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CQC prosecute owner of York care home

11 April 2017
Lamel Beeches
  • Media,
  • Care homes with nursing

A housing trust that failed in its duty to provide safe care and treatment has today (Tuesday 11 April 2017) been ordered to pay £163,185.15 in fines and costs by Leeds Magistrates’ Court following the death of a 98-year-old man in their care.

The Care Quality Commission (CQC) brought the prosecution against the owners of Lamel Beeches, a care home in York, following two offences of failing to provide safe care and treatment with one offence resulting in avoidable harm to a resident, Mr Colley, and a second offence resulting in people using this service being exposed to a significant risk of avoidable harm.

This is the fifth prosecution that CQC has brought against providers since inheriting special enforcement powers from the Health and Safety Executive and local authorities in April 2015.

The registered provider, Joseph Rowntree Housing Trust, based in York, pleaded guilty to both offences.

Kevin Donnelly, prosecuting, told the court that In August 2015, 98-year-old Alfred Colley fractured his hip during a fall at the home but was discharged back to Lamel Beeches after treatment in hospital.

Less than four weeks later he fell out of bed and re-fractured his hip. He died in hospital.

The court was told that this fall was avoidable if Lamel Beeches had followed correct procedures around bed rail safety.

A safety consultant had previously identified that 14 beds needed bed rail extensions to prevent the occupants falling – but the provider had not authorised the work, until after Mr Colley’s accident. There were four other incidents where Mr Colley had become trapped in the bed rail, or attempted to climb over it, prior to breaking his hip.

When CQC inspectors visited the care home in November 2015, they found concerns around the use of bedrails used by all 10 people they checked on, suggesting that insufficient action had been taken to deal with risks or to keep people safe. 

The Joseph Rowntree Housing Trust was fined £100,000 for failing to provide safe care and treatment to Mr Colley and £50,000 for failing to provide safe care and treatment which exposed people to a significant risk of avoidable harm. They were also ordered to pay the prosecution costs of £13,000.15 and a £170.00 victim surcharge.

In a victim impact statement, Michael Colley, Alfred’s son said:

“Although my father was very old and increasingly frail, I was still able to take him out for brief trips, and he maintained his former interests in golf, rugby and cricket as a spectator. He engaged enthusiastically with family matters, taking particular delight when new great grandchildren visited." 

“Any bereavement is distressing, but these circumstances have made my father’s death particularly so. At the age of 98, death is not an improbable event. However, my father underwent unnecessary pain and distress. He deserved a better death.”

Debbie Westhead, CQC’s Deputy Chief Inspector for Adult Social Care said:

“It is clear that the provider in this case had failed to keep safe the frail people in its care.  They had not ensured that the bed rails were being safely used. Risk assessments were not suitable, staff had not been trained and they had not taken action to deal with the risks which had been identified."

“This was avoidable. We know that Mr Colley had fallen out of bed, or become trapped in the rails a number of times - but still too little was done to keep him safe."

“Taken together, the provider's poor governance and leadership at the home led to unsafe care and treatment on the part of its employees and it is for this reason that we have taken action in this case. 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."


For further information please contact CQC Regional Engagement Officer Kerri James by email or by phone on 07464 92 9966. 

Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here.

Please note: the press office is unable to advise members of the public on health or social care matters. For general enquiries, please call 03000 61 61 61.

Last updated:
29 May 2017

Notes to editors

CQC last inspected Lamel Beeches care home in March 2017 and rated the service as Good overall. To view the latest report visit our website.

On 1 April 2015, the CQC inherited special enforcement powers, from the Health and Safety Executive (HSE) and local authorities, which means that we can now prosecute against providers including individuals, where health and safety incidents have occurred resulting in serious harm or death to a person, or people receiving care, from a provider registered with CQC.

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.

Providers are required to notify CQC of deaths and any other incidents prescribed in the Regulations so that CQC can identify any trends and/or make further enquiries to determine whether the provider is providing a safe service and is compliant with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.