Recipient

Care First Class (UK) Limited

First report 21 Jul 2017•Latest report 21 Jul 2017

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. 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: 7
Stated actions: 11

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

11stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Care First Class (UK) Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

21 Jul2017
Birmingham and Solihull
Concerns raised8
1. Unavailability of a registered care home manager
2. Failure to offer analgesia to residents reporting pain after a fall
3. Failure to ensure carers read residents’ care plans and risk assessments
1. Insufficient staffing capacity to accompany residents assessed as at risk of falls when mobilising
2. Failure to record routine resident checks
3. Failure to make the falls protocol clearly available to staff
4. Failure to sufficiently educate and assess staff on falls policy awareness and application
5. Failure to follow the falls protocol requiring immobilisation and medical attention after a painful fall
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 10
1. Action
  Provide new-resident needs information at each daily handover.
  Stated completed
2. Action
  Monitor staff records and address issues arising from record completion.
  Stated in progress
3. Action
  Put care plans and risk assessments in place specifying supervision requirements during mobilisation.
  Stated completed
1. Action
  Record residents’ hourly or two-hourly nightly checks on signed night-check sheets.
  Stated completed
2. Action
  Include the falls policy in recorded staff supervision to clarify responsibilities after a resident fall.
  Stated completed
3. Action
  Disseminate the falls protocol to staff and incorporate it into new-staff induction.
  Stated completed
4. Action
  Implement read-and-sign care-plan sheets for staff caring for newly admitted residents.
  Stated completed
5. Action
  Add the falls policy to staff-meeting agendas as a lessons-learned item.
  Stated planned
6. Action
  Maintain a manager in post at Cherry Lodge.
  Stated completed
7. Action
  Register the Cherry Lodge manager with CQC.
  Stated planned
Respondent positions 1
1. Position
  Residents may mobilise without waiting for assistance, creating risk despite care plans requiring supervision and staff assisting when they observe this.
  Disputes the concern
AI-generated summary

James Albert Harris · 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

James Albert Harris died in hospital on 3 April 2017 after a fall at his care home, sustaining a fractured neck of femur and subsequently deteriorating with pneumonia, Clostridium difficile infection and underlying health conditions. Concerns included inadequate falls-policy awareness and application, failure to seek medical attention after he reported pain, lack of analgesia, inadequate records of routine checks, and the care home being without a registered manager.

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 Care First Class (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of a registered care home manager
Wider context from the report
“6. The home is currently without a registered manager and has been for sometime. ”
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 Care First Class (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to offer analgesia to residents reporting pain after a fall
Wider context from the report
“4. Mr. Harris was not offered any analgesia despite his reports of pain. ”
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 Care First Class (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure carers read residents’ care plans and risk assessments
Wider context from the report
“1. At the time of his fall none of his carers ████████ had not read his care plan or risk assessments. ”
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 Care First Class (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staffing capacity to accompany residents assessed as at risk of falls when mobilising
Wider context from the report
“2. His care plan stipulated that he was at medium risk of falls and should be accompanied when mobilising yet he mobilised to the bathroom from the lounge without assistance because the only member of staff present in the lounge was assigned to a resident requiring one to one observation and therefore could not accompany Mr. Harris. ”
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 Care First Class (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to record routine resident checks
Wider context from the report
“5. Records of routine checks on residents are not made. Therefore whilst it was asserted that Mr. Harris was checked hourly throughout following the fall there is no evidence that the checks were carried out, by whom and what was found. ”
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 Care First Class (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to make the falls protocol clearly available to staff
Wider context from the report
“3. Having fallen Mr. Harris complained of pain in his groin. The home’s ‘Protocol for all Falls’ included that if the resident complains of pain in any part of the body following a fall they ought not to be moved and medical attention should be sought. Medical attention was not sought and Mr. Harris was returned to his room. The three carers who gave evidence at the inquest ████████ ████████ and ████████ all gave evidence that they had not seen the document entitled ‘Protocol for all Falls’ prior to Mr. Harris’ fall on the 26th January 2017, although ████████ and ████████ were not found to be credible witnesses, ████████ was credible. Evidence of police investigations identified that the Protocol ought to have been clearly available for staff around the home as a result of issues raised by the CQC prior to this incident. ”
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 Care First Class (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to sufficiently educate and assess staff on falls policy awareness and application
Wider context from the report
“All of the above contribute to a concern that staff at Cherry Lodge are not being sufficiently educated at falls policy and assessed on their awareness and application of policies, and also that there is inadequate record keeping. ”
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 Care First Class (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to follow the falls protocol requiring immobilisation and medical attention after a painful fall
Wider context from the report
“3. Having fallen Mr. Harris complained of pain in his groin. The home’s ‘Protocol for all Falls’ included that if the resident complains of pain in any part of the body following a fall they ought not to be moved and medical attention should be sought. Medical attention was not sought and Mr. Harris was returned to his room. The three carers who gave evidence at the inquest ████████ ████████ and ████████ all gave evidence that they had not seen the document entitled ‘Protocol for all Falls’ prior to Mr. Harris’ fall on the 26th January 2017, although ████████ and ████████ were not found to be credible witnesses, ████████ was credible. Evidence of police investigations identified that the Protocol ought to have been clearly available for staff around the home as a result of issues raised by the CQC prior to this incident. ”
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
Provide new-resident needs information at each daily handover.

Verbatim wording from the response
“1) Read and sign sheets have been implemented so that staff read and sign care plans individually when residents are admitted to the home. The aim is that these are completed in a timely manner within 72 hours of a service user arriving, and staff will read and sign them the expectation being within one week. On point of admittance information is given at handover three times a day so that staff are aware of needs of a new resident.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 1 · response
Published 2 December 2017
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
Monitor staff records and address issues arising from record completion.

Verbatim wording from the response
“6) There is a manager in post at Cherry Lodge at present. ████████ does have registration for another service and will register with CQC in due course. Staff are being spoken to individually at Cherry Lodge as to their understanding and their roles and responsibilities in the event of any accident or incidents in the home. Management staff are monitoring records that staff are completing and addressing any issues arising from this.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 2 · response
Published 2 December 2017
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
Put care plans and risk assessments in place specifying supervision requirements during mobilisation.

Verbatim wording from the response
“2) Care plans and risk assessments are in place. Care plans stipulate if a resident requires supervision on mobilising and staff do endeavour to be with residents when walking. Unfortunately, some residents will not always wait for staff to assist and therefore put themselves at risk. If staff observe a resident mobilising independently and are aware that they should be accompanied then they will always assist.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 1 · response
Published 2 December 2017
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
Record residents’ hourly or two-hourly nightly checks on signed night-check sheets.

Verbatim wording from the response
“4) Records of nightly checks are in place. This identifies when residents were checked either hourly or two hourly at their request. This is then recorded on the night check sheet and signed by staff on duty.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 1 · response
Published 2 December 2017
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
Include the falls policy in recorded staff supervision to clarify responsibilities after a resident fall.

Verbatim wording from the response
“7) The falls policy now forms part of the Staff member’s supervision which is recorded. This is to clarify the member of staff understands their role and responsibility and what is expected when a service user has a fall. It will also be on the staff meeting agenda as a lessons learnt.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 2 · response
Published 2 December 2017
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
Disseminate the falls protocol to staff and incorporate it into new-staff induction.

Verbatim wording from the response
“3) Protocol for falls – this document has been given to all staff and a signed copy is kept on their personnel file. This has also been made part of the induction protocol for new staff.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 1 · response
Published 2 December 2017
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 read-and-sign care-plan sheets for staff caring for newly admitted residents.

Verbatim wording from the response
“1) Read and sign sheets have been implemented so that staff read and sign care plans individually when residents are admitted to the home. The aim is that these are completed in a timely manner within 72 hours of a service user arriving, and staff will read and sign them the expectation being within one week. On point of admittance information is given at handover three times a day so that staff are aware of needs of a new resident.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 1 · response
Published 2 December 2017
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
Add the falls policy to staff-meeting agendas as a lessons-learned item.

Verbatim wording from the response
“7) The falls policy now forms part of the Staff member’s supervision which is recorded. This is to clarify the member of staff understands their role and responsibility and what is expected when a service user has a fall. It will also be on the staff meeting agenda as a lessons learnt.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 2 · response
Published 2 December 2017
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
Maintain a manager in post at Cherry Lodge.

Verbatim wording from the response
“6) There is a manager in post at Cherry Lodge at present. ████████ does have registration for another service and will register with CQC in due course. Staff are being spoken to individually at Cherry Lodge as to their understanding and their roles and responsibilities in the event of any accident or incidents in the home. Management staff are monitoring records that staff are completing and addressing any issues arising from this.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 2 · response
Published 2 December 2017
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
Register the Cherry Lodge manager with CQC.

Verbatim wording from the response
“6) There is a manager in post at Cherry Lodge at present. ████████ does have registration for another service and will register with CQC in due course. Staff are being spoken to individually at Cherry Lodge as to their understanding and their roles and responsibilities in the event of any accident or incidents in the home. Management staff are monitoring records that staff are completing and addressing any issues arising from this.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 2 · response
Published 2 December 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Residents may mobilise without waiting for assistance, creating risk despite care plans requiring supervision and staff assisting when they observe this.

Verbatim wording from the response
“2) Care plans and risk assessments are in place. Care plans stipulate if a resident requires supervision on mobilising and staff do endeavour to be with residents when walking. Unfortunately, some residents will not always wait for staff to assist and therefore put themselves at risk. If staff observe a resident mobilising independently and are aware that they should be accompanied then they will always assist.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 1 · response
Published 2 December 2017
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 raised8

Unavailability of a registered care home manager

Failure to offer analgesia to residents reporting pain after a fall

Failure to ensure carers read residents’ care plans and risk assessments

Insufficient staffing capacity to accompany residents assessed as at risk of falls when mobilising

Failure to record routine resident checks

Failure to make the falls protocol clearly available to staff

Failure to sufficiently educate and assess staff on falls policy awareness and application

Failure to follow the falls protocol requiring immobilisation and medical attention after a painful fall

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.10

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 10

Respondent positions 1