Credenhill Court Rest Home

Private and voluntary organisations · Residential care home

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First report 6 Mar 2024•Latest report 6 Mar 2024

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: 100%
Concerns addressed: 2
Stated actions: 8

Concerns and recipient responses

Statements from Credenhill Court Rest Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

6 Mar2024
Herefordshire
Concerns raised2
1. Deficiencies in procedures for escalation or non-escalation after a fall and subsequent medical intervention
2. Deficiencies in the quality and completion of residence care documentation
Actions described in response 6
1. Action
  Review the falls protocol and maintain monthly falls audits, professional escalation, post-fall reviews, and 24–48-hour monitoring.
2. Action
  Carry out daily audits of written daily notes and continue supporting staff to maintain documentation quality.
3. Action
  Advance-email weekly ward-round resident lists to the GP surgery and record visiting clinicians’ actions in care plans.
1. Action
  Implement written daily handover sheets and add completed handovers to residents’ daily records.
2. Action
  Support senior care staff through weekly documentation discussions and regularly review and audit resident notes.
3. Action
  Review and audit care plans monthly or when required.
Respondent positions 1
1. Position
  The existing falls protocol is considered effective, with concerns outside its parameters referred to appropriate health professionals.
  Existing arrangements considered sufficient
AI-generated summary

John Patrick MacGREGOR · 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

John Patrick MacGREGOR fell at a care home on 2 April 2023 and was not admitted to hospital until 13 April 2023, by which time he was profoundly unwell. He was treated for a hydropneumothorax, fractures and infection, but deteriorated and was placed on an end-of-life pathway; concerns included the quality and completion of care-home documentation and procedures for escalation or non-escalation after a fall.

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 Credenhill Court Rest Home; that does not assign responsibility.
PFD Monitor interpretation
Deficiencies in procedures for escalation or non-escalation after a fall and subsequent medical intervention
Wider context from the report
“Evidence was heard regarding: (a) The quality of residence care documentation and its completion. (b) Procedures regarding escalation or non-escalation following a fall and subsequent medical intervention ”
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 Credenhill Court Rest Home; that does not assign responsibility.
PFD Monitor interpretation
Deficiencies in the quality and completion of residence care documentation
Wider context from the report
“Evidence was heard regarding: (a) The quality of residence care documentation and its completion. (b) Procedures regarding escalation or non-escalation following a fall and subsequent medical intervention ”
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
Review the falls protocol and maintain monthly falls audits, professional escalation, post-fall reviews, and 24–48-hour monitoring.

Verbatim wording from the response
“• The falls protocol has been reviewed and we believe it is affective and each fall is taken on its own merit, any concerns beyond the parameter of the protocol we seek support and guidance from the appropriate health professionals i.e. doctors or paramedics and this documented. The falls continue to be audited each month to highlight any trends and to ensure the correct professional has been contacted. Any minor fall that takes place at Credenhill Court Rest Home the senior on duty emails the GP care home admin group and this resident is then reviewed on the weekly ward round and notes are added to their individual patient records. Each resident regardless of the severity of the fall and their capacity have 24-48 hour monitoring in the form of blood pressure, pulse and body map notes.”

Source location
Response from Credenhill Court
Page 1 · response
Published 14 March 2024
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
Carry out daily audits of written daily notes and continue supporting staff to maintain documentation quality.

Verbatim wording from the response
“• I will carry out daily audits of the daily notes that have been written and continue to support staff to ensure that the quality of our written documentation is upheld.”

Source location
Response from Credenhill Court
Page 2 · response
Published 14 March 2024
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
Advance-email weekly ward-round resident lists to the GP surgery and record visiting clinicians’ actions in care plans.

Verbatim wording from the response
“• I have reviewed our weekly ward round and a list of residents that need to be seen are emailed to the GP surgery 24 hours in advance. Once the residents have been seen we now receive a record of actions taken by the GP/ECP that visited. These actions are then added to the individual resident’s health notes within their care plan and any omissions can be identified.”

Source location
Response from Credenhill Court
Page 1 · response
Published 14 March 2024
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 written daily handover sheets and add completed handovers to residents’ daily records.

Verbatim wording from the response
“• In addition to our verbal handover and residents information board on display to all care staff in the office, to facilitate and capture more extensive notes for the daily records we have implemented a written daily handover sheet that care staff will complete and this will then be added to each residents daily records.”

Source location
Response from Credenhill Court
Page 2 · response
Published 14 March 2024
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
Support senior care staff through weekly documentation discussions and regularly review and audit resident notes.

Verbatim wording from the response
“• Senior care staff have been supported through weekly discussions to ensure they are confident in documenting the needs of each resident, they are able to capture everything on a day to day basis and any concerns raised are being addressed and documented. The notes are being regularly reviewed and audited.”

Source location
Response from Credenhill Court
Page 1 · response
Published 14 March 2024
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
Review and audit care plans monthly or when required.

Verbatim wording from the response
“• Care plans continue to be regularly reviewed and audited monthly or when required.”

Source location
Response from Credenhill Court
Page 2 · response
Published 14 March 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 existing falls protocol is considered effective, with concerns outside its parameters referred to appropriate health professionals.

Verbatim wording from the response
“• The falls protocol has been reviewed and we believe it is affective and each fall is taken on its own merit, any concerns beyond the parameter of the protocol we seek support and guidance from the appropriate health professionals i.e. doctors or paramedics and this documented. The falls continue to be audited each month to highlight any trends and to ensure the correct professional has been contacted. Any minor fall that takes place at Credenhill Court Rest Home the senior on duty emails the GP care home admin group and this resident is then reviewed on the weekly ward round and notes are added to their individual patient records. Each resident regardless of the severity of the fall and their capacity have 24-48 hour monitoring in the form of blood pressure, pulse and body map notes.”

Source location
Response from Credenhill Court
Page 1 · response
Published 14 March 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

Deficiencies in procedures for escalation or non-escalation after a fall and subsequent medical intervention

Deficiencies in the quality and completion of residence care documentation

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.6

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 6

Respondent positions 1