Concerns raised 6 Lack of clear and timely internal and external fall reporting View source Failure to clearly document medical advice obtained after resident falls View source Failure to promptly re-evaluate and amend care plans after significant events View source Failure to provide effective, individually tailored monitoring measures for residents at high risk of falls View source Failure to obtain timely medical advice after a resident fall View source Failure to maintain accessible and retained resident records View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 12
Action
Operate RADAR incident reporting with mandatory fall details, investigation workflows, escalation prompts and regulatory notification requirements.
Stated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Remind Home Managers about available falls-reduction equipment and include equipment availability in regular audits of home practice.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025. View source
Action
Apply the Group Falls Policy and supporting flowcharts covering falls protocols, referrals, care planning, risk assessment and post-fall actions.
Stated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Provide mandatory falls-awareness training and refresher training for care and clinical staff through blended learning and face-to-face delivery.
Stated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Review care plans and risk assessments after falls, near misses or other changes in need, updating them where required.
Stated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Publish and distribute an archiving guide setting standards for record storage, safekeeping and retention across the Group.
Stated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Pilot electronic care records at several homes to support digitisation of intensive manual record-keeping processes.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025. View source
Action
Analyse falls incidents monthly, validate home practice through regional reviews and use trend monitoring to identify and address emerging risks.
Stated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Conduct daily documentation checks, monthly file checks and regular care-plan sampling to identify omissions, errors and compliance issues.
Stated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Deliver record-keeping, care-plan and documentation training covering contemporaneous entries, professional visits, emerging risks, RADAR records and archiving.
Stated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Develop and roll out additional learning-management guidance on GDPR and the safekeeping and storage of records.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025. View source
Action
Prompt visiting healthcare professionals to sign in, accompany visits with senior staff, document advice and recommendations, and record information for handovers and audit.
Stated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source See 9 more actions
×
AI-generated summary
Sylvia Margaret Louisa SAVAGE · 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 Margaret Louisa Savage died on 25 April 2023 at the University Hospital of North Durham from bronchopneumonia, following a fall from her bed at Redwell Hills Care Home on 18 March 2023 and subsequent injuries and decline in health. The concerns included unclear fall-reporting arrangements, ineffective monitoring of her mobilisation, inadequate post-fall medical assessment, missing or insufficient care records, and failure to promptly reassess her care plan after falls.
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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and timely internal and external fall reporting
Wider context from the report “1. There was I heard no clear definition of when to report falls externally & internally - this to me is perhaps the reason why the fall Mrs Savage suffered on 1/2/23 was not recorded internally, all be it CQC were notified on this occasion. The fall on 18/3/23 was not reported to CQC and whilst I understand staff at the care home did not know the outcome of Mrs Savage's treatment in hospital - she left the home by ambulance and did not return. This seems an occurrence worthy of reporting – It strikes me some clearer reporting structure is necessary - timely and accurate reporting both internally and to regulators allows for those concerned to assess the care home and decide on whether there are risks/issues that need addressing and protect residents. I would suggest over reporting is preferable to under reporting.
” 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly document medical advice obtained after resident falls
Wider context from the report “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly re-evaluate and amend care plans after significant events
Wider context from the report “5. The evidence I have heard is after Mrs Savage's fall on 1/2/23 and when it became clear the sensor mat was not working as intended - this should have prompted staff to return to the care plans and re-evaluate them - it did not . Indeed one care home witness stated as Mrs Savage had not had 3 falls in 3 months no change to her plan was needed. Given the second fall Mrs Savage had some weeks later gave her injuries that led to her death this approach appears flawed. Whilst I acknowledge work is ongoing in this area it appears that prompt re-evaluation of the care plans after events such as a fall are necessary to prevent injury and death - I would ask for some reassurance that significant events are captured by staff and in turn their significance is carefully considered and if necessary changes made to 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective, individually tailored monitoring measures for residents at high risk of falls
Wider context from the report “2. The evidence is clear that the provided sensor mat was not an efficient way of monitoring Mrs Savage when she attempted to mobilise . It was well known in the home that Mrs Savage defeated it's purpose by moving or unplugging it. There seems to have been a lack of thought as to an alternative measure . The wall mounted sensor, for example was seen by the expert as a reasonable measure - the home manager said he could consider them and the regional manager indicated they were used in the company, but not at the care home where Mrs Savage was residing. It seems to me the council should have an armoury of measures to pick from to tailor to the needs of the individual resident not just limited to one particular measure . The risk of death is obvious to others if persons at high risk of falls are not known to be moving by those charged with looking after them.
