Tragically a vulnerable person died and a family lost a love one due to the failings of this service. In respect to the family at this time I have amended this article to remove the name of their love one, however, the news paper and CQC report both name the vulnerable person.
A Shrewsbury care home owner and its former manager
have been fined over £50,000 at Telford Magistrates’ Court today
(Tuesday, 20 September) after admitting they failed to provide safe
care.
The prosecution was brought against the company and Alison Gough following an investigation into the death of a service user at Coton Hill House care home.
The Service User died at the Berwick Road home on 11 April 2015. His death was referred to the coroner as errors with the administration of his anti-coagulant medication had been identified. A post mortem examination revealed he died as a result of a pulmonary thromboembolism and deep vein thrombosis.
The Service User had been prescribed anti-coagulant medication on his discharge from the Royal Shrewsbury Hospital, where he had been taken after falling ill at the home in February 2015.
Jenny Ashworth, prosecuting, told the court that when CQC inspectors looked at the Service Users medication records there were a number of omissions and errors.
The dosage for his anti-coagulant drug was inaccurately recorded, as was the length of time for which he should be given the drug and, when the drug ran out, the home failed to ensure more was ordered.
According to the home’s records this meant the Service User was not given this medication for up to 30 days before he died.
Ms Ashworth said, while the Service Users death could not be directly linked to his not receiving this medication, CQC found people living at Coton Hill House had generally been put at risk of significant harm because of the home’s management and recording of the medicines people received.
Inspectors found repeated failures by the home in ensuring anti-depressants, pain relief and medication to treat Alzheimer’s disease and manage a thyroid disorder were in stock.
Allergy information was not recorded and the home failed to consistently and accurately record the times medicines were administered - creating a risk of overdose.
There were also several failures to record the strength of medication given to people and medicines went missing from stock.
Deb Holland, 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 the family and, like them, hope this case prompts other care home operators and managers to review their medicine management systems to better ensure people’s safety".
“It is vital that care services accurately record the medicines people are given and that, when these run out, they make every effort to replenish stocks to ensure people continue to receive the right treatment and are not left at risk of harm. Our inspectors were shocked by what they found at Coton Hill House".
“It was the serious and repeated failures in the home’s management of medicines that led to CQC’s prosecution of the provider, Coverage Care Services Limited, and the home’s registered manager".
“As the registered provider and home’s manager, Coverage Care Services Limited and Alison Gough had a specific legal duty to ensure care and treatment was provided in a safe way. Following the death of this Service User we found they had failed to do this by not ensuring medicines were managed in a safe way".
“If we find that a care provider has put people in its care at serious risk of harm, we will consider holding them to account using our powers to prosecute."
Sadly, as something we now hear all too much about this is a clear breach in Safeguarding
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.
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