Barons Park Care

Private and voluntary organisations · Nursing home

Pin Request correction

First report 30 Jul 2014•Latest report 30 Jul 2014

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Leicester City and South Leicestershire

    AI-generated summary

    Christopher John Royal · 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

    Christopher John Royal suffered a cardiac event on 25 January 2013 and was found collapsed in the en-suite bathroom of Baron’s Park Nursing Home; CPR was unsuccessful. Concerns included unreliable 15-minute observation records, inadequate emergency response and first-aid training, and the potential impact of lengthy staff shifts on care.

    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 Barons Park Care; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain effective and current first aid training and competence

    Wider context from the report

    “2) Evidence was taken that the Matron did not have a valid First Aid Certificate at the time of this event; it had expired in 2011. There was evidence that the nursing home staff response to this medical emergency was inadequate and insufficient. One member of staff said although First Aid trained she did not feel competent to carry out CPR. First Aid training is essential in a Nursing Home environment, and there should be in place a proper system to ensure training is provided, updated, effective and understood. An annual system of review and/or appraisal may assist in the monitoring process and allow staff feedback and concerns reporting. ”
    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 Barons Park Care; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure shift patterns support safe health care

    Wider context from the report

    “3) Matron said she regularly worked a 13.5 hour shift as it meant less travelling time as many staff lived a distance from the home. This length of shift may not be conducive to good health care and may have contributed to the poor care given that evening to Mr. Royal. Consideration should be given to whether shifts of this length are for the benefit of the residents or the staff, and if any perceived benefits outweigh any potential problems this type of shift pattern may create. ”
    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 Barons Park Care; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide a designated and accountable system for carrying out and recording observations

    Wider context from the report

    “1) Mr. Royal was on 15 minute observations. The observations were not carried out by a designated member of staff; there was no system in place; the recorded observations were unreliable and inaccurate; recordings were not made by the staff who had actually observed Mr. Royal. Consideration should be given to a more robust, safe and accountable observation system, and proper training and auditing to ensure this is in place and operating effectively. ”
    Open source report
Back to top

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