Concerns raised 3 Failure of record keeping to reflect residents’ needs View source Failure to accurately record incidents as they occur View source Insufficient staffing levels for required care View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Review and implement new compliance systems and reporting processes.
View source
Action
Review the staffing structure and revise recruitment and induction processes.
View source
Action
Review and implement new care-planning processes.
View source
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AI-generated summary
William Stanton RUTHERFORD · 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
William Stanton RUTHERFORD was a temporary resident receiving one-to-one care at Baedling Manor Care Home and died in hospital on 5 January 2021 after sustaining multiple rib fractures and developing pneumonia following a fall. Concerns were raised that staffing levels were below the minimum requirement and that record keeping did not accurately reflect residents’ needs or incidents.
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. The report was sent to Alcyone Healthcare North East Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of record keeping to reflect residents’ needs
Wider context from the report “(2) I have previously raised concerns regarding the standard of record keeping at Baedling Manor Care Home. I have not received a response to my previous concerns which I repeat again. This is the second death where a resident has died following a fall at Baedling Manor Care Home and I am concerned that the record keeping does not reflect the needs of the residents or accurately record incidents as they occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alcyone Healthcare North East Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record incidents as they occur
Wider context from the report “(2) I have previously raised concerns regarding the standard of record keeping at Baedling Manor Care Home. I have not received a response to my previous concerns which I repeat again. This is the second death where a resident has died following a fall at Baedling Manor Care Home and I am concerned that the record keeping does not reflect the needs of the residents or accurately record incidents as they occur .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alcyone Healthcare North East Ltd; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing levels for required care
Wider context from the report “(1) I am concerned that staffing levels were below the minimum requirement on 27 and 28 December 2020. Mr Rutherford was for one to one care and I am concerned that the appropriate number of staff were not available .
” Open source report
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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 Review and implement new compliance systems and reporting processes.
Verbatim wording from the response “• Full review and implementation of new compliance systems and reporting processes” Source location 2022-0118-Response-from-Alcyone-healthcare_Published
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 Review the staffing structure and revise recruitment and induction processes.
Verbatim wording from the response “• Staffing structure review and revised recruitment and induction processes” Source location 2022-0118-Response-from-Alcyone-healthcare_Published
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 Review and implement new care-planning processes.
Verbatim wording from the response “• Full review and implementation of new care planning processes” Source location 2022-0118-Response-from-Alcyone-healthcare_Published
Open published response
Concerns raised 3 Failure to report incidents or make statutory notifications without delay View source Failure to maintain accurate and up-to-date resident care records and care plans View source Failure to ensure staff understand residents’ lifting care needs View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 2
Action
Review and implement new compliance systems and reporting processes.
View source
Action
Review and implement new care-planning processes.
View source
×
AI-generated summary
Margaret Elizabeth Greenacre · 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
Margaret Elizabeth Greenacre, known as Betty, was a care home resident who suffered an unwitnessed fall on 30 August 2020, sustaining significant soft tissue damage to her lower right leg. She deteriorated after the injury and died in hospital on 18 September 2020. Concerns included late or missing statutory notifications of incidents and poor care-home record keeping, including care plans that were not updated and did not accurately reflect residents’ needs.
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. The report was sent to Alcyone Healthcare North East Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to report incidents or make statutory notifications without delay
Wider context from the report “1. On 4th September 2020 the Care Quality Commission received information from a whistle-blower regarding information of a safeguarding nature in that a service user had fallen and was taken to hospital having sustained a leg and head injury. This was confirmed to be Betty who died on 18th September 2020. Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 provides that registered persons must notify the Care Quality Commission, without delay. The Care Quality Commission contacted Baedling Manor Care Home on 8th September 2020. Statutory notification was received at the Care Quality Commission on 12 September 2020. It is of concern to me that the Care Quality Commission were notified of concerns by a whistle-blower and, that statutory notification was not made until 12 days after the incident. It came to light during the inquest that an incident also arose in July 2020 but no reports have been submitted to date. It is of concern to me that matters are not being reported or are being notified late which may prevent incidents being investigated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alcyone Healthcare North East Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and up-to-date resident care records and care plans
Wider context from the report “2. I have concerns with regard to the standard of record keeping at Baedling Manor Care Home, I am concerned that the care notes did not present an accurate picture of a resident and did not reflect what a resident was like and therefore what their needs were. It was accepted in evidence that the record keeping was very poor, the care plans were not changed or updated. In fact, upon the appointment of a new home manager, every resident’s care plan has been reviewed and updated. The information provided in the care plan contradicted the information provided in evidence and it appears staff may have had difficulty understanding Betty’s care needs for lifting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alcyone Healthcare North East Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff understand residents’ lifting care needs
Wider context from the report “2. I have concerns with regard to the standard of record keeping at Baedling Manor Care Home, I am concerned that the care notes did not present an accurate picture of a resident and did not reflect what a resident was like and therefore what their needs were. It was accepted in evidence that the record keeping was very poor, the care plans were not changed or updated. In fact, upon the appointment of a new home manager, every resident’s care plan has been reviewed and updated. The information provided in the care plan contradicted the information provided in evidence and it appears staff may have had difficulty understanding Betty’s care needs for lifting.
” 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 Review and implement new compliance systems and reporting processes.
Verbatim wording from the response “• Full review and implementation of new compliance systems and reporting processes” Source location 2022-0119-Response-from-Alcyone-Healthcare_Published
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 Review and implement new care-planning processes.
Verbatim wording from the response “• Full review and implementation of new care planning processes” Source location 2022-0119-Response-from-Alcyone-Healthcare_Published
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations