A care provider that failed in its duty to provide safe care and treatment has been fined £24,000 and ordered to pay £14,000 towards the cost of the prosecution, and a £170 victim surcharge, by North Tyneside Magistrates’ Court.
The Care Quality Commission brought the prosecution following the death of an 83-year-old woman at Gretton Court care home in Hartlepool.
The provider, The Hospital of God at Greatham, previously pleaded guilty at South Tyneside Magistrates’ Court, on 13 March 2019, to two offences: failing to provide safe care and treatment resulting a resident being exposed to a serious risk of avoidable harm, and a failure to provide safe care and treatment to the residents of Gretton Court from being exposed to a significant risk of avoidable harm.
The court heard how a new resident was admitted to Gretton Court on 25 November 2015. Due to them being at risk of falling from bed when resting, it was decided that they needed bed rails and passive infrared sensors (PIR), that sound an alarm when they detect movement. The resident’s need for bed rails was reassessed throughout 2016 and they were found to be of low risk of falling from bed. However, the provider had failed to ensure that staff, responsible for assessing these needs and the safe use of bed rails, had received appropriate training. A relevant safety policy was also not available. The bed rails remained in use.
In the early morning of 25 December 2016 the resident was found, having passed away and trapped between their bed and bed rails, the infrared sensors had not activated. A post mortem revealed they did not die as a result of the incident but had suffered a heart attack due to severe coronary artery disease.
On 30 December CQC conducted a comprehensive inspection, in response to concerns raised. The inspection found that health and safety checks were not always completed and the management of risks at the home was poor. Care plans were also not being updated and the provider was not ensuring improvements were identified or addressed. The service was rated Requires Improvement overall. Two requirement notices were issued, meaning the provider was required to report back to CQC on how it intended to make improvements to the service.
Investigations conducted by CQC after the resident’s death confirmed that the bed rails had been previously broken between October and November, and the provider had repaired them. However, evidence collected showed that the bed rails were again broken during December 2016 but went unnoticed and therefore remained unrepaired for a number of weeks.
Prosecuting Counsel Ryan Donoghue, acting for CQC, told the court that The Hospital of God at Greatham failed to provide safe care and treatment and exposed the concerned resident, and other people in the home, to a significant risk of avoidable harm. The failures were due to the provider not ensuring staff were competent in their roles and supported by relevant safety policies. There were additional failures in correctly using and maintaining the PIR sensor system and the safe use and maintenance of bed rails. The combination of which led people to being exposed to significant risk of harm.
The Hospital of God at Greatham was fined £24,000 for failing in its duty to provide safe care and treatment to residents in the home and ordered to pay £14,000 towards the cost of the prosecution and a £170 victim surcharge.
Sue Howard, Deputy Chief Inspector of Adult Social Care, said:
“Everyone who depends on services is entitled to safe high-quality care and to be protected from harm. We found this provider had failed to ensure risks to people had been fully assessed or actions taken to prevent people from being exposed to avoidable harm.
“The combination of a lack of the home assessing risk and its poor governance meant that it failed to identify where improvements were needed and ultimately resulted in CQC taking this action.
“We would like to offer our sincere condolences to everyone concerned with the death of the resident.
“Where we find poor care, we will always consider using our enforcement powers to hold providers to account and to ensure the safety of the people using services.”
CQC returned to Gretton Court in March 2018 and rated it Good overall, and in each of the key questions we ask: is the service safe, effective, caring, responsive and well-led?
