Recurring concern

Inadequate staff competence in care planning

First to latest report 16 Oct 2015 — 2 Jun 2026

Reports that mention this concern
11
Times this concern has been raised
11
Stated actions linked to this concern
18

What this concern includes

Includes failures of staff training, competence assurance or demonstrated understanding specifically concerning preparation, interpretation or use of care plans, including care-plan requirements and their relationship to identified risks.

What is not included
  • Excludes deficiencies in the care-planning process itself where staff competence is not identified as the unsafe condition.
  • Excludes training or competence failures concerning risk assessment, nutritional assessment or other processes unless care planning is also a material part of the asserted concern.
  • Excludes failures to communicate, audit, review or implement care plans where staff competence is not the shared condition.
  • Excludes generic staff training deficiencies not specifically tied to care planning.

Reports and published responses 11 reports

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

  1. Inner North London

    AI-generated summary

    John William BIRD · 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

    John William Bird, aged 92, fell at his care home on the evening of 29 April 2014 and later died from the injury sustained. The principal concerns were that the falls risk assessment was not available at the inquest and that the carer who found him appeared unfamiliar with his risk assessment and care plan, despite Mr Bird being assessed as at very high risk of falls.

    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

    Failure to ensure staff familiarity with residents’ risk assessments and resulting care plans

    Wider context from the report

    “You were unable to detail in court the entirety of the falls risk assessment you had undertaken for Mr Bird, because you did not bring the record of the risk assessment to the inquest, despite the nature of Mr Bird’s death and a written request from my coroner’s officer. However, you were confident that you had assessed Mr Bird as being at very high risk of falls, as a consequence of his level of cognitive impairment coupled with his ability to walk without assistance. (This is, of course, a very difficult combination.) Yet the carer who found Mr Bird after his fall, did not appear to have any familiarity with risk assessments. Even allowing for possible language difficulties (the carer is not a native English speaker), he assessed Mr Bird’s ability to mobilise unaided as “fine”, and did not see any particular risks for him. When I put the carer’s evidence to you in court, you told me that he should know about the risk assessments. You later agreed in evidence that, as manager of the care home, it is your responsibility to ensure that all staff are familiar with risk assessments and the resulting care plan for each resident. ”

    Source location

    John William BIRD · Prevention of Future Deaths report
    Page 2 · 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