Care provider prosecuted by CQC after fatal accident at nursing home

Published: 14 June 2016 Page last updated: 12 May 2022
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A care provider that failed in its duty to provide safe care and treatment has been fined £190,000 by Bradford Magistrates’ Court.

The Care Quality Commission brought the prosecution following the death of a 62-year-old man who broke his neck in a fall from a shower chair at a nursing home in Smithies Moor Lane, Birstall, West Yorkshire.

The registered provider, St Anne’s Community Services, based in Leeds, pleaded guilty to an offence of failing to provide safe care and treatment resulting in avoidable harm to a service user.

The court was told that Kevin McNally, who had Down’s syndrome, epilepsy, dementia and a severe learning disability, had lived in the nursing home since 2012.

In April 2015 two care workers had gone to Mr McNally's bedroom to help him take a shower using a shower commode chair. The shower chair fell forwards while he was loosely strapped in. Staff attempted to resuscitate him, but he was pronounced dead in hospital.

Jenny Ashworth, prosecuting, told the court that the provider had failed to adequately control the risk of serious injury and the accident was avoidable.

The risk of people sustaining injuries because safety or posture belts were not used or adjusted properly was well known. The provider had failed to ensure staff understood how to fit the strap safely and failed to carry out effective equipment audits.

In 2008 and again nine days before the accident the Medicines and Healthcare Products Regulatory Agency issued safety alerts intended to raise awareness of the dangers - but St Anne’s Community Services failed to ensure the alerts were brought to the attention of care and nursing staff.

In a statement, Kevin's sister Moira told the court she would visit her brother every Monday and Friday at the care home and how she remembered his love for Elvis and his lovely nature.

St Anne’s Community Services was fined £190, 000 for failing in its duty to provide safe care and treatment under the Health and Social Care Act 2008 Regulations and ordered to pay £16,000 towards the cost of the prosecution and £120 victim surcharge.

Debbie Westhead, Deputy Chief Inspector of Adult Social Care, said: "This accident was entirely avoidable. The risk of people sustaining serious injuries because safety or posture belts are not used properly has been well known for some time. Yet St Anne’s Community Services failed in its duty to ensure that care and treatment was provided in a safe way, and as a result Kevin McNally died. It is a tragedy which need not have happened.

"When serious incidents occur, we now have additional powers to hold providers to account in the courts. In future if we find that a care provider has put people in its care at risk of harm, we will always consider using those powers to the full to prosecute those who are responsible."

If we find that a care provider has put people in its care at risk of harm, we will always consider holding them to account using our powers to prosecute.

Debbie Westhead, Deputy Chief Inspector of Adult Social Care

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.