Care home incident, audit systems
Systems for audits, incidents, and accidents monitoring in care homes are not fully embedded or mature.
317 items
8 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
90match
Rosecroft Residential Care Home
The provider must send CQC a report detailing the action they are going to take to ensure compliance with Regulation 18 Registration Regulations 2009 regarding notifications of other incidents.
Matched on
terms: care, home, incident
CQC action
86match
Roky Care Ltd
The provider must ensure effective auditing systems are in place to identify areas of improvement.
Matched on
terms: audit, care, system
PFD report
85match
Arnold Ward
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.
Matched on
terms: care, home, system
PFD report
81match
Derrick Rivers
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.
Matched on
terms: audit, care, home
PFD report
81match
Peter Furness
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.
Matched on
terms: care, home, incident
PFD report
81match
Peter Howarth
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.
Matched on
terms: care, home, incident
PFD report
81match
Edward Mallaby
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.
Matched on
terms: care, home, incident
PFD report
81match
Pauline Brumfitt
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.
Matched on
terms: care, home, incident
PFD report
81match
Colm McCabe
Care home staff failed to follow policies on recruitment, training, and patient reviews. Ineffective auditing missed significant care omissions, and investigations lacked candour.
Matched on
terms: audit, care, home
PFD report
81match
Margaret Greenacre
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.
Matched on
terms: care, home, incident
PFD report
81match
Beryl Ellison
Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's fatal overdose of oxycodone.
Matched on
terms: care, home, system
PFD report
81match
Sylvia Prichard
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.
Matched on
terms: audit, care, home, system
PFD report
81match
Sheila Nicholls
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.
Matched on
terms: care, home, incident
PFD report
81match
James Siddons
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.
Matched on
terms: care, home, incident
PFD report
81match
June Phillips
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.
Matched on
terms: care, home, incident
CQC action
81match
Copperfields Residential Home
There are audit processes and other systems in place but these are not robust enough to assess, monitor and continually improve the service.
Matched on
terms: audit, home, system
CQC action
81match
Barton Park Nursing Home
Oversight was not being managed appropriately as there was no registered persons who were accountable for the day to running of the home. Auditing and record keeping was poor, and there were numerous gaps and inadequately recorded information regarding people's care needs.
Matched on
terms: audit, care, home
CQC action
81match
Ivydene Care Home
They told us a member of staff had been given this responsibility during 2016 and they would make sure that these audits were recorded in the future to show where improvements were needed where required.
Matched on
terms: audit, care, home
LGO / SPSO decision
74match
PSOW-202106081 - A Care Home
Mrs A complained about the actions of Aneurin Bevan University Health Board (“the Health Board”) in relation to the care provided to her late mother, Mrs B. Specifically, Mrs A complained that Mrs B’s needs (as set out in her Care Plan) were not met, there was a failure to ensure appropriate assessments were undertaken in a timely...
Matched on
terms: care, home
LGO / SPSO decision
74match
24-006-556 - Ideal Care Homes Ltd
Summary: Ms A and her sister Ms B complain that the care provider gave notice on their late father’s placement without due reason and they had to find another placement at short notice for their elderly father who has dementia. The care provider failed to meet Mr X’s needs and gave notice inappropriately; the care provider agrees to...
Matched on
terms: care, home
PFD report
73match
Dylan Henty
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.
Matched on
terms: incident, system
CQC action
73match
Orton Manor Nursing Home
Implement overall analysis of accidents and incidents to identify any trends or patterns.
Matched on
terms: home, incident
PFD report
69match
Jean Gillespie
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.
Matched on
terms: care, home
PFD report
69match
Robert Davidson
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.
Matched on
terms: care, home
PFD report
69match
Mildred Griffiths
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.
Matched on
terms: care, home
PFD report
69match
Sophie Bennett
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.
Matched on
terms: care, home
PFD report
69match
Ruth Gregory
Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.
Matched on
terms: care, home
PFD report
69match
Margaret Melia
The report cites inadequate discharge and pre-assessment processes between Lakeview Care Home and Dovetail Care Home regarding the requirement of subcutaneous fluids.
Matched on
terms: care, home
PFD report
69match
Keith Whetton
The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.
Matched on
terms: care, home
PFD report
69match
Elaine Renshaw
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.
Matched on
terms: care, home
PFD report
69match
Rachel Johnston
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.
Matched on
terms: care, home
PFD report
69match
Catherine Jux
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.
Matched on
terms: audit, home
PFD report
69match
Henry Doll
Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.
Matched on
terms: care, home
PFD report
69match
Javed Iqbal
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.
