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Cheltenham care home fined £495K after life-changing resident attack

A care provider has been ordered to pay £495,170 at Cirencester Magistrates’ Court, after it failed to protect residents from avoidable harm.

Lifeways Community Care Limited, which operated Alstone House in Cheltenham, Gloucestershire, was fined £460,000 in court on Tuesday 28 September 2021. It was also ordered to pay a £170 victim surcharge and £35,000 costs to the Care Quality Commission (CQC) which brought this prosecution.

Alstone House was a residential care home that supported adults who had physical disabilities, learning disabilities and some who had acquired brain injuries.

In 2017 the Care Quality Commission received information from healthcare professionals regarding the standards of care at Alstone House and undertook an inspection on 15 February 2017. The service was subsequently rated as inadequate. CQC later received confirmation that Alstone House would be closing.

A month later in March 2017, a person (VDC) who was living at Alstone House, phoned for an ambulance. The attending paramedic said it was apparent that VDC had recently physically assaulted two agency care workers.

As the paramedic was leaving the call out, they were immediately called back into Alstone House by staff. VDC had subsequently gone into another resident’s room and locked the door behind them trapping them both in the room together. The agency staff tried to break down the door to enter the room as it was apparent that the other resident (LM) was being attacked, but they were unable to do so.

After 30 minutes VDC left the room of their own volition. During this time VDC had physically assaulted LM and left them with life changing facial injuries. The paramedic immediately took LM to hospital.

On that eventing, the staff ratio at Alstone House should have been two agency staff plus a duty permanent staff member who would know all the bedroom codes and where bedroom keys were kept. However, they didn’t turn up for work that evening. When the agency staff contacted the on-call manager for support, they did not answer the duty phone, forcing the agency staff to call the police. Lifeway’s failure to properly assess the risk of being unable to obtain access to a locked bedroom led to a service user (VDC) who could be unpredictable and violent assaulting LM and seriously injuring them.

Lifeways Community Care Limited pleaded guilty to failing to provide safe care and treatment to LM, resulting in them being caused avoidable harm.

Rebecca Bauers, CQC head of inspection for adult social care, said:

“Regardless of whether a service is closing, there is an expectation that it must provide the standard of care people have a right to expect, with right levels of staffing at every available opportunity.

“Alstone House failed LM in its specific legal duty to protect them and other residents from being exposed to a significant risk of harm. It has also failed in its duty of care to the agency staff working at the service.”


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