Learning From Safety Incidents: Lessons From CQC Cases for Care Homes

Learning From Safety Incidents: Lessons From CQC Cases for Care Homes

CQC publishes short case studies of real incidents and prosecutions so others can avoid them. Here are the lessons and a practical checklist to apply them in your service.

CQC’s “Learning from safety incidents” series describes critical issues, what happened and the steps providers can take to prevent them, from choking and falls from windows to hypothermia, wheelchairs, sepsis, medicines and capacity and consent. The common thread is known risks that were not assessed, acted on or communicated. Use each case to test your own systems: risk assessment, handover of specialist advice, maintenance, monitoring and escalation.

CQC says the people affected by incidents often say, “I don’t want this to happen to anyone else.” Its learning from safety incidents resources are designed for that purpose. At the time of writing the series covers 14 issues, including choking, falls from windows, hypothermia, wheelchairs, sepsis, medicines, sexual safety, capacity and consent, and denture adhesive.

This guide summarises the cases we have read, draws out the lessons and gives you a checklist to run in your own service. It supports Regulation 12 and your wider CQC compliance work. The cases are real and some involve deaths and serious injury.

Choking and Swallowing Difficulties

CQC prosecuted a care home provider in 2017 after a man with swallowing difficulties choked on porridge. A speech and language therapist (SALT) had recommended a pre-mashed diet and sitting upright, but the provider did not pass the advice on, did not review his diet and did not update his care records for six weeks. Even then it did not say how staff should support him. His SALT assessment was not sent to hospital with him, he choked again and developed aspiration pneumonia. The provider admitted failing to provide safe care and treatment.

Lessons: have detailed plans for people at risk of choking; make sure care and kitchen staff know the exact food and drink consistencies; update records immediately; send assessments with people when they go to hospital. See Regulation 14.

Falls From Windows

In 2018 CQC prosecuted a nursing home provider and registered manager after a resident, identified as at risk of panic attacks and falling, died after falling from a second-floor window with no restrictors. The last environmental risk assessment was from 2004, and no suitable individual risk assessment had been done. The provider was fined £16,500 and the manager £1,000, each with a victim surcharge. CQC says windows can be fitted with restrictors that stop them opening more than 100 mm. It also noted the service later deteriorated and was rated Inadequate.

Lessons: keep environmental risk assessments current; individually assess residents at risk; fit restrictors; check they remain in place. The registered manager had responsibility under the home’s health and safety policy, so policy must be put into practice. See Regulation 15.

Hypothermia and Heating Failure

An ambulance was called to a care home in November 2016 and found a resident with severe hypothermia and pneumonia. Both boilers had failed and her window could not close. Staff had not checked her overnight or responded to her deterioration. She died that afternoon. CQC restricted admissions and issued a notice to propose cancelling the provider’s registration, and the home closed. CQC notes older people and those with reduced mobility, mental capacity or ability to communicate are at particular risk.

Lessons: have a contingency plan for heating failure; check people at risk regularly; escalate deterioration promptly; and notify CQC where an event stops the service running safely. See notifications and urgent enforcement.

Wheelchairs and Equipment

CQC prosecuted a care home provider after a resident’s foot became trapped under a standard communal wheelchair, causing life-changing fractures. The person had an adapted wheelchair with extended footplates but staff often used the standard one. Their foot had come off the footplate on several occasions. CQC found the provider knew the risks of communal wheelchairs but did not assess and mitigate them. It pleaded guilty to failing to provide safe care and treatment.

Lessons: assess equipment risks per person; ensure equipment is fit for purpose and used correctly; act on near misses. Incidents with potential for harm matter.

Other Issues in the Series

CQC’s series also covers safe management of medicines (treatment and assessment), unsafe management of sepsis, promoting sexual safety, capacity and consent, and denture adhesive gel. Read the full cases on CQC’s site and apply the same questions. For medicines, see what to do after a medication error. For capacity and consent, see Regulation 11 and MCA and DoLS.

A Checklist to Test Your Own Service

• Specialist advice: does SALT, dietitian, GP or physio advice reach every care worker and the kitchen, and appear in care plans within days?
• Transfers: do hospital transfer packs include current risk assessments and care instructions?
• Premises: are environmental risk assessments current, and are windows, heating, hot water and fire safety checked and recorded?
• Equipment: is each person’s equipment assessed, and is communal equipment suitable for everyone who uses it?
• Monitoring: are people at risk checked regularly, with clear triggers for escalation?
• Learning: do you review near misses and incidents, share lessons with staff and re-audit?
• Governance: do managers and providers see incident trends monthly? See Regulation 17.

Making Learning Stick

Use each case as a team discussion at a governance or staff meeting and record the actions. CQCLogic’s incident log records incidents, including those with CQC and RIDDOR flags, the audit schedule tracks findings and re-audit dates, and the governance meetings module records actions. Task tracking assigns each lesson to a named person with a deadline. See how to run a governance meeting and incident management log.