Recurring concern

Insufficient care-home staffing capacity for residents’ required care

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First reported 6 Nov 2013•Latest report 5 Dec 2025

Definition

What this concern includes

Includes failures of care-home staffing capacity, deployment or cover that leave residents without required care or assistance, including insufficient staff for two-carer care, assisted mobilisation, feeding, medication distribution, personal care and other essential resident needs.

Not included

  • Excludes nursing staffing shortages outside care-home resident care.
  • Excludes generic management, training, competence or documentation deficiencies unless they directly result in insufficient care-home staffing capacity.
  • Excludes failures limited to one resident’s care plan or one isolated staff omission where inadequate staffing capacity is not identified.
  • Excludes staffing deficiencies in hospitals, prisons, transport services or other non-care-home settings.
Reports
19

Distinct published reports

Individual concerns
20

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
12

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission4
Department of Health and Social Care4
Acer Mews1
Ambassador House1
Care First Class (UK) Limited1
Glenholme Holdingham Grange1
Gwern Alyn Care Home1
Hc-One Limited1
Ideal Carehomes (Number One) Limited1
Isle of Wight Adult Safeguarding Team1
Isle of Wight NHS Trust1
Moundsley Hall Nursing Home Limited1
MyMil Limited1
NHS England1
Priory Group1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West London

    AI-generated summary

    Sophie Bennett · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sophie Elizabeth Alice Bennett died at Kingston Hospital from injuries caused by applying a ligature at Lancaster Lodge, a care home operated by RPFI. The Jury identified concerns about inadequate governance, staffing, training, documentation, leadership and oversight, and found contributory errors or omissions in risk management, including failure to follow advice to take Sophie to A&E, inadequate observation and poor control of access to ligature items.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient staffing levels

    Wider context from the report

    “The governance of Lancaster Lodge, and of the staff, and others, working there during the material period, was inadequate in the following respects: 1. There was no “registered manager” who met the statutory criteria. 2. The staff were (despite RPFI’s assertions to the contrary), generally, untrained, unqualified and too few in number. 3. There were no, or no adequate, checks and controls by the staff, or by the acting manager, on the keeping of essential documents, including risk assessments and progress notes, which were, in consequence, themselves inadequate, unreliable and misleading - with corresponding risk to the safety of the residents. 4. The changes to which the determined circumstances refer were made following an audit by ████████ out: • ████████ was not qualified clinically, or in the field of mental health, to conduct that audit; • the audit conducted by him (which led to the proposals for change) took only a single day, which was grossly inadequate; • there was no, or no adequate, consultation with the staff, or by the staff with the residents, regarding the substantial changes introduced, and to be made; and • the changes were introduced at a “launch”, with no, or no adequate regard to the negative impact of their sudden introduction on the mental stability of the residents. 5. Leadership and oversight by the Board of RPFI was grossly inadequate, in relation to: • the need to have in place robust employment procedures; • the matters listed under paragraphs 1 to 4 above; • the appointments of the clinically unqualified ████████ and, later, the clinically unqualified art therapist as Clinical Lead, of a statutorily-approved registered manager, and of an adequate number of trained and qualified staff; • supervision and control of the changes introduced at ████████ instigation; • decisions made by the (unqualified) acting manager and staff in relation to the treatment to be given to the residents, and other steps required to meet their needs, and safety; • communication with other agencies involved in the care of the residents; • the keeping and production (including to the Court, for the purpose of the inquest) of the Board’s own records, communications and contracts; and • knowledge and performance of the Board’s fundamental obligations, including their duty of candour (not least in the Board having failed to fulfil its mandatory obligation to report to the CQC five instances of admission of Lancaster Lodge residents to hospital). 6. Advice to the acting manager was provided by ████████ - the founder of RPFI - and significant decisions regarding Lancaster Lodge and the residents, were made by her (in each case as a “consultant” to the Board, rather than by the Board of RPFI), and were followed by RPFI staff, when: • ████████ was neither a director, nor a Trustee, of RPFI (one Board member describing her role as “somewhat ambiguous”, and the evidence suggesting that she was a “shadow director”); and • ████████ had never visited Lancaster Lodge, and had never met (or had any knowledge, firsthand, knowledge of the residents). 7. The possibility of there being: • a conflict between the interests of ████████ (who, it appears, may have had a personal or family connection with the ownership of Lancaster Lodge) and those of RPFI itself; and • financial impropriety, in relation to the lease under which Lancaster Lodge was (it seems) held. 8. The post-death investigations carried out on behalf of RPFI: • were inadequate, verging on self-serving, and not objective; and • give rise to concerns as to their veracity and accuracy (the authorship of certain supposedly contemporaneous statements being denied by the staff member whose name appears on them as their maker). 9. The facts that: • a director and trustee of RPFI is also the Chairman of RCI; and • ████████ appears to have some family connection with the owner of RCI’s premises give rise to concerns in relation to RCI corresponding to those itemised under paragraphs 5 to 7 above. ”

