A care provider based in Aylesbury, Buckinghamshire, has been fined for failing to provide safe care and treatment and exposing a resident at Lent Rise House, a care home in Burnham, Berkshire, to significant risk of avoidable harm.
The Fremantle Trust provides a number of care and support services in Buckinghamshire, Bedfordshire, Berkshire, Milton Keynes and Hertfordshire. Lent Rise provides care for up to 60 people with dementia and learning disabilities.
The Fremantle Trust was fined £2,000 and ordered to pay £7,000 in prosecution costs at High Wycombe Magistrates Court on 1 February 2021, in a prosecution brought by the Care Quality Commission (CQC).
The provider pleaded guilty to failing to provide safe care and treatment and exposing a resident at Lent Rise House, Mr John Widdall, to significant risk of avoidable harm, in December 2017.
The court heard that Mr Widdall suffered from tetraplegia as a result of an incident which took place at Wexham Park Hospital in Slough, where he was insufficiently assessed and cared for following a fall at a previous care home. The tetraplegia left him at risk of choking on his saliva or other substances. Mr Widdall also suffered from advanced dementia.
Upon admission to the care home, a nursing support plan was completed for Mr Widdall which specified that he required oral suctioning to remove any excess saliva or other secretions, to prevent him from choking. During Mr Widdall’s stay at Lent Rise House, oral suctioning should have only been carried out by nursing or care staff who had been appropriately trained to do so.
All new staff, including agency staff, were required to complete an induction on their first day of duty and to sign a form confirming that they had done so. The induction specified that certain clinical tasks, including oral suctioning, were restricted to appropriately qualified and trained staff.
On 16 December 2017, Mr Widdall’s wife was visiting her husband at Lent Rise House when she witnessed an untrained agency worker attempting to suction her husband’s mouth. She intervened to stop this immediately.
The following day, the provider notified CQC about the incident and a decision was taken to prevent the agency worker from working at the home in future. A reminder was also sent to all staff to advise them that certain tasks could only be carried out by appropriately qualified individuals.
There was no evidence that the agency worker involved in the incident had completed an induction or that they had read Mr Widdall’s care plan. Furthermore, they had not been trained by the provider to undertake the suctioning procedure.
The provider appeared at High Wycombe Magistrates’ Court on 15 October 2020 and entered a guilty plea to the single offence of failing to provide safe care and treatment, contrary to Regulations 12(1) and 22(2)(b) of the Health and Social Care Act 2008 regulation 2014.
The Fremantle Trust failed to provide safe care and treatment in a number of areas, exposing John Widdall to a significant risk of avoidable harm, thereby constituting a criminal offence.
The failures can be summarised as follows:
- A failure to have in place a written policy and/or procedure regarding the completion of suctioning, which had been read by all staff, including agency staff, at the care home.
- A failure to ensure that, in the absence of such a written policy or procedure, all staff at the home, including agency staff, were aware that only appropriately trained nursing and care staff were permitted to complete oral suctioning.
- A consequential failure to ensure that only sufficiently skilled, competent and trained persons were permitted to complete Mr Widdall’s oral suctioning.
Rebecca Bauers, Head of Adult Social Care Inspection in CQC’s south region, said:
“Every person using care services deserves to receive good quality, safe care and to be protected from avoidable harm. In this case, Mr Widdall was placed in a situation that could have put him at risk of harm had it not been for his wife’s timely intervention.
“As with all care providers, The Fremantle Trust has a legal duty to ensure that care and treatment are provided in a safe way. On this occasion, it failed to do so because it did not ensure that all staff were aware that only appropriately qualified and trained personnel could use the oral suctioning equipment.
“Where we find that a care provider has put people in its care at serious risk of harm, we will always take action to ensure that people are safe and hold providers to account.”
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