Learning Lessons from Safety Incidents and Prosecutions

How CQC reports can help

When something goes wrong in a care service setting, the usual reaction is to want to prevent it from ever happening again. Whilst accidents continue to take place, lessons can be learnt from investigating how the accident happened in the first place. These lessons can be used to try to prevent a similar thing from happening in the future.

The Care Quality Commission (CQC) has collected information on previous incidents in care settings as part of their ‘Learning from safety incidents’ series and as press releases following prosecutions. Here we examine some key examples and detail the steps that can be taken to prevent them from happening in your care service environment.

Fall from window incident

CQC describe an incident where a resident of a registered nursing home died after falling from a window on the second floor. There were no window restrictors on the window that prevented it from opening more than 100 mm and the victim had a history of severe panic attacks and falls.

Following conviction, the provider received a £16,500 fine and the registered manager received a £1,000 fine for failing to provide safe care and treatment. In particular, there was no up-to-date environmental risk assessment. Also, no individual risk assessment was in place for the victim identifying their risk of falling from an unrestricted window. Furthermore, measures outlined in HSE guidance to mitigate risks in care homes had not been implemented.

The case illustrates the importance of assessing risk in individual premises and for each individual resident. Where risks are identified, measures to prevent falling from a height may be required.

Hypothermia incident

Many residents in the care sector are vulnerable to hypothermia which can develop after a short and minor drop in room temperature. Residents with reduced mental capacity and/or mobility or sensory impairment are at risk but so are all care receivers who cannot communicate that they are exposed to cold.

The risks are illustrated by an incident in a care home in November 2016. A long-term resident who was a wheelchair user required an ambulance. She was diagnosed with hypothermia and pneumonia.

It was found that the care environment was located in a poorly insulated building with high ceilings and large rooms. At the time of the incident, there was no heating or hot water. Also, thanks to a broken catch, the window in her room could not be shut properly. Her deteriorating condition had not been acted upon because staff had not checked on her during the night and had not responded to her needs during the day. Sadly, she passed away after being admitted to hospital.

Rigorous enforcement action was taken to rectify the situation and protect other residents. Admissions were restricted and the provider’s registration was cancelled. A review was also commissioned by the local authority safeguarding adults board.

The case illustrates the importance of having contingency plans in place in case heating fails in the winter months.

Risks presented by other residents

In 2017 an incident occurred in a residential care home that supported adults with physical and learning disabilities and acquired brain injuries. A previous CQC inspection had found that the service was inadequate and plans were in place to close it.

The incident began when a resident assaulted two agency staff. Paramedics attended and as they were leaving, the same resident locked themselves and another resident in a room where they proceeded to carry out an assault. Staff tried to break down the door but were unsuccessful and eventually the perpetrator let them in. The victim suffered life-changing facial injuries.

An investigation revealed that a number of factors had contributed to the incident. In particular, it was clear that the staff on duty should have been able to gain access to the room where the assault was taking place. The investigation established that the residence should have been staffed by two agency staff and a permanent staff member during that evening. However, the permanent member of staff did not turn up for work which meant that no one on site knew the access codes for the bedrooms or where the emergency keys were kept. Also, the on-call manager did not answer the phone when they were contacted for support.

The operator had failed to assess the risks posed by an unpredictable and violent resident and had failed to ensure that staff could access a bedroom. They pleaded guilty to failing to provide safe care and treatment which resulted in avoidable harm. After pleading guilty the operator was fined £495,170 and ordered to pay £35,000 in costs.
A spokesperson for CQC said, “I hope this prosecution reminds care providers that they must always ensure people’s safety and manage risks to their wellbeing.”

Another incident involving an assault of a female resident was reported in a care home in Nottinghamshire and resulted in a prosecution under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations require care providers to implement systems and processes, such as risk assessments, to prevent physical and mental harm.

The provider had failed to manage a male resident who had exhibited an escalating pattern of sexualized behaviour towards other residents and was found guilty of failing to protect their residents from significant risk of avoidable harm.

Prior to the assault, a total of 79 incidents were recorded over 18 months including inappropriate verbal and physical sexualised behaviour and assault. Following each incident, the service should have reviewed its risk assessments to respond appropriately and take all reasonable steps to protect people. However, this did not happen and the risk was not managed appropriately. Finally, he entered a woman’s room and raped her. Having been found guilty, the care provider was fined £363,000 and costs of £12,441.28.

A spokesperson for CQC commented, “The company’s failure to protect a vulnerable woman in its care from a resident who was known to present a sexual threat is appalling. The crime she was subjected to was avoidable. Similarly, the company’s lack of safeguards to protect all residents at the home from the risk of abuse was unacceptable.”


Issue 7: Falls from windows – Care Quality Commission

Health and safety in care homes – Health and Safety Executive

Issue 8: Hypothermia – Care Quality Commission

Cheltenham care home provider ordered to pay £495,170 after failing to provide safe care and treatment – Care Quality Commission

Nottinghamshire care provider fined after woman was raped – Care Quality Commission

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