Care home safety is slammed by the Care Quality Commission

Safety in care homes has been criticised by the Care Quality Commission with 23% rated as requiring improvement and 2% as inadequate.

The CQC said the low ratings were ‘concerning’ and ‘indicate poor quality’. The study, in which data was pulled from 33,000 inspections of 24,000 services, said:

“Poor safety can mean systems and processes that are not adequate for managing medicines or determining staffing levels.”

The report found there were ‘often unsafe levels’ of staff in the care homes, and even when ‘appropriate numbers’ of staff were in place, often they were lacking in the appropriate skills to have a positive impact on safety.  Unfortunately, where appropriate numbers of staff were in place, if they did not have the necessary skills this could have an impact on safety.

During one inspection of a service that was rated as inadequate, the CQC found the manager did not know what skills their agency workers had, and did not have the skills needed to support the people with complex needs.

Staff training was also a factor on safety, particularly in areas such as infection control, risk assessments, safeguarding and medicines.

The study of care homes is the first time the body has undertaken such in-depth analysis since its new regulatory regime in October 2014, and also since April 2015, when it took over health and safety responsibilities from the Health and Safety Executive. During this period, it has prosecuted five care providers.

While all five prosecutions so far have related to a breach in safe care and treatment requirements, the cases have covered a wide range of safety issues, including medication errors, uncovered radiators and use of bed rails.

The CQC found a number of recurring themes such as: issues with documentation and allocation of medicines, risk assessments, equipment, and staff training.

The five prosecutions included:

  • A provider was fined £190,000 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 West Yorkshire.
  • A provider was fined £50,000 and a former manager £665 after the death of a resident at Cotton Hill House care home, following errors with the administration of his anti-coagulant medication.
  • A provider was fined £24,600 following an incident when a 79 year old woman fell against an uncovered radiator and suffered serious burns.
  • A provider was fined £82,430 following 14 offences for failing to provide safe care and treatment, failure to notify the CQC of the deaths of ten residents, and failure to notify regarding three serious incidents.
  • A provider was fined £163,185 after two offences with one resulting in avoidable harm to a resident who died in hospital after falling out of bed and re-fracturing his hip.

Member of Public struck by fencing wire

R M Contractors Limited aka RMC, a civil engineering company, and a contractor working on behalf of a tree surgery company Complete Tree Services (CTS) have been sentenced after a member of the public was injured by fencing wire and needing surgery to remove pieces from her neck.

Redditch Magistrates’ Court heard that a member of the public was in her garden, when she was sprayed with pieces of fencing wire that had become entangled in a mechanical flail. As the head of the flail was lifted, ejected pieces were directed towards her garden. She was struck twice, once in the leg and once in the neck.

The incident, which occurred on 18 May 2015 sparked an investigation by the Health and Safety Executive (HSE).  The investigation found the contractor RMC who had engaged the sub-contractor CTS to carry out the flailing, had failed to properly plan this work to ensure the suitable controls had been identified and implemented.  They both failed to check the area for obstructions or follow safe procedures should such an event occur.

R M Contractors Limited, of Pipers Road, Park Farm Industrial Estate, Redditch, Worcestershire, pleaded guilty to breaching Regulation 15(2) of the Construction (Design and Management) Regulations 2015, and was fined £180,000 and ordered to pay costs of £22,000.

Matt Lea of Little Luddington Farm, Stratford-Upon-Avon, Warwickshire, pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974, and has been sentenced to 120 hours community order and ordered to pay costs of £3600.

Speaking after the hearing HSE inspector Chris Gregory said:

“Members of the public have a right to expect to be able to enjoy their garden without any risk of being hit by flying debris from neighbouring work activity.”

Uncontrolled Fire results in company fine

Vertellus Specialties UK Limited, of St Anns Wharf, Newcastle upon Tyne, has been fined after an uncontrolled fire at the company’s Seal Sands premises in Middlesbrough in the early hours of 14 May 2014.

Teesside Crown Court heard the fire involved large quantities of dangerous substances including Vitride, which led to this fire being declared a major incident. The Vitride was in drums and each one burst open causing a large fireball.  No one was injured as a result of this fire, but police declared a major emergency and the road was closed for several hours.

An investigation by the Health and Safety Executive (HSE), Environment Agency (EA) and Cleveland Fire Brigade (CFB) found that Vertellus failed to adequately maintain its equipment; and failed to ensure the equipment was suitable to control temperature or prevent ignition to an uncontrolled release.

Vertellus Specialties UK Limited has pleaded guilty to breaching Regulation 4 of the Control of Major Accident Hazards Regulations 1999.

The company has been fined £135,000 and ordered to pay costs of £37,653.12.

Speaking after the hearing HSE inspector Stephen Britton said:

“Luckily no one was injured as a result of this uncontrolled fire.

Duty holders, particularly those who could be subject to a major incident, need to carry out robust planning to prevent and control major accidents. All engineering disciplines should be used, using outside assistance if needed. Here, there was a failure to recognise how a leak could develop into a larger problem.”

Builders jail sentence is boosted

A building contractor, Norman McKenzie’s who was fined £3,000 and given a suspended 15-month custodial sentence over the death of a labourer, has had his sentence increased at the Court of Appeal in Northern Ireland.

Ivan Reilly, the owner of Portadown farm had contracted McKenzie to assist with the construction of a three-bay farm shed at his premises.

On 20 January 2015, McKenzie’s employees Petyo Hristanov and two other Bulgarian nationals were constructing the shed roof. They were hoisted up in a box attached to the front of a telescopic handler driven by McKenzie, but had to climb on to the roof to complete the work.  It was here that the sheeting became slippery when it started to rain and Hristanov slid off the roof. He fell almost 5 m and sustained fatal head injuries. One of the victim’s co-workers had tried to stop him falling and was subsequently pulled from the roof, sustaining minor injuries.

The court replaced Norman McKenzie’s suspended sentence with a custodial one which, it said, would act as a warning to the construction industry that offenders of gross negligence who put workers’ lives at risk would be sent to prison.


The investigation, led by Health and Safety Executive Northern Ireland (HSENI) along with the Police Service for Northern Ireland, found no safety measures had been implemented and a risk assessment had not been carried out. It concluded that McKenzie “completely failed to assess the risks associated with this job”.

McKenzie pleaded guilty to manslaughter and counts of failing to ensure the safety of an employee, failing to carry out a risk assessment, and failing to take measures to prevent a fall from height.

However, the Director of Public Prosecutions for Northern Ireland referred the sentence to the Court of Appeal on the ground that he considered it to be unduly lenient.

The Court of Appeal concluded that a deterrent sentence was reasonable because there is no rational reason why individuals prosecuted for such offences “tend to escape prosecution”. It said a deterrence was also necessary to warn to construction industry in general of the consequences of failing to ensure the safety of workmen.

On 18 May the Court of Appeal revoked the suspended sentence handed to McKenzie for manslaughter and imposed a custodial sentence of 24 months (12 months to be served in prison on 12 months on license). The £3,000 fine previously levied was waived.