    Source location

    Sophie Bennett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Coventry

    AI-generated summary

    Ruth Marian Perkin · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ruth Marian Perkin was admitted to a care home on 9 February 2018, suffered two falls shortly afterwards, and was found to have a right neck of femur fracture after the second fall. She underwent hip repair, later contracted pneumonia, and died on 29 March 2018. The principal concern was that discharge to the care home while her needs were still being assessed, together with staffing and care arrangements, may have increased her risk of falls and death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient staffing to provide required supervision for residents at risk of falls

    Wider context from the report

    “(4) I was informed by the Care Home Manager that if Mrs Perkin not suffered a fracture and had been returned to the care of the Care Home after her second fall, she would have suggested to the hospital that, in view of Mrs Perkin’s tendency to act in disregard of care instructions, she was in fact most likely in need of 1:1 care. (5) I was informed that for the 20 residents at the Care Home there are 5 staff on duty during the day, reducing to 3 staff at night, and my concern is that Mrs Perkin’s discharge to the Care Home under the D2A scheme, when her needs were still being assessed, actually placed her at an increased risk of falls and death as a result. ”

    Source location

    Ruth Marian Perkin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Birmingham and Solihull

    AI-generated summary

    James Albert Harris · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    James Albert Harris died in hospital on 3 April 2017 after a fall at his care home, sustaining a fractured neck of femur and subsequently deteriorating with pneumonia, Clostridium difficile infection and underlying health conditions. Concerns included inadequate falls-policy awareness and application, failure to seek medical attention after he reported pain, lack of analgesia, inadequate records of routine checks, and the care home being without a registered manager.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient staffing capacity to accompany residents assessed as at risk of falls when mobilising

    Wider context from the report

    “2. His care plan stipulated that he was at medium risk of falls and should be accompanied when mobilising yet he mobilised to the bathroom from the lounge without assistance because the only member of staff present in the lounge was assigned to a resident requiring one to one observation and therefore could not accompany Mr. Harris. ”

    Source location

    James Albert Harris · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Put care plans and risk assessments in place specifying supervision requirements during mobilisation.

    Verbatim wording from the response

    “2) Care plans and risk assessments are in place. Care plans stipulate if a resident requires supervision on mobilising and staff do endeavour to be with residents when walking. Unfortunately, some residents will not always wait for staff to assist and therefore put themselves at risk. If staff observe a resident mobilising independently and are aware that they should be accompanied then they will always assist.”

    Source location

    2017-0334-Response-by-Care-First-Class-UK
    Page 1 · response
    Published 2 December 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Registered Provider remains responsible for employing sufficient suitably qualified staff to support service users safely.

    Verbatim wording from the response

    “The Registered Provider is responsible for ensuring sufficient numbers of suitably qualified, competent, skilled and experienced care staff are employed in order to minimise and reduce the risk of harm to service users, (Regulation 18 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). If there is a lack of care staff there is a risk that service users will not receive the level of support required to keep them safe from risk of harm.”

    Source location

    2017-0334-Response-by-Care-Quality-Commission
    Page 4 · response
    Published 2 December 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Residents may mobilise without waiting for assistance, creating risk despite care plans requiring supervision and staff assisting when they observe this.

    Verbatim wording from the response

    “2) Care plans and risk assessments are in place. Care plans stipulate if a resident requires supervision on mobilising and staff do endeavour to be with residents when walking. Unfortunately, some residents will not always wait for staff to assist and therefore put themselves at risk. If staff observe a resident mobilising independently and are aware that they should be accompanied then they will always assist.”

