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Managing risk & accountability in care homes – a balanced exercise

Have you risk assessed? Do you know the potential cost? Sharon Dysart examines the risks facing local authorities in light of the increasing number of claims relating to accidents in care homes and the rise in pressure sore related claims. She considers how local authorities can review their systems and procedures from a risk management perspective and the documentation that should be in place.


In October 2014 the Care Quality Commission (CQC) rolled out a new inspection framework for adult social care with a focus on five key questions to be asked of all services: are they safe, effective, caring, responsive and well-led?

Between October 2014 and February 2017 the CQC completed around 33,000 inspections of 24,000 adult social care locations and found a fifth of services required improvement and a number were deemed inadequate. Of the five key areas, 'safety' and 'well-led' scored the poorest.  Notably, whilst community social care services (such as supported living and shared services) were rated the best overall, nursing homes remained the biggest concern.

Assessing the risk

Residents within a care setting are entitled to receive care that is safe and takes account of their individual needs. A risk assessment must be carried out and thereafter reviewed on a regular basis to ensure that sensible and proportionate measures are in place to control the level of risk. Reviews of the assessment will hopefully help to address whether more should be done to reduce the level of risk where a resident's needs are susceptible to change.

Common types of accidents include:

  • falls;
  • scalding/burns;
  • bedrail entrapment

It is evident that sensible risk assessment decisions should be tailored to the specific needs of each resident while still encouraging them to carry out tasks that they are able to. Put another way, the key is to make a balanced decision between managing the needs of each resident and reducing the risk of injury while maintaining their independence insofar as is possible. The whole point of a care assessment is to allow service users to live their lives as fully as possible without restricting reasonable activities.

Balancing the risk – what must be considered?

  • Real Risk?  Is the likelihood of harm realistic?  There is no point in preventing residents carrying out tasks that they can perform safely and which actually enhance their quality of life, by adopting a risk adverse attitude (some care organisations may do this for a fear of things that may go wrong or perhaps if they have already had bad experiences);
  • There has to be interaction with the service user, carer (if any) and family when carrying out a risk assessment in order to achieve outcomes that both matter to them and are manageable within a risk setting;
  • Finally, there is a need to control those risks flowing from an individual's choice by putting in place sensible controls.

Moving & Handling – risk of falling

A great proportion of moving and handling taking place within nursing homes includes assisting in person transfers, provision of treatment and in the provision of day to day care e.g. bathing.

It is important that each care home has a moving and handling policy in place which will recognise the risks involved. The home should record what it is doing to reduce the level of risk, which should undoubtedly include risk assessing and the controls in place to reduce those risk areas identified. There should also be arrangements for staff training and a review of the provision of equipment and its maintenance.

A moving and handling assessment should be carried out to include details of the individual's moving and handling needs. This should identify what the individual can do independently e.g.

  • are they able to support their own weight?
  • are they at risk of falling?
  • can they assist with transfers?
  • do they need repositioning?

Secondly, there needs to follow a consideration as to what equipment is required in order to reduce the risks, for example, the number of staff required to assist with transfers, the type of chair/ bed, hoist etc. that is required. Hoists and their use is a key area. It is of utmost importance that the correct type of hoist and size of sling is used as the incompatibility of hoist and sling can result in insecure attachment between the two and a person slipping through if too large.

Thirdly, the assessment and the control measures in place should be recorded on the service user's care plan.

It is important that there are arrangements in place to monitor handling activities to ensure that correct techniques and equipment are being used. This cannot be emphasised enough when we consider that serious injury or worse can occur.

There is also the risk of falls from windows and if this risk is identified, measures should be implemented to utilise window restrictors to prevent windows being opened wide enough to enable a resident to actually climb through.


In relation to burns and scalds it is important to note that burns can also occur on hot pipes and radiators (not just from hot water) and thus it is crucial to consider this when undertaking a risk assessment. Mobility will play a key factor in determining how quickly an individual will be able to react to hot water/hot surface and thus control measures are likely to include setting temperatures so that they cannot cause burns/scald injuries.

Bedrail entrapment

It is important that mattresses are properly fitted where bed rails are fitted so that there are no gaps to avoid the individual becoming trapped.

Pressure Sores

Care homes must be aware of the risks of persons residing with them developing pressure sores (bed sores).

Pressure sores can occur quickly especially where a person's mobility has been affected. It is important that medical advice is sought as soon as possible as if left untreated, pressure sores will develop and grow in size and may need surgical intervention.

Specialist equipment (mattress, repose cushion etc.) should also be provided as soon as possible and while it is vital that repositioning is carried out regularly, it is of utmost importance that this is properly documented on the person's file. In those circumstances, where the NHS is providing medical care in a care home setting, it is important that all records are accurately kept up to date on the person's file. Failure to do so means that the care home is unable to evidence that they have complied with policy and medical instruction and will leave themselves open to litigation.

Damages for personal injury arising from pressure sores can prove to be a costly exercise ranging from a few thousand pounds for a Grade 1 pressure sore to around £20,000 for a Grade 4 pressure sore. It ought to be remembered that individuals can develop a number of sores and some can lead to infection and damage to other areas of the body such that damages can prove to be extremely expensive.


In light of the rise in accidents occurring in care homes it is vital that internal procedures are improved and the correct documentation is in place. While this can appear to be an onerous exercise in light of resource issues and staff retention, it ought to be undertaken thoroughly when considering the potential financial burden local authorities face, incurred on costly litigation.

Sharon Dysart is a Senior Associate at DWF and acts for a number of local authorities. Should you wish to discuss any of the issues arising from this article please contact her at sharon.dysart@dwf.law or alternatively on 0759 118 9883.

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This information is intended as a general discussion surrounding the topics covered and is for guidance purposes only. It does not constitute legal advice and should not be regarded as a substitute for taking legal advice. DWF is not responsible for any activity undertaken based on this information.