Recipient

Globe Court Care Home

First report 11 Aug 2023•Latest report 11 Aug 2023

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: 0%
Concerns addressed: 0
Stated actions: 0

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

11 Aug2023
Inner North London
Concerns raised6
1. Failure to update care plans and risk assessments in light of significant developments
2. Staff unfamiliarity with risk assessments and care plans
3. Failure to review care plans at identifiable times
1. Failure to preserve old care plans in their contemporaneous format
2. Failure of risk assessment to specify responses to identified risks
3. Failure of risk assessment to engage with the particular patient
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Doris Irene URCH · 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

Doris Irene Urch, aged 90, fell at a care home on 6 February 2023 after support was not offered while she was ambulating. She sustained an acute left frontal intracranial haemorrhage and died on 28 February 2023. Concerns included inadequate fall-risk assessment and care planning, staff unfamiliarity with the care plan, failure to update it after an earlier fall, and inadequate preservation of historical care plans.

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 Globe Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to update care plans and risk assessments in light of significant developments
Wider context from the report
“(4) The care plan/risk assessment was not updated in light of a fall in November/December 2022. I was concerned that potentially significant developments might not be being taken into account in keeping the care plan under review. ”
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 Globe Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Staff unfamiliarity with risk assessments and care plans
Wider context from the report
“(3) Staff seemed unfamiliar with the risk assessment/care plan, which I consider more of a systemic problem. It is unclear if/when care plans were reviewed by 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 Globe Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to review care plans at identifiable times
Wider context from the report
“(3) Staff seemed unfamiliar with the risk assessment/care plan, which I consider more of a systemic problem. It is unclear if/when care plans were reviewed by 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 Globe Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to preserve old care plans in their contemporaneous format
Wider context from the report
“(5) The system does not preserve old care plans in their contemporaneous format which is a serious shortcoming which has the potential to hinder future investigations. I encourage that system to be reviewed. ”
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 Globe Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of risk assessment to specify responses to identified risks
Wider context from the report
“(2) The Risk Assessment did not make no recommendations or suggestions as to what to do about the risks identified. ”
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 Globe Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of risk assessment to engage with the particular patient
Wider context from the report
“(1) The Question and Answer tickbox form for Risk Assessment seemed to me to leave much to be desired. It was excessively binary and meant that those who filled it in did not need to “engage” with the particular patient. ”
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 raised6

Failure to update care plans and risk assessments in light of significant developments

Staff unfamiliarity with risk assessments and care plans

Failure to review care plans at identifiable times

Failure to preserve old care plans in their contemporaneous format

Failure of risk assessment to specify responses to identified risks

Failure of risk assessment to engage with the particular patient