    Source location

    2017-0334-Response-by-Care-First-Class-UK
    Page 1 · response
    Published 2 December 2017

    Open published response

  4. Bedfordshire and Luton

    AI-generated summary

    ETHELINE DE-GALE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Etheline De-Gale fell while mobilising from bed at a care setting on the night of 7/8 March 2016. Hospital admission was declined, follow-up with a doctor did not occur as recommended, and an ambulance attended the following afternoon; she later underwent surgery, contracted bronchopneumonia and died from a pulmonary embolism on 16 March 2016. Concerns included an insufficiently clear care plan, inadequate guidance on risk assessments, limited staffing, and the apparent failure to follow paramedic recommendations.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient staffing capacity for assisting residents requiring two carers

    Wider context from the report

    “(3) There were only 2 members of staff on duty, which compromised the safety of other residents when a resident required 2 members of staff to assist. ”

    Source location

    ETHELINE DE-GALE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient staffing capacity for best-interests decisions and hospital accompaniment

    Wider context from the report

    “(4) There were only 2 members of staff on duty, which potentially could compromise decisions made in the best interests of a resident. One carer accompanying a resident to hospital would clearly create a problem and that could potentially be seen as a basis for not admitting a resident to hospital. ”

    Source location

    ETHELINE DE-GALE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Staffing levels complied with regulations and did not make hospital admission inappropriate.

    Verbatim wording from the response

    “The numbers of staff on duty at the time of the incident were in line with regulation and are allocated based on need of our residents. At night time the residents are in bed and mostly sleep. There is a requirement of staff to regularly check those residents who require care and to attend residents when they call for assistance. It would be rare for two residents to call at the same time, however, should this be the case, a staff member would attend each resident independently, assess the need for the call, ensure the resident was safe and then prioritise the tasks with their colleague in order to assist the residents. The duty of the care staff attending a resident is to acknowledge the individual risk. In this case LR willingly left EDG on the side of the bed, without thought of her falling.”

    Source location

    2017-0058-Response-Ambassador-House-Home
    Page 2 · response
    Published 6 March 2017

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Olive Wilmott · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Olive Wilmott was found on the floor of a communal area of a residential care home after suffering a hip fracture. The Inquest concluded that she died from the effects of a urine infection and severe dementia, with the hip fracture a contributory factor. Concerns included possible pushing that was not effectively investigated or referred for safeguarding, and a lack of evidence that required 15-minute observations were provided amid insufficient night-shift staffing.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient overnight staffing for dementia unit residents’ needs

    Wider context from the report

    “2. That Miss Wilmott was assessed as requiring observation at 15 minute intervals, but there was no evidence that this had been in place and at the time of the event there were insufficient staff in place for her and other residents’ needs (one staff member dedicated per floor of the dementia unit during the night shift). ”

    Source location

    Olive Wilmott · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Nottinghamshire

    AI-generated summary

    Elsie Marjorie Brown · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient night-time staffing for residents requiring assistance from two carers

    Wider context from the report

    “8. That the night time provision of two staff members to cover the main Lodge and two to cover the Horton Suite (two separate but joined buildings) was not seen as a minimum requirement to ensure the health and safety of residents when at least one resident in each building needed the assistance of two carers, but that only three were regularly rostered for the night shift. ”

    Source location

    Elsie Marjorie Brown · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Clarify Horton Suite admission criteria to restrict admission to reasonably independent, low-falls-risk residents.

    Verbatim wording from the response

    “We take note of the Coroner’s recommendations and have clarified the criteria for admissions to the Horton suite so that safety levels are maintained. The Horton suite only caters for residents that are reasonably independent (require the support of one carer, if any) and are at low risk of falls. We do not intend having residents that require the support of 2 staff on the Horton suite but, in the rare circumstances that this could occur, we will ensure that we have a minimum of 4 staff on duty throughout the building to ensure that both areas of the home have adequate support.”

    Source location

    Elsie-Brown-Response
    Page 4 · response
    Published 4 December 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide a minimum of four staff across the building when a Horton Suite resident requires support from two carers.

    Verbatim wording from the response

    “We take note of the Coroner’s recommendations and have clarified the criteria for admissions to the Horton suite so that safety levels are maintained. The Horton suite only caters for residents that are reasonably independent (require the support of one carer, if any) and are at low risk of falls. We do not intend having residents that require the support of 2 staff on the Horton suite but, in the rare circumstances that this could occur, we will ensure that we have a minimum of 4 staff on duty throughout the building to ensure that both areas of the home have adequate support.”

