Care home safety and capacity
157 items
2 sources
Care homes failing to protect service users from risks due to inadequate premises maintenance and inappropriate admission practices.
Cross-Source Insight
Care home safety and capacity has been flagged across 2 independent accountability sources:
1 inquiry rec
156 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (156) — showing 100 most recent
Ronald Nelson
Concerns: Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
Overdue
Peter Thompson
Concerns: Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents timely escalation of deteriorating conditions.
Response: Bank Close House has strengthened documentation expectations for handovers and instructed staff to immediately request blood glucose tests from external professionals for ill diabetic residents. Blood glucose monitoring equipment is …
Responded
Jean Waldron
Concerns: An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice for carers.
Response: Ignite Health and Homecare Services has reinforced guidance to all staff, issued formal reminders on escalation procedures for clinical concerns, and reviewed existing supervision and audit processes to ensure adherence …
Responded
Ramona Harbott
Concerns: Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure sores for a high-risk patient.
Response: Barchester Healthcare has engaged a Clinical Development Nurse to provide weekly training on wound care and pressure ulcer prevention at Windmill Manor Care Home. They have also commenced implementing an …
Overdue
Dorothy Macdonald
Concerns: Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately refer to specialist falls teams.
Response: Springcare has revised falls risk assessment documentation, introduced new falls training for existing and new staff, and begun auditing assessments. Westwood Hall has also implemented a new policy to refer …
Responded
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
Abdullah Ali
Concerns: Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.
Response: Granddwell Estates confirms that an Improvement Notice was served for the property, and the required remedial works for the extensive mould were undertaken, with temporary accommodation offered to residents. The …
Responded
Brian Lloyd
Concerns: Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical intervention.
Response: High Meadows Care Home has updated its catheterisation policy, created and disseminated a new Catheter Emergency and Escalation Protocol, and provided staff training. They also reconfigured their telephone system and …
Response: High Meadows Care Home has implemented an 'Escalation Protocol for Team Leads' (Version 1.0, implemented 23/10/2025) outlining how staff must recognise, respond to, and promptly escalate clinical concerns, specifically referencing …
Responded
Gloria Simon (2)
Concerns: Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP declined and failed to consistently take, record, and act on basic patient observations.
Response: Riversdale Care Home has updated its 'Request for Care Form' to correctly identify as a 'Care Home'. They have also revised their policy to send letters to out-of-district GPs for …
Responded
Theo Treharne-Jones
Concerns: The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a vulnerable child.
Response: ABTA disputes the recommendation for additional security chains on hotel room doors, stating they could create fire safety risks and hinder evacuation, though their existing guidance allows for such measures …
Response: TUI has decided not to take any further action, disputing the recommendation for additional security measures like chains due to the unacceptable fire safety risks they believe such devices would …
Responded
Pauline Stirling
Concerns: Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite safeguarding referrals contributed to poor patient safety and persistent record-keeping failures.
Response: Malhotra Group has implemented an electronic care recording system (Nourish) which now includes specific fields for positional tilts and enhanced wound management oversight. They have also updated their Position Change …
Overdue
Beatrice Smith
Concerns: No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training or guidance, risking a repeat of inadequate practices.
Response: Harbour Healthcare Limited completed a Serious Untoward Incident Root Cause Analysis, introduced daily safety huddles, implemented Wound Care Champions, and provided comprehensive staff training on wound management and safeguarding. They …
Overdue
Marion Jones
Concerns: A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and also neglected to use a crash mat, resulting in a fall that contributed to her decline.
Responded
Maureen Batchelor
Concerns: The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing efforts, posing an unacceptable risk to patient safety.
Overdue
Margaret Douglas
Concerns: The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced carers lacked adequate communication skills and understanding of patient requirements.
Overdue
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
Raymond Jennings
Concerns: The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and could not demonstrate improved systems to prevent reoccurrence of this significant failing.
Responded
Neville McKenzie
Concerns: Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable risk of deaths from choking.
Responded
Sheila Wexler
Concerns: A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a turning system, leading to suboptimal patient care and prolonged immobility.
Responded
Diane Poole
Concerns: A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.
Responded
Paul Batchelor
Concerns: A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though briefed, are not formalized into care home policy.
Responded
James Capstick
Concerns: Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure to perform basic life checks and CPR correctly highlighted training deficiencies and lack of defibrillator availability.
Responded
Terrence Taylor
Concerns: Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate attempts to defeat them. Care home operators are unaware these standards may not provide sufficient security.
