Care plan failures
Care plans not accurately reflecting individual needs or care provided, and ineffective systems for quality assurance and continuous improvement.
4,505 items
10 sources
7 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
LGO / SPSO decision
90match
24-022-879 - Barchester Healthcare Homes Limited
Summary: The Care Provider failed to update Mrs Y’s care plan to reflect a change in her care needs around continence. There was also a failure to ensure Mrs Y saw a chiropodist regularly. This caused avoidable distress for which the Care Provider has apologised, completed staff training and introduced a new policy around continence care. This action...
Matched on
terms: care, failure, plan
CQC action
86match
Bellevue Healthcare Limited
The provider must ensure care plans are person-centred, accurately reflect individual needs and risks, are regularly reviewed, and include specific plans for short-term conditions.
Matched on
terms: care, plan
Inquiry recommendation
83match
WATE-(33) - Base care plans on comprehensive assessment, prepared with child consultation
The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Matched on
terms: care, plan
Inquiry recommendation
83match
LAMI-64 - Ensure nursing care plans account for suspected deliberate harm in hospitalised children.
When a child is admitted to hospital and deliberate harm is suspected, the nursing care plan must take full account of this diagnosis.
Matched on
terms: care, plan
CQC action
83match
The Laurels Residential Home - Draycott
People's care plans did not always reflect the care people needed and the care provided. The informal systems used to ensure the quality of the service and ensure necessary improvements were carried out had not been effective.
Matched on
terms: care, plan
Inquiry recommendation
82match
COVID-M3.9 - Standardised Advance Care Planning
The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for clinicians to ascertain and record their patients' wishes and preferences for future care and treatment in order to...
Matched on
terms: care, plan
Inquiry recommendation
82match
R18 - Care planning system
Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff.
Matched on
terms: care, plan
CQC action
82match
Holly Court Care Home
electronic care plans required review to ensure they accurately reflected people's support needs
Matched on
terms: care, plan
Inquiry recommendation
78match
WATE-(37) - Prepare and periodically review leaving care plans for all looked after children
A leaving care plan should be prepared for each looked after child, in consultation with that child, a year in advance of the event and should be reviewed periodically thereafter until the child ceases to require or be eligible for further support.
Matched on
terms: care, plan
Inquiry recommendation
78match
WATE-(34) - Designate social worker responsible for care plan implementation and child supervision
An appropriate social worker should be designated as the person responsible for the implementation of the care plan and supervision of the looked after child.
Matched on
terms: care, plan
CQC action
78match
Park Grange Care Home
The care plans we looked had not always been updated on a regular basis, some sections were not completed appropriately or were inaccurate. This meant we could not be sure people were receiving appropriate care and support to meet their needs.
Matched on
terms: care, plan
CQC action
78match
Attwood's Manor Care Home
The provider must ensure people's records are kept up to date as and when a person's needs have changed and daily notes reflect the care people need according to the plan of care.
Matched on
terms: care, plan
CQC action
78match
Spindrift Care Home Limited
People's care needs were not thoroughly assessed. Plans of care had not been designed with the person to meet people's needs and achieve their preferences.
Matched on
terms: care, plan
CQC action
78match
Grace 247 Care Wiltshire
Care planning did not always demonstrate people's needs and the support they required. Regulation 9(1)(a)(b)(c)(3)(b)
Matched on
terms: care, plan
CQC action
77match
Benedict House Nursing Home
The registered provider must immediately commence a thorough and comprehensive review of all service users' care plans and risk assessments to ensure they fully reflect people's current needs and the registered provider must provide the Care Quality Commission with details of the system operated to secure this by no later than 5pm on Friday 08 July 2016.
Matched on
terms: care, plan
LGO / SPSO decision
77match
23-020-972 - London Borough of Merton
Summary: There was delay by the Council in reviewing Ms Y’s care and support plan causing avoidable uncertainty. There was delay in complaint handling and a failure to provide a response, causing avoidable distress and time and trouble. The Council will make a payment, apologise, make a decision on funding and review procedures to minimise the risk of...
Matched on
terms: care, failure, plan
LGO / SPSO decision
76match
21-006-581 - London Borough of Richmond upon Thames
Summary: Mrs D complains about the Council’s handling of her son F’s Education, Health and Care plan. She says it did not adhere to the Special Educational Needs and Disabilities Code of Practice. Mrs D says she had to pay for privately arranged therapy and F missed education due to the Council’s failures. We find fault by the...
Matched on
terms: care, failure, plan
PFD report
73match
John Bird
The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, leading to an untrained carer inaccurately assessing a high-risk patient's mobility.
Matched on
terms: care, plan
PFD report
73match
Maurice Camfield
Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.
Matched on
terms: care, plan
PFD report
73match
Walter Willows
Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, leading to inadequate dietary adjustments.
Matched on
terms: care, plan
PFD report
73match
Etheline De-Gale
Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.
Matched on
terms: care, plan
PFD report
73match
John Davies
There was no risk assessment plan when the resident's needs changed from care to nursing, the District Nursing Team was unaware of the change, and patient records lacked detail with little communication between the care home and the District Nursing Team.
