Why should you read this?
When something goes wrong in health and social care, the people affected and staff often say, "I don't want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue – what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
People who use health and social care services should be protected from injuries when using wheelchairs. Wheelchairs must be fit for purpose and risk assessed to keep people safe.
Everyone has the right to be kept safe while receiving care. If providers do not assess the risks to the health and safety of everyone using their services, or if they fail to mitigate those risks, incidents and injuries can happen.
Prosecution by CQC
CQC recently prosecuted a care home provider for exposing someone using their service to a significant risk of avoidable harm, which resulted in a life-changing injury.
Before the incident, the person had been experiencing difficulties with mobility and had sometimes been confused and agitated. They had been provided with an adapted wheelchair with extended footplates for their own use, and staff helped them get around in it. However, staff mainly used a standard wheelchair for communal use within the care home. On several occasions, the person's foot had come away from the footplate when using a standard wheelchair, resulting in a risk of it getting trapped.
On the day of the incident, while pushing the person down a slope in a standard wheelchair, the staff member noticed resistance and found the person's foot caught underneath. The staff member replaced the person's foot on the footplate and continued the journey.
Afterwards, the person complained about pain in the affected leg and was taken to hospital for further assessment.
The person was found to have significant, life-changing fractures to their leg and, at one stage, it was thought it may have to be amputated. The person spent 16 weeks in bed with their leg in a cast, before being discharged from hospital to a different service. Unfortunately, they did not make a full recovery and their physical health was permanently affected by the incident.
Our investigation found that, although the provider knew the risks associated with the use of a communal wheelchair, the care home failed to take adequate steps to assess and mitigate those risks.
At prosecution, the provider pleaded guilty to a failure to provide safe care and treatment, resulting in exposure to a significant risk of avoidable harm to a person using the service. The provider was fined £14,000, and ordered to pay a £170 victim surcharge, and £11,000 costs to CQC.
What happened next?
As well as taking criminal enforcement action against this provider, we have also carried out 3 inspections since the incident. For the first 2 inspections, we rated the care home as requires improvement, providing detailed feedback to the registered manager on each occasion.
At the third inspection, we found progress had been made and rated the home as good. The service had improved its leadership, management systems and governance, and there were effective policies and procedures in place to manage health and safety risks.
The registered manager and provider were more proactive and had introduced new systems to make sure they maintained oversight. This included standardised equipment checks, and recruiting a new member of staff to audit and record these checks.
We will continue to monitor how the service is embedding these improvements.
What can you do to avoid this happening?
To manage the risk of injuries to people from wheelchairs, you need to:
- develop and implement adequate moving and handling plans
- develop and implement a risk assessment specific to a person's use of a wheelchair
- have adequate policies and procedures to support staff in managing these risks
- assess a person's mental capacity to decide about using a wheelchair, especially one not provided specifically for them
- provide staff with the training, skills and knowledge required to safely use a wheelchair
- seek the support of other professionals, such as occupational therapists, where required.
The Health and Safety Executive produces guidance on moving and handling equipment.
The Royal College of Occupational Therapists produces guidance and principles for the assessment and provision of equipment in care homes.
The National Institute for Health and Care Excellence has produced guidance covering decision-making and mental capacity.
The Mental Capacity Act Code of Practice says what you must do when you act or make decisions on behalf of people who can't act or make those decisions for themselves.
Learning from safety incidents
Each of these pages describes a critical issue: what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.