The CQC recently published a press release about the prosecution of a registered manager (RM) of a nursing home, for two offences of failing to provide safe care and treatment, resulting in avoidable harm. Whilst more often, we see care providers prosecuted as the body carrying on regulated activities, in this instance, the CQC brought a prosecution against the RM, who received a fine of just over £55,000.

While such personal prosecutions remain rare, the CQC can use its enforcement powers against directors and registered managers and will do so where:

• an offence has been committed with the individual’s consent or connivance, or is attributable to neglect on their part; and
• there is clarity about the individual’s accountability as opposed to the service provider.

In this case, the offences related to choking and falls.

Choking

The choking incident was in relation to a resident who had been admitted to the home in October 2018. On 6 November 2019, she was eating dinner in the dining room and began choking. Sadly, she died in hospital later that day.

Prior to this, the resident had been involved in three other choking incidents and should have been referred to a speech and language therapist after the second incident occurred, in order to ensure the risks were properly assessed. The CQC found that the RM did not safely assess, monitor or manage the risk and did not make a referral.

Falls

The second incident occurred in January 2020, when a resident had a fall in the dining room at the home. At 3 am the next morning, a motion sensor showed that the resident had left his bed and was found on the floor. Later that morning he was taken to hospital, diagnosed with a fractured left neck of femur and passed away just a few days later. The fall and subsequent injury were found to have contributed to his death.

Following admission to the home, he had suffered at least 14 falls and it was found that the RM had failed to mitigate the risk of falls, did not ensure that the care records were kept up to date and failed to ensure that John was promptly referred to appropriate services, such as the falls team, GP and local authority.

While the prosecution was brought again the RN, the sad facts should also act as a reminder to providers of the need to carry out risk assessments, seek appropriate guidance from medical professionals and then mitigate the identified risks, keeping the measures under regular review, particularly following any further incidents or a change in circumstances, to understand if a different approach is required. Decisions and the thought process behind them should always be documented carefully.

For more information, please contact Freya Cassia, Molly Quinney or a member of the regulatory team.