Responded
Terence Manning
Concerns: Inaccurate record-keeping, due to carers transposing details from other residents, led to incorrect dietary information for a resident, posing a risk to future patient safety.
Overdue
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
Edith Alden
Concerns: Inconsistent fall risk assessments and care plans, coupled with staff lacking clarity on mitigation, meant high-risk residents were often unsupervised in communal areas or bedrooms, leading to preventable falls.
Responded
Sandra Senior
Concerns: Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.
Responded
Blanche Knowles
Concerns: Staff lacked adequate training and clear operational communication regarding the critical importance of immediate 'cooling by running water' for burn injuries.
Overdue
Michael Pegg
Concerns: Hospital clinicians failed to apply critical NICE guidelines for adrenal insufficiency, compounded by overcrowded settings and high staff turnover, which poses a risk to patient safety.
Responded
Nicholas Cork
Concerns: Inadequate welfare check procedures, inconsistent recording, an unreliable IT system, and missed opportunities to assess a vulnerable resident led to a significant delay in discovering their condition.
Responded
David Hemmings
Concerns: Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, contributing to an accidental fall and subsequent fatal complications from surgical treatment.
Overdue
Julia Murphy
Concerns: The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and insufficient staff training and risk assessment for a resident with evolving dementia.
Overdue
Margaret Austin
Concerns: The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and a majority of staff lacking essential falls training.
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
Norma Kyte
Concerns: Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small coverage area, risking undetected falls and potential non-compliance with manufacturer instructions.
Overdue
Linda Oldland
Concerns: Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a cardiac arrest, and incorrectly reported a DNAR, indicating policy and training deficiencies.
Responded
Doris Urch
Concerns: The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were unfamiliar with care plans, and the system failed to preserve historical records.
Responded
Eileen Walsh
Concerns: The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed faulty alarms, conflicting record-editing policies, and an internal investigation that missed key facts, mirroring CQC concerns.
Responded
Sean Heeney
Concerns: Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to dangerous delays.
Responded
Janet Smith
Concerns: Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to a preventable fall and death.
Responded
Tarik Drakes
Concerns: Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating an environment where drug use and safeguarding risks are prevalent.
Responded
Peter Seaby
Concerns: Informal staff arrangements and insufficient staffing levels led to inadequate supervision of residents. There was also a lack of post-incident review and management oversight.
Responded
Mary White
Concerns: Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no updated policy for managing enhanced care in single-room environments.
Responded
Evelyn Burcham
Concerns: Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer remote control features.
Responded
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
Hazel Mayho
Concerns: Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors and distracted staff. The care home lacks effective exit control or alert systems to prevent vulnerable residents from entering alone.
Responded
Cristofaro Priolo
Concerns: Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to unsafe feeding practices and a failure to recognise and respond to cardiac arrest.
Responded
Michael Humphries
Concerns: Inadequate wound care knowledge, poor documentation, and ineffective specialist referral pathways in a care home setting led to difficulties in charting wound progress and providing correct care.
Overdue
Joyce Dennis
Concerns: Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor documentation and communication within the care home created significant risks.
Overdue
Norman Barnes
Concerns: Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and risk assessments, leading to inadequate and potentially unsafe care delivery.
Overdue
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
Mark Athias
Concerns: The nursing home lacked essential sterile catheter supplies, leading to a patient's emergency hospital admission and subsequent deterioration.
Responded
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
Dorothy Pegg
Concerns: The provided text indicates general concerns exist that risk future deaths, but does not detail the specific issues or systemic failures identified by the coroner.
Responded
Stephen Verrall
Concerns: The CQC's failure to routinely check window restrictors, combined with a nursing home's un-manned weekend reception, allowed residents without capacity to leave unaccompanied, posing a significant risk.
Responded
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
Albert Rowlands
Concerns: Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement also increased the risk of falls during toilet access.
Responded
John Dickinson
Concerns: Inconsistent and insufficient record-keeping, coupled with assumptions about food refusal, prevented a holistic view of the patient and delayed the recognition of deterioration.
Responded
Dorothy Seekings
Concerns: Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents of patient care plans.
Responded
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
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
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
Eric Bird
Concerns: The care home failed to follow falls protocols, including not calling 999 after head injuries, delaying emergency services, and not updating care plans or identifying patterns in the deceased's repeated falls.
