NHS, has been fined £40,000 after pleading guilty to two offences of failing to provide safe care and treatment to two residents at Rossendale Nursing Home in Lancashire.
Caroline Taylforth, who established her first residential care home in 1997, was prosecuted by the CQC. She was the registered manager at Rossendale Nursing Home at the time of the incidents, and admitted mistakes she had made that meant two residents did not receive safe care and treatment, and resulted in "avoidable harm" while in her care, said a CQC spokesperson.
The first offence was for failures in the care of resident Patricia Sutton, aged 77, who was admitted to the home on 11 October 2018 and had a significant medical history. On 6 November 2019, Patricia Sutton was eating dinner in the dining room and started choking. She was taken to hospital and died later that day.
Ms Sutton had previously been involved in three other choking incidents and should have been referred to a speech and language therapist after the second one occurred to properly assess the risks, said the CQC. However, Ms Taylforth "did not safely assess, monitor or manage the risk or make this referral", the CQC concluded.
In addition, a referral was made to a dietician who requested further information within 2 weeks of a letter dated 31 July 2019. However, there was no evidence that Ms Taylforth had provided this information, and the referral was subsequently closed.
Risks of Falls Ignored
The CQC also prosecuted Ms Taylforth for another incident concerning Dereck John Chapman, aged 82, who was admitted to the home on 22 October 2019 with multiple health issues and was also prone to having falls.
Following admission to the home, Mr Chapman suffered at least 14 falls. Ms Taylforth "failed to mitigate" the risk of falls and "failed to ensure" Mr Chapman was promptly referred to appropriate services, such as the falls team, GP, and local authority following known incidents, particularly those resulting in injuries, criticised the CQC.
On 13 January 2020, Mr Chapman had a fall in the dining room at the home. At 3.00 am the next morning, a motion sensor showed that John had left his bed and he was found on the floor. Later that morning he was taken to hospital and was diagnosed as having a fractured left neck of femur. A few days later his condition deteriorated, and he died on 3 February 2020.
"The fall and subsequent injury contributed to his death," a CQC spokesperson declared.
Ms Taylforth, as the registered manager of the home, was "required to maintain oversight of people's care, and ensure people's care records were accurate and up to date", as well as ensure any appropriate referrals were made to ensure people were receiving safe care and treatment. "In these cases, this did not happen," the CQC spokesperson said.
Ms Taylforth, 62, pleaded guilty to two counts of causing avoidable harm by failing to provide adequate care. In addition to the £40,000 fine, she was also ordered to pay a £181 victim surcharge and £15,000 costs to the CQC which brought the prosecution.
Care Home Previously Placed in Special Measures
In 2016, CQC placed the care home in special measures having been found to be "failing to provide care which was safe, effective, caring, responsive, or well led". The home was told that they "must make improvements to protect the safety and welfare of people living there".
In a subsequent inspection in June 2021, CQC inspectors concluded: "The provider has repeatedly failed to assess, monitor and improve the quality of the service. This left people at risk of avoidable harm," and rated the home as "inadequate".
Since this latest inspection, the risk had been "mitigated" because commissioners terminated their contract with the service," the CQC said. All service users had been moved to alternative placements and no one was currently living at the home.
"Significant high risk safeguarding concerns led to a multi-agency decision to stop commissioning care from the provider," a statement from Blackpool Council, Lancashire County Council, and the NHS said.
Alison Chilton, CQC deputy director of operations for the north, said that the two residents were "seriously let down" by the care they received from Ms Taylforth at Rossendale Nursing Home, which sadly led to their deaths. She added that Ms Taylforth had "failed in her duty" as registered manager to protect the two residents from an avoidable risk of harm in a place they should have been safe and receiving the best possible care to meet their individual needs.
"This fine is not representative of the value of their lives," Ms Chiltern emphasised, "but this, and the prosecution reminds all care providers they must always ensure people's safety and manage risks to their wellbeing," she warned.