Recurring concern

Insufficient care home management capacity and oversight

First to latest report 4 Dec 2013 — 9 Apr 2025

Reports that mention this concern
11
Times this concern has been raised
12
Stated actions linked to this concern
22

What this concern includes

Includes deficiencies in care-home management capacity or availability, including too few managers, absence of an on-site manager when required, and comparable failures that leave the care home without effective operational oversight.

What is not included
  • Excludes frontline care staffing shortages where the concern is patient or resident care capacity rather than management capacity.
  • Excludes staff knowledge, training or competence deficiencies that are not specifically part of care-home management oversight.
  • Excludes failures of registration or qualification alone unless they directly contribute to inadequate management capacity or oversight.
  • Excludes generic organisational governance deficiencies not specifically concerning operational management of a care home.

Reports and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  1. 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

    Regular absence of a manager at the home

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026