Responded
Michael Yemm
Concerns: The patient was placed in an unsuitable care home, inappropriately discharged by the hospital despite warnings, and suffered an inpatient fall due to inadequate supervision and care for his confused state.
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
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
Anthony Slack
Concerns: The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.
Responded
Geoffrey Banks
Concerns: A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, compounded by a poor investigation by untrained staff.
Responded
Jean Williams
Concerns: Bed levers are improperly fitted by untrained staff without patient assessment, and policy gaps hinder reporting concerns. Miscommunication prevents trained professionals from fitting them, and there is a risk of supplying levers without essential safety straps for Divan beds.
Responded
Lee Davies
Concerns: The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, compounded by a lack of observation and CCTV in the garden.
Responded
Mary Brady
Concerns: Open waste paper baskets in communal areas posed a choking hazard, exacerbated by improper disposal of clinical waste. Staff also failed to document or risk-assess a resident's habit of ingesting non-food items, leading to an incomplete understanding of risk.
Responded
Norman Baxter
Concerns: No specific concerns were detailed in the provided text for this report beyond a general statement of risk.
Responded
Edna Davenport
Concerns: The care home failed to provide a disabled patient with a call alarm or adequate observations, lacked documentation for care plans, and did not properly assess or manage the risk posed by an aggressive resident, leading to an assault and neglect of head injury monitoring.
Overdue
John Gregory
Concerns: Inadequate staff standards, inconsistent encouragement of fluid intake, and failure to monitor and respond to a patient's deteriorating condition, including inaccurate record-keeping, contributed to significant neglect.
Overdue
Roy Campbell
Concerns: Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not properly implemented or enshrined in policy with mandatory staff training.
Responded
Eileen Pollard
Concerns: Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
Overdue
Kenneth Clarke
Concerns: The nursing home lacked formal policies for crucial areas including resident observation, food storage security, managing dementia residents, and caring for patients on liquid diets.
Overdue
Jake Lee
Concerns: The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, and performed incorrect resuscitation, demonstrating severe gaps in emergency response.
Overdue
Donald Elliott
Concerns: Contradictory evidence regarding care home staffing levels and compliance with training/supervision regulations, coupled with unaddressed witness non-attendance, raises concerns about adequate care provision.
Responded
John Long
Concerns: Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and training for one-to-one care were inadequate, risking patients being left unattended.
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
Sidney Baker
Concerns: Poor record-keeping, including incorrect care plan entries and lack of documentation for referrals, indicates inadequate staff training and poses risks to patient care and safety.
Responded
Andrew Hogg
Concerns: A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper risk reassessments, internal investigations, and proactive measures or equipment to prevent repeated incidents.
Responded
Averil Skoric
Concerns: There is a lack of clear national and local guidance for care home staff on safe sleeping positions for vulnerable adults who lack capacity, increasing the risk of unsafe sleeping.
Responded
Mary Hoare
Concerns: Care providers rely on incomplete applicant information and fail to routinely seek GP records or complete thorough service user assessments before admission. This leads to unsuitable placements and a lack of post-admission care plans and risk assessments.
Overdue
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
Edna Evans
Concerns: The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.
Overdue
Robert Lowe
Concerns: Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.
Overdue
Irene Collins
Concerns: Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.
Overdue
Barbara Humphreys
Concerns: Inadequate bed rail safety was due to incorrect mattress use, poor staff training, absent risk assessments and policies, and delays in care plan completion. There was also a failure to inform families of medically relevant events.
Overdue
Robert Rostron
Concerns: Critical over-reliance on inadequately inducted agency nurses as senior staff led to unfamiliarity with essential policies, records, and patient care plans, resulting in medication errors.
Responded
James Delaney
Concerns: Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different homes created confusion and potential risks.
Overdue
James Francis
Concerns: Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There were also significant delays in seeking medical attention for deteriorating health and insufficient information provided to paramedics.
Responded
Kathleen Smith
Concerns: Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.
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
Bethany Tenquist
Concerns: Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights critical deficiencies in self-harm prevention protocols.
Responded
Bryan Gray
Concerns: There was an absence of window restrictors on multiple windows within the building, posing an ongoing fall risk for residents, despite one having been replaced post-incident.
Overdue
Kenneth Bardsley
Concerns: Lack of minimum qualifications for lift engineers, a systemic failure to act on regulatory examination findings, and absent care home and lift company protocols for managing maintenance risks contributed to safety concerns.
Overdue
John Duckenfield
Concerns: Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care reasonable despite these issues.
Responded