CQC Prosecution Of Ashburton House Is A Reminder We Cannot Ignore

The Case That Frames This Piece

The recent prosecution of Ashburton House Care Home brought all of this back to mind.

At Plymouth Magistrates’ Court on 26 September 2025 the provider admitted failing to provide safe care and treatment after the death of Mr Robin Lee. The total financial penalty came to £62,340.30. Mr Lee lived with dementia, used a zimmer frame and had a known history of going upstairs. On the day of the incident there were two staff on duty. He entered another resident’s upstairs room and fell down steps, sustaining a traumatic brain injury.

I am not here to second guess every detail. I am here to talk about what this says about daily reality and what should change.

Lived Reality Of Falls In Care

I have worked in care homes since 2009, and in that time I have seen how dangerous and heart-breaking a fall can be. Managing residents at high risk of falls is never straightforward. Many are mobile, restless and determined to move about even when it is unsafe. Getting one to one support is not easy, and sometimes we need two to one to keep some residents safe.

I once wrote about an incident that happened to me personally where a resident was harmed unintentionally when I tried to help. I found myself in deep trouble with safeguarding investigations. If anyone is interested you can read it on my Medium blog.

Many times I have felt the system fails those at highest risk, especially when dementia is involved. People can be confused, disoriented and sometimes aggressive. Families may struggle to accept how risky things have become. Doctors are often reluctant to prescribe anything that might calm agitation because of concerns about chemical restraint.

On paper we say multidisciplinary. In practice we often talk more than we act together. I am not trying to avoid the responsibilities that providers and organisations must take, but sometimes policy on its own is not enough.

The Quiet Truths Of Dementia Care

Dementia care is a constant balancing act between safety, freedom and compassion. A resident can be physically strong, move with purpose and still be very unsafe. Gentle assistance can still trigger some residents, and they can become physically or verbally abusive.

Staff can be scared. Yes, there are trainings on managing challenging behaviour, but there is a reality check as the quote goes that "everyone has a plan until they are punched in the face". Trainings also tell staff to protect their own safety and to allow a controlled fall if preventing it would make things worse. Sometimes that is the least harmful option.

Staff often write brief notes in care settings. It is not because they do not care. It is because they are tired, short staffed or they underestimate the seriousness. When a multidisciplinary team reads those notes later the situation can look less urgent than it really was. Patterns vanish into noise.

Pressure, Placement And The Revenge Eviction Trap

Managers live with competing pressures. They hold the legal duty to keep people safe. They face pressure to fill beds. Assessments can be rushed. When behaviour changes it can be very hard to move a person to a more suitable setting.

I often feel there is a taboo that homes charge a lot of money and should be able to manage everything, and sometimes families work against the home rather than with it. If a manager tries to end a placement they risk accusations of a revenge eviction. They are criticised either way.

I am not talking about this particular incident because I was not there and I do not know the inner details. I am talking about general, real difficulties in preventing harmful incidents.

Suitability And Environment

When I read that the resident had tried to climb stairs before falling I asked the uncomfortable question. Was this the right environment. Would a more secure or specialist unit have reduced the risk that led to this prosecution. Some homes can close off stairwells and zone spaces. Older properties cannot always do that.

It increasingly looks like dementia care for mobile residents is safer in purpose built homes with secured units than in older buildings where stairs and layouts are harder to control. It should not be a gamble.

The Caregraph View

This tragedy is a reminder that continuous risk assessment, timely escalation and honest reflection about suitability of placement are not optional. They are essential parts of good care.

We cannot keep waiting for the next report or fine to tell us what we already know. Dementia care needs stronger collaboration, more realistic staffing models and a system that supports those who give care as well as those who receive it.