” 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain timely medical advice after a resident fall
Wider context from the report “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accessible and retained resident records
Wider context from the report “4. The absence of records has hindered my investigation into Mrs Savage's death. The expert in her evidence made it clear - good recording keeping allows staff to monitor changes in condition, allows new staff or those returning from time off to reacquaint themselves with residents condition and allows clinicians to make diagnosis - without access to good records I can see a clear risk to the care of residents . It is also surprising to me the complete reliance on paper records which in Mrs Savage’s case have been lost . I would have expected to see electronic recording of information and electronic storage of it. I note the roll out of this in the company has been paused whilst the company is awaiting sale and my concern is whether the electronic recording and storage will be implemented - to me immediate access to records of a resident or the absence of them creates a concern .
” 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 Operate RADAR incident reporting with mandatory fall details, investigation workflows, escalation prompts and regulatory notification requirements.
Verbatim wording from the response “The Group operates a digital incident management platform (RADAR) which allows team members of all grades to report incidents affecting residents, team members and any visitors to the care home. The system also offers prompts to ensure appropriate categorisation of the incident and to support necessary further actions including referral to external agencies and management by regional support teams.” Source location Response from Four Seasons Healthcare
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 Remind Home Managers about available falls-reduction equipment and include equipment availability in regular audits of home practice.
Verbatim wording from the response “Following the concerns noted at the inquest, regional teams have reminded all Home Managers as to the scope of equipment available to them through the Group procurement department, to support falls reduction. This equipment is available to any resident, in accordance with their assessed needs and risk assessment. Regional teams will incorporate this into their regular audit of home practices.” Source location Response from Four Seasons Healthcare
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 Apply the Group Falls Policy and supporting flowcharts covering falls protocols, referrals, care planning, risk assessment and post-fall actions.
Verbatim wording from the response “A Falls Process Flowchart has formed part of the new system in place after April 2021. Since April 2021, all care and clinical team members must complete falls awareness training, delivered by a learning management system complemented by on-site face to face training.” Source location Response from Four Seasons Healthcare
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 Provide mandatory falls-awareness training and refresher training for care and clinical staff through blended learning and face-to-face delivery.
Verbatim wording from the response “The Clinical Risk Management Policy (also exhibited to ████████’s statement) was adopted by the Group in 2021, with a body of supporting material for guidance on falls risk and post-falls management. Falls Awareness training was introduced as part of an induction program to new home starters across the Group from April 2020 and then as mandatory training for all care and clinical team members from April 2021.” Source location Response from Four Seasons Healthcare
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 care plans and risk assessments after falls, near misses or other changes in need, updating them where required.
Verbatim wording from the response “Mrs Savage had been admitted to the Home initially as a temporary placement on 14 December 2022. For new admissions, upon receipt of a referral or enquiry, details about the person to be admitted to our homes will be taken and a pre-admission assessment will be completed. The information obtained at the pre-admission stage will seek to include everything that the home requires to ensure that the needs of the person can be met safely, and to ensure that there is continuity of care, treatment and support for the person, and this information is used to commence formulation of care plans and risk assessments, including mobility needs and falls risk. All risk assessments are to be completed within 12 hours of admission and care plans finalised within 72 hours, these documents are reviewed monthly as a minimum, or as a change in resident need is identified.” Source location Response from Four Seasons Healthcare
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 Publish and distribute an archiving guide setting standards for record storage, safekeeping and retention across the Group.
