A care provider and registered manager that failed in its duty to provide safe care and treatment have been ordered to pay fines and costs totalling £45,695 by Leeds Magistrates’ Court.
The Care Quality Commission brought the prosecution following a serious incident at Sherrington House Nursing Home, Bradford, in 2015. The service is operated by Lister House Limited.
On Tuesday 15 May 2019 the provider pleaded guilty to the offence of failing to provide safe care and treatment resulting in avoidable harm to one of the residents, Mrs Morag ‘Ruby’ Wardman. Catherine Carpenter, registered manager, pleaded guilty to failing to provide safe care and treatment.
The court heard how Ruby was admitted to Sherrington House Nursing Home on 27 December 2015 for 15 days of respite care. Ruby was dependent on support from family and carers to maintain an independent lifestyle. Prior to this a reddening area on her right knee that had been identified by a district nurse, when visiting Ruby at home on 24 December 2015.
The court heard further, that a dressing was applied to prevent pressure sores forming and was cleaned and renewed daily by her son, David Wardman and his partner Paul Harris. A care plan prepared by Mr Wardman and his partner, spare dressings and information about reddening area were provided to the home.
On 12 January 2016 Ruby returned home via ambulance. On returning home, Mr Wardman prepared her for a bath when he noticed broken sores and severe skin damage to the front and back of Ruby’s right knee. Throughout January and early February, Ruby was visited and treated by several healthcare professionals, including a GP. By 10 February Ruby’s condition had worsened and the pressure sores were so serious she died two days later.
A post mortem was performed, determined that the cause of death was septicaemia and bronchopneumonia (inflammation of the lungs), caused by a grade four pressure ulcer of the right knee.
Prior to Ruby being admitted to the home CQC visited the service in September 2015 to check whether improvements identified in a previous inspection had been made. Inspectors reported medicines were not managed well, inconsistencies in recording whether people were receiving pressure care in line with their care needs and concerns about the service’s ability to identify areas for improvement.
Prosecuting Counsel Ryan Donoghue, acting for CQC, told the court that Lister House Limited had failed to provide safe care and treatment to Ruby and exposed her to avoidable harm. The registered manager at the time, Catherine Carpenter, had failed to provide safe care and treatment to the residents, of Sherrington Court Nursing Home, from being exposed to a significant risk of avoidable harm.
Although the home was aware of Ruby’s vulnerability to developing pressure sores, no additional checks or cleaning of Ruby’s Knee had been performed. There was no wound management in place – evidence showed staff did not understand their roles and responsibilities and there was a failure to provide management oversight on admissions and readmissions to the home.
As a result of the provider’s policy and procedural errors – the area was never checked, and the dressing never changed during Ruby’s admission or discharge, Ruby’s condition was allowed to develop into irreversible skin damage which led to her health worsening and ultimately her death.
Lister House Limited was fined £40,000 for failing in its duty to provide safe care and treatment to Mrs Wardman and ordered to pay £4000 towards the cost of the prosecution and a £120 victim surcharge.
Catherine Carpenter was fined £750 for failing in her duty to provide safe care and treatment to the residents of Sherrington House Nursing Home and ordered to pay £750 towards the cost of the prosecution and a £75 victim surcharge.
Sue Howard, Deputy Chief Inspector of Adult Social Care, said:
“Prior to Ruby staying in the home we had concerns over the care being provided, including the care of pressure areas. As a provider and registered manager, Lister House Limited and Catherine Carpenter, had a legal duty to ensure care and treatment was provided in a safe way.
“We found there was a lack of attention, appropriate management and understanding of responsibilities which led to this very unfortunate situation. It is an incident which need not have happened. We appreciate how distressing this has been for the family and friends involved and offer our condolences.
“Where we identify poor care, we will always consider using our enforcement powers to hold providers to account as we have done in this case.
CQC inspected Sherrington House Nursing Home in August 2018 and it was rated Required Improvement overall. It is currently awaiting reinspection.