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18th July 2022

CQC urges care providers to assess and manage risks effectively

The CQC is warning care providers of their duty to assess and manage all risks to ensure people are kept safe.

The appeal comes after a care provider was fined more than £1,500,000, after failing to meet a resident’s nutritional and hydration needs and protect them from avoidable harm in 2018.

The provider was fined at Crawley Magistrates Court last month (June). It was also ordered to pay a £170 victim surcharge and £27,000 costs to the Care Quality Commission (CQC) which brought the prosecution.

The case centred around a male resident (MC) who was admitted to the care home after being discharged from hospital. While at the hospital, he was referred to a speech and language therapist (SALT) who advised he was at risk of choking and needed a special diet of soft foods.

No choking risks identified

Risk assessments were carried out by the provider but did not identify any choking risks, in addition, a care plan was amended to state that the MC ‘eats a normal diet and drinks normal fluids.’ A choking risk assessment was completed and, again, no choking risks were identified.

On 20 May 2018, the resident was having lunch at the dining room table, when he started to choke and became unresponsive. A post-mortem found he had eaten large pieces of meat and concluded the cause of death was choking on food.

It was found that staff did not understand how to prepare the correct diet or to safely support the resident to eat and drink. The service also failed to maintain accurate care records and the advice of the SALT was not fully incorporated into the resident’s care plans and risk assessments. He was therefore given unsafe and inappropriate foods from the time of his admission until his death.

The provider pleaded guilty to failing to provide safe care and treatment to MC, resulting in him being exposed to significant risk of harm which ultimately led to his death.

A tragic death

Hazel Roberts, CQC head of inspection for adult social care, said: “Our sympathies are with MC’s family following his tragically needless death. [The provider] failed in its legal duty to protect him from being exposed to significant harm.”

She added that the majority of care providers do an excellent job but said the CQC will take action against providers who put people in their care at risk of harm.

“I hope the outcome of this prosecution reminds care providers of their duty to assess and manage all risks to ensure people are kept safe”.

*All information is correct at the time of publishing. Use of this material is subject to your acceptance of our terms and conditions.

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