Nottinghamshire home admits failure

A Nottinghamshire care home owner has been ordered to pay more than £54,000 at Nottingham Magistrates’ Court following an incident in which a 94-year-old man fell and suffered a fractured femur.

Mrs Rhoda Ellis and Mr Michael Ellis, who run Woodthorpe View Care Home in Nottingham, were fined £30,000 in court on Monday 11 March, having previously pleaded guilty to failing to provide safe care and treatment to Mr Albert Kendal at a hearing in December 2018. 

Mrs Ellis, who was the registered manager at the home at the time of the incident, was charged separately in her capacity as registered manager and fined an additional £10,000. The Care Quality Commission (CQC) cancelled Mrs Ellis’s status as registered manager in September 2018 following enforcement action. 

In addition, the husband and wife team were ordered to pay a £170 victim surcharge in their capacity of provider and Mrs Ellis was ordered to pay an additional £170 victim surcharge in her capacity as registered manager. They were also ordered to pay £13,873.28 costs, as a result of the prosecution brought by the CQC.

The prosecution was brought after Mr Kendal, who was known as Ted, suffered a fractured femur following a fall at the Woodthorpe Drive home on 3 November 2016. 

Mr Kendal was found on the stairs of the home after a carer heard a loud bang at around 6.30am.  He was admitted to hospital as a result of his injuries and, due to a resulting change in care requirements, was later transferred to a local nursing home where he died on 10 May 2017.

Following the incident a safeguarding investigation was carried out by Nottinghamshire County Council. CQC also carried out an inspection of the service on 6 November when, the court heard, “a number of failings” were found.

A further CQC inspection in February 2017 found significant failures in relation to how the provider identified, assessed and managed the risks associated with falls. 

Records showed 10 incidents concerning Mr Kendal’s mobility and balance had been recorded over the 15 month period leading up to the incident.

Ryan Donoghue, prosecuting, said: “Mr Kendal was known to be a gentleman who was at high risk of falling. No measures had been put in place by the care home to ensure that any risk of him falling could be prevented or alleviated.” 

Neither member of staff on duty at the time of the fall had received first aid training, and the home did not appear to have carried out regular audits of falls to identify if there was any recurring theme or trend, that could have assisted them in preventing Mr Kendal from falling. 

The court heard that Woodthorpe View Care Home had failed to take all reasonable steps to ensure safe care and treatment was provided; and that as a result he suffered serious avoidable harm. Mr Kendal suffered a broken hip and a bump to his head in the fall. This resulted in a significant change in his care needs.

Summing up Judge Jonathan Taaffe addressed Mr Kendal’s family, who were in court, saying: “It sounds to me like Ted led a full and valuable life. It’s clear he was a character who was much loved and I am sorry for your loss. This is a shocking case.

"This was a gentleman who was elderly and should have received the best care. The care home had been warned time and time again of his difficulties and he had previous falls.”

The court heard that following his fall the home did not call for an ambulance but called NHS 111 who said they should call for a GP. By the time Mr Kendal was seen by a GP and subsequently taken to hospital, he had been waiting for treatment for nearly 12 hours.

“The pain he must have been in must have been unbearable. While I accept the 111 service had been called, it is not a matter of rocket science that for a man with brittle bones, who had fallen downstairs, an ambulance should have been called. That’s evidence of a systematic failing of the home. It led to an elderly gentleman suffering and he should not have suffered.”

Mr and Mrs Ellis both pleaded guilty to failing to deliver safe care and treatment at Nottingham Magistrates Court on 17 December 2018. The case was adjourned for sentencing until 11 March. 

Maggie Hannelly, head of adult social care inspection for CQC in the central region, said:
“Mr Kendal and his family had every right to expect good, quality care and we welcome that the provider has accepted full responsibility in this case.  

“We appreciate how distressing this has been for Mr Kendal’s family and we hope this case prompts other care home operators to review the care they provide to ensure people’s safety. 

“It was the serious failure of the home to protect people from avoidable harm that led to CQC’s prosecution of the provider and registered manager. In their role as providers, Mr and Mrs Ellis 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 risks had been fully assessed and measures were in place to prevent harm to Mr Kendal.

“Where we find any care provider has put people in its care at serious risk of harm, we will take action to ensure that people are safe and hold providers to account.”

CQC inspected Woodthorpe View Care Home in July 2018. As a result it is currently rated as 'requires improvement' overall. Inspectors will return to the home to check on what improvements have been made in due course.  



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