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Suffolk care home and manager fined for providing unsafe care

26 January 2018
Highcliffe House Nursing Home
  • Media,
  • Care homes with nursing

A Suffolk care home owner and manager were fined at Ipswich Magistrates’ Court yesterday (Thursday, 25 January) after admitting they failed to provide safe care and treatment.

Highcliffe House Limited, which runs Highcliffe House Nursing Home in Felixstowe, was fined £16,500, plus a £170 victim surcharge, and its manager, Alison Quilter-Cudworth, was fined £1,000, plus a £170 victim surcharge, in a prosecution brought by the Care Quality Commission.

The prosecution was brought against the company and Quilter-Cudworth following an investigation into the death of a resident, William George Willmott.

Mr Willmott was found dead outside the Cobbold Road home on 14 July 2016 after falling from his second floor bedroom window which, at the time, did not have window restrictors. A post-mortem examination revealed Mr Willmott had sustained significant injuries as a direct result of the fall.

Bena Brown, prosecuting, told the court: “Both defendants failed a vulnerable man who relied on each of them to keep him safe. In addition the defendants exposed other service users to risk of harm.”

The home had undergone previous health and safety audits when the need for window restrictors in residents’ rooms was highlighted. In addition, a CQC inspection in May 2016 found a lack of support, care planning and risk assessments for people who use services in distress.

“At the time of his death William was recognised by care staff to be suffering from severe anxiety and depression. He had been identified as at risk of ‘severe panic attack leading to disturbed behaviour’ and of falling,” added Ms Brown.

“The defendants took insufficient action to ensure staff caring for William understood how to manage his anxiety and depression. Furthermore, they failed to address environmental factors such as putting window restrictors in place which had been a long term concern and how to mitigate risk. It is the prosecution’s case that the accident resulting in William sustaining fatal injuries was entirely avoidable and the overall responsibility for health and safety lies with the registered provider and registered manager, who both had a clear role in ensuring that safe care and treatment was provided to William.”

CQC carried out an urgent, focused, inspection at Highcliffe Nursing Home as a result of Mr Willmott’s death. This found a lack of environmental risks assessments at the home and the window in Mr Willmott’s room opened up to 50 centimetres. As a result of the inspection, urgent conditions were imposed requiring the provider to fix windows and review all health and safety at the service. Admissions to the home were also restricted and the home was placed into special measures.

Jemima Burnage, Head of Adult Social Care Inspection for CQC in the Central region, said:

“While we welcome the fact that both the provider and manager accepted responsibility in this case, we would always rather not be in the position of having to take action because vulnerable people have been failed by those providing their care."

“We appreciate how distressing this has been for Mr Wilmott’s family and, like them, hope this case prompts other care home operators and managers to review their properties and systems to better ensure people’s safety. It is vital that people using care services are not left at risk of harm."

“Our inspectors were shocked and saddened by what happened at Highcliffe House Nursing Home and took immediate action to protect people living at the home following Mr Willmott’s death. It was the serious failure of the home to protect people from avoidable harm that led to CQC’s prosecution of the provider and the home’s manager."

“In their roles as provider and registered manager, Highcliffe House Limited and Quilter-Cudworth had a specific legal duty to ensure care and treatment was provided in a safe way. We found they had failed to do this by not ensuring suitable window restrictors were in place that would prevent any person, including Mr Willmott, from falling from the building."

“Where we find any care provider has put people in its care at serious risk of harm, we will consider holding them to account by using our powers to prosecute."

Highcliffe House Nursing Home complied with the conditions CQC imposed after Mr Willmott’s death. The home is currently rated as Requires Improvement and is subject to ongoing monitoring.


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Last updated:
26 January 2018

Notes to editors

Mr Wilmott’s family have asked for privacy at this time, however a statement from the family is available on request from CQC.

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 describes a provider and registered manager'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.

There are four ratings that CQC can give to health and social care services: outstanding, good, requires improvement and inadequate.

  • Outstanding - the service is performing exceptionally well.
  • Good - the service is performing well and meeting expectations.
  • Requires improvement - the service isn't performing as well as it should and CQC have told the service how it must improve.
  • Inadequate - the service is performing badly and CQC have taken action against the person or organisation that runs it.

Providers are required by law to display their ratings on their premises and on their website so the public can see them quickly and easily. This should be done within 21 days of the publication of their inspection report.

CQC published a comprehensive ‘state of care’ report about adult social care services from 2014 to 2017 which can be viewed on our website.

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.