Last week, the CQC issued a press release announcing that a Nottinghamshire care home had been fined over £150,000 for failing to protect its residents from avoidable harm, after a resident with a history of problematic and aggressive behaviour caused another resident to fall and sustain a head injury.

After taking the matter to Nottingham Magistrate’s Court, it was found that the service had not acted adequately to protect the victim and other residents from the risk posed and had failed to resolve issues that CQC had raised following two inspections of the home in the year before the incident – such as responding to risk and improving care plans for residents who challenged the service.

The care providers ultimately pleaded guilty to failing to provide safe care and treatment to the victim and to exposing other residents to a “significant risk of avoidable harm” due to their inadequate management of the known threats to the residents’ safety.

It’s an upsetting incident that not only serves as a cautionary tale, but - expensive fines aside - also highlights the very human costs of failing quality assurance and risk management in a healthcare setting. It raises the question of why the care providers missed so many chances to improve and resolve the safety issues that the CQC had raised.

The fact that they had been put on notice at least a year before the incident shows that this wasn’t an unfortunate one-off lapse, but rather a continued and systemic failing. How could it be that the risks went unmanaged, even when they’d been highlighted so clearly? Why were critical actions not undertaken to make the changes the CQC had mandated? How was it that the care provider did not ensure that what needed to get done was actually done - especially in a matter as fundamental and crucial as resident safety?

Questions like these underscore the critical need for a clear and robust quality assurance system that not only highlights where things are going wrong, but also helps healthcare providers ensure that they do something about it. With such a system in place, it would have been far easier for them to make assurance a daily part of everyone’s roles, to identify where safety management was inadequate, plan the necessary actions, assign them to the relevant front-line staff and track compliance.

Without a joined-up system in place, planned actions can go unmonitored, standards can slip, staff can be unsure of what needs to be done and when…and unfortunate yet entirely avoidable incidents are more likely to happen.

It’s all too easy to forget that quality assurance and risk management isn’t about ticking boxes off a list. There’s are very real human costs involved as well when it isn’t managed well.

Robert Hobbs

Chief Executive Officer

InPhase’s Chief Executive and Founder, Robert has been the visionary leading InPhase to be one of the UK's leading providers of management, governance and assurance solutions, and helping organisations align their actions and goals more easily and efficiently with InPhase's suite of integrated apps.