Recipient

Hill Care Group

First report 29 Jul 2025•Latest report 29 Jul 2025

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Care-home operator. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 200%
Concerns addressed: 22
Stated actions: 27

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.

200%published responses found

27stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

29 Jul2025
Northumberland
Concerns raised8
1. Failure to conduct speech and language therapy assessment using referral information, eating observation and care records
2. Failure to ensure staff have current Basic Life Support and First Aid at Work training
3. Lack of staff training and competence in care plans, MUST, BMI calculation and nutritional risk assessment
1. Failure to refer residents identified as high nutritional risk to appropriate clinical services
2. Failure to ensure food provided conforms to residents' identified diet plans
3. Failure to provide pertinent referral information to speech and language therapy
4. Failure to ensure agency staff receive and have verified induction
5. Delays in care assistant intervention when a resident shows signs of choking
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 12
1. Action
  Deliver an IDDSI diet competency assessment to all staff and require completion by 30 September 2025.
  Stated in progress
2. Action
  Operate an electronic training platform with expiry alerts and scheduled weekly compliance reports for home managers.
  Stated completed
3. Action
  Deliver face-to-face modified-food preparation training to Hill Care cooks and chefs, including practical preparation of different consistencies.
  Stated in progress
1. Action
  Reissue Basic Life Support and IDDSI/Dysphagia training electronically with defined completion timeframes.
  Stated in progress
2. Action
  Conduct a pre-meal safety pause to confirm dining-room awareness of special diets and correct meal provision, with Regional Manager observation during visits.
  Stated completed
3. Action
  Deliver face-to-face emergency first aid training to all staff by 14 October 2025.
  Stated in progress
4. Action
  Develop and deliver refresher training on assessments for nurses and senior care assistants, repeat it on a three-year cycle, and monitor completion electronically.
  Stated in progress
5. Action
  Use revised agency induction forms to verify first aid, mandatory training, modified-diet awareness and daily nutritional-report awareness.
  Stated completed
6. Action
  Require Regional Managers to check compliance with mandatory and refresher training through governance systems.
  Stated completed
7. Action
  Implement a competency assessment for all catering team members.
  Stated completed
8. Action
  Verify agency workers’ training credentials before shifts and reiterate mandatory training requirements to the agency supplier.
  Stated completed
9. Action
  Provide serving-trolley reference sheets showing each resident’s IDDSI level and nutritional needs, with daily review at flash meetings.
  Stated completed
Respondent positions 1
1. Position
  The measures described are considered sufficient to satisfy the concerns, so no further safety work is proposed.
  No action considered necessary
AI-generated summary

Joan WHITWORTH · 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

Joan Whitworth, a resident of Oaks Care Home with advanced dementia and a DNACPR order, died there on 3 March 2023 after choking caused by massive aspiration. Concerns included the adequacy of the speech and language assessment, staff training and induction, delayed intervention when she showed signs of choking, and food being prepared contrary to her diet plan.

