An adult social care provider, Yorklea Limited, has been ordered to pay £4,621.11 after admitting it failed to inform the appropriate person regarding the deteriorating health of Mrs Joan Ball (known as Bernadette) at the time it occurred, and it failed to apologise for her health declining.
The Care Quality Commission (CQC) brought the prosecution after it emerged that Yorklea Limited failed to inform Bernadette’s family about a deteriorating pressure sore as it developed, or after her death, which is a legal requirement that organisations act in an open and transparent way around people’s care.
They entered a guilty plea for failing in their CQC duty of candour under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. For this offence. Yorklea Limited was fined £1,125.00 and also ordered to pay a £112.00 victim surcharge and £3,384.11 costs.
Yorklea Limited runs Yorklea Nursing Home in Manchester, which at the time of the incident could support up to 35 people.
On 11 May 2021, Bernadette, 77-years-old, was admitted to the service after being discharged from hospital and placed on an end-of-life care pathway.
From 12 May 2021 Bernadette had redness at the base of her back which steadily developed into a pressure sore. From 28 May 2021 a nurse at the service put in place a wound care plan which required Bernadette to have pressure relief every two-hours, and a protective foam dressing to prevent it getting infected.
On 15 June 2021 it was found that there was significant tissue deterioration and Bernadette was referred to a tissue viability nurse. Then on 13 July 2021, the tissue viability nurse reviewed Bernadette again and noted that the ulcer was now a category 4 pressure ulcer with the bone visible to the base of the wound.
The ulcer appeared infected, and there were concerns with osteomyelitis (or bone infection) due to exposed bone and there was a high risk of sepsis.
On 17 July 2021, Bernadette was transferred to St Ann’s Hospice where she received palliative care. She sadly died on 26 July 2021.
The family did not receive an apology from Yorklea Limited until 8 February 2024, nearly three years after the incident.
Alison Chilton, CQC deputy director of operations in the north said:
“Our sympathies are with Bernadette’s family following this tragic death, and we were concerned that the provider Yorklea Limited, did not take the opportunity to inform the family or apologise at the earliest opportunity.
“All care providers have a duty to be open and transparent with people living in their services and their loved ones, particularly when something goes wrong, and this case sends a clear message that we will not hesitate to take action when that does not happen.
“People using any type of health or social care service have a right to be informed about all elements of their care and treatment – and all providers have a responsibility to be open and honest with those in their care.
“Yorklea Limited failed to meet that responsibility in a timely manner, which is why the CQC took this action.”
