Summary: Mrs Y complained, on behalf of her late mother, Mrs X, that Woodlands House Care and Nursing did not properly manage Mrs X’s move to the home’s nursing unit, did not follow Mrs X’s care plan in terms of medication and nutrition, and did not identify symptoms of an infection. We found no fault with the Nursing Home’s actions.

The complaint

1. Mrs Y complains about the care provided to her late mother, Mrs X, by Woodlands House Care and Nursing (the Nursing Home). Mrs X’s care was funded partly by London Borough of Merton (the Council) and partly by NHS Funded Nursing Care.
2. Specifically, Mrs Y complains:

• the Nursing Home did not properly manage Mrs X’s move within the home, from its residential unit to its nursing unit. Mrs Y says this should have been done gradually, but this did not happen;
• following the move to the nursing unit, there was a lack of communication within the Nursing Home between nursing staff and care staff who had previously cared for Mrs X and knew her well, which would have helped identify any concerns;
• the Nursing Home did not follow Mrs X’s care plan while she was in the nursing unit, and did not review or update the plan. Mrs Y said this included not administering Mrs X’s medication in line with the care plan, and a lack of personal care and support with eating and drinking; and
• the Nursing Home did not recognise Mrs X’s symptoms and changed behaviour while in the nursing unit were a result of a urinary tract infection (UTI).

3. Mrs Y said the sudden move to the nursing unit caused Mrs X confusion and fear. Mrs Y queries whether Mrs X developed a UTI because she did not get the care she should have had, and that her health then deteriorated. Mrs Y also said this caused her great distress.
4. As an outcome of her complaint, Mrs Y wants the Nursing Home to improve its services so this does not happen to anyone else. She would like the Nursing Home to improve communication, listen to residents’ families, improve liaison between nursing staff and care staff at the home, and provide training in identifying UTIs in residents who cannot communicate.

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The Ombudsmen’s role and powers

5. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
6. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
7. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
8. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

9. I considered evidence provided by Mrs Y and the Nursing Home, as well as relevant law, policy, guidance and clinical advice.
10. Mrs Y, the Nursing Home, and the Council 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

NHS Funded Nursing Care

11. Mrs Y’s complaint includes elements of social care the Council is responsible for as commissioner. It also includes elements of nursing care which fall under the jurisdiction of the Health Service Ombudsman. Following the approach of the Health Service Ombudsman, we consider Woodlands Care and Nursing as provider of the nursing care to be the responsible organisation for the nursing elements of Mrs X’s care.
12. I am also investigating the Council as commissioner of Mrs X’s social care at Woodlands House.

Nursing and Midwifery Council guidance

13. The Nursing and Midwifery Council (NMC) guidance, The Future Nurse: Standards of Proficiency for Registered Nurses (2018), is relevant to the nursing issues raised in Mrs Y’s complaint.

Fundamental Standards of Care

14. 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.

Background

15. Mrs X had a diagnosis of dementia. She had been living at home, but after a fall, she moved to the Nursing Home, where she lived on the residential unit for several years.
16. In March 2024, it was felt that Mrs X’s needs had changed, and she had an assessment to decide whether she was eligible for NHS Continuing Healthcare (CHC). The assessment found Mrs X’s needs did not meet eligibility for CHC. However, Mrs X’s needs met the criteria for an NHS Funded Nursing Care (FNC) contribution. The following month, Mrs X moved from the residential unit of the Nursing Home to the nursing unit.
17. A month after moving to the nursing unit, Mrs X was admitted to hospital with an infection. Sadly, Mrs X died following a urinary tract infection (UTI), which Mrs Y explained developed into sepsis.
18. Mrs Y complained to the Nursing Home, raising concerns that Mrs X’s move to the nursing unit had not taken place gradually, as it should have done, that the Nursing Home failed to act on Mrs X’s symptoms of a UTI, and had not followed Mrs X’s care plan.
19. The Nursing Home responded to Mrs Y. She was dissatisfied with the response and complained to the Ombudsmen.
20. As Mrs Y has raised several issues in her complaint, I have considered these under separate headings, below.

