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Care provider prosecuted by CQC after burns incident at care home

1 February 2017
  • Media

A care provider that failed in its duty to provide safe care and treatment has today (Wednesday 1 February 2017) been ordered to pay £24,600 in fines and costs by Highbury Magistrates’ Court.

The Care Quality Commission (CQC) brought the prosecution following an incident when a 79 year old woman fell against an uncovered radiator at Manor House Residential Home in Morden and received serious burns.

The registered provider partnership, Mr Dudley and Mrs Helene Sessford, pleaded guilty to an offence of failing to provide safe care and treatment resulting in avoidable harm to a resident at the home.

The court was told that Mrs Kathleen Walters, who had dementia and speech difficulties, fell and sustained serious burn injuries following prolonged contact with an uncovered radiator in her en-suite bedroom in November 2015.

Mrs Walters was found on the floor at around 8.20am. She had last been seen at 7.10am. She was observed to have a large burn to her back with skin visible on the uncovered radiator. When she was asked how long she had been there by staff she “placed her hands far apart”.

She was admitted to the Burn’s Unit of Chelsea and Westminster hospital. The burns were assessed as seven percent of total body surface area involving the back and flank. She later received skin grafts. Mrs Walters spent a significant amount of time in hospital post-surgery.

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

She said there was clear evidence, given the nature of the burns, that had the radiator been covered Mrs Walters would not have been harmed. In addition the absence of a pressure sensor mat meant staff were not immediately alerted that she had got out of bed.

Debbie Ivanova, CQC’s Deputy Chief Inspector of Adult Social Care, said: “This incident was entirely avoidable. The risk of people sustaining serious burns from uncovered radiators is something all care homes should be aware of. Mrs Walters was known to be at high risk of falling over. Yet the registered provider failed in its duty to ensure that care and treatment was provided in a safe way, and as a result Mrs Walters was seriously burned.

"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."

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Last updated:
29 May 2017

Notes to editors

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 describes a provider's duty to ensure that care or treatment is provided in a safe way. It is one of a series of fundamental standards introduced following the Mid Staffordshire NHS Inquiry led by Sir Robert Francis.


The 2014 Regulations make it a criminal offence to fail to comply with Regulation 12(1) where the failure to provide safe care or treatment results in avoidable harm to a service user or exposes a service user to a significant risk of exposure to avoidable harm. It is a defence for the registered provider to establish on the balance of probabilities that they took all reasonable steps and exercised all due diligence to ensure safe care and treatment was provided. The maximum penalty for this offence is an unlimited fine.


The 2014 Regulations took effect on 1 April 2015 and coincided with a transfer of enforcement responsibility for health and safety incidents in the health and social care sector from the Health and Safety Executive and local authorities to CQC.


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.