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 Hill Care Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct speech and language therapy assessment using referral information, eating observation and care records
Wider context from the report
“1. Whilst pertinent information was not provided to SALT, I am concerned that at assessment on 21 February 2023 there was no reliance upon the information provided in the referral to SALT which identified a concern for her swallow, coughing, weight loss choking. Instead the assessment was based on the verbal account of a member of care home staff. There was no observation of the deceased eating and there was no inspection of her care records. ”
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 Hill Care Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure staff have current Basic Life Support and First Aid at Work training
Wider context from the report
“2. Basic Life Support and First Aid at Work I am concerned that a Registered General Nurse and a Senior Care Assistant were not in date with their training in Basic Life Support and First Aid at Work. I am further concerned that it could not be confirmed if an Agency Care Worker was up to date with their training in Basic Life Support and First Aid at Work. ”
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 Hill Care Group; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff training and competence in care plans, MUST, BMI calculation and nutritional risk assessment
Wider context from the report
“3. Training I am concerned that a Senior Care Assistant could not recall having received any formal training in the preparation of Care Plans, no training on MUST or calculating BMI yet was completing care plans and documents. I am further concerned than when the Senior Care Assistant completed the Nutritional Risk Assessment, on three dates the deceased was identified as high risk yet there was no referral to the GP, dietician or consideration of referral to SALT. I am concerned that in the absence of training there was not an understanding of the assessment. ”
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 Hill Care Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer residents identified as high nutritional risk to appropriate clinical services
Wider context from the report
“3. Training I am concerned that a Senior Care Assistant could not recall having received any formal training in the preparation of Care Plans, no training on MUST or calculating BMI yet was completing care plans and documents. I am further concerned than when the Senior Care Assistant completed the Nutritional Risk Assessment, on three dates the deceased was identified as high risk yet there was no referral to the GP, dietician or consideration of referral to SALT. I am concerned that in the absence of training there was not an understanding of the assessment. ”
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 Hill Care Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure food provided conforms to residents' identified diet plans
Wider context from the report
“5. Normal Diet IDDSI L7 easy chew and to avoid difficult textures. I am concerned that a chef in evidence at the inquest was not aware that breaded fish was not a suitable food stuff in the diet identified for the deceased. I am concerned that other residents could be fed inappropriate food stuffs that are not in line with their identified diet plans. ”
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 Hill Care Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide pertinent referral information to speech and language therapy
Wider context from the report
“1. Whilst pertinent information was not provided to SALT, I am concerned that at assessment on 21 February 2023 there was no reliance upon the information provided in the referral to SALT which identified a concern for her swallow, coughing, weight loss choking. Instead the assessment was based on the verbal account of a member of care home staff. There was no observation of the deceased eating and there was no inspection of her care records. ”
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 Hill Care Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure agency staff receive and have verified induction
Wider context from the report
“4. Agency staff - induction I am concerned that an agency member of staff remained in the dining room and was last seen standing next to the alarm bell cord. The care assistant did not intervene immediately when the deceased showed signs of choking and instead sought help. I am further concerned that it could not be confirmed if the agency staff had undergone an induction. ”
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 Hill Care Group; that does not assign responsibility.
PFD Monitor interpretation
Delays in care assistant intervention when a resident shows signs of choking
Wider context from the report
“4. Agency staff - induction I am concerned that an agency member of staff remained in the dining room and was last seen standing next to the alarm bell cord. The care assistant did not intervene immediately when the deceased showed signs of choking and instead sought help. I am further concerned that it could not be confirmed if the agency staff had undergone an induction. ”
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
Deliver an IDDSI diet competency assessment to all staff and require completion by 30 September 2025.

Verbatim wording from the response
“1e. We have developed and issued a competency assessment to check staff knowledge of IDDSI diets.”

Source location
Response from Hill Care Group
Page 2 · response
Published 30 July 2025
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 an electronic training platform with expiry alerts and scheduled weekly compliance reports for home managers.

Verbatim wording from the response
“1a. We have changed the electronic platform on which we record staff training since the death of Joan Whitworth in March 2023. The new platform offers an additional function in that it will alert the staff member when training is due to expire, meaning timely reminders and arrangements for refresher training can take place. Further to this, an automated report has been scheduled for the Home Manager to receive a compliance report at the same time each week in order that they are fully aware of training that is nearing expiry and can therefore remind staff to complete promptly.”

Source location
Response from Hill Care Group
Page 1 · response
Published 30 July 2025
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 face-to-face modified-food preparation training to Hill Care cooks and chefs, including practical preparation of different consistencies.

Verbatim wording from the response
“4a. A specialist IDDSI training provider has been sourced and face to face training in preparation of modified foods is being delivered to all Hill Care Cooks and Chefs between the dates 13 September 2025 and 22 October 2025. This training will give chefs and cooks the opportunity to practically prepare meals of different consistencies and further their knowledge regarding appropriate and inappropriate foods for specific IDDSI level diets. The chef and cook at The Oaks will attend on 13th September and 24th September 2025.”

Source location
Response from Hill Care Group
Page 3 · response
Published 30 July 2025
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
Reissue Basic Life Support and IDDSI/Dysphagia training electronically with defined completion timeframes.

Verbatim wording from the response
“1d. We have reissued Basic Life Support and IDDSI/Dysphagia training to all staff on the electronic system and have allocated a specific timeframe in which this training is to be completed. All staff will have completed face to face emergency first aid training by 14th October 2025.”

Source location
Response from Hill Care Group
Page 2 · response
Published 30 July 2025
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 a pre-meal safety pause to confirm dining-room awareness of special diets and correct meal provision, with Regional Manager observation during visits.

Verbatim wording from the response
“4d. Following the death of Mrs Whitworth, we introduced a safety pause before real meals. This consists of the senior person on duty confirming that the team within the dining room are aware of any special diets and that the kitchen have provided the correct diet. The Regional Managers observe this to monitor practice when they visit the home.”

