Care home incident, audit systems
58 items
2 sources
Systems for audits, incidents, and accidents monitoring in care homes are not fully embedded or mature.
Cross-Source Insight
Care home incident, audit systems has been flagged across 2 independent accountability sources:
1 inquiry rec
57 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (57)
Bonita Cleary
Concerns: A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Pending
Ronald Nelson
Concerns: Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
Overdue
Alan Peet
Concerns: A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, leading to poor documentation and compromised care.
Overdue
Richard Worswick
Concerns: Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home also lacked an escalation policy for such unclear care plans.
Response: Bamford Grange Care Home has issued refresher guidance on existing policies for re-admission and wound care monitoring, ensuring all calls to external teams are documented (including unsuccessful ones with mitigation …
Response: Stockport NHS Foundation Trust has issued a Trust-wide alert (20 November 2025) requiring two copies of Transfer of Care documentation to be printed: one for the patient and one for …
Responded
Margaret Taylor
Concerns: A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care home staff, risking future deaths.
Responded
Stephen Lawrence
Concerns: A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home manager, indicating an ongoing risk to residents.
Responded
Vera Fortey
Concerns: Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.
Responded
Sonia Sore
Concerns: The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed rails.
Responded
Javed Iqbal
Concerns: Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and did not follow GP advice, compounded by inadequate post-death investigation and training.
Responded
June Phillips
Concerns: Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure to learn from incidents and properly monitor patient deterioration.
Responded
James Siddons
Concerns: A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning from the incident and future death prevention.
Responded
Sheila Nicholls
Concerns: The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient and performed by untrained staff.
Responded
Sylvia Prichard
Concerns: The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues were compounded by ineffective oversight and auditing.
Responded
Alfred Sparrow
Concerns: Care home staff failed to provide necessary assistance with food and fluid intake and made false care note entries, indicating a systemic failure that jeopardises resident safety.
Responded
Frederick Boyd
Concerns: Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures for deteriorating patients created significant safety risks.
Responded
Sylvia Nash
Concerns: Insufficient understanding and communication between agencies regarding multi-disciplinary decision-making for patient care, particularly observation removal, led to confusion over responsibilities and incorrect procedures.
Responded
Irene White
Concerns: Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative measures like TED stockings, and inadequately mobilized her post-discharge.
Overdue
Jennifer Rackley
Concerns: A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, and involved staff could not be identified.
Overdue
Beryl Ellison
Concerns: Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's fatal overdose of oxycodone.
Overdue
Dorothy Spiby
Concerns: A resident's fall incident was poorly documented, not investigated, lacked a formal incident report, and showed no evidence of learning to prevent future occurrences.
Responded
Colm McCabe
Concerns: Care home staff failed to follow policies on recruitment, training, and patient reviews. Ineffective auditing missed significant care omissions, and investigations lacked candour.
Overdue
Karen Redding
Concerns: Care staff failed to check medication contents upon request and did not ensure a doctor's review after the resident disclosed an overdose, despite her declining help.
Responded
Henry Doll
Concerns: Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.
Overdue
Tripta Bhanote
Concerns: Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced care teams, and accurate identification of Do Not Attempt Resuscitation (DNAR) status.
Overdue
Eldine Lashley
Concerns: The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately recorded the frequency of checks performed.
Overdue
Catherine Jux
Concerns: A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, which staff did not notice, indicating an inadequate auditing process.
Overdue
Pauline Brumfitt
Concerns: The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and neglecting timely reporting or investigation of incidents.
Overdue
Rachel Johnston
Concerns: The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, investigating, or suspending staff misconduct.
Overdue
Clara Freeman
Concerns: Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, accurate medical recording, and awareness of post-fall complications.
Responded
Margaret Greenacre
Concerns: The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely missed. Record-keeping was very poor, hindering staff's understanding of resident needs.
Responded
Marion Glover
Concerns: Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was unsuitable for confused residents, posing a wandering risk.
Responded
Edward Mallaby
Concerns: The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls detection. Observation protocols were unclear, and no rapid learning exercise followed the incident.
Responded
Peter Howarth
Concerns: The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.
Responded
Norman Baxter
Concerns: No specific concerns were detailed in the provided text for this report beyond a general statement of risk.
Responded
Elaine Renshaw
Concerns: Inadequate controlled drug check processes in care homes resulted in unaccounted drugs and inaccurate stock sheets, highlighting a national lack of clear guidelines for controlled drug handling and recording.
Overdue
Keith Whetton
Concerns: The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.
Responded
Barry Liffen
Concerns: A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.
Overdue
Arnold Ward
Concerns: Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There was no system to follow up on unresponsive referrals.
Responded
Dylan Henty
Concerns: Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication compliance systems, and inconsistent reporting/monitoring for absconding incidents.
Responded
Margaret Melia
Concerns: There was an inadequate discharge and pre-assessment process between care homes concerning the requirement for subcutaneous fluids.
Overdue
Patrick Kelly
Concerns: Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care needs.
Responded
Yong Hong
Overdue
Sophie Bennett
Concerns: The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.
Overdue
Ruth Gregory
Concerns: Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.
Responded
George Goldby
Concerns: Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.
Responded
Lea Hunsley
Concerns: The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.
Responded
David Sketchley
Concerns: The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Responded
Mildred Griffiths
Concerns: The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing lesions and uses an inverse scoring method.
Responded
Geoffrey Spencer
Concerns: A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.
Responded
Robert Davidson
Concerns: Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour was not transferred between facilities.
Responded
Norman Beard
Concerns: Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.
Overdue
Rebecca Gilbank
Responded
Marie Quinn
Concerns: Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to query excess medication.
Overdue
Jean Gillespie
Concerns: Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.
Responded
Peter Furness
Concerns: The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.
Responded
Derrick Rivers
Concerns: The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Overdue
Shona Campbell
Concerns: Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had access to ligatures, and risk assessments were not properly updated.
Pending