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.
Falls from windows often result in serious or fatal injuries, but they are avoidable.
You must assess risks at your premises. Where you identify the risk of someone falling from a high window, you must take adequate precautions. For example, you can fit window restrictors.
Prosecution by CQC
In 2018, CQC prosecuted a provider and registered manager of a nursing home. A resident died on 14 July 2016 after falling from his second-floor bedroom window. At the time the window did not have window restrictors.
The resident had been identified as at risk of severe panic attack and of falling.
The provider and manager admitted they failed to:
- provide safe care and treatment by failing to take measures to prevent falls from windows. For example, by fitting restrictors that prevent windows from opening more than 100 mm.
The registered provider and manager both had a role to play in ensuring that safe care and treatment was provided. The registered manager had overall health and safety responsibilities within the terms of their Health and Safety Policy Statement. However, they failed in their duty to ensure that this policy was put into practice. They failed to:
- Complete an up-to-date environmental risk assessment. The last one was in 2004.
- Carry out a suitable individual risk assessment in relation to the person’s risk of falling from unrestricted windows.
- Implement other measures to mitigate the risk, in line with the health and safety guidance for care homes.
The court ordered the provider to pay:
- a £16,500 fine
- a £170 victim surcharge
The court ordered the registered manager to pay:
- a £1,000 fine
- a £170 victim surcharge
The service remains a concern
Immediately after the incident in 2016 we took urgent action to safeguard others using the service. The provider demonstrated to us that they had mitigated further risks. For example, they fitted window restrictors throughout the service. Unfortunately, in April 2018, we found the service had deteriorated again. We rated them as inadequate against the safe key question and inadequate overall. We continue to act to ensure people’s safety using our enforcement processes.
What can you do to avoid this happening?
To manage the risk of falls to residents, you need to assess the risks:
- arising from the premises
- for individual residents. Where specific residents are at risk, you may need to carry out further measures to prevent them falling from a height.