Matched on
terms: care, home
CQC action
69match
Aaron Abbey Care Services Limited
The registered manager's systems and processes to monitor quality and safety in the service were not established and operated effectively to ensure compliance with their legal requirements. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Matched on
terms: care, system
LGO / SPSO decision
69match
22-000-526a - Akari Care (22 000 526a)
Summary: Mr B complained about the actions of a Care Provider because he says his late mother’s rings went missing in one of its nursing homes. He also said the Council did not do enough to investigate the matter. We did not find fault by the Council. The Care Provider failed to follow its procedures as it did...
Matched on
terms: care, home
PHSO casework decision
69match
P-001447 - A care home in the Warrington area
Mrs X complains staff at a care home in the Warrington area lost her father's dentures.
Matched on
terms: care, home
PHSO casework decision
69match
P-002447 - A care home in the Birmingham area
Mr O complains that staff at the care home did not properly monitor his mother when she was moving and this led to her having several unwitnessed falls.
Matched on
terms: care, home
LGO / SPSO decision
69match
24-018-019 - Barchester Healthcare Homes Limited
Matched on
terms: care, home
LGO / SPSO decision
69match
21-005-089 - Country Court Care Homes 3 OpCo Limited
Summary: Mrs X complained on behalf of Mrs Y, about the care she received at Tallington Care Home (the Care Provider). She says Mrs Y was put at risk and when family raised concerns, staff were aggressive. We found the Care Provider did cause injustice to Mrs Y and Mrs X because staff did not always follow care...
Matched on
terms: care, home
LGO / SPSO decision
69match
21-011-877 - Longfield (Care Homes) Limited
Summary: Ms Z complained about an inaccurate invoice for outstanding care fees. Based on the information available, I intend to find fault in the actions of the Care Provider for failing to identify and prevent an accumulation of arrears. This fault has caused an injustice to Ms X, and we have proposed recommendations to the Care Provider.
Matched on
terms: care, home
LGO / SPSO decision
69match
21-004-973 - Barchester Healthcare Homes Limited
Summary: Mrs D complains about the standard of care and support her father (Mr H) received while in residential care. Among other things, Mrs D says the Care Provider failed to meet Mr H’s health and care needs and provided him medication he was not prescribed. We found some fault by the Care Provider in relation to its...
Matched on
terms: care, home
LGO / SPSO decision
69match
23-011-659 - Barchester Healthcare Homes Limited
Summary: Mrs X complains, on behalf of her father, Mr Y, Barchester Healthcare Homes Limited mishandled the pre-admission process and failed to ask relevant questions before her father moved into in the home. She says the Care Provider failed to engage with her or social services to complete a re-assessment. Mrs X also complained the Care Provider took...
Matched on
terms: care, home
LGO / SPSO decision
69match
23-020-716 - Bupa Care Homes (AKW) Limited
Summary: We will not investigate this complaint about adult social care in a residential care home. The Care Provider has accepted failings in communication and record keeping, has apologised, and has spoken with staff to improve service. It is unlikely an Ombudsman investigation would add to this or lead to a different outcome.
Matched on
terms: care, home
LGO / SPSO decision
69match
23-020-500 - Heathfield Care Homes Limited
Summary: Mrs B complains about the care home’s delay in calling an ambulance for her mother and says her mother suffered dehydration and pressure sores because of the care home’s failures in care. We have not found fault in the way the care home decided to call an ambulance or its provision of liquids when Mrs B’s mother...
Matched on
terms: care, home
LGO / SPSO decision
69match
24-020-592 - Barchester Healthcare Homes Limited
Summary: We will not investigate this complaint about adult social care during a short respite break at a care home. The Care Provider accepted some fault, apologised, offered £200, and gave staff training to improve future service. We are satisfied with its actions in response to the complaint, and it is unlikely we would achieve anything further.
Matched on
terms: care, home
CQC action
65match
B&H Care Ltd
The provider must ensure all reportable incidents and events, including alleged abuse, are reported to the Care Quality Commission (CQC) as required under Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.
Matched on
terms: care, incident
PHSO casework decision
65match
P-003058 - Care Quality Commission
Mr and Mrs B complain the Care Quality Commission failed to properly inspect the Nursing Home. The also say It failed to act on intelligence it received about the Nursing Home before the inspection and it did not take account of relevant evidence during the inspection. They also complain about its communication with them.
Matched on
terms: care, home
LGO / SPSO decision
65match
NIPSO-16874 - Belfast Health and Social Care Trust
The Ombudsman has found that the Belfast Health and Social Care Trust made a concerted attempt to resolve a complainant’s concerns about the care and treatment provided to her father while he was the resident of a Belfast nursing home.
Matched on
terms: care, home
LGO / SPSO decision
65match
21-018-569c - The Coach House Residential Home (21 018 569c)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or the Trust. The identified faults caused avoidable distress...
Matched on
terms: care, home