Inspire You Care Ltd

Private and voluntary organisations · Private limited company

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First report 26 Nov 2025•Latest report 26 Nov 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 5

Concerns and recipient responses

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

26 Nov2025
Birmingham and Solihull
Concerns raised3
1. Lack of carer understanding of the need for repositioning to mitigate pressure sores
2. Failure to undertake frequent repositioning of a bed-bound person
3. Lack of carer training on pressure sores, skin assessment or repositioning
Actions described in response 3
1. Action
  Conduct competency spot checks of staff after the training period.
2. Action
  Provide further training in wound prevention.
3. Action
  Explore working with Access Group to establish skin-check and repositioning options in daily digital records where needed.
Respondent positions 2
1. Position
  Staff state that they understood the importance of repositioning bed-bound service users and had appropriate skills or training to support Celia.
  Disputes the concern
1. Position
  Staff state that Celia was repositioned during all four daily care visits, despite repositioning not being recorded in daily logs.
  Disputes the concern
AI-generated summary

Celia Marion PHILLIPS · 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

Celia Marion PHILLIPS had a complex medical history and was bed bound, receiving care at home four times a day. She was admitted to hospital on 27 April 2025 with a probable chest infection, acute kidney injury and dehydration; a fractured ventriculo-peritoneal shunt had eroded through the skin and was protruding. She died on 1 May 2025 from multiple organ failure and sepsis of unknown origin, with the malfunctioning shunt contributing to her neurological decline and predisposing her to infection and dehydration. Concerns included a lack of evidence that she was repositioned or that carers had received training on pressure sores, skin assessment and repositioning, and she was found to have a deep tissue injury and a grade 1 pressure sore on admission.

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 Inspire You Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Lack of carer understanding of the need for repositioning to mitigate pressure sores
Wider context from the report
“1. The deceased was bed bound. 2. On the 12th March the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day. 3. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning. 4. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore. ”
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 Inspire You Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake frequent repositioning of a bed-bound person
Wider context from the report
“1. The deceased was bed bound. 2. On the 12th March the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day. 3. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning. 4. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore. ”
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 Inspire You Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Lack of carer training on pressure sores, skin assessment or repositioning
Wider context from the report
“1. The deceased was bed bound. 2. On the 12th March the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day. 3. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning. 4. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore. ”
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 competency spot checks of staff after the training period.

Verbatim wording from the response
“– Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. – Staff will undergo refresher training on Record Keeping and Communication. – Staff will also undertake further training in Wound Prevention. – These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. – Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.”

Source location
Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 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 further training in wound prevention.

Verbatim wording from the response
“– Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. – Staff will undergo refresher training on Record Keeping and Communication. – Staff will also undertake further training in Wound Prevention. – These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. – Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.”

Source location
Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 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
Explore working with Access Group to establish skin-check and repositioning options in daily digital records where needed.

Verbatim wording from the response
“– Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. – Staff will undergo refresher training on Record Keeping and Communication. – Staff will also undertake further training in Wound Prevention. – These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. – Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.”

Source location
Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 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
Staff state that they understood the importance of repositioning bed-bound service users and had appropriate skills or training to support Celia.

Verbatim wording from the response
“– Carers informed the management team that they were aware Celia was bed bound as they read her care plan. Carers said they had the appropriate skills/training to support her whilst she was in bed. This includes the importance of repositioning her at an appropriate interval when they attended their care calls. They also understood that if there were any concerns around Celia skin then this should be immediately informed to the district nurses. – When staff were asked that it was not reported in the daily logs that Celia was repositioned, staff admitted that this was their failing part due to poor record keeping and not mentioning this important information in the daily notes.”

Source location
Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 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
Staff state that Celia was repositioned during all four daily care visits, despite repositioning not being recorded in daily logs.

Verbatim wording from the response
“– Staff stated that as mentioned before they did reposition Celia at all four daily visits as this would have to take place due to them having to complete personal care tasks for Celia at each visit.”

Source location
Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 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 raised3

Lack of carer understanding of the need for repositioning to mitigate pressure sores

Failure to undertake frequent repositioning of a bed-bound person

Lack of carer training on pressure sores, skin assessment or repositioning

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.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 3

Respondent positions 2