Care Home Health related deaths

Action Taken (AI summary) The CQC has taken regulatory actions by requiring the care home to submit an action plan, conducting a focused inspection, publishing an 'Inadequate' rating report, and issuing a Warning Notice regarding record keeping and care plan compliance. They will continue to monitor the service closely. Mulberry Court Care Home has implemented new systems and processes for record keeping and care plan compliance, including an enhanced staff training programme and updated care plan templates and risk assessments. They have also strengthened clinical oversight and communication processes following hospital discharge.

Action Taken (AI summary) Bank Close House has instructed staff to request a blood glucose test from external healthcare professionals if a diabetic resident shows signs of illness and has asked GP surgeries to provide each diabetic resident’s HbA1c level.

Action Taken (AI summary) The agency has reinforced guidance to staff clarifying that wound care is outside their scope, issued formal reminders about escalating clinical concerns, and reviewed supervision processes to ensure adherence to scope-of-practice boundaries.

Action Taken (AI summary) Westwood Hall Nursing Home has adopted an approach of referring any resident who has fallen to the Falls Team, regardless of the circumstances, and staff have been made aware of this. Springcare are reviewing their Falls Policy and implementing a system to chase up referrals made to the Falls Team.

Action Taken (AI summary) NHS Lancashire and South Cumbria ICB has changed and refined processes for sharing information when transferring patient funding to ensure all relevant details are shared with receiving ICBs. They now make clear to care providers when responsibility has transferred and hold weekly internal case progression meetings.

Action Taken (AI summary) The care home has issued refresher guidance to staff on existing policies, emphasizing documentation of hospital communications, and implemented enhanced observations for unstageable pressure ulcers. They've also implemented a sepsis risk assessment for residents with chronic wounds and conduct regular audits of wound care entries. A Trust-wide alert was issued on 20 November 2025 regarding Transfer of Care documentation, ensuring two copies are printed. A Trust-wide audit will take place in February 2026 to check for documentation in patient records and a task and finish group will work on improving the quality of the discharge checklist starting January 2026.

Action Taken (AI summary) High Meadows Care Home provided staff training on catheterisation, documentation, and escalation, updated care plans to reflect the coroner's concerns, and reconfigured the telephone system to ensure calls are answered promptly. They have also ensured that portable phones are available in each unit, supported by several signal amplifiers installed throughout the home. High Meadows Care Home has created and implemented an escalation protocol for team leads, effective 23/10/2025, to ensure prompt and effective response to clinical or safety concerns.

Action Taken (AI summary) The care home revised its policy regarding new residents who are out of district with their own GP to register them with a local GP. In addition, a new audit has been developed on the company's digital systems which is completed 48 hours after the resident is admitted.

Action Taken (AI summary) Care UK has reinforced training, updated documentation, emphasized communication requirements, and improved medication knowledge among staff. They have updated the care home's contact list to include on-call numbers for team leaders and emphasized the need for hospital staff to ensure its return with the resident on discharge.

Action Taken (AI summary) Oak Tree Mews Care Home has implemented changes including a new manager, full pre-assessments, updated care plans, a senior lead appointment, protected lunch times, dining area layout changes, amended staff lunch breaks, visitor declarations for food, a digital signing in system and staff First Aid Training.

Action Taken (AI summary) Care UK has updated its admission checklist, care plan forms, and audit processes to ensure pre-admission assessments for bed rails are completed and documented, and that care plans are comprehensive and up-to-date. They also clarified falls management and prevention policy and high/low beds should be considered as an alternative to bed rails.

Action Taken (AI summary) The care group has implemented several changes, including revising its admissions policy, conducting mandatory training on challenging behaviour, implementing a new PCS training schedule, and conducting internal and organizational audits of care documentation. They also have updated the homes E-learning resources to cover updated expectations.

Action Taken (AI summary) Ashton Lodge Care Home has already implemented several changes including conducting medication reviews, introducing structured rotas for staff in lounges, providing refresher training on falls prevention, and conducting daily supervision briefings. A full review of communal area layouts is underway.

Action Taken (AI summary) Aspray House has implemented multiple changes including revising policies, providing staff training, purchasing equipment (defibrillator, anti-choking vest, pictorial choking first aid posters) updating care notes, and creating a flow chart for emergencies. They have also removed the management involved in the incident.

Action Taken (AI summary) Alexandra Homes has updated their Report on Action Taken to Prevent Future Deaths, building on a previous report. Actions include introducing a new resident observation record, revising the client referral form, and implementing a compatibility profile and impact assessment.

Action Taken (AI summary) The care home implemented an action plan addressing management of falls, record keeping, and staff training, including fall prevention training and training on the Care Docs Portal. The manager who was in post prior to September 2024 returned to her role as Care Home Manager in May 2025.

Action Taken (AI summary) Maven Healthcare has implemented mandatory post-incident debriefing, created an organizational lesson learned document, and reviewed policies/procedures for bed rails and falls risk management, and implemented an electronic care planning system. Staff refresher training on falls prevention was completed in January 2025, and electronic care planning was implemented in January 2025 and fully embedded by the end of March 2025.

Action Taken (AI summary) The council's Health and Safety team reviews incident reports for environmental factors contributing to falls, contacts care homes to investigate and make recommendations, and reports trends to the Adult Social Care Management Team. They also ensure that environmental risks are addressed alongside individual care plans.

Action Taken (AI summary) Red Oaks Care Home has strengthened processes for pressure management care, including additional training, increased monitoring by senior staff, and alterations to the notification process for serious injuries to involve the Operations Manager.