Dunstable attack probe care home residents at risk of harm - CQC

Sheila Hartman, pictured in happier times

People living at a care home where an 88-year-old woman died after an alleged attack by a fellow resident were at potential risk of harm, a report said.

The Care Quality Commission (CQC) report criticised staffing levels, safety and care at Ridgeway Lodge in Dunstable, Bedfordshire.

Richard Uridge, the son of Sheila Hartman, who died from head injuries, said the report made "grim reading".

HC One, which runs the home, said it had been addressing "shortfalls".

Mrs Hartman was taken to hospital with head injuries on 2 October and died that day.

Bedfordshire Police said it was still investigating the death.

The force confirmed a second woman from the home, who was in her 90s, was also taken to hospital and was still receiving specialist care.

Richard Uridge said the report confirmed that the "home wasn't safe, effective or caring"

Inspectors rated the home as "requires improvement" in all areas, following visits on 13, 18 and 27 October.

The home, which looks after up to 61 people with long-term conditions, mostly dementia, was caring for 52 adults at the time, the CQC said.

The inspection was prompted "in part by notification of an incident following which a person using the service died".

The CQC said that the circumstances surrounding the death were not being examined in its latest report, but the incident was being further investigated by the watchdog.

"However, the information shared with CQC about the incident indicated potential concerns about the management of risk of dementia care and staffing levels," the report said.

The home would continue to be monitored and the CQC said it would "take further action if needed".

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The report found "breaches in relation to safety management, staffing, person-centred care and the leadership of the home".

It said there were staff shortages and "staff did not have effective training and competency checks in place".

The CQC said managers and the provider did not always investigate events and it found services were not always safe, effective, caring, responsive and well-led.

Staff shortages "placed people at potential risk of harm", but staffing levels had been temporarily increased following the incident.

However, it said that over the past three months, there had been fewer night-time staff than "the number the provider had defined as being safe, but no action had been taken about this".

It put people at "risk of harm, especially those who needed more support at night".

Ridgeway Lodge, on Brandreth Avenue, Dunstable, looks after adults with dementia, and was rated as "requires improvement" in two reports in 2020 and 2022

The CQC report said: "We believed people were at risk of experiencing harm and staff lacked knowledge and understanding about abuse and harm."

People in the home told inspectors they felt safe, it found.

Mr Uridge, from Shropshire, said: "The CQC inspection report makes grim reading and I'm afraid confirms what we feared all along - that the home wasn't safe, effective or caring.

"Unless action is taken, not just in this home but elsewhere too, then older vulnerable people like my mother will continue to suffer and sadly to be injured and die."

The CQC said that following the incident the managers had worked "with the police, local authority and safeguarding team".

A spokesman for Ridgeway Lodge said: "We are pleased that the CQC have recognised the steps we have taken around increasing staffing levels and note the positive feedback from residents and relatives.

"However, we recognise there are further improvements needed to meet the high standards our residents and their loved ones rightfully expect and deserve."

He added that since October it had "commenced actions and embedded new practices to specifically address these shortfalls".

Regarding the death of Mrs Hartman it said it was working closely with the relevant authorities to establish the full facts surrounding her death.

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