Source location
Response from Hill Care Group
Page 3 · response
Published 30 July 2025
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 face-to-face emergency first aid training to all staff by 14 October 2025.

Verbatim wording from the response
“1d. We have reissued Basic Life Support and IDDSI/Dysphagia training to all staff on the electronic system and have allocated a specific timeframe in which this training is to be completed. All staff will have completed face to face emergency first aid training by 14th October 2025.”

Source location
Response from Hill Care Group
Page 2 · response
Published 30 July 2025
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 deliver refresher training on assessments for nurses and senior care assistants, repeat it on a three-year cycle, and monitor completion electronically.

Verbatim wording from the response
“2a. We can confirm that the Senior Care Assistant had received training as she had previously undertaken a 12 week Care Home Assistant Practitioner (CHAP) course. However, we acknowledge that measures were not in place to verify knowledge, nor was a schedule of refresher training in place to ensure she felt confident to carry out assessments and develop care plans. As a result of this, we have reviewed the content of the training that we deliver and have a plan for our internal quality improvement team to deliver training on assessments to nurses and senior care assistants as a refresher and build this into our training programme to be repeated on a 3 year cycle. We will monitor this schedule using our electronic training platform.”

Source location
Response from Hill Care Group
Page 2 · response
Published 30 July 2025
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
Use revised agency induction forms to verify first aid, mandatory training, modified-diet awareness and daily nutritional-report awareness.

Verbatim wording from the response
“3a. We have reviewed the induction forms for all agency roles that we use in our homes to ensure that they capture information that allows us to see that agency care assistants have up-to-date first aid training. For agency senior care assistants and nurses we have modified our form to ensure we check that mandatory training is in place and in date, and that residents modified diets are discussed and the worker is aware of the IDDSI and nutritional report that is reviewed daily.”

Source location
Response from Hill Care Group
Page 2 · response
Published 30 July 2025
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
Require Regional Managers to check compliance with mandatory and refresher training through governance systems.

Verbatim wording from the response
“1b. We have added additional checks to our governance systems meaning that Regional Managers will also check for compliance with mandatory training (that includes refresher training) as part of their role.”

Source location
Response from Hill Care Group
Page 1 · response
Published 30 July 2025
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 a competency assessment for all catering team members.

Verbatim wording from the response
“4b. We have developed and introduced a competency assessment to all members of the catering team.”

Source location
Response from Hill Care Group
Page 3 · response
Published 30 July 2025
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
Verify agency workers’ training credentials before shifts and reiterate mandatory training requirements to the agency supplier.

Verbatim wording from the response
“1c. With regard to the agency care worker, we have reviewed the system by which we check the skills and training credentials of agency workers. Profiles for workers are now received and checked for each care worker prior to their shift; this now includes the training they have completed and the dates of completion. Since then, we have reiterated with our agency staff supplier the mandatory training that is required of their workers and that this must be kept up to date.”

Source location
Response from Hill Care Group
Page 1 · response
Published 30 July 2025
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 serving-trolley reference sheets showing each resident’s IDDSI level and nutritional needs, with daily review at flash meetings.

Verbatim wording from the response
“4c. We have introduced a reference sheet which highlights every residents’ IDDSI level and additional nutritional needs which is available to all staff on each serving trolley. This form is reviewed at the daily ‘flash’ meeting to ensure that changes in need are documented without delay.”

Source location
Response from Hill Care Group
Page 3 · response
Published 30 July 2025
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 measures described are considered sufficient to satisfy the concerns, so no further safety work is proposed.

Verbatim wording from the response
“We trust that these measures are sufficient to satisfy your concerns.”

Source location
Response from Hill Care Group
Page 3 · response
Published 30 July 2025
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 raised8

Failure to conduct speech and language therapy assessment using referral information, eating observation and care records

Failure to ensure staff have current Basic Life Support and First Aid at Work training

Lack of staff training and competence in care plans, MUST, BMI calculation and nutritional risk assessment

Failure to refer residents identified as high nutritional risk to appropriate clinical services

Failure to ensure food provided conforms to residents' identified diet plans

Failure to provide pertinent referral information to speech and language therapy

Failure to ensure agency staff receive and have verified induction

Delays in care assistant intervention when a resident shows signs of choking

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

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 12

Respondent positions 1