Summary: Mr X complained about Bunkers Hill Care Home run by United Health Group Limited and its poor communication with his family and the hospital when his late step-father, Mr Y, became unwell. He also complained it did not have enough staff on duty. The Care Provider was at fault. It failed to notify Mr Y’s family when he became unwell and was taken into hospital. The Care Provider has accepted it was at fault and apologised to Mr Y’s family. It also made changes to its service to prevent a recurrence of fault. This was appropriate. There was no fault in the number of staff on duty.

The complaint

1. Mr X complained about the actions of Bunkers Hill Care Home, of United Health Group Limited, in relation to his late step-father, Mr Y. He said the Care Home:
• did not respond properly to the family’s concerns about Mr Y’s health;
• poorly communicated with Mr Y’s family and the hospital when Mr Y became acutely unwell, when he was admitted into hospital and when he died; and
• had one member of staff working when Mr Y became acutely unwell.
2. Mr X said it caused him and the family distress. He wanted the Care Provider to recognise it was at fault and to put service improvements in place to prevent a recurrence of fault.

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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)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

7. I spoke with Mr X and considered information he provided.
8. I considered information provided by the Care Provider.
9. Mr X and the Care Provider had the opportunity to comment on the draft version of this decision. I considered any comments received before making a final decision.

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What I found

What happened

10. Mr Y had complex health needs and resided in Bunkers Hill Care Home from April 2022. Bunkers Hill Care Home provides nursing care to residents who have significant health needs. Mr Y required staff to support him with all activities of daily living. A District Nurse Team also visited Mr Y regularly for leg care. The Care Home had Mr Y’s wife, Mrs Y, as his next of kin.
11. In August 2024, Mr Y’s family visited him and said they had told staff they were concerned he did not look well. Mr X said staff assured the family Mr Y was fine.
12. The following day, Mr Y became unwell. As a result, the nurse on duty called the paramedics to attend to Mr Y. Mr Y was admitted into hospital. The Nurse did not inform Mr Y’s family of this.
13. The day after Mr Y’s admission into hospital, the hospital staff contacted Mrs Y to provide her with an update on Mr Y’s condition.
14. Mr Y’s condition had deteriorated whilst he was in hospital. He died four days after his admission. Mr X said the family went to the Care Home the day after Mr Y had died to collect Mr Y’s belongings.

Mr X’s complaint with the Care Provider

15. Shortly after Mr Y’s death, Mr X complained to the Care Provider. He said staff:
• did not act on Mr Y’s family’s concerns about his health which they had raised the day before his hospital admission;
• failed to inform the family when Mr Y became unwell and was admitted into hospital;
• did not contact Mr Y’s family whilst he remained in hospital;
• did not liaise with the hospital whilst Mr Y remained there; and
• did not contact Mr Y’s family after he had died.
16. The Care Provider responded to Mr X’s complaint and said:
• its records showed staff had no concerns with Mr Y’s health the day before he was admitted into hospital. The District Nursing Team had also visited Mr Y prior to his hospital admission and had reported no concerns;
• it accepted the Nurse on Duty had failed to inform Mr Y’s family of his ill health and hospital admission. The Care Provider said the Nurse had to attend to another urgent medical matter at the time the paramedics had arrived to see to Mr Y and so had unfortunately forgotten to call Mr Y’s family. It said it had addressed the error with the Nurse and had implemented some changes to prevent a recurrence of fault. The Care Provider apologised to Mr X and said it had spoken to and written to Mrs Y about its lack of communication and apologised to her too; and
• it had liaised with the hospital whilst Mr Y remained there.
17. Mr X remained unhappy and complained to us. In his complaint to us, Mr X said when the family went to the Care Home to collect Mr Y’s belongings, staff were not aware Mr Y had died.

The Care Provider’s response to my enquiries

18. In response to my enquiries, the Care Provider:
• shared daily notes of Mr Y’s care dated a few days before his hospital admission. The notes did not reflect any concerns with Mr Y’s health. The notes also included the visit he had received from the District Nurse Team;
• shared a meeting record which showed it had addressed the poor communication with the Nurse;
• provided evidence it had addressed the incident with the wider team and had implemented new measures which would prompt staff to contact family/next of kin when a resident was taken into hospital;
• shared a contact record which showed its clinical lead had contacted the hospital whilst Mr Y remained there. The Clinical Lead was aware the hospital had updated Mr Y’s family on his condition;
• said the Registered Manager of the Care Home called Mrs Y shortly after Mr Y had died and offered their condolences. The Registered Manager had also apologised for failing to inform her of Mr Y’s hospital admission; and
• shared its staffing allocation document which said the Care Home had more than one member of staff working when Mr Y became unwell.

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Findings

19. The Care Provider’s records showed staff at the Care Home had no concerns with Mr Y’s condition prior to his hospital admission. Staff had assured Mr Y’s family he had been well. The Care Provider was not at fault.
20. The Care Home should have contacted Mr Y’s family when he became unwell and was admitted into hospital. As a result, Mr Y’s family were not aware he was in hospital until informed by the hospital the following day. This was fault and caused the family distress. The Care Provider has accepted its communication was poor and addressed the matter with the Nurse who was on duty and the wider team. It has implemented measures to prevent a recurrence of fault. It also apologised to Mr Y’s family. This was appropriate and what we would expect the Care Provider to do.
21. Mr X said the Care Home did not communicate with the family whilst Mr Y was in hospital. The hospital provided Mr Y’s family with updates on his health. We would not expect the Care Home to contact Mr Y’s family at the time as he was under the care of the hospital. There was no fault with the Care Provider.
22. Mr X said the Care Home did not liaise with the hospital during Mr Y’s admission. Evidence shows the Care Home had contacted the hospital during this period. There was no fault with the Care Provider.
23. Mr X said the Care Home did not contact Mr Y’s family after he had died. The Care Provider told Mr X in its complaint response to him it had already spoken with Mrs Y. The Care Provider provided us evidence the Registered Manager of the Care Home had called Mrs Y after Mr Y had died. There was no fault with the Care Provider.
24. Mr X said when Mr Y’s family visited the Care Home the following day after Mr Y had died, staff told the family they were not aware Mr Y had died. I have not investigated this issue further. There is no evidence Mr X raised this complaint with the Care Provider and gave it the opportunity to respond. Even if I had investigated it further, it is unlikely I would have found fault. Mr Y’s family visited the Care Home the day after his death, so it is possible not all staff were aware of this at that time.
25. Mr X said there was only one member of staff on duty when Mr Y became unwell. The Care Provider provided evidence there was more than one staff member on duty when Mr Y became unwell. Therefore, I cannot say the Care Provider was at fault.

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Final Decision

26. I have now completed my investigation. The Care Provider was at fault. It has already taken appropriate action to remedy the injustice caused and to prevent a recurrence of fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman