Bupa Care Homes

Private and voluntary organisations · Multi-service care provider

Pin Request correction

First report 31 Mar 2014•Latest report 9 Mar 2018

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
2

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 Bupa Care Homes linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Gloucestershire

    AI-generated summary

    David Anthony Sketchley · 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

    David Anthony Sketchley, a resident of Ashley House Nursing Home, died after falling through a gap in a bariatric commode chair and sustaining a traumatic perianal injury. The report identified concerns about inadequate supervision, unclear care-plan requirements and definitions of supervision, and insufficient documented assessment of the commode’s suitability.

    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 Bupa Care Homes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to define required levels of resident supervision in care plans and guidance

    Wider context from the report

    “At the time of the incident Mr Sketchley was to be supervised. The evidence that I heard was the main carer thought that whilst on the commode Mr Sketchley was to be supervised at all times. The care plan dictated that generally Mr Sketchley was to be supervised regularly. I heard no evidence that staff understood exactly what level of supervision was required. I heard from Demelza James that it is deemed acceptable to not observe / watch a resident who is being supervised but just to listen to them. I heard no evidence that Mr Sketchley’s care plan stated this was a sufficient level of supervision, nor that there are any guidelines to assist staff when making decisions about the level of supervision a resident requires. ”
    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 Bupa Care Homes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain required visual observation during resident supervision

    Wider context from the report

    “At the time of the incident Mr Sketchley was to be supervised. The evidence that I heard was the main carer thought that whilst on the commode Mr Sketchley was to be supervised at all times. The care plan dictated that generally Mr Sketchley was to be supervised regularly. I heard no evidence that staff understood exactly what level of supervision was required. I heard from Demelza James that it is deemed acceptable to not observe / watch a resident who is being supervised but just to listen to them. I heard no evidence that Mr Sketchley’s care plan stated this was a sufficient level of supervision, nor that there are any guidelines to assist staff when making decisions about the level of supervision a resident requires. ”
    Open source report

  2. London (East)

    AI-generated summary

    Roy Joseph Godfrey · 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

    Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

    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 Bupa Care Homes; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequacy of investigation documentation following a safety incident

    Wider context from the report

    “7. I heard a great deal of evidence from the London Ambulance Service in relation to a thorough investigation they had conducted into this case. They had the assistance of an independent clinical advisor and had identified all of the relevant issues. They had taken all of the action required to address those issues. BUPA Care Homes however had provided a one page document headed “Summary of Investigation”. This was the only investigation document ”
    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 Bupa Care Homes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of nursing staff to establish a fallen patient’s medical and medication history

    Wider context from the report

    “5. The Deputy Manager confirmed that the qualified member of staff who attended when Mr Godfrey sustained his fall should have been aware of the increased risk of bleeding as a result of the long term warfarin. She confirmed that he may not have had access to the medication chart. It is my view that a qualified member of the nursing staff who attends a patient who has suffered a fall should make themselves aware of both the patient’s medical history and medication history. ”
    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 Bupa Care Homes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to carry out directed neurological and physical observations after a fall

    Wider context from the report

    “2. The staff at the care home accepted the responsibility of Mr Godfrey’s care following the paramedic’s assessment. They agreed to observe Mr Godfrey during the night. The actual checks carried out by the staff were not in accordance with the direction given by the paramedic. The senior care worker confirmed that she did not examine the swelling or check for alertness. 3. The Deputy Manager who gave evidence at the inquest confirmed that the checks carried out by the staff were not in her view appropriate. She would have expected the pupils to have been checked and checks to ensure that the patient was alert and orientated. ”
    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 Bupa Care Homes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to appropriately record post-fall checks in clinical records

    Wider context from the report

    “4. The Deputy Manager who gave evidence confirmed that the checks that were carried out on Mr Godfrey were not appropriately recorded in the clinical records. ”
    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 Bupa Care Homes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure awareness of bleeding risk after head injury in elderly patients taking warfarin

    Wider context from the report

    “1. Mr Godfrey was an elderly patient who was at risk of falling and who was on long term warfarin. There is an increased risk of bleeding to elderly patients on warfarin who sustain a head injury. Neither the care staff who attended to Mr Godfrey on the evening of the 23rd July 2013 or the paramedic appeared to have been aware of the increased risk of such bleeding in an elderly patient who had sustained a minor head injury. The inquest heard clear evidence from the London Ambulance Service in relation to further training that was to be provided to their staff in relation to this risk. In addition, amendments are to be considered to the LAS guidance, to highlight this risk to all staff. ”
    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