Verbatim wording from the response “A new “How to Guide” for archiving was published and distributed throughout the Group in October 2024, providing clear standards and expectations around the care, storage and safe keeping of records. A training module on the Group’s learning management system is also being developed and roll out is expected shortly. This will be additional guidance for the Home’s teams in relation to GDPR and the safekeeping and storage of records.” Source location Response from Four Seasons Healthcare
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 Pilot electronic care records at several homes to support digitisation of intensive manual record-keeping processes.
Verbatim wording from the response “The process for daily record-keeping and storage of records has been explained to each member of the team and recorded in supervision notes, countersigned to confirm understanding. Throughout 2024 the Group rolled-out electronic medicines administration records (‘eMAR’) as part of continued investment in our homes, notwithstanding a sales process launched in June 2024. The system removes a lot of the paper in the medication process and with live reporting supports improved visibility at home and regional level. This investment in eMAR followed a wholesale Wi-Fi upgrade programme and serves to modernise and digitise a key area of how we work. The Group is piloting electronic care records at several homes as part of continued efforts to digitise intensive manual processes. In the meantime, the importance of proper record-keeping and archiving is a regular agenda item at flash meetings.” Source location Response from Four Seasons Healthcare
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 Analyse falls incidents monthly, validate home practice through regional reviews and use trend monitoring to identify and address emerging risks.
Verbatim wording from the response “Each home in the Group is required to complete an incident analysis each month which is produced via the RADAR system, this is then validated during the Regional Manager Provider Validation Review which is” Source location Response from Four Seasons Healthcare
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 Conduct daily documentation checks, monthly file checks and regular care-plan sampling to identify omissions, errors and compliance issues.
Verbatim wording from the response “• The Senior Care team and Home Manager are completing daily checks of room documentation and the information recorded on that to ensure quality and accurate content.” Source location Response from Four Seasons Healthcare
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 Deliver record-keeping, care-plan and documentation training covering contemporaneous entries, professional visits, emerging risks, RADAR records and archiving.
Verbatim wording from the response “We acknowledge the shortcomings in record-keeping at Redwell Hills as addressed in the Home Manager’s statement of 1 December 2023. Record-keeping training and guidance has been heavily promoted within the Home since the issues were identified in connection with Mrs Savage’s death. All existing clinical and care team members have been required to refresh mandatory courses on record-keeping training. Care plan and documentation training was booked for team members at the Home as a face-to-face course following the incident and has taken place regularly with multiple sessions covering the full care team, the last taking place on 8 August 2024. The courses have covered contemporaneous noting of daily events, professional visits and emerging risks, entries in the Group’s incident management system, RADAR, and proper archiving.” Source location Response from Four Seasons Healthcare
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 Develop and roll out additional learning-management guidance on GDPR and the safekeeping and storage of records.
Verbatim wording from the response “A new “How to Guide” for archiving was published and distributed throughout the Group in October 2024, providing clear standards and expectations around the care, storage and safe keeping of records. A training module on the Group’s learning management system is also being developed and roll out is expected shortly. This will be additional guidance for the Home’s teams in relation to GDPR and the safekeeping and storage of records.” Source location Response from Four Seasons Healthcare
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 Prompt visiting healthcare professionals to sign in, accompany visits with senior staff, document advice and recommendations, and record information for handovers and audit.
Verbatim wording from the response “All visiting professionals including General Practitioners will now be prompted and requested to complete the Visitors Book on arrival to the Home and to await a member of the team to announce their arrival so that they can be accompanied on all visits by a senior member of the care or clinical team, to ensure that any advice or recommendations can be communicated as needed. Senior Care Assistant staff or a Unit Manager on duty will go with the healthcare practitioner when they attend and review and treat our residents. The Senior Carer will then document information in the Healthcare Professionals Visit form. The information recorded will confirm the time and date of the visit and the name of the practitioner.” Source location Response from Four Seasons Healthcare
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 It cannot be established that Mrs Savage would have responded better to a different sensor measure.
