Recipient

Elm Tree Court Care Home

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First report 26 Sep 2022•Latest report 26 Sep 2022

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. East Riding and Hull

    AI-generated summary

    Robert Norman Howell · 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

    Robert Norman Howell, who was susceptible to falls, fell backwards in his room at Elm Tree Court care home on 12 April 2022 and struck his head. He sustained a subdural haematoma and died in hospital on 20 April 2022. Concerns included failures to share vital information about residents’ falls risks and care needs, inadequate access to care plans, and a lack of understanding of falls policies.

    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 Elm Tree Court Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to reliably cascade vital caring and risk information to care staff

    Wider context from the report

    “(1) Team Leaders held handovers between themselves, it was then up to the individual Team Leader to decide what to pass on to the staff responsible for caring. It became apparent during evidence that often vital caring and risk needs were not always cascaded to the staff interacting with the residents. As such vital information to those responsible for providing care was often 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 Elm Tree Court Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure care staff read and familiarise themselves with care plans and residents’ needs and risks

    Wider context from the report

    “(2) Care plans were held in the office. Staff were not instructed to read the care plans. It was left to an individual carer to decide if they wished to seek out the care plan. No time was set aside for staff to familiarise themselves with the care plan or individual needs and risks of the residents. Vital information could therefore be missed by those responsible for providing care. ”
    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 Elm Tree Court Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of understanding of falls policies among staff

    Wider context from the report

    “(3) Evidence showed a lack of understanding about the falls policies 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 Elm Tree Court Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to define information to be passed to all staff and verify their understanding

    Wider context from the report

    “(4) It was acknowledged that the home did have procedures introduced since Mr Howell’s death however it became evident that there was still a breakdown in communication and vital information was not being shared. There appeared to be a lacuna in what information should be passed to all staff and how confirmation of understanding was checked. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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