Care First Homes

Private and voluntary organisations · Care-home operator

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First report 7 Oct 2016•Latest report 7 Oct 2016

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

Concerns and recipient responses

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

7 Oct2016
Stoke-on-Trent and North Staffordshire
Concerns raised16
1. Failure to refer to a dietician
2. Shortage of food and other equipment
3. Use of a medically unqualified home manager
1. Failure to follow up abnormal blood test results
2. Delays in referral to Tissue Viability Nurses
3. Lack of clear policies and procedures
4. Failure to follow Tissue Viability Nurses advice
5. Shortage of care staff
6. Failure to involve District Nursing Teams
7. Failure to refer to a physiotherapist
8. Failure to provide an upgraded mattress
9. Minimal GP involvement
10. Failure to complete turning charts
11. Use of an unregistered home manager
12. Poor management and absences of management staff
13. Failure to refer to mental health services
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Norman Arthur BEARD · 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

Norman Arthur BEARD suffered a fall, was admitted to hospital, and later transferred to Daisy Bank Nursing Home, where he developed serious pressure sores, dehydration and significant weight loss. He died at Abbey Court Nursing Home on 14 February 2015. Concerns included delayed referral and inadequate treatment of pressure sores, shortages of staff and essential supplies, incomplete care records, inadequate response to weight loss and minimal GP involvement.

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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer to a dietician
Wider context from the report
“(6) Mr Beard lost a significant amount of weight. There was no referral to a dietician, physiotherapist, mental health services or involvement of District Nursing Teams. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Shortage of food and other equipment
Wider context from the report
“(3) Financial difficulties led to shortage of staff, food and other equipment. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Use of a medically unqualified home manager
Wider context from the report
“(1) The home known as Daisy Bank Cheddle has now closed however there are three other care homes which remain under that same ownership of ████████ and managed by the same Chief Executive, Mr Tee. (2) Poor management and absences of management staff was evident during the inquest. The home manager was not registered and was not medically qualified. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to follow up abnormal blood test results
Wider context from the report
“(7) The involvement of the GP was minimal and there was no follow up when blood tests revealed an abnormality. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Delays in referral to Tissue Viability Nurses
Wider context from the report
“(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed. Turning charts were not filled in and an upgraded mattress was not provided. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear policies and procedures
Wider context from the report
“(4) There were no clear policies and procedures in place. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to follow Tissue Viability Nurses advice
Wider context from the report
“(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed. Turning charts were not filled in and an upgraded mattress was not provided. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Shortage of care staff
Wider context from the report
“(3) Financial difficulties led to shortage of staff, food and other equipment. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to involve District Nursing Teams
Wider context from the report
“(6) Mr Beard lost a significant amount of weight. There was no referral to a dietician, physiotherapist, mental health services or involvement of District Nursing Teams. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer to a physiotherapist
Wider context from the report
“(6) Mr Beard lost a significant amount of weight. There was no referral to a dietician, physiotherapist, mental health services or involvement of District Nursing Teams. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide an upgraded mattress
Wider context from the report
“(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed. Turning charts were not filled in and an upgraded mattress was not provided. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Minimal GP involvement
Wider context from the report
“(7) The involvement of the GP was minimal and there was no follow up when blood tests revealed an abnormality. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete turning charts
Wider context from the report
“(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed. Turning charts were not filled in and an upgraded mattress was not provided. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Use of an unregistered home manager
Wider context from the report
“(1) The home known as Daisy Bank Cheddle has now closed however there are three other care homes which remain under that same ownership of ████████ and managed by the same Chief Executive, Mr Tee. (2) Poor management and absences of management staff was evident during the inquest. The home manager was not registered and was not medically qualified. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Poor management and absences of management staff
Wider context from the report
“(1) The home known as Daisy Bank Cheddle has now closed however there are three other care homes which remain under that same ownership of ████████ and managed by the same Chief Executive, Mr Tee. (2) Poor management and absences of management staff was evident during the inquest. The home manager was not registered and was not medically qualified. ”
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 Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer to mental health services
Wider context from the report
“(6) Mr Beard lost a significant amount of weight. There was no referral to a dietician, physiotherapist, mental health services or involvement of District Nursing Teams. ”
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 raised16

Failure to refer to a dietician

Shortage of food and other equipment

Use of a medically unqualified home manager

Failure to follow up abnormal blood test results

Delays in referral to Tissue Viability Nurses

Lack of clear policies and procedures

Failure to follow Tissue Viability Nurses advice

Shortage of care staff

Failure to involve District Nursing Teams

Failure to refer to a physiotherapist

Failure to provide an upgraded mattress

Minimal GP involvement

Failure to complete turning charts

Use of an unregistered home manager

Poor management and absences of management staff

Failure to refer to mental health services