A CARE provider and former registered manager who failed in their duty to provide safe care and treatment have been ordered to pay fines and costs totalling £45,695.

The Care Quality Commission brought the prosecution following a serious incident at Sherrington House Nursing Home, in Manningham, Bradford, in 2015. The service is operated by Lister House Limited.

At Leeds Magistrates’ Court.this week, the provider pleaded guilty to the offence of failing to provide safe care and treatment resulting in avoidable harm to one of the residents, Mrs Morag ‘Ruby’ Wardman. It was fined £40,000, ordered to pay £4,000 towards the cost of the prosecution and a £120 victim surcharge.

Catherine Carpenter, registered manager, pleaded guilty to failing to provide safe care and treatment. She was fined £750 and ordered to pay £750 towards the cost of the prosecution and a £75 victim surcharge.

The court heard how Ruby was admitted to Sherrington House Nursing Home on December 27, 2015 for 15 days of respite care. Prior to this a reddening area on her right knee that had been identified by a district nurse, when visiting Ruby at home on December 24, 2015.

The court heard further, that a dressing was applied to prevent pressure sores forming and was cleaned daily by her son and his partner. A care plan prepared by the couple, spare dressings and information about reddening area were provided to the home.

On January 12, 2016, Ruby returned home via ambulance. Her son prepared her for a bath when he noticed broken sores and severe skin damage to the front and back of Ruby’s right knee. Through January and early February, Ruby was visited and treated by several healthcare professionals. By February 10, Ruby’s condition had worsened and the pressure sores were so serious she died two days later.

A post mortem determined the cause of death was septicaemia and bronchopneumonia (inflammation of the lungs), caused by a grade four pressure ulcer of the right knee.

Prior to Ruby being admitted to the home, CQC visited the service in September 2015 to check whether improvements identified in a previous inspection had been made. Inspectors reported medicines were not managed well, inconsistencies in recording whether people were receiving pressure care in line with their care needs and concerns about the service’s ability to identify areas for improvement.

Sue Howard, deputy chief inspector of Adult Social Care, said: “Prior to Ruby staying in the home we had concerns over the care being provided, including the care of pressure areas. As a provider and registered manager, Lister House Limited and Catherine Carpenter, had a legal duty to ensure care and treatment was provided in a safe way. We found there was a lack of attention, appropriate management and understanding of responsibilities which led to this very unfortunate situation. It is an incident which need not have happened. We appreciate how distressing this has been for the family and friends involved and offer our condolences.

"Where we identify poor care, we will always consider using our enforcement powers to hold providers to account as we have done in this case."

CQC inspected Sherrington House in August 2018 and it was rated Required Improvement overall. It awaits reinspection.