BUPA Care Homes (CFC Homes) Ltd has been fined £400,000 and ordered to pay costs of more than £15,000 following serious failings in its bedrail management systems in one of its care homes.
Carlisle Crown Court heard how Beacon Edge Specialist Nursing Home in Penrith, Cumbria had failed to ensure the risk management of bedrails through appropriate assessment and also failed to suitably train staff in the assessment and safe use of bedrails.
The case related to the case of an elderly patient at the nursing home who had previously fallen from bed, and subsequently suffered a severe deterioration in health, ultimately leading to her death. The company failed to ensure the patient’s bedrail assessment was suitable and sufficient, and failed to review the situation following the fall.
The reviews of the bedrail assessment should have identified further measures that could have reduced the risk of falls, but the staff who carried out the initial assessment and reviews had not been adequately trained for the purpose. Furthermore, measures identified to protect the patient were not implemented correctly, and increased checks on the resident were not carried out as instructed by a medical professional.
After the hearing, HSE Inspector Carol Forster said: “The need for adequate risk assessment and management of third party bedrails has been recognised in the healthcare sector for a number of years and guidance and advice has been published by the relevant bodies to this effect. Bedrails are used to protect vulnerable people from falling out of bed but each patient should be assessed individually and appropriate measures taken to protect them from falls from bed. Staff working with bedrails must be appropriately trained in the use of bedrails and in the patient assessment process.
“In this case there was a lack of appropriate assessment of the residents’ changing needs and review of the control measures in place to protect her. The measures that were in place were not used correctly in that the sensor pad (which would have alerted staff to the resident’s being out of bed) was not switched on. The company failed to comply with the expected standards in bedrail management and training and I hope this case will send a strong message to others with responsibilities for bedrail management.”
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