The Health & Safety Executive publishes a very sad story here and it is indeed a message to all those – including care providers – who fail to understand the importance of systems, care plans, risk assessments, record-keeping, staff training and communication. To mention but a few.
“The UK’s biggest care home provider has been ordered to pay £170,000 in fines and costs after a vulnerable resident choked to death on fish and chips during an entertainment evening at its Chorley premises.”
“The company, of Groves Road in Douglas, Isle of Man, was fined £125,000 and ordered to £45,000 towards the cost of the prosecution.”
“Our hope is that the seriousness and financial implications of this case for the company will ensure that nothing like this will ever happen again at a Four Seasons or any other care home. This would mean that Rita’s tragic death will not have been entirely in vain.”
Care in the UK 
This had baffled me since the story was first published. Were those on hand to help for the entertainment evening not the usual care and nursing staff from the main part of the home?
Care is care, and the ‘usual’ staff have a duty they can’t opt out of – and that is to communicate with all staff about the particular needs of all residents. Whether they do that at handover, verbally, or written in the records, someone is responsible for communication. Activities Coordinators also have responsibility. Problems often come with the use of Agency staff who may not bother to find out about the needs of the residents, even though they should. Healthcare assistants aren’t regulated; nursing staff are.
There was apparently no care plan and no risk assessment carried out by the care home, so their system is at fault. A vital assessment was missing – and if it’s missing, it can’t be communicated to the staff.
A tragic and sad failing by the care home. A death that could have been avoided.
On 11 February 2014, the care provider Four Seasons Health Care was fined £4000 by the CQC for failing to have a registered manager at the same care home Euxton Park. As per CQC website here:http://www.cqc.org.uk/directory/1-135674397
No I understand that poor records (or lack of) inevitably leads to poor care but what baffles me is the circumstances immediately beforehand that led to somebody handing a full plate of fish and chips to staff for Mrs Smith (and whom presumably had never prepared any of her food during the month she’d been living at the home) Whoever was unfortunate enough to have been given the food for her can’t possibly have provided Mrs Smith with care or assisted her with meals until then either.
The report refers to the incident having happened in another part of the premises used for entertainment which is why I wondered if staff there are not part of the usual care team.
It’s still appalling though I agree and I can’t understand how or why any home wouldn’t complete pre-admission assessments and have a care plan in place from the day someone steps foot through the door but the events of that day are particularly baffling.
There’s a lot I can’t understand about how many care homes function (or rather don’t function). I’ve learned a heck of a lot over the last 10 years, during which I’ve really had to deal with systems that have left me bewildered . It’s not over yet either. My hell is still ongoing, and there’s nothing I can do to shift it into gear.
It’s one learning curve I’d like all so-called decision-makers to meet and, more importantly, to understand. Too many blind eyes turned, for my liking. Call me old-fashioned if you will, but it’s all to do with standards, and as long as shoddy standards are allowed to creep in and then to exist, nothing’s going to change. Managers must manage.
Managers also turn a blind eye to what is going on, so they don’t have to deal with it. I am a registered nurse of 35 years, I have worked in every aspect/department of nursing. I thought I would take a job in a care home and wined down my nursing career as the hospitals were getting more and more stressful. Well I have never in all my career experienced such stress and frustration as I did working in this care home. Two staff finally after going to the home manager several times were sacked for gross misconduct. (I am a safe guarding trainer as well). But the final straw was over a major safeguarding incident that was happening which resulted in that person dying, I was ignored when I reported my concerns and those of the care staff and other nurses. I have never experienced such sadness and unjust in the whole of my career and when someone whistle blew to CQC they didn’t even bother to come in and investigate, they just told the manager to have a debrief meeting. So in my eyes CQC are complete waste of space. I hasten to add I left and now work as an agency nurse, I don’t I mince my words if I see that something is wrong whilst I am on duty and have raised concerns, but I have always told the managers that I was going to do this and why and quess what they have always asked me to go back and work for them when a shift was available. So to conclude don’t trust CQC go to the papers if on one takes notice.