Verbatim wording from the response “The Group has access to a range of sensor equipment to support the needs of residents, including infrared motion detectors. Sensor mats are often favoured as they alert teams to a resident attempting to mobilise and can be moved with the resident if they choose to sit in lounge areas, for example. Infrared motion detectors can be troublesome for residents who can walk short distances independently as they will ring constantly when the resident is moving around their bedroom and the noise and consequential agitation that may be experienced may lead to further risk of harm or injury. It cannot be said with any certainty that Mrs Savage would have responded better to a different sensor measure, but it is acknowledged that the care provided to Mrs Savage following her falls on 1 February and 18 March 2023 was reactive rather than” Source location Response from Four Seasons Healthcare
Open published response
Concerns raised 1 Failure to supervise syringe medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Beryl ELLISON · 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
Beryl Ellison was receiving end-of-life care at Alexandra Care Home and was found deceased there on 28 June 2022. The inquest concluded that her death resulted from underlying poor health in combination with taking an excessive quantity of prescribed medication. Concerns included unsupervised access to syringe medication, prior family reports about medication being left in her room, and the absence of an explanation for the excessive oxycodone concentration found after her death.
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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise syringe medication
Wider context from the report “Mrs Ellison was resident at Alexandra Care Home and was found deceased on 28th June 2022 by staff. Her family expressed concern that she had been left with syringe medication unsupervised by staff and raised concerns about this with the care home both historically and four days prior to her death. A post mortem examination revealed Mrs Ellison to have an excessive concentration of oxycodone in her system which was likely to exceed any acquired tolerance level. The evidence heard at inquest revealed no explanation as to why Mrs Ellison was found to have taken the excessive quantity of oxycodone which contributed to her death. Furthermore, the systems at the care home were stated categorically to be the same as those that were in place prior to Mrs Ellison's death .
” 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 Conduct weekly observations of medicine rounds.
Verbatim wording from the response “• Weekly observations of drug rounds are now completed.” Source location Response from Four Seasons Health Care Group
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 Write and share a specific medication risk assessment when medication-management risk is identified, retaining it with medication records.
Verbatim wording from the response “Where a risk to medication administration or management is identified for any resident, a specific medication risk assessment will be written and shared with the nursing and care team to ensure awareness of the specific risk and control measures in place. For ease of reference and to ensure that this potential risk is highlighted at each drug round to the member of staff administering medication, a copy of this risk assessment will be held alongside the medication administration records for the individual resident.” Source location Response from Four Seasons Health Care Group
Open published response
31 Jan 2022 Colm MCCABE · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 8 Failure to audit management effectiveness adequately View source Failure to conduct staff appraisals appropriately View source Failure to train staff adequately View source Failure to carry out full and candid investigations and produce corresponding reports View source Insufficient training of managers in full and candid investigations View source Failure to carry out 72-hour reviews View source Failure to identify and clarify blood sugar monitoring issues View source Failure to recruit staff appropriately View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Colm MCCABE · 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
Colm McCabe, aged 79, was admitted to hospital with hyperglycaemia after his blood sugar levels were not monitored and insulin administration was not clarified at the care home. He was transferred to hospital on 22 March 2021 and died there on 24 March 2021; the inquest concluded that natural causes were contributed to by neglect. Concerns included staff recruitment, training and appraisal, ineffective auditing, failures to clarify and monitor diabetes care, and the candour and completeness of investigations by the care home.
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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to audit management effectiveness adequately
Wider context from the report “2. Whilst I was advised that a new management team is working at this care home, I remain concerned about auditing of the effectiveness of this . We heard evidence that auditing was taking place at the time of this death, but this appears to have missed significant factors , including the fact that a 72 hour review was not carried out, that neither the 72 hour review nor any subsequent management of the patient picked up the blood sugar monitoring issue, nor did they seek clarification of this point with the hospital, the GP or community diabetic nurses.
” 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct staff appraisals appropriately
Wider context from the report “1. A number of the policies referred to at the inquest were in fact already in place at the time of this death. Many of these were not followed. I remain concerned about recruitment of staff, training of staff, and appraisals of staff .
” 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to train staff adequately
Wider context from the report “1. A number of the policies referred to at the inquest were in fact already in place at the time of this death. Many of these were not followed. I remain concerned about recruitment of staff, training of staff , and appraisals of staff.
