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Hospital patient using a walking frame

Care home downgraded and ordered to pay over £25,000 after failing to provide safe care and causing avoidable harm

Press reports of a recent prosecution show the importance of managing safety risks.

A resident being cared for by The Red House Welfare & Housing Society suffered a fractured thigh bone and damaged knee. The accident could have been avoided.

On 22 December 2022 the provider was fined £14,000. It was also ordered to pay a £170 victim surcharge and £11,000 costs. The BBC reported the court heard the provider also reached a compensation settlement with the resident’s family.

The resident was injured when her foot fell from the footplate of her wheelchair while being pushed. Her foot caught underneath the wheelchair.  At hospital she was diagnosed with a fractured thigh bone and damaged knee. She spent 16 weeks with her leg in a cast. Following a lengthy stay in hospital she was discharged to a different home.

The case is particularly disappointing, because the provider knew of the risk before the accident. The accident followed a risk assessment noting her feet could fall off the footboard of manual wheelchairs.  Surprisingly a section of the risk assessment for control measures was blank.

Providers have a legal duty to ensure residents receive safe care.  They also have a duty to appropriately manage risks to their wellbeing. The key statutory provisions are regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Regulation 12 requires care and treatment to be provided safely. It lists some of the steps required to be taken. These include doing all that is reasonably practicable to mitigate safety risks when caring for residents. Regulation 22 makes failure to comply a criminal offence in certain circumstances, such as where failure results in avoidable harm to a resident.

The law recognises accidents can happen when providers are not at fault. The provider would have been not guilty if it had taken all reasonable steps and exercised all due diligence to provide safe care.

If the provider had taken all reasonable steps to protect the resident the accident could have been avoided.

Louise Broddle, CQC head of inspection for adult social care, said:

People receiving regulated care and treatment have the right to expect known risks to their safety will be appropriately managed, so the Red House Welfare & Housing Society’s failure to ensure it adequately responded to this resident’s needs is unacceptable. 

If it had used the information it had, it could have implemented measures that could have meant this resident may not have sustained an injury. Its failure to respond adequately to known risks associated with her care exposed her to a significant risk of avoidable harm.    

The vast majority of people receive good care from healthcare providers who take all reasonable steps to ensure their safety. However, when a provider puts people in its care at risk of harm, we take action to hold it to account and protect people.  

I hope this prosecution reminds healthcare providers of their legal duty to always take all reasonable steps to ensure people’s safety.

The prosecution resulted in adverse publicity for the provider. The accident appears to have prompted a focused inspection by the CQC examining whether the home was safe and well-led. The inspection report rated the home as requiring improvement for both of these areas. The home’s overall rating changed from good to requires improvement.

At the time of the focused inspection the home was rated as being good overall and good for each key question. 30 people were living in the home.  Following the ratings downgrade there was a subsequent inspection when 25 people were living in the home.  If the home’s capacity remained at 34 this would be a decrease in occupancy from 88% to 74%.  It is hard to assess the impact of the downgrade on occupancy.  At another time when the home was rated as being good overall and good for each key question 26 people were living in the home.

If an unfortunate event leads to a risk of prosecution please contact Rich Eldridge or Bridget Sanger early so we can help select the best way forward.


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Bridget Sanger

Senior Associate

Bridget defends, represents and advises companies and individuals investigated and/or prosecuted in the criminal courts, with particular specialism in regulatory work surrounding agriculture and regulatory work surrounding care homes
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