In our regulatory round-up ebriefings, we have been discussing for some time the steady rise in the number of prosecutions brought by the CQC. Aside from telling us about the CQC’s potential enforcement approach moving forward, prosecutions also act as a reminder for providers as to potential risk areas and give an opportunity for providers to review their own relevant processes to ensure they are safe and effective. 

Against this context, we have highlighted two recent CQC prosecutions below.

The risk of falls

A Bradford care provider operating Greystones Nursing Home has been fined £5,000 after failing to protect a resident from exposure to a significant risk of avoidable harm. In addition to the fine, the provider was ordered to pay £5,000 costs and a £181 victim surcharge. 

The provider was prosecuted by the CQC due to the care provided to resident William ‘Billy’ Allen. Mr Allen moved to the home in November 2019 and was assessed as being at high risk of falls. Over a period of four months, there were 23 recorded incidents of Mr Allen falling, placing himself on the floor and being found by staff and having unexplained injuries. Mr Allen was admitted to hospital following six of these events.

The provider was found to have failed to:

• take sufficient action following these incidents to mitigate the risks reoccurring;
• review and update risk assessments and care plans;
• ensure the safe management of medicines in the home. 

While there is a fine line between balancing the liberty of residents and reducing the risk of fall events as far as is reasonably practicable, this prosecution serves as an important reminder that providers must continually monitor, review and update risk assessments and care plans to ensure the provision of safe and responsive care, making appropriate referrals where necessary. Where a series of incidents occurs, providers must ensure they assess these incidents both individually and as a collective (whether or not injuries are sustained), identifying any patterns and any potential risk factors, and taking action to mitigate the risk of reoccurrence. Sadly, minor incidents can often be a warning sign before a major incident arises.

The risk of scalding and burning 

Saltutem LD Bidco IV Limited was fined £100,000 following a CQC prosecution for failing to protect a resident from avoidable harm and ordered to pay costs of £17,500 and a £181 victim surcharge.

The provider operates Birchwood Care Home in Buckinghamshire. In February 2020, a 53-year-old resident 'MP' was supported by two care workers to take a bath. MP was lowered into the bath via a hoist without the water temperature being checked. MP expressed discomfort and was removed from the bath while cold water was added. After having her bath, staff noticed her feet were red and MP reported being in pain. Later, the skin on her feet began to blister and peel. MP was admitted to hospital overnight and sustained second-degree immersion scalds from the top of her ankles to the soles of her feet. 

The CQC found that the provider's support plans, policies and risk assessments did not provide adequate guidance to care workers on safe water temperature in line with HSE guidelines. 

Individuals in care homes are at an increased risk of scalding and burning due to a number of potential factors such as reduced mobility, sensory impairment or reduced mental capacity. HSE guidance states that water temperatures must not exceed 44°C. 

The prosecution demonstrates that providers must take a holistic approach to assessing risk, considering all aspects of the delivery of care and support. Where risks are identified, providers must provide guidance to staff on the measures necessary to remove or mitigate these risks. This guidance should be clear, practical and readily accessible to staff.