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What should happen to a care manager whose poor performance put residents at risk?

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A case study showing an example of how poor management and record-keeping led to a nurse being the subject of a Nursing and Midwifery Council fitness to practise hearing

The charge 

Nurse A did not ensure an adequate standard of care was provided to residents. For one resident, leg dressings were not changed as often as required, or documents did not support that this had been done, and their mobility care plan had not been reviewed since 2015. In addition, the resident was discharged from the hospital with MRSA but this was not effectively communicated to staff and the need for infection control procedures was not emphasised.

The background

Nurse A was employed as the manager of a care home. In 2016 unannounced

Care Quality Commission inspections highlighted significant failings and raised concerns with Nurse A’s practice. The inspections found that the measures in place did not meet the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Care and treatment were delivered in ways that exposed service users to significant risks to their health, safety and welfare, and support staff lacked the information to deliver safe and effective care.  Care was not respectful and did not uphold the dignity of service users.

Documentation relating to medicines management for 16 service users was reviewed and ineffective procedures that placed those residents at risk of harm were found. There was a wide range of issues, including: poor records of medicines administration; medication being out of stock; service users going for long periods without medication; out-of-date medication being used, and issues with medication being administered covertly.

The service was rated ‘inadequate’ and placed in special measures.

At the hearing

Nurse A admitted all of the charges. Nurse A accepted responsibility for her failings, particularly in relation to the poor management of care plans, standards of care not being met and inadequate measures in place. She informed the panel that, despite her frequent and repeated verbal requests for more staff, and resources for staff training, she was told there was no money for this.Nurse A said she had reflected on her actions and she felt deep regret for her conduct.

She stated that if she found herself in a situation

in which patient safety was compromised, she would immediately report her concerns to her line manager and, if the response was inadequate, she would go to the relevant authorities. 

The panel determined that Nurse A’s conduct breached the Code. The panel noted at no point did Nurse A undertake a formal staff capacity assessment. 

In the panel’s judgement, registered nurses are personally accountable for their nursing practice and have an individual responsibility and overriding duty to patient care. 

The panel determined that Nurse A’s actions fell significantly below the standard required of a registered nurse and therefore amounted to misconduct. 

The panel took into account that Nurse A made admissions to the charges from the outset, accepted responsibility for her failings, that she had engaged positively with the NMC’s regulatory process, and that she had reflected on her failings and demonstrated insight and remorse. 

The panel took into account that she had been practising as a registered nurse since the incidents without any concerns and

it noted the positive references submitted on her behalf. The panel determined that the likelihood of repetition of Nurse A’s misconduct was minimal.

Results of the fitness-to-practise panel


The ftp panel can impose four different sanctions: 

  • Caution: the nurse or midwife is cautioned for their behaviour, but is allowed to practise without restriction

  • Conditions of practice: this will prevent a registrant from carrying out certain types of work or working in a particular setting, it may require them to attend occupational health or do retraining. The order can be applied for up to three years and must be reviewed by an FTP panel again before expiry
  • Suspension: the nurse or midwife will be suspended from practice for a period of initially not longer than one year, but this can be extended after review by an FTP panel

  • Striking off: a nurse or midwife is removed from the register and not allowed to practise in the UK. The nurse or midwife must apply to be readmitted to the register

Share what you believe is the right action for the NMC panel to take below and then find out what they decided: Final panel decision and reasons

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