Carrying out a risk assessment is only the starting point in ensuring the safety of service users, with the recent prosecution of The Red House Welfare and Housing Society clearly highlighting this. On 22 December 2022, The Red House Welfare and Housing Society was fined £14k by Chelmsford Magistrates Court for failure to manage known risks, affecting the care received by a woman at its home in Sudbury.

The resident was a wheelchair user, suffering from mobility issues, confusion and agitation. On multiple occasions whilst under the home’s care, her foot had fallen from the wheelchair’s footplate as she was being pushed, becoming caught underneath and at times stuck. The frequency of this was enough to mean that external healthcare professionals had noted that the recurrence presented as a continued risk. However, in spite of this recognition, the provider did not take adequate steps to safely manage the risks, such as developing manual handling plans and risk assessments specific to the resident.

On 12 March 2019, whilst being pushed to the dining room by a staff member of the home, the carer noticed some resistance, realising that the resident’s foot had come off the footplate once more. They repositioned her foot and continued the journey. Sadly, the resident later reported pain and her knee was found to be swollen. A GP was called, who referred the woman to hospital where a fracture to her thigh bone and damage to her knee joint was identified. It led to the resident spending 16 weeks with her leg in a cast and a long time in hospital before she was discharged to a different service.

This distressing incident serves as a reminder that risk assessments are not simply a box-ticking compliance exercise and are very much only the first step in promoting the safety of residents. Not only do risk assessments need to be carried out and documented carefully, but they should be specific to the individual person supported, with appropriate and tailored measures then put in place to mitigate the risks identified. Risk assessments should be reviewed regularly to evaluate whether the measures contained within them remain effective or whether a different approach is needed. Providers should then ensure that any action required is clearly communicated to all relevant staff, with updates shared as and when they arise. It is also essential that providers identify any additional training needs for staff in relation to the specific risks for people supported and ensure that all relevant staff receive that training.

For further advice, please contact Molly Quinney or a member of the regulatory team.