” 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out full and candid investigations and produce corresponding reports
Wider context from the report “3. I heard evidence about investigations carried out by the home, and the fact that initial responses to enquiries from the CQC suggested that the management had been appropriate. I am concerned to know to what extent care homes run by Four Seasons carry out full and candid investigations and produce reports accordingly , and what training is given to managers in this respect?
” 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of managers in full and candid investigations
Wider context from the report “3. I heard evidence about investigations carried out by the home, and the fact that initial responses to enquiries from the CQC suggested that the management had been appropriate. I am concerned to know to what extent care homes run by Four Seasons carry out full and candid investigations and produce reports accordingly, and what training is given to managers in this respect?
” 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out 72-hour reviews
Wider context from the report “2. Whilst I was advised that a new management team is working at this care home, I remain concerned about auditing of the effectiveness of this. We heard evidence that auditing was taking place at the time of this death, but this appears to have missed significant factors, including the fact that a 72 hour review was not carried out , that neither the 72 hour review nor any subsequent management of the patient picked up the blood sugar monitoring issue, nor did they seek clarification of this point with the hospital, the GP or community diabetic nurses.
” 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and clarify blood sugar monitoring issues
Wider context from the report “2. Whilst I was advised that a new management team is working at this care home, I remain concerned about auditing of the effectiveness of this. We heard evidence that auditing was taking place at the time of this death, but this appears to have missed significant factors, including the fact that a 72 hour review was not carried out, that neither the 72 hour review nor any subsequent management of the patient picked up the blood sugar monitoring issue , nor did they seek clarification of this point with the hospital, the GP or community diabetic nurses .
” 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 Four Seasons Health Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to recruit staff appropriately
Wider context from the report “1. A number of the policies referred to at the inquest were in fact already in place at the time of this death. Many of these were not followed. I remain concerned about recruitment of staff , training of staff, and appraisals of staff.
” Open source report
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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 training compliance monthly across operational portfolios and use reviews and audits to identify corrective action.
Verbatim wording from the response “Additional learning and development - Learning and development that is based on a team’s/team member’s specific needs, identified either as knowledge gaps (information that employees need to know or understand but currently don’t), or skills gaps (actions that employees need to be able to carry out or perform but currently can’t). This is usually identified as part of the processes of supervision, annual appraisal or compliance (i.e. to meet the requirements of a particular service or local authority contract). It often leads to the development of personal improvement plans, which are regularly updated, reviewed and monitored.” Source location 2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
Open published response
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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 Improve the training platform to align team-member training with Group policies, statutory frameworks and safe-care requirements.
Verbatim wording from the response “1. The Group has introduced a “Policy of the Month” in order to raise awareness of company policies, practices and procedures. This is cascaded to all regional support teams and to homes via a weekly update by the Chief Operating Officer, with Home Managers cascading this to care home based team members during Daily Flash Meetings. The Group’s training platform has been improved to ensure that all team members are provided with relevant training that reflects the Group’s policies, practices and benchmarks. The platform is closely aligned to current statutory frameworks. All team members are guided through the principles and expectations of these as they complete each training module on the platform.” Source location 2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
Open published response
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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 Improve recruitment processes through Group Recruitment Team support and address new employees’ additional learning and development needs.
Verbatim wording from the response “To align with Group training and policies, recruitment processes have been improved and all Departments are supported by the Group’s Recruitment Team. Additional learning and development needs are reviewed and addressed by Operational Managers once employment of the individual has commenced.” Source location 2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
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 Improve supervision and appraisal through themed, observational and clinical supervision, addressing identified practice and training needs.
Verbatim wording from the response “The Group has reviewed and improved its supervision and appraisal process to provide a responsive and flexible framework that enables Home Managers to support their teams to give their best, develop and grow, and to manage the personal and professional challenges associated with working in the care sector. The improved process covers the areas of themed supervision, delivered on a one-to-one or group basis to provide a space for reflection and discussion about specific themes, cases or issues arising, whereby discussions encourage open dialogue and insight to enhance learning and improve practice. Observational supervision is now conducted as a supportive measure to review direct care practice and knowledge; should areas of improvement be identified during the observational session these are addressed with the employee.” Source location 2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
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 Conduct audits using multiple and independent sources, and validate audit data through further interrogation of reported outcomes.
