Recipient

Holmleigh Care Homes LimitedIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 26 Mar 2021•Latest report 26 Mar 2021

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. 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 Holmleigh Care Homes Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: ████████ Managing Director, Holmleigh Care Homes Ltd., Unit 1, Mill Place, 90 Bristol Road, Gloucester, GL1 5SQ.

    Worcestershire

    AI-generated summary

    Rachel Bernadette Johnston · 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

    Rachel Bernadette Johnston, who had significant physical and learning disabilities, underwent dental surgery and was discharged to Pirton Grange Nursing Home, where she developed aspiration pneumonia and an unsurvivable hypoxic brain injury. She died there on 13 November 2018. The principal concerns were inadequate physiological observations and failure to seek emergency medical assistance, followed by inadequate internal investigation and disciplinary procedures concerning the nurses involved, including delayed reporting to the NMC.

    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 Holmleigh Care Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to prevent nursing staff from working at Pirton Grange again when appropriate after investigation

    Wider context from the report

    “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death; (2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for: (a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy; (b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents; (c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and (d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC. ”
    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 Holmleigh Care Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify and investigate possible misconduct by nursing staff

    Wider context from the report

    “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death; (2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for: (a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy; (b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents; (c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and (d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC. ”
    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 Holmleigh Care Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to impose interim suspension of nursing staff where needed to protect residents

    Wider context from the report

    “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death; (2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for: (a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy; (b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents; (c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and (d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC. ”
    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 Holmleigh Care Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to report likely nursing staff misconduct to the NMC

    Wider context from the report

    “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death; (2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for: (a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy; (b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents; (c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and (d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC. ”
    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