regularly checked.

60. It explained it investigated Mrs K’s claim that the mat had been left unplugged, and the investigation did not find any evidence to confirm this. The NH explained that Mr K did not experience any falls during his stay. It further explained that staff conducted regular hourly checks, and that Mrs K spent long periods with her father during the day, which included times when these checks were conducted.

61. We can see from the information that Mr K had a detailed care plan in place that focused on managing his mobility and falls risk. The care plan was designed to address his individual needs and accounted for the varying nature of his condition. It acknowledged that he had ‘good days and bad days’ due to his advanced Parkinson’s and recommended daily assessments to ensure care was adapted to his needs.

62. The care plan also assessed Mr K as being at low risk of wandering. To ensure his safety, he had two hourly checks overnight. During the day, Mr K was initially placed on hourly observations, which were later increased to every 15 minutes when his needs required closer monitoring.

63. After reviewing the information our adviser gave their view that Mr K had a comprehensive care plan in place. Based on the information available, we see no evidence that Mr K’s sensor mat was left unplugged.

64. It appears the NH acted in accordance with reasonable standards of care and put appropriate measures in place to ensure Mr K’s safety. The measures put in place, such as regular monitoring, the use of sensor mats, and daily reassessments, were designed to reduce his risk of falls and address his specific needs arising from his advanced Parkinson’s.

65. We acknowledge the concern expressed by Mrs K regarding her father’s care. We have found no evidence to show that the NH unplugged the sensor mat or failed to manage his mobility and falls risks effectively. It is also important to note that there were no recorded falls during his time at the NH.

66. Our view is that the NH appropriately implemented a care plan tailored to Mr K’s needs, in line with NICE guidance and reasonable care standards. For this reason, we will take no further action on this complaint.

No qualified staff to change catheter

67. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have found no indications that something has gone wrong

68. Mrs K says the NH had only one member of staff qualified to change her father’s catheter. She says because of this Mr K experienced frequent catheter blockages and infections, which caused him significant pain, and to become unwell and confused.

69. NICE guidance on infection prevention for urinary catheters explains that a written protocol should be in place to ensure safe procedures are followed. This includes inserting, maintaining, and removing the catheter as soon as it is no longer necessary to minimise the risk of infection.

70. Section 6.2 and 6.3 of the NMC standards of proficiency for registered nurses requires nurses to: select and use appropriate continence products, insert, manage and remove catheters for all genders, support individuals with self-catheterisation if needed, and manage bladder drainage. These standards apply only to registered nurses.

71. Mr K had a long-term urinary catheter from the time of his admission to the NH. A urinary catheter is a flexible tube used to empty the bladder and collect urine in a drainage bag.

72. Our adviser explained that NH’s typically employ a skill mix of nursing staff, and not all are registered with the NMC. The catheter-related standards outlined by the NMC apply only to registered nurses, as these procedures require specific training and expertise. Catheter change and insertion is not considered an emergency intervention like Cardiopulmonary Resuscitation (an emergency procedure used when a person's heart stops beating or they stop breathing), which all staff must be competent and regularly trained in.

73. We can see that Mr K had a care plan in place which recognised he had a history of frequent urinary tract infections and constipation. The plan included guidance on how these risks should be managed.

74. The records show that Mr K’s catheter was changed by a nurse when it became blocked, after attempts to clear the blockage with a washout (used to clear blockages) had been attempted and were unsuccessful. From early July, the NH sought advice from its GP and the continence team on Mr K’s catheter care. Later that month, The NH also consulted with a specialist nurse to seek further advice.

75. Our adviser explained that Mr K’s care plan was appropriate for his individual needs and outlined suitable steps for managing risks related to his catheter and overall health. They said the NH delivered care in line with Mr K’s care plan and sought advice from healthcare professionals, such as his GP, the continence team, and a specialist nurse, when required.

76. Our adviser gave their view that it was reasonable for the NH to wait for a qualified nurse to undertake catheter changes or maintenance, as this avoids the risk of complications from untrained staff performing the procedure.

77. It appears the NH took all reasonable steps to manage Mr K’s catheter care and acted appropriately and in line with recognised guidance and standards. It adhered to NICE guidance on infection prevention and met the NMC standards for registered nurses regarding catheter care.

78. Mr K’s care plan addressed his health risks, such as urinary tract infections and constipation, and the NH followed it this plan correctly. Staff took reasonable steps to manage catheter care, including resolving blockages, consulting healthcare professionals when needed, and ensuring procedures were carried out by trained and competent staff.

79. We appreciate Mrs K’s concern about her father’s health, particularly the distress caused by his painful catheter blockages. We found no evidence to suggest that the NH’s actions caused any undue delays or fell below the expected standard of care.

80. Based on the evidence provided, our view is that the NH managed Mr K’s catheter care in a safe and proper manner and that procedures were carried out safely and appropriately by qualified staff, in line with guidance and professional standards.

81. We will take no further action on this complaint, and we wish Mrs K all the best for the future.

1. We have carefully considered Mrs K’s complaint about a Nursing Home in the Staffordshire area (the NH). We are sorry to hear about the distressing experience Mrs K and her father, Mr K, have been through, and we acknowledge the concerns she has raised regarding his care.

2. While we recognise Mrs K’s concerns about the care provided to her father, we have not identified any indications anything went seriously wrong in the way the NH managed his care. Where the NH did make mistakes, we can see it took appropriate steps to address the errors promptly and ensure Mr K’s safety.

3. We will explain our decision in detail below. We hope this will help Mrs K to understand our decision and give some reassurance about what happened.