Mrs X’s move to the nursing unit

21. Mrs Y explained she was satisfied with the decision to move Mrs X to the nursing unit. However, she was concerned about the way the Nursing Home handled the move. Mrs Y said that because of Mrs X’s dementia, she had requested that her move take place gradually, rather than as a sudden change for Mrs X. Mrs Y also said Mrs X’s new room was supposed to be set out in the same way as her room in the residential unit, but this did not happen. Mrs Y said these changes caused Mrs X confusion and distress, and led to a significant change in Mrs X.
22. The CQC Fundamental Standards of Care, Regulation 9: person-centred care says that providers must make sure the person, or a person lawfully acting on their behalf, is involved in the planning, management and review of their care and treatment. The guidance says the care and treatment of service users must be appropriate, meet their needs, and reflect their preferences.
23. The assessment which found Mrs X’s needs eligible for NHS FNC did not specify how a move from the residential unit should be managed. After the assessment, Mrs Y contacted the Nursing Home to request that Mrs X’s move to the nursing unit should be done gradually. The Nursing Home documented Mrs Y’s wishes about this in the records. The notes say staff discussed this with Mrs Y, over the telephone and by email, and advised her that after the move to the nursing unit, Mrs X “could spend time on the second [residential] floor if she is well enough to be taken out of bed and transferred in her wheelchair to the second floor.” The Nursing Home also said staff who knew Mrs X well would continue to support her to settle.
24. The Nursing Home said Mrs X’s room in the nursing unit was directly below her previous room, with the same orientation and the same view. I recognise Mrs Y stated the orientation was different. The records show that the morning after the move to the nursing unit, Mrs X was taken back to the residential unit to spend time with residents and interact with staff, as requested by Mrs Y.
25. The records indicate the Nursing Home acknowledged Mrs Y’s wishes about how she considered the move to the nursing unit should happen, and was in regular contact with her about this. The Nursing Home agreed to Mrs Y’s request and said Mrs X could spend time on the residential unit if she was well enough to do so, and the records show a visit to the residential unit took place. I recognise Mrs X may have expected more visits and more time spent on the residential unit after the move. However, there is evidence within the records that the Nursing Home involved Mrs Y in planning the transition to the nursing unit, considered Mrs Y’s wishes about how this should be managed, and arranged for Mrs X to visit the residential unit at Mrs Y’s request. Therefore, the Nursing Home acted in line with the CQC regulation on person centred care, by involving Mrs Y in planning Mrs X’s care and considering her preferences, and we found no fault by the Nursing Home in how it managed Mrs X’s move to the nursing unit.

Communication

26. Mrs Y complained there was a lack of communication between staff in the Nursing Home residential area, who knew Mrs X well, and staff in the nursing unit. Mrs Y said that had communication been better, staff who knew Mrs X well would have known her behaviour was not usual for her, and could have raised concerns about a possible infection earlier.
27. The Nursing Home said because it operated an electronic care plan and medication system, information about Mrs X was accessible to both nursing and residential staff. The Nursing Home also said that there was discussion between staff from both units before Mrs X’s transfer, and that this was the usual process when someone was moving between units. The Nursing Home said its staff, apart from registered general nurses who remain on the nursing unit, are rotated across the home, and therefore all staff were aware of the changes in Mrs X’s care needs, although Mrs Y disagreed with this. It also said senior staff working across both the residential and nursing units were involved in the process of Mrs X’s transfer to the nursing unit.
28. I recognise Mrs Y’s view that there was a lack of communication between Nursing Home staff, and that she considers this meant staff who knew Mrs X well were not able to raise concerns about changes in her behaviour. However, I have not seen any indication that a lack of communication between staff meant concerns were not raised. The records indicate that when Mrs Y raised concerns about Mrs X’s behaviour after she moved to the nursing unit, the Nursing Home appropriately arranged a GP review (please see the section on recognition of symptoms, below) in response to her concerns.

Care provided including nutrition and medication

29. Mrs Y complained the Nursing Home failed to follow Mrs X’s care plan after she moved into the nursing unit, specifically that it failed to support her with eating and drinking, and that Mrs X was not given prescribed medication.
30. The CQC Fundamental Standards of Care, Regulation 14: Meeting nutritional and hydration needs is intended to make sure people who use services have adequate nutrition and hydration to sustain life and good health and reduce the risks of malnutrition and dehydration. Therefore, care providers must ensure that people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so.
31. CQC guidance on Regulation 14 also says providers must follow people’s consent wishes if they refuse nutrition and hydration unless a best interests decision has been made.
32. The NMC Standards, referred to in paragraph 13, state:

• “5. Use evidence-based, best practice approaches for meeting needs for care and support with nutrition and hydration, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions.
• 5.1 observe, assess and optimise nutrition and hydration status and determine the need for intervention and support
• 5.3 assist with feeding and drinking and use appropriate feeding and drinking aids.”

