Investigation into care home death finds CQC and council were slow to act


An investigation into the death of a 95 year old care home resident who died of hypothermia following the failure of its boilers has said the CQC and council were slow to respond to the situation.

The woman, who was referred to as Mrs E, was believed to have been a resident at the Pine Heath Care Home in Holt, Norfolk, which was closed by its owner, Diamond Care (UK) Limited in May last year, the Eastern Daily Press reported.

Joan Maughan, chair of the Norfolk Safeguarding Adult Board, said: “Ms E sadly died of pneumonia and hypothermia in November 2016 and it is clear from this review that there were failures in health and safety standards at the care home where she was living.”

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The report documents how the home’s two boilers failed in summer and October 2016 so that residents were without hot water and heating for a number of weeks.

It found that the CQC and Norfolk County Council made a “slow start” in responding to the situation, adding that agencies were hampered by the attitude and responses of the care home owner.

Ms Maughan added that care agencies could have “worked more effectively together, followed up concerns more robustly and used professional curiosity to challenge each other and the owner”.

Restrictions were imposed on new admissions to the home and a proposal was made to cancel its registration before its closure in May 2017.

The CQC rated Pine Heath ‘inadequate’ in a report published in July 2017 following an inspection in March of that year.

James Bullion, executive director of adult social services, said: “As a council we do not have any enforcement powers but we do monitor care quality as part of our contracts with providers and we can and do arrange alternative care for residents where there are serious concerns about quality or safety. With more than 360 care homes in the county, looking after about 9,000 residents this is a significant task.

“In this case we visited the home to seek assurances that steps were being taken to keep residents warm and safe. However, we could have looked for more evidence that these steps were being carried out.”

The council said it was examining how it could strengthen its Quality Assurance team so that it could increase monitoring,

A CQC spokesperson said: “CQC was part of the review regarding the death of a lady who had been receiving care in Norfolk and we are aware of the outcome published by Norfolk Safeguarding Adults Board.

“We have examined what happened in this case and are working with the local authority to ensure that any lessons from the review are learned. Our sympathies are with the family of the lady who died.”

Tags : CQCDeathInadequate
Lee Peart

The author Lee Peart


  1. Just another example of why CQC doesn’t work: too late, too remote, too busy with things that don’t matter. Inspection has to be local, responsive, and relevant to what really matters.

  2. Yes, Maurice, inspectors and regulators need to understand what they are looking at and believe that residential care can be a “positive choice”. (This year is the 30th anniversary of “A Positive Choice” – the Wagner Report.”

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