Care provider fined after resident put at 'significant risk of avoidable harm' at Lent Rise House care home

06:35PM, Wednesday 03 February 2021

A care provider has been fined for failing to provide safe care and treatment and exposing a resident at Burnham’s Lent Rise House to ‘significant risk of avoidable harm’.

The Fremantle Trust, based in Aylesbury, which provides care and support in a number of counties including Buckinghamshire and Berkshire, was fined £2,000 and ordered to pay £7,000 in prosecution costs on Monday, February 1 at High Wycombe Magistrates Court.

The prosecution was brought by the Care Quality Commission (CQC).

The care provider pleaded guilty for failing to provide safe care and treatment and exposing Lent Rise House resident John Widdall to ‘significant risk of avoidable harm’, in December 2017.

The court heard that Mr Widdall suffered from tetraplegia due to an incident which happened at Slough’s Wexham Park Hospital where he was ‘insufficiently assessed and cared for’, after a fall at a previous care home.

The tetraplegia left him at risk of choking on his saliva and other substances and he also had advanced dementia.

Upon his admission to the care home in Coulson Way, a nursing support plan was completed, stating that Mr Widdall required oral suctioning to remove any excess saliva and other secretions to stop him from choking.

This procedure was only supposed to be carried out by nursing or care staff who had been appropriately trained.

All new staff members and agency staff were required to complete an induction on their first day and sign a form confirming they had done this.

Mr Widdall’s wife was visiting him at Lent Rise House on Saturday, December 16, 2017, when she saw an untrained agency worker attempting to suction her husband’s mouth and intervened to stop it.

The next day, the care provider notified the CQC about this incident and a decision was made to prevent the agency worker from working at the care home in the future.

All staff were also sent a reminder that certain tasks should only be performed by individuals who were ‘appropriately qualified’.

The Care Quality Commission said there was no evidence that the agency worker in question had completed an induction or that they had read the care plan for Mr Widdall, or been trained to carry out the suctioning procedure.

The Fremantle Trust appeared at High Wycombe Magistrates’ Court on Thursday, October 15 last year and entered a guilty plea to the single offence of failing to provide safe care and treatment.

Rebecca Bauers, head of adult social care inspection in CQC’s south region, said: “Every person using care services deserves to receive good quality, safe care and to be protected from avoidable harm. In this case, Mr Widdall was placed in a situation that could have put him at risk of harm had it not been for his wife’s timely intervention.

“As with all care providers, The Fremantle Trust has a legal duty to ensure that care and treatment are provided in a safe way. On this occasion, it failed to do so because it did not ensure that all staff were aware that only appropriately qualified and trained personnel could use the oral suctioning equipment.

“Where we find that a care provider has put people in its care at serious risk of harm, we will always take action to ensure that people are safe and hold providers to account.”

Sara Livadeas, chief executive at The Fremantle Trust, said: “We are sorry that this incident involving an agency worker occurred in one of our care homes in December 2017.

“We want all of our residents to receive the best possible care at all times.

“We have reviewed our processes to make sure that such an event does not happen again and have also significantly reduced the use of agency staff.

“I am pleased to say the Lent Rise House is rated Good by CQC on all 5 criteria.”


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