Recipient

Bamford Grange Care Home

First report 8 Jan 2015•Latest report 7 Nov 2025

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
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Bamford Grange Care Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

7 Nov2025
Manchester South
Concerns raised4
1. Failure to maintain a clear, effective and documented communication system for wound management care plans
2. Lack of a clear escalation policy for wound care concerns when residents arrive
3. Limited documentation of wound care concerns and escalation attempts
1. Lack of clarity in wound care plans and wound management instructions
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Richard Charles Worswick · 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

Richard Charles Worswick, who had Parkinson’s disease, frailty and complex health needs, developed an infected spinal wound and died from sepsis at Stepping Hill Hospital on 19 May 2025. The principal concerns were unclear communication and documentation of the wound-care plan between the hospital and care home, together with unclear escalation arrangements and limited documentation of concerns and escalation attempts.

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 Bamford Grange Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain a clear, effective and documented communication system for wound management care plans
Wider context from the report
“The inquest heard evidence that when he was discharged to the care home from the acute hospital that the care home felt that they did not understand what was required regarding wound care because the care plan regarding wound care was not clear .The Trust did not have a copy of what information had been provided. As a consequence of this, there was a lack of clarity regarding wound management. The Trust did not, the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation to care plans that included wound management. The home did not have a clear escalation policy for actions to be taken when a resident arrived, and their staff were unclear how they were being asked to manage a wound by the hospital. In addition, the documentation surrounding concerns and attempts to escalate was limited. ”
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 Bamford Grange Care Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of a clear escalation policy for wound care concerns when residents arrive
Wider context from the report
“The inquest heard evidence that when he was discharged to the care home from the acute hospital that the care home felt that they did not understand what was required regarding wound care because the care plan regarding wound care was not clear .The Trust did not have a copy of what information had been provided. As a consequence of this, there was a lack of clarity regarding wound management. The Trust did not, the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation to care plans that included wound management. The home did not have a clear escalation policy for actions to be taken when a resident arrived, and their staff were unclear how they were being asked to manage a wound by the hospital. In addition, the documentation surrounding concerns and attempts to escalate was limited. ”
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 Bamford Grange Care Home; that does not assign responsibility.
PFD Monitor interpretation
Limited documentation of wound care concerns and escalation attempts
Wider context from the report
“The inquest heard evidence that when he was discharged to the care home from the acute hospital that the care home felt that they did not understand what was required regarding wound care because the care plan regarding wound care was not clear .The Trust did not have a copy of what information had been provided. As a consequence of this, there was a lack of clarity regarding wound management. The Trust did not, the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation to care plans that included wound management. The home did not have a clear escalation policy for actions to be taken when a resident arrived, and their staff were unclear how they were being asked to manage a wound by the hospital. In addition, the documentation surrounding concerns and attempts to escalate was limited. ”
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 Bamford Grange Care Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity in wound care plans and wound management instructions
Wider context from the report
“The inquest heard evidence that when he was discharged to the care home from the acute hospital that the care home felt that they did not understand what was required regarding wound care because the care plan regarding wound care was not clear .The Trust did not have a copy of what information had been provided. As a consequence of this, there was a lack of clarity regarding wound management. The Trust did not, the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation to care plans that included wound management. The home did not have a clear escalation policy for actions to be taken when a resident arrived, and their staff were unclear how they were being asked to manage a wound by the hospital. In addition, the documentation surrounding concerns and attempts to escalate was limited. ”
Open source report
8 Jan2015
Manchester South
Concerns raised4
1. Failure to adequately induct and familiarise agency staff with residents and identification methods
2. Lack of resident identification information and cards for agency staff
3. Failure to retrieve the correct resident file
1. Failure to clearly mark residents’ rooms for identification
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

George Hulme · 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

On 25 June 2014, George Hulme was assaulted by another resident at Bamford Grange Nursing Home, collapsed and required CPR. The wrong resident file, which recorded a DNR, was retrieved after he was incorrectly identified, and CPR ceased; concerns included inadequate resident identification systems, induction and room labelling for agency staff and emergency responders.

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 Bamford Grange Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to adequately induct and familiarise agency staff with residents and identification methods
Wider context from the report
“2) Agency members of staff are supposed to have an induction and tour of the home upon their first visit. This did not take place adequately to sufficiently familiarise the staff with the residents or any method of correctly identifying residents. ”
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 Bamford Grange Care Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of resident identification information and cards for agency staff
Wider context from the report
“1) Agency members of staff on duty did not have any information to assist with the identification of residents. Whilst a system of key cards was supposed to operate within the home, the agency staff on duty had no such card to identify residents. ”
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 Bamford Grange Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to retrieve the correct resident file
Wider context from the report
“3) An incorrect file was retrieved resulting in a potentially inappropriate treatment of an unconscious resident. ”
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 Bamford Grange Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to clearly mark residents’ rooms for identification
Wider context from the report
“4) The residents’ rooms are not clearly marked internally or externally to denote who resides in the room giving rise to confusion over identification in the event of emergency treatment being required by an unconscious resident attended to by staff or medical practitioners not familiar with their identity. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised4

Failure to maintain a clear, effective and documented communication system for wound management care plans

Lack of a clear escalation policy for wound care concerns when residents arrive

Limited documentation of wound care concerns and escalation attempts

Lack of clarity in wound care plans and wound management instructions

Concerns raised4

Failure to adequately induct and familiarise agency staff with residents and identification methods

Lack of resident identification information and cards for agency staff

Failure to retrieve the correct resident file

Failure to clearly mark residents’ rooms for identification