    Source location

    Elsie-Brown-Response
    Page 4 · response
    Published 4 December 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Four night staff were not considered routinely necessary because the two areas formed one linked building and staffing levels were based on residents’ dependency.

    Verbatim wording from the response

    “Langwith Lodge Residential Home has two named areas but is one building and everything in the main ‘Lodge’ is linked with the ‘Horton Suite’. All the systems that make the home safe, such as fire alarms and the ‘carer assist system’, (colloquially called ‘nurse call’), work equally in all areas of the home and are linked together, so staff across the building know when someone requires assistance. The Horton suite is accessible both at the front and rear of the main lodge through internal doors. We have the two identified areas to distinguish between the ‘traditional care home’ and the Horton suite which is marketed to more independent residents. Dependency checks are completed for all residents to support safe staffing numbers.”

    Source location

    Elsie-Brown-Response
    Page 4 · response
    Published 4 December 2015

    Open published response

  7. Isle of Wight

    AI-generated summary

    Barbara Monica May Cooke · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Barbara Monica May Cooke, an 84-year-old resident of Waxham House Residential Care Home, developed severe pressure ulcers, sepsis and multiple organ failure, and died in hospital on 11 April 2014. The report raised concerns about inadequate staffing, delays in toileting and cleaning, failure to recognise and manage infection risks associated with pressure sores, and gaps in communication and safeguarding procedures after her admission and death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate staffing levels for meeting residents’ care, medication, comfort and dignity needs

    Wider context from the report

    “1. During the course of the evidence, it became clear that the resident to staff ratio of 20:2 during between 2 p.m. and 9 p.m. was inadequate to deal with all the residents’ needs at Waxham House. (The staffing levels at other times also appeared inadequate for the numbers of residents.) The staffing levels did not allow for one staff member to safely distribute medication to the residents without interruption; provide teas for the residents and cater for their other reasonable needs in an acceptable timeframe. I was concerned that residents were being left for two and a half hours, sitting in their own excrement, waiting to be taken to the toilet and cleaned, and that there were insufficient staff to attend to a resident who was clearly dying. Moreover, I am concerned that there were insufficient staff members to escort residents away from a resident who was being attended to by paramedics, thereby denying this lady any dignity in her last moments. ”

    Source location

    Barbara Monica May Cooke · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  8. Leicester City and South Leicestershire

    AI-generated summary

    Marjorie Evelyne Keogh · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marjorie Evelyne Keogh, a resident of Scraptoft Court Residential Care Home, fell through a first-floor landing balustrade while transferring to breakfast on 6 March 2010 and died the following day from bilateral pneumonia and multiple injuries. Concerns included the assessment of her suitability for a first-floor room, staffing levels and the absence of a manager, inconsistent risk and manual-handling assessments, and the strength and compliance of staircase furniture.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate staffing ratios to residents

    Wider context from the report

    “(2) Concerns were raised as to the staffing ratio to residents, and the lack of a manager at the home on that morning. The evidence indicated that as regards the latter point this was a regular occurrence. Please provide written evidence of current staffing requirements. ”

    Source location

    Marjorie Evelyne Keogh · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Staffing levels are based on residents’ needs, and current staffing exceeds guidance because fewer residents require nursing care.

    Verbatim wording from the response

    “2. There is no legislative prescriptive staffing level for care homes. Our staffing levels are based on needs of residents; we care for residents with residential care needs and nursing needs.”

    Source location

    Response from My Mil Limited
    Page 2 · response
    Published 23 February 2014

    Open published response

  9. Worcestershire

    AI-generated summary

    Henry MCQUOID · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Henry McQuoid, a resident at Moundsley Hall Home with dementia and swallowing difficulties, choked on food while eating lunch and died. The report raised concerns that there may have been insufficient staff to assist residents who needed help with feeding, with some staff reportedly feeling understaffed and too many agency staff being employed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient staffing for resident feeding assistance

    Wider context from the report

    “(1) Evidence given by the family suggested that there were an insufficient number of staff to provide assistance with eating for each resident who required it and that the family had been told by some members of staff that they themselves felt under staffed with too many agency staff being employed and thus a possibility that some residents who needed help in feeding might not receive it. ”

    Source location

    Henry MCQUOID · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026