Verbatim wording from the response “Accordingly, action has been taken to conduct audits via multiple sources, including completion by team members independent to the homes, promoting a validation approach to audits carried out. The review of data produced by audit has also been improved. Whereas previously if data indicated consistent high outcome scores, this was viewed as assurance that a home was compliant. A different approach is now adopted so that this is now interrogated further utilising an independent team member validation approach to obtain assurance as to the accuracy of the outcomes presented to the wider business.” Source location 2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
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 Operate the RADAR incident-management system with designated workflows and regularly reviewed prompts for incident reporting and investigation.
Verbatim wording from the response “3. The Group operates an incident management system via the RADAR platform; this is a fundamental change to the previous system DATIX, an incident management system commonly used in the sector and which was in use by the Group prior to April 2021. Whereas the DATIX system was controlled by the external program developers, which restricted our ability to invoke change when this was required to meet the needs of our business, the RADAR system allows for full participation and control to reflect Group practices and to enable positive change by the Group. Every incident reported has a designated workflow to guide and prompt team members as to the information required and notifications that may be required; these workflow steps are regularly reviewed to support improved reporting and investigation.” Source location 2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver bespoke training for Home Managers on conducting, documenting and evidencing continuous improvement through audits.
Verbatim wording from the response “2. Through reflection and review, it has been recognised that the Group Governance and Audit system was not utilised at The Berkshire Care Home in the way for which it was intended. The completion of the audit process is reliant upon human elements, namely the importance of understanding the process, an honest and accurate approach to completion and the ability to execute this through comprehensive and open reporting. Accordingly, work is now in progress with the Group Care Quality and Assurance Teams to develop and deliver bespoke training to all Home Managers on how to conduct and document an audit and evidence continuous improvement. Further to this, it is recognised that the completion of audits should not be the responsibility of one individual as this may result in a restricted overview without checks and balances.” Source location 2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Simplify and improve the Root Cause Analysis function with additional guidance and prompts linked to incident reporting.
Verbatim wording from the response “A Root Cause Analysis function aligned to incident reporting has been simplified and improved with additional guidance and prompts to support team members. Furthermore, the Group has developed a bespoke training module to guide team members on how to conduct an investigation; this is directly aligned to the RADAR incident management system, workflow steps and effective completion of a Root Cause Analysis under sector standard principles and is delivered nationally across the Group. The training has been developed using a ‘lessons learned’ approach and guides managers through the process of completing a timely, thorough and effective investigation with a focus on openness and transparency, mirroring duty of candour principles.” Source location 2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver nationally a bespoke investigation-training module covering timely, thorough, open and transparent investigations and lessons learned.
Verbatim wording from the response “A Root Cause Analysis function aligned to incident reporting has been simplified and improved with additional guidance and prompts to support team members. Furthermore, the Group has developed a bespoke training module to guide team members on how to conduct an investigation; this is directly aligned to the RADAR incident management system, workflow steps and effective completion of a Root Cause Analysis under sector standard principles and is delivered nationally across the Group. The training has been developed using a ‘lessons learned’ approach and guides managers through the process of completing a timely, thorough and effective investigation with a focus on openness and transparency, mirroring duty of candour principles.” Source location 2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A Group-wide 72-hour review process is not considered necessary because audit and other changes provide sufficient checks.
Verbatim wording from the response “During the course of the inquest, Ms ████████ gave evidence about 72-hour reviews, which were carried out, at The Berkshire Care Home. These reviews were introduced by Ms ████████ at a local level at The Berkshire Care Home, following the death of Mr McCabe and as an additional check as to compliance with process in response to the issues which became apparent following Mr McCabe’s death: they were not incorporated into the Group’s general policies applicable to the delivery of care at all homes. I am sorry for the confusion in this regard. Following consideration of the audit and other changes outlined in this letter it has not been considered necessary to implement 72 hour reviews as a standard process across the Group.” Source location 2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations