Recipient

Ashley Gardens Care Centre

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First report 6 Dec 2013•Latest report 14 Feb 2022

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Ashley Gardens Care Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Mid Kent and Medway

    AI-generated summary

    Norman Barnes · 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

    Norman Barnes died after choking on food while eating lunch at Ashley Gardens Care Centre. His meal was not prepared as minced or moist, contrary to the recommendation in his SALT assessment and care plan. Staff were aware of his Parkinson’s disease but were not aware of, or did not refer to, key information in his care plan and risk assessments.

    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 Ashley Gardens Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of care home staff to refer to care plans and risk assessments when delivering patients’ daily needs

    Wider context from the report

    “Evidence was given by health care staff who were responsible for personal care which included service of and delivery of meals at Ashley Gardens Care Centre that: (1) Whilst they were aware Mr Barnes had a background of Parkinson’s disease and this by its very nature often causes difficulties in chewing and swallowing, they were not aware of the contents of the care plan which reflected the recommendations of the SALT assessment for a ‘moist and minced’ diet for this resident. (2) Care Home staff who attend to patients who should be referring to key information contained within care plans and risk assessments to understand and effectively deliver a patient’s daily needs and requirements had not and it was of concern to note that they were not fully aware of important information contained in these documents. ”
    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 Ashley Gardens Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of care staff to know the care-plan dietary recommendations for residents with swallowing difficulties

    Wider context from the report

    “Evidence was given by health care staff who were responsible for personal care which included service of and delivery of meals at Ashley Gardens Care Centre that: (1) Whilst they were aware Mr Barnes had a background of Parkinson’s disease and this by its very nature often causes difficulties in chewing and swallowing, they were not aware of the contents of the care plan which reflected the recommendations of the SALT assessment for a ‘moist and minced’ diet for this resident. (2) Care Home staff who attend to patients who should be referring to key information contained within care plans and risk assessments to understand and effectively deliver a patient’s daily needs and requirements had not and it was of concern to note that they were not fully aware of important information contained in these documents. ”
    Open source report

  2. Mid Kent and Medway

    AI-generated summary

    Keith Barton · 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

    Keith Barton, who had Alzheimer’s disease and dementia and was at risk of choking, choked and died while eating breakfast alone in his room at a nursing home on 5 February 2013. The principal concerns included unclear communication of the required level of supervision, periodic rather than constant checks while eating, incomplete incident reporting, and limits on staff access to dysphagia awareness training.

    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 Ashley Gardens Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of sufficient dysphagia-awareness training places for all staff members

    Wider context from the report

    “(2) That external training in relation to dysphagia awareness which had been put in place following the death of Mr. Barton could not be delivered to all staff members because of constraints on the number of places available (which could potentially be resolved by in-house training) ”
    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 Ashley Gardens Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to seek clarification of required supervision and monitoring from the speech and language therapist

    Wider context from the report

    “(1) That clarification as to the level of supervision and monitoring was not sought from the speech and language therapist in a case where the recommendation required clarification ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026