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CQC find failings at two care homes

A care home owner and manager have been fined after a resident died in a fall from a second floor window, reports the Care Quality Commission (CQC).

Highcliffe House Limited, which runs Highcliffe House Nursing Home in Felixstowe, Suffolk, was fined £16,500 plus a £170 victim surcharge at Ipswich Magistrates’ Court. Manager Alison Quilter-Cudworth, was fined £1,000 plus a £170 victim surcharge in a prosecution brought by the CQC.

The prosecution was brought against the company and Quilter-Cudworth following an investigation into the death of a resident, William George Willmott.

cqc failings clipboardMr Willmott was found dead outside the Cobbold Road home in  2016 after falling from his second floor bedroom window which, at the time, did not have window restrictors. A post-mortem examination revealed Mr Willmott had sustained significant injuries as a direct result of the fall.

Bena Brown, prosecuting, told the court: “Both defendants failed a vulnerable man who relied on each of them to keep him safe. In addition the defendants exposed other service users to risk of harm.”

The home had undergone previous health and safety audits when the need for window restrictors in residents’ rooms was highlighted. In addition, a CQC inspection in May 2016 found a lack of support, care planning and risk assessments for service users in distress.

“At the time of his death William was recognised by care staff to be suffering from severe anxiety and depression. He had been identified as at risk of ‘severe panic attack leading to disturbed behaviour’ and of falling,” added Ms Brown.

“The defendants took insufficient action to ensure staff caring for William understood how to manage his anxiety and depression. Furthermore, they failed to address environmental factors such as putting window restrictors in place which had been a long term concern and how to mitigate risk. It is the prosecution’s case that the accident resulting in William sustaining fatal injuries was entirely avoidable and the overall responsibility for health and safety lies with the registered provider and registered manager, who both had a clear role in ensuring that safe care and treatment was provided to William.”

CQC carried out an urgent, focused, inspection at Highcliffe Nursing Home as a result of Mr Willmott’s death. This found a lack of environmental risks assessments at the home and the window in Mr Willmott’s room opened up to 50 centimetres. As a result of the inspection, urgent conditions were imposed requiring the provider to fix windows and review all health and safety at the service. Admissions to the home were also restricted and the home was placed into special measures.

Jemima Burnage, head of adult social care inspection in the central region, said: “While we welcome the fact that both the provider and manager accepted responsibility in this case, we would always rather not be in the position of having to take action because vulnerable people have been failed by those providing their care.

“We appreciate how distressing this has been for Mr Wilmott’s family and, like them, hope this case prompts other care home operators and managers to review their properties and systems to better ensure people’s safety. It is vital that people using care services are not left at risk of harm.

“Our inspectors were shocked and saddened by what happened at Highcliffe House Nursing Home and took immediate action to protect people living at the home following Mr Willmott’s death. It was the serious failure of the home to protect people from avoidable harm that led to CQC’s prosecution of the provider and the home’s manager.

“In their roles as provider and registered manager, Highcliffe House Limited and Quilter-Cudworth had a specific legal duty to ensure care and treatment was provided in a safe way. We found they had failed to do this by not ensuring suitable window restrictors were in place that would prevent any person, including Mr Willmott, from falling from the building.

“Where we find any care provider has put people in its care at serious risk of harm, we will consider holding them to account by using our powers to prosecute.”   

Highcliffe House Nursing Home complied with the conditions CQC imposed after Mr Willmott’s death. The home is subject to ongoing monitoring.

High court refuses to grant injunction against CQC’s report of ‘inadequate’ home

Meanwhile, the CQC appeared in the High Court to defend its decision to publish a report on a care home which it had rated inadequate.

The owners of Ashworth Grange care home in Dewsbury, West Yorks, had applied for an injunction to prevent CQC publishing the report. During an inspection in September 2017, the provider was  found to have failed to provide care as required by regulations.

At the High Court last week, Ideal Carehomes (Number One) Limited, were refused an injunction and the judge awarded the CQC full costs of more than £15,000. The report has now been published on the CQC website.

Debbie Westhead, deputy chief inspector of adult social care, said: “It is our duty to ensure that health and social care services provide people with safe, effective, compassionate, high-quality care.

“People have the right to know the quality of care they are receiving – in this case a service that was inadequate. We have a statutory responsibility to publish the reports of our inspection, as confirmed by the High Court in this case.”

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