Introduction
It is beneficial for providers to periodically review the Care Quality Commission (“CQC”) press releases in order to identify common issues and strengthen their practice.
Towards the end of 2023, CQC brought several prosecutions against providers who failed to provide safe care and treatment in relation to resident falls. Although these cases have distinct facts, they all demonstrate the importance of having effective risk assessments and care plans in place in relation to falls management.
Care Plans and Risk Assessments
In November 2023, a provider pleaded guilty to an offence of failing to discharge their duties under Regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A resident, aged 93, had a known history of experiencing falls, as demonstrated by a pre-admission assessment. Nevertheless, the resident suffered from numerous falls during her stay at the home. The care home was ordered to pay a fine of £20,000, on top of £181 for victim surcharge and £27,500 costs to CQC. CQC found that the home failed to provide necessary support to reduce the likelihood of falls, despite the fact that monthly reviews of the resident’s care plans and risk assessments were being conducted. Care plans and risk assessments should have identified how effective the measures implemented were and whether any further action was required.
In another case, a 75-year-old resident was admitted to a care home in November 2019 and was assessed as being at a high risk of falls. During the resident’s time at the home, there had been 23 recorded incidents where the resident had either fallen, placed himself on the floor and been found by staff or had unexplained injuries. The resident was admitted to hospital on six of these occasions. It was held that the home failed to take sufficient action and did not implement measures to prevent these risks from reoccurring. Furthermore, the home did not review, or update risk assessments and care plans as required.
It is imperative that providers produce thorough risk assessments and bespoke care plans to ensure the safety of their service users and that they ensure these are up to date and effective.
Reporting
Additionally, it is of fundamental importance that providers and staff maintain a transparent culture and actively report falls and changes in behaviour.
A resident passed away following several falls in 2020. CQC brought a prosecution against the Registered Manager, who was fined £830 and ordered to pay £181 in victim surcharge and £1500 in costs to CQC. The resident had been admitted to the service in question on 24 January 2019. It was well noted that there was a high risk of falls occurring, and the resident could only walk short distances under supervision with a walking stick. As the resident’s health deteriorated, he suffered from several falls. To rule out a head injury, the resident was admitted to North Manchester Greater Hospital on 24 January 2020 and sadly died four days later. The Registered Manager was prosecuted in November 2023 for failing to ensure that the resident’s risk assessments and care plans were adequate in dealing with the management of his falls. In addition, the home failed to report and respond appropriately to the changes in behaviour, such as the deterioration in his presentation and showing signs of confusion.
Guidance
It is essential for providers to stay up to date on guidance issued or promoted by the regulator. CQC provide links to relevant guidance on their website which can be found here.
GOV.UK provides key guidance on falls management to inform professional practice very generally speaking. It acknowledges the individual impact that front-line health and care professionals can have by routinely asking service users about falls, recognising signs of potential risk, and assessing potential medical conditions which might predispose a service user to the risk of falling.
It also highlights how social care managers and senior leaders in the industry hold important positions by considering their role in falls prevention. Managers can make a real difference by ensuring that care is in line with national clinical guidelines.
The NICE Falls in older people: assessing risk and prevention guidance has not been updated since 12 June 2013 but provides important specific clinical guidance for staff to follow. It gives detail about the type of risk assessment required and expectations of staff.
It is important to note that this guidance is scheduled to be updated. Currently we anticipate having sight of a draft guidance consultation in Autumn 2024 and the anticipated publication date is 26 March 2025 so it will be essential for providers to keep an eye out for any changes.
Conclusion
From reviewing these cases, it is abundantly clear that providers must produce sufficiently detailed personalised care plans and risk assessments for each of their service users. It is a fact of life that accidents occur, but it is how services handle them that is of fundamental importance. Having an open and honest culture is vital.
In a recent prosecution, it was outlined by CQC that as the regulator, they do not have the legal powers to prosecute individual staff failures, only to prosecute against the failures at provider level or by the registered manager.
Any setting can experience issues, but the key element is the learning culture that arises when things go wrong. These cases highlight how services should prioritise care plans and risk assessments in relation to falls management, as well as reviewing any trends in accidents and incidents and implementing changes where required to reduce the risk of falls as part of a safety culture. In order to do this appropriately, it is of the utmost importance for providers to remain up to date with appropriate guidance.
About the Authors
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| Lucy Bowker | Liberty Lawson |
| Solicitor | Trainee Solicitor |
| Tel: 01483 451 900 | Tel: 01483 451 900 |
| Email: lucy@gordonsols.co.uk | Email: liberty@gordonsols.co.uk |