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Nursing home prosecuted by CQC over serious burns injury

20 October 2017
Elmwood Nursing Home
HC-One Limited
  • Media

A care provider that failed in its duty to provide safe care and treatment has today (Thursday 19 October 2017) been ordered to pay £59,570.58 in fines and costs by Camberwell Magistrates’ Court.

District Judge Andrew Sweet issued a £45,000 fine and also ordered the payment of £14,570.58 prosecution costs and a £150 victim surcharge.

The Care Quality Commission (CQC) brought the prosecution following an incident when a 72 year old woman was burned after sitting on a portable heater at Elmwood Nursing Home in Croydon.

The registered provider HC One Limited 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 the nursing home had been experiencing difficulties with its heating system during January 2016. They placed some oil filled electric heaters in residents' bedrooms and communal areas.

Late one night a member of staff found Mrs Polly Dunkley, who has vascular dementia, sitting on one of the portable heaters. As staff put her back to bed they noticed a burn to the back of her thigh.

Although they called the NHS 111 service, staff did not appreciate the severity of the burn or follow the appropriate wound management procedure.

It was only the following morning, and after Mrs Dunkley had experienced a fall, that paramedics arranged for her to go to hospital.

She eventually spent 72 days in hospital, including 28 days in the specialist burns unit at Chelsea and Westminster Hospital after receiving a skin graft to treat her burns.

Bena Brown, prosecuting, told the court that the provider had failed to ensure that the risk of burns and scalding from portable electric heaters was safely managed. As a result Mrs Dunkley and other people using the service were exposed to a significant risk of avoidable harm.

The heater manufacturer took the view that the use of these portable heaters was inappropriate for vulnerable people. At the time of the incident, Mrs Dunkley was not being appropriately supervised by staff at the home.

Debbie Ivanova, CQC’s Deputy Chief Inspector of Adult Social Care, said: “This painful injury could have been avoided if HC-One Limited had taken responsibility to protect the people in their care.

"The risk of older people sustaining serious burns from hot surfaces is something all care homes should be aware of but the provider failed to ensure that a suitable risk assessment was carried out for the use of the heater in Mrs Dunkley's room - and as a result she was seriously burned.

"When serious incidents occur, we now have the powers to prosecute those who are responsible. 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 hold them to account in the courts."


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Last updated:
20 October 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.