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Care of a disabled person in a residential care home (14HDC00007)
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(14HDC00007, 4 December
Disability service provider ~ Caregiver ~ Standard of care ~
Care planning ~ Monitoring ~ Hours worked ~ Cerebral palsy ~
Obstructive sleep apnoea ~ Epilepsy ~ Rights 4(1), 4(4)
A 20-year-old man lived three nights per week in a residential
care home and required 24-hour care because of his acute
obstructive sleep apnoea, cerebral palsy and epilepsy. He was
unable to walk and used a wheelchair. The other four nights per
week he lived at home with his parents.
One night, the man was cared for overnight by a sole caregiver
at the care home who was also caring for three other clients with
complex needs. The caregiver on duty was to remain awake during the
night, and complete client and household duties during the
On the night in question, the caregiver's shift started at 11pm.
At approximately 11.10pm, the caregiver transferred the man to his
bed. The man's night-time care plan contained information about his
medication regimen and sleep system. The caregiver was required to
check the man frequently, and record on an hourly checklist that he
had done so.
At approximately 3am, the man woke up. The caregiver left the
man on his back in bed for 10‒25 minutes before transferring him to
his wheelchair. At approximately 5am, the caregiver transferred the
man from his wheelchair back to bed, with the bed raised at the
head end, in order to perform his personal cares. The caregiver
said that he went to the ensuite bathroom to wet a flannel and,
when he came back, the man had moved so that he was diagonal on the
bed, and he was struggling to breathe. The caregiver said that he
tried to move the man back into position (lying straight on the
bed), but the man's breathing became more difficult, and he stopped
At 5.21am, the caregiver called 111 and spoke to a call handler.
The call handler was advised that a male was unconscious and not
breathing. Under the guidance of the call handler, the caregiver
performed CPR until two ambulances arrived at 5.33am. The man was
taken to hospital, where he died at 8am.
It was held that the caregiver failed to comply with the man's
night-time care plan, in that he did not attach the man's shoulder
harness after transferring him into his wheelchair, or place a
pillow under his head and shoulders after transferring him back to
bed to perform personal cares. For these reasons, the caregiver did
not provide services to the man with reasonable care and skill and
breached Right 4(1).
It was also held that the residential care home did not provide
services to the man with reasonable care and skill, as its care
planning for the man did not meet the accepted standard.
Information and training was provided at house meetings but the
care home did not have an adequate system in place to verify
whether the caregiver had accessed or received the information and
training provided when he missed house meetings. For these reasons,
the residential care home breached Right 4(1) of the Code.
In addition, the hours the caregiver was allowed to work
following a disciplinary process put at risk the clients he cared
for, including the man. Accordingly, the care home failed to
minimise the potential harm to the man and breached Right 4(4).
Adverse comment was made about the residential care home's
monitoring of the caregiver's performance.