Recipient

Berrycroft Manor

First report 12 Jun 2015•Latest report 12 Jun 2015

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 4

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.

100%published responses found

4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

12 Jun2015
Manchester South
Concerns raised5
1. Inadequate and unstructured safeguarding investigation processes
2. Failure to test care home employees’ accounts during investigations
3. Inadequate observation of clients
1. Lack of clear rules governing when windows may be open
2. Insufficient care for clients’ general welfare
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Add window-opening and closing checks to room visits and document residents’ window-opening choices in care plans.
  Stated completed
2. Action
  Implement room-visit charts with senior-care-staff checks and hourly, or 15-minute meal-room, resident observations.
  Stated completed
3. Action
  Deliver rolling dignity training for all staff, focusing on personal-care standards and dignity.
  Stated in progress
AI-generated summary

Sidney Barnett · 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

Sidney Barnett, a care home resident whose health was gradually declining, was found inadequately clothed and cared for, struggling to eat alone and unattended, and later died in hospital from pneumonia on 3 January 2015. The principal concerns were inadequate observation and general welfare, unclear rules about open windows, and inadequate and insufficiently structured safeguarding investigations.

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 Berrycroft Manor; that does not assign responsibility.
PFD Monitor interpretation
Inadequate and unstructured safeguarding investigation processes
Wider context from the report
“4. As a result of these matters a safeguarding alert was raised by the hospital team, and this was investigated by the Adult Safeguarding Team at the Council. Both a member of that investigation and the Chairperson of the meetings, agreed that the level of inquiry had been inadequate and that they ought not to have concluded that the ‘complaint’ was unsubstantiated. 5. The system for looking into these matters is vague and unstructured and will inevitably lead to an insufficiency of investigation. Too much reliance is placed on what the “Care home” employees say, without testing that and further querying what actually happened. ”
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 Berrycroft Manor; that does not assign responsibility.
PFD Monitor interpretation
Failure to test care home employees’ accounts during investigations
Wider context from the report
“4. As a result of these matters a safeguarding alert was raised by the hospital team, and this was investigated by the Adult Safeguarding Team at the Council. Both a member of that investigation and the Chairperson of the meetings, agreed that the level of inquiry had been inadequate and that they ought not to have concluded that the ‘complaint’ was unsubstantiated. 5. The system for looking into these matters is vague and unstructured and will inevitably lead to an insufficiency of investigation. Too much reliance is placed on what the “Care home” employees say, without testing that and further querying what actually happened. ”
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 Berrycroft Manor; that does not assign responsibility.
PFD Monitor interpretation
Inadequate observation of clients
Wider context from the report
“1. Whilst at Berrycroft, the level and quality of observation of the client appears to have been inadequate. ”
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 Berrycroft Manor; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear rules governing when windows may be open
Wider context from the report
“3. The 'cleaner' at the care Home “opens the windows, whatever..” There seemed to be no clear rule in place as regards the appropriateness of the windows being open. ”
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 Berrycroft Manor; that does not assign responsibility.
PFD Monitor interpretation
Insufficient care for clients’ general welfare
Wider context from the report
“2. There was an insufficiency of care shown to the deceased in terms of his general welfare (whether he was warm enough, whether he was washed and shaved, whether he was able to take his meals safely, whether his clothing was adequate and clean etc.). ”
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
Add window-opening and closing checks to room visits and document residents’ window-opening choices in care plans.

Verbatim wording from the response
“The room visit checks incorporate a section for the opening and closing of windows. The home is a new build with insulated walls and has heating on 24 hours a day, seven days a year a resident may wish to have the window open if they become to warm this choice must be documented in the care plan.”

Source location
2015-0222-Response
Page 1 · response
Published 12 June 2015
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
Implement room-visit charts with senior-care-staff checks and hourly, or 15-minute meal-room, resident observations.

Verbatim wording from the response
“All resident’s with in the home have a room visit chart in place, this is to be completed by care staff and checked by Senior care staff. This form must be completed when a resident wishes to remain in their room and or takes meals in their rooms. A resident is to be checked hourly and every fifteen mins if meals are taken in rooms.”

Source location
2015-0222-Response
Page 1 · response
Published 12 June 2015
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
Deliver rolling dignity training for all staff, focusing on personal-care standards and dignity.

Verbatim wording from the response
“All personal care forms to be completed in care plans documentation must be made if a residents refuses care. A rolling programme of dignity training (DELIVERED BY THE MANAGER) is in place for all staff focusing on personal care standards and dignity.”

Source location
2015-0222-Response
Page 1 · response
Published 12 June 2015
Open published response

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 raised5

Inadequate and unstructured safeguarding investigation processes

Failure to test care home employees’ accounts during investigations

Inadequate observation of clients

Lack of clear rules governing when windows may be open

Insufficient care for clients’ general welfare

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

Actions described in response 3