33. Mrs X’s care plan said she was to be given medication covertly in her food, including antibiotics to prevent a UTI. Mrs Y complained the Nursing Home did not give Mrs X adequate support with eating and drinking, and that this meant she missed the medication she needed.
34. Mrs X had a ‘Food, nutrition and mealtimes’ care plan in place while at the Nursing Home. The records indicate that this care plan was reviewed regularly, including after Mrs X moved to the nursing unit. The care plan said Mrs X required the assistance of one staff member to eat and drink, and required prompting and encouragement. Mrs X’s food and drink preferences were documented within the care plan.
35. As noted above, Mrs X had a diagnosis of dementia, and the records indicate she also had reduced swallow capacity. The records and care plan show Mrs X needed a pureed diet, although I recognise Mrs Y disagreed that Mrs X needed pureed food and felt this meant she lost interest in eating. However, Mrs X had been assessed and reviewed by a dietitian, and was it was documented she required pureed food and normal consistency fluids. Mrs X was also prescribed a once daily nutritional supplement, which the records indicate she rarely refused. The care plan states that Mrs X would spit out her food if she did not like it.
36. The nursing records from Mrs X’s time in the nursing unit show that staff assisted and encouraged Mrs X with eating and drinking. Two days after Mrs X moved to the nursing unit, it was documented that she “had not been eating and drinking as expected” and had been spitting food out. The Nursing Home at this point requested a further assessment from the dietitian.
37. The records show that the Nursing Home provided support to Mrs X with eating and drinking that was in line with the national guidance referred to above. As set out in the CQC Fundamental Standards, Regulation 14: Meeting nutritional and hydration needs, providers must follow people’s consent wishes if they refuse nutrition and hydration. The records indicate Mrs X did spit her food and drink out, and encouragement and prompting with eating were given. This was in line with the relevant guidance.
38. Mrs Y also complained that because the Nursing Home did not support Mrs X with eating, this meant she did not get the medication she needed, because this was given covertly in her food.
39. The NMC standards referred to above, say nurses should “understand the principles of safe and effective administration and optimisation of medicine.” The Royal Pharmaceutical Society (RPS) has issued “Professional guidance on the administration of medicines in healthcare settings” (2019). This says records should be kept of all medications administered or withheld, as well as those declined. “When a medication is not administered, or refused, details of the reason why (if known) are included in the record and, where appropriate, the prescriber multidisciplinary team is notified in accordance with the organisational policies and procedures. Appropriate action is taken as necessary.”
40. Mrs X’s care plan said her medication should be covertly administered, as agreed by her family, GP, pharmacist, and nurse. We found that no additional support would be needed to do this, as Mrs X was already receiving appropriate assistance, encouraging and prompting to eat and drink.
41. The medication administration record (MAR) shows which medications were administered to Mrs X. It also states how they were given, the dose, time and who gave them. The MAR was therefore in line with the RPS guidance referred to in paragraph 43, above.
42. The records show that Mrs X spat out her medication on two occasions, both on the same day. These were Pivmecillinam, an antibiotic used for UTIs, and a laxative, Docusate. The MAR says there was one occasion when the antibiotic was not given. In this instance, the records do not state that further support or encouragement was provided. However, the records indicate that the Nursing Home provided support with giving medication that was in line with the NMC nursing standards, the RPS national guidance and Mrs X’s covert medication care plan. While there was one occasion, as noted above, when support to take the antibiotic was not documented, this was unlikely to have had an impact on Mrs X, as the records show she took her antibiotic at all other times. I found no fault by the Nursing Home in its administration of Mrs X’s medication.

Recognition of symptoms

43. Mrs Y complained the Nursing Home did not recognise Mrs X’s symptoms and changed behaviour while in the nursing unit as indicating a UTI. She said there was a rapid change in Mrs X’s behaviour that did not improve, and the Nursing Home should have identified that this was a UTI.
44. The NMC Code sets out the professional standards of practice and behaviour for nurses, midwives and nursing associates. This says (section 8): “respect the skills, expertise and contributions of your colleagues, referring matters to them where appropriate” and “work with colleagues to preserve the safety of those receiving care… share information to identify and reduce risk.” 
45. The records say Mrs X’s family raised concerns that Mrs X’s behaviour had changed, and the Nursing Home therefore asked for a GP review the same day. The Nursing Home also carried out physiological observations using a tool called the National Early Warning Score (NEWS2). The records indicate Mrs X became settled, and that staff continued observations. A GP telephone review took place that day.
46. Two days later, Mrs X was seen by the GP, who also spoke to Mrs Y about Mrs X’s condition. Mrs X was reviewed again by the GP a week later, and no acute concerns were documented.
47. Therefore, the records indicate the Nursing Home escalated concerns to the GP, which was in line with the NMC standards referred to above. I found no fault by the Nursing Home on this point.

Summary

48. I recognise that this was a very distressing time for Mrs Y. Based on the available information, I have not found fault by the Nursing Home in how it managed Mrs X’s move to the nursing unit, or followed her care plan in terms of nutrition and medication.

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Decision

49. I found no fault by the Nursing Home in how it managed Mrs X’s move to the nursing unit, or followed her care plan in terms of nutrition and medication, and I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman