Serious failings found at Wolverhampton care home where resident died

By Richard Guttridge | Wolverhampton | Health | Published:

An investigation into a care home prompted by the death of a resident has unearthed a series of major failings over care and safety.

The CQC found serious failings

Police launched an investigation into the death of a resident at Oaks Court House in Chapel Ash, Wolverhampton, but later concluded there was no evidence of neglect.

The home has been placed into special measures by the health watchdog, which rated it inadequate and warned it will take steps to close it down if it does not see improvement.

The Care Quality Commission (CQC) listed a raft of failings it found following an inspection of the home, on Oaks Crescent, the most serious of which surrounded fire safety and ensuring residents were protected from the risk of falls and other accidents.

It said "people had been placed at significant risk of harm".

The fire service was called in to carry out an immediate inspection of the premises, such was the alarm around fire safety practices.

The watchdog also said it had not been notified of an allegation of abuse at the home to which the police were called.

Officers were alerted after a 83-year-old woman died after suffering a head injury at the home in November last year. It had been alleged she had been assaulted by another resident but West Midlands Police said there was no CCTV, witnesses or forensic evidence to support the claim.


Further details surrounding the person who died at the home were not provided. The CQC said its inspection "was prompted in part due to concerns received about the management of falls and incidents and by a specific incident, following which a person using the service died" but as it was subject to a criminal investigation it was unable to delve further into the circumstances.

But inspectors, who visited in March, did look at other aspects of care at the home, which was given the worst possible rating of inadequate overall and ratings of inadequate for being safe and well-led. It got requires improvement ratings for being effective, caring and responsive.

Fire doors were propped open, while evacuation and fire risk assessment plans were "inadequate".

When one resident suffered a fall they were advised to use their bell to call for help, despite suffering dementia meaning they were prone to forget any instructions. Not enough was done to ensure people at risk of falling out of bed were protected, the CQC said.


Requests to go to the toilet were "sometimes ignored by staff and staff walked away as people spoke to them".


The CQC report said: "People had been placed at significant risk of harm. The provider had failed to ensure people were protected against the risk of fire. After our inspection we liaised with the fire service to address this and the provider took immediate action to reduce the risk of harm to people.

"The management of risk to people's health and welfare was poor and the measures in place did not fully reduce these risks.

"The provider had failed to ensure adequate infection control practices were followed, which placed people at risk of cross infection.

"Staff struggled to meet people's needs in a timely way during busier times of the day. Accidents and incidents were not monitored to ensure the risk of reoccurrence could be reduced and lessons learnt where needed."

A West Midlands Police spokesman said: "It was alleged the woman sustained her injury after being assaulted by another resident about a week earlier.

"We launched an investigation. However, there were no witnesses, no CCTV, no forensic evidence and ultimately no evidence to corroborate an assault.

"Our investigation concluded there was no evidence of neglect by any carers or the management within the home.

"The police investigation has now be filed and referred to HM Coroner."

The owner of the care home declined to comment.

Richard Guttridge

By Richard Guttridge
Investigations Editor - @RichG_star

Investigations Editor for the Express & Star.

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