Matched on
terms: care, plan
PFD report
73match
Constance Connolly
The report describes failures in the handover of patients needing urgent follow-up, including a doctor not following up on a scan they ordered, and a breakdown in communication between different care teams resulting in a cancelled appointment and no further action.
Matched on
terms: care, failure
PFD report
73match
Janet Williams
The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care co-ordinator dismissed family concerns, cancelled vital appointments, and made un-noted retrospective entries after the patient's death.
Matched on
terms: care, plan
PFD report
73match
Maud Patrick
Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and insufficient staffing and senior nursing leadership.
Matched on
terms: care, failure
CQC action
73match
Utmostcare Limited
We recommend the service review their approach, to ensure care planning, including arrangements for care reviews and staff deployment, is focused on the person's whole life, to ensure care plans fully reflect physical, mental, emotional and social needs, including people's preferences, interests and aspirations.
Matched on
terms: care, plan
PPO recommendation
73match
The Head of Healthcare at Parc
The Head of Healthcare at Parc should ensure that CVOP meetings are clinically multidisciplinary, that effective care plans are created and implemented, and that the meetings are accurately minuted.
Matched on
terms: care, plan
CQC action
73match
Aspirations (Northampton)
Some care plans did not contain all the required information to ensure staff knew people's individual needs. For example, one person's care plan and risk assessment did not include the information of their thickened fluids and pureed food.
Matched on
terms: care, plan
CQC action
73match
Verve Health
The service must ensure that care plans meet client’s individual needs and preferences and are personalised, holistic and recovery oriented.
Matched on
terms: care, plan
CQC action
73match
The Homestead (Crowthorne) Limited
The registered person failed to ensure records reflected a clear care and treatment plan of people's individual needs and preferences.
Matched on
terms: care, plan
LGO / SPSO decision
72match
20-001-927 - London Borough of Redbridge
Summary: Miss X complains that the Council failed to provide special educational provision for her daughter in line with her Education, Health and Care plan. She also complains that the Council ignored her request for a personal budget and failed to respond to her complaint. Miss X says her daughter lost out on provision she was entitled to...
Matched on
terms: care, failure, plan
CQC action
71match
Ashbourne House - Torquay
People's care plans did not meet their needs and were not reflective of their wishes and preferences. People's care plans were not always effectively reviewed to ensure they were reflective of the care being delivered.
Matched on
terms: care, plan
PFD report
69match
Kathryn Sawyer
A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future plans.
Matched on
terms: failure, plan
PFD report
69match
Sybil Roberts
A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, leading to repeated falls due to unupdated care plans.
Matched on
terms: care, plan
PFD report
69match
Leonard Hudson
Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.
Matched on
terms: care, failure
PFD report
69match
Michael Lyons
The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did not specify choking prevention measures, and staff lacked crucial awareness regarding food preparation.
Matched on
terms: care, plan
PFD report
69match
Rasharn Williams
The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital medical instruction notice for the child was also not displayed due to transitional arrangements.
Matched on
terms: care, plan
PFD report
69match
Joanna Bowring
Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.
Matched on
terms: care, plan
PFD report
69match
Clifford Crofts
A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute pain. Significant delays occurred in obtaining a CT scan.
Matched on
terms: care, plan
PFD report
69match
Pamela Thurston
The care home failed to update the care plan for a patient with a choking risk and left her unsupervised to eat after a 17-hour period without food, leading to choking and subsequent death.
Matched on
terms: care, plan
PFD report
69match
Dorothy Imisson
The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.
Matched on
terms: care, plan
PFD report
69match
Malcolm Bennett
Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate emergency department transfer, potentially contributing to the death.
Matched on
terms: care, plan
PFD report
69match
Michael Uriely
Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow guidelines and recognise deteriorating patient condition.
Matched on
terms: care, failure
PFD report
69match
Robert Cardwell
Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.
Matched on
terms: care, failure
CQC action
69match
Clova House Residential Care Home
The provider told us they would make arrangements for this information to be included in the main care plan in future.
Matched on
terms: care, plan
CQC action
69match
Assured Care Formby
Care plans did not detail people's likes. dislikes and preferences. People had not always been involved in planning their care.
Matched on
terms: care, plan
CQC action
69match
Ashdale Care Home
At the last inspection, staff did not have clear care plan guidance on how to support people. The provider gave inspectors an example of a 'dummy care plan'. However, this example document lacked guidance on what information would be within care plans to ensure staff had clear guidance to follow.
Matched on
terms: care, plan
CQC action
69match
WhiteHorse Care - Brownhills
Care plans did not capture how people were supported to achieve their personal goals and aspirations. They also did not always capture how people were supported to develop their everyday skills. Ensuring this information was documented within the care records would ensure people received the personalised support, encouragement and motivation to reach their goals and aspirations.
Matched on
terms: care, plan
PPO recommendation
69match
The Head of Healthcare at HMP Buckley Hall
The Head of Healthcare at HMP Buckley Hall should ensure that all prisoners identified as having a severe and enduring mental illness have comprehensive care plans.
Matched on
terms: care, plan
PPO recommendation
69match
The Head of Healthcare
The Head of Healthcare should ensure that care plans are created for all patients with suspected coronary heart disease.
Matched on
terms: care, plan