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Care UK Community Partnerships Limited faced a substantial penalty of £1.5 million at Crawley Magistrates’ Court for failing to meet a resident’s nutritional and hydration needs, resulting in avoidable harm. This fine was accompanied by a £170 victim surcharge and £27,000 in costs to the Care Quality Commission (CQC), which prosecuted the case. The care provider operates several homes, including Mill View in East Grinstead, where the incident occurred.
In April 2018, an 86-year-old male resident, referred to as MC, was transferred from East Surrey Hospital to Mill View. A speech and language therapist (SALT) had previously advised that MC was at risk of choking and required a diet of soft foods. Despite this, a subsequent choking risk assessment by a Care UK team leader failed to identify any risks, and MC’s care plans were inappropriately adjusted to indicate he could consume a normal diet. Tragically, MC choked on large pieces of meat and passed away four days after the care plan alteration.
This incident underlines the critical need for care home managers to ensure the safety and appropriate care of all residents, especially those with specific medical needs. Here are some essential steps to avoid similar failures:

Steps to Improve:

1. Adhere to Professional Advice:

Always incorporate and strictly follow recommendations from health professionals like speech and language therapists into the resident’s care plans.

2. Accurate and Thorough Risk Assessments and Care Plans:
Regularly update and review risk assessments and care plans to reflect any changes in a resident’s condition or medical advice. Ensure these assessments are thorough and take into account all potential risks.
3. Effective Staff Training:
Continuously train staff on the specific care needs of residents, including dietary requirements and emergency procedures like choking. Make sure all team members understand the importance of following the care plans designed for each resident.
4. Maintain Detailed Care Records:
Keep accurate and detailed records of residents’ dietary needs, care plans, and any medical advice received. Regular audits of these records can help ensure compliance and safety.
5. Engage with Families and Residents:
Regularly communicate with residents and their families about their care plans and any changes. Their involvement can provide additional oversight and ensure that care remains personalised and safe.
6. Implement Continuous Improvement Measures:
As demonstrated by Care UK, it is vital to learn from incidents. Improving record-keeping practices, retraining staff, and adjusting operational procedures like dining times are all steps that can significantly mitigate risks.

This case serves as a poignant reminder of the responsibilities care providers have in managing risks to ensure safety within their facilities. It is not only about compliance but about upholding a trust that families place in these institutions to care for their loved ones.

Keep it safe, keep it accuSafe!

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