Shrewsbury care home and manager fined for providing unsafe care
A Shrewsbury care home owner and its former manager have been fined over £50,000 at Telford Magistrates’ after admitting they failed to provide safe care.
Coverage Care Services Limited was fined £50,000 plus a £120 victim surcharge and one of its former managers, Alison Gough, was fined £665 and a £66 victim surcharge in a prosecution brought by the Care Quality Commission.
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.
Dennis Wootton, aged 78 years, 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.
Mr Wootton 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 Mr Wootton’s 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 Mr Wootton was not given this medication for up to 30 days before he died.
Ms Ashworth said, while Mr Wooton’s 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 Mr Wootton’s 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 Mr Wootton’s death 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."
In a statement Diane Edwards, Dennis Wootton’s middle daughter, on behalf of their family said:
“My daughter Karla and I had been looking after Dad at his home for almost twelve months before he was admitted to Coton Hill House care home. Between us we visited Dad every day, cooked meals and took them over for him and his partner, who sadly died just a few weeks before we lost Dad. We would sit with them while they ate, then wash up and have a cup of tea before leaving them to settle for bed.
“Dad was a very sociable person, chatty and well liked among his friends. He and his late partner were regulars at the country and western dances in Shropshire. They used to go every week until he became unwell.
“Before Dad he was admitted to Coton Hill House he was still enjoying trips out with us; a cup of tea in the Castle in Wem, shopping in the Co-op or a meal out now and again. He was always up for anything, until things started to become difficult and awkward when his late partner also became ill.
“He always made the effort to visit all the family members before he became unwell. We’d chat with a cup of tea and he’d wander around our gardens advising us and giving us plants or cuttings. He was a passionate gardener and he loved sharing his much valued knowledge.
“Having been so close to Dad and having spent a lot of time with him during his last twelve months at his own home, moving dad into a nursing home was a hard decision to make. But his partner fell ill and was hospitalised and we found ourselves with no other choice but to find emergency respite care, so he was admitted to Coton Hill House.
“After a lot of consideration we decided it would be ideal to get dad a permanent place at the home as we didn't want to disrupt or confuse him with a further move; and he’d made a few friends already. He was also looking better, well fed, clean shaven with a new haircut. He wore clean clothes, although they were not always his and we lost a few along the way, but we thought he'd be safe at Coton Hill House. It was close by to visit, we could still enjoy trips out with Dad and he would have the benefit of staff caring for him in a safe environment. Settling Dad into the home therefore became a priority.
“Once Dad was settled we visited him two or three times a week. We were starting to think about taking him out for a pub meal or a walk but we sadly didn't get the chance.
“The last twelve months has taken its toll on us all. Funeral arrangements are hard enough on their own but the added stress of an inquest and a criminal investigation with court hearings a year on has been difficult to cope with.
“We hope this case prompts other care home operators and managers to review their medicine management systems to ensure vulnerable people are kept safe.”
