Recipient

Connaught House Care Home

First report 2 Jan 2024•Latest report 2 Jan 2024

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: 2
Stated actions: 2

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

2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

2 Jan2024
Birmingham and Solihull
Concerns raised2
1. Failure to involve the care home in decisions about removal of observations
2. Failure to understand and follow the correct inter-agency decision-making process
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Continue advocating for residents’ assessed care needs, including required 1:1 support.
  Stated in progress
Respondent positions 4
1. Position
  Connaught House did not remove Sylvia’s 1:1 observations; enhanced care remained in place throughout her stay.
  Disputes the concern
1. Position
  Changing how care funding is assessed or agreed is outside the respondent’s power; it can advise but cannot compel Council or ICB funding.
  Outside remit
2. Position
  The P2 team is responsible for reviewing placed residents’ care needs and determining the appropriate long-term placement.
  Redirects responsibility
3. Position
  There was no communication or understanding failure concerning Sylvia’s need for 1:1 observations or the information provided to other agencies.
  Disputes the concern
AI-generated summary

Sylvia May NASH · 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

Sylvia May NASH fell at The Orchards Nursing Home on 11 March 2023 and sustained a fractured neck of femur, which was surgically fixed at Birmingham Heartlands Hospital. She developed septic shock and died in hospital on 14 April 2023. Concerns were raised that agencies did not adequately understand or follow the process for decisions such as removing 1:1 observations, and that communication about responsibilities was insufficient.

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 Connaught House Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to involve the care home in decisions about removal of observations
Wider context from the report
“1. It was clear both from the evidence and subsequent correspondence that the correct process for making decisions, such as (but not exclusively), removal of 1:1 observations, is not understood adequately by all parties who should be involved in that decision making process. 2. Whilst the Council understood this to be a multi-disciplinary process involving any professional involved in the patient’s care, the care home, Connaught House, indicated that this decision rests solely with the Council. 3. This is concerning for two reasons. Firstly, the correct procedure is not understood and therefore has not been followed. Secondly, the fact that the care home, where the patient resides is of the view that they are not responsible for making decisions as to removal of observations ahead of transfer. They, in my view, should be pivotal in this decision as the organisation who have had the most contact with the patient and therefore in a position to provide important information as to risk and behaviour. 4. I am concerned that the communication and understanding of the correct process between agencies is insufficient. ”
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 Connaught House Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to understand and follow the correct inter-agency decision-making process
Wider context from the report
“1. It was clear both from the evidence and subsequent correspondence that the correct process for making decisions, such as (but not exclusively), removal of 1:1 observations, is not understood adequately by all parties who should be involved in that decision making process. 2. Whilst the Council understood this to be a multi-disciplinary process involving any professional involved in the patient’s care, the care home, Connaught House, indicated that this decision rests solely with the Council. 3. This is concerning for two reasons. Firstly, the correct procedure is not understood and therefore has not been followed. Secondly, the fact that the care home, where the patient resides is of the view that they are not responsible for making decisions as to removal of observations ahead of transfer. They, in my view, should be pivotal in this decision as the organisation who have had the most contact with the patient and therefore in a position to provide important information as to risk and behaviour. 4. I am concerned that the communication and understanding of the correct process between agencies is insufficient. ”
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
Continue advocating for residents’ assessed care needs, including required 1:1 support.

Verbatim wording from the response
“I do not believe that it is within our power to make any changes to the way that funding is assessed or agreed by the Council or the ICB and we will continue to provide 1:1 care where we have assessed that it is required and continue to advocate for the residents in our care.”

Source location
Response from Connaught House
Page 3 · response
Published 8 January 2024
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
Connaught House did not remove Sylvia’s 1:1 observations; enhanced care remained in place throughout her stay.

Verbatim wording from the response
“The Regulation 28 Order suggests that Connaught House could make some changes to its procedures with respect to the cessation of 1:1 care and we strongly disagree with this conclusion. At no stage did Connaught House remove the 1:1 care for Sylvia and we kept this in place despite not being paid for this expensive provision. The P2 team are fully and solely responsible for the review of the care needs of any individual they place in a P2 bed and for the funding levels available to the new care setting they choose to send the resident to. Connaught House can only provide the information but are not in any position to dictate this decision in any way, shape or form.”

Source location
Response from Connaught House
Page 1 · response
Published 8 January 2024
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
Changing how care funding is assessed or agreed is outside the respondent’s power; it can advise but cannot compel Council or ICB funding.

Verbatim wording from the response
“I do not believe that it is within our power to make any changes to the way that funding is assessed or agreed by the Council or the ICB and we will continue to provide 1:1 care where we have assessed that it is required and continue to advocate for the residents in our care.”

Source location
Response from Connaught House
Page 3 · response
Published 8 January 2024
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
The P2 team is responsible for reviewing placed residents’ care needs and determining the appropriate long-term placement.

Verbatim wording from the response
“The Regulation 28 Order suggests that Connaught House could make some changes to its procedures with respect to the cessation of 1:1 care and we strongly disagree with this conclusion. At no stage did Connaught House remove the 1:1 care for Sylvia and we kept this in place despite not being paid for this expensive provision. The P2 team are fully and solely responsible for the review of the care needs of any individual they place in a P2 bed and for the funding levels available to the new care setting they choose to send the resident to. Connaught House can only provide the information but are not in any position to dictate this decision in any way, shape or form.”

Source location
Response from Connaught House
Page 1 · response
Published 8 January 2024
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
There was no communication or understanding failure concerning Sylvia’s need for 1:1 observations or the information provided to other agencies.

Verbatim wording from the response
“4. There is no issue with our communication or understanding of the need for 1:1 observations and this again was ably demonstrated by the care we delivered to Sylvia and the information we provided to the wider multi-disciplinary team. I would be extremely interested in the changes the Council have undertaken to adopt in light of this Regulation 28 Order as I believe the issue was not around our provision of information but rather whether there was an acceptance that this level of care was required or whether the Council could find an alternative placement that was cheaper. Connaught House did not decide that Sylvia needed to leave its care and nor did we decide that these 1:1 observations were not required. This decision was taken by others.”

Source location
Response from Connaught House
Page 3 · response
Published 8 January 2024
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 raised2

Failure to involve the care home in decisions about removal of observations

Failure to understand and follow the correct inter-agency decision-making process

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.1

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.4

Actions described in response 1

Respondent positions 4