Care home operators have a legal duty to, so far as is reasonably practicable, ensure the safety of their staff and residents. In order minimise the risk of failing to comply with this duty, care home operators must ensure that there is an adequate number of competent staff members working in their facilities at all times. However, for a multitude of reasons impacting the sector, there has been increasing reports of care homes across the UK being understaffed and of this, either directly or indirectly, resulting in otherwise avoidable incidents.

Two relatively recent examples from care homes in England, which highlight some of the potential consequences that can arise when operators fail to ensure safe staffing levels within their facilities, are discussed below.

Recent Cases

  1. Lifeways Community Care Limited, operator of Alstone House in Cheltenham, was fined over £495,000 in late 2021 after a resident (X) was attacked by another service user (Y). X was in their bedroom when Y entered, locked the door, and assaulted them. This resulted in X sustaining severe permanent facial injuries. The staff members who were on duty at the time (all agency workers) were unable to get into the room or contact the duty manager and so ultimately had to call the police for help. On the night in question, there should have been at least one permanent staff member on duty (who would have known the codes to access all the bedrooms in case of any incidents, as well as the location of all the bedroom keys). However, the permanent staff member who was due to work that night did not show up for their shift, and members of management did not arrange for anyone else to cover in their absence, leaving the care home inadequately staffed as a result. Cirencester Magistrates’ Court found that this was an avoidable incident caused by poor management and unsafe staffing levels. The Care Quality Commission (CQC) have said that they "hope this prosecution reminds care providers that they must always ensure people’s safety and manage risks to their wellbeing".
  2. Chiltern View Care Home, based in Bedfordshire and operated by Benslow Management Company Limited, recently received negative publicity in the national news after a CQC inspectors' report, published in late 2022, found that residents had been put at risk of harm due to staff shortages. According to the report, residents' basic care and support needs were not being attended to due to there not being "enough staff". Examples were given of certain residents frequently being left for over 18 hours without being offered any food and of others being left "in wet clothing" or "naked in their bedroom waiting for care". It was also reported that medication was not being managed safely at the home and that too much reliance was being placed on agency staff. Chiltern View is now being closely monitored by the CQC and is currently prohibited from taking in any new residents.


The Scottish Parliament has recently passed the Health and Care (Staffing) (Scotland) Act 2019 which puts the duty of care home operators to ensure safe staffing levels into statutory form. The legislation, which is due to be fully implemented by 2024, will also give the Care Inspectorate more powers to monitor and regulate staffing levels within care homes. It would therefore be prudent of care home operators to look at their staffing arrangements now and take steps to rectify any problems that are identified.


Although, in the current climate, staff recruitment and retention is challenging - adequate staffing remains essential to ensuring compliance with legal duties and reducing the risk of incidents. That said, simply having adequate numbers is not enough. Permanent and temporary staff also need to be competent and well equipped to manage risks and deal with potential incidents. All staff should be appropriately trained and familiar with the care home's policies, procedures and risk assessments. In addition, knowledge sharing in relation to service users' needs should be facilitated and managers should be easily contactable should any issue arise. For further comment on this please follow the link to a previous blog.


Lynn Livesey

Legal Director

Laura McMillan

Partner & Director of Advocacy

Stephen Kirk

Trainee Solicitor