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Care provider prosecuted by CQC after fatal accident at nursing home

14 June 2016
St Anne's Community Services - Smithies Moor Lane
St Anne's Community Services
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A care provider that failed in its duty to provide safe care and treatment has been fined £190,000 by Bradford Magistrates’ Court.

The Care Quality Commission brought the prosecution 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 Smithies Moor Lane, Birstall, West Yorkshire.

The registered provider, St Anne’s Community Services, based in Leeds, pleaded guilty to an offence of failing to provide safe care and treatment resulting in avoidable harm to a service user.

The court was told that Kevin McNally, who had Down’s syndrome, epilepsy, dementia and a severe learning disability, had lived in the nursing home since 2012.

In April 2015 two care workers had gone to Mr McNally's bedroom to help him take a shower using a shower commode chair. The shower chair fell forwards while he was loosely strapped in. Staff attempted to resuscitate him, but he was pronounced dead in hospital.

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

The risk of people sustaining injuries because safety or posture belts were not used or adjusted properly was well known. The provider had failed to ensure staff understood how to fit the strap safely and failed to carry out effective equipment audits.

In 2008 and again nine days before the accident the Medicines and Healthcare Products Regulatory Agency issued safety alerts intended to raise awareness of the dangers - but St Anne’s Community Services failed to ensure the alerts were brought to the attention of care and nursing staff.

In a statement, Kevin's sister Moira told the court she would visit her brother every Monday and Friday at the care home and how she remembered his love for Elvis and his lovely nature.

St Anne’s Community Services was fined £190, 000 for failing in its duty to provide safe care and treatment under the Health and Social Care Act 2008 Regulations and ordered to pay £16,000 towards the cost of the prosecution and £120 victim surcharge.

Debbie Westhead, Deputy Chief Inspector of Adult Social Care, said: "This accident was entirely avoidable. The risk of people sustaining serious injuries because safety or posture belts are not used properly has been well known for some time. Yet St Anne’s Community Services failed in its duty to ensure that care and treatment was provided in a safe way, and as a result Kevin McNally died. It is a tragedy which need not have happened.

"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."

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.


In January 2016 CQC conducted an unannounced inspection of Smithies Moor Lane to check that the provider had made improvements which had been required by inspectors. The report is available on the St Anne's Community Services - Smithies Moor Lane profile page.

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.