Litch Care Services Limited

Private and voluntary organisations · Domiciliary care provider

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First report 1 Jul 2022•Latest report 1 Jul 2022

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Sefton St Helens & Knowsley

    AI-generated summary

    Joan RICHARDSON · 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 RICHARDSON, a frail 98-year-old woman living in supported accommodation, became increasingly unwell at home and was admitted to hospital on 4 May 2020. She had pneumonia, a fractured neck of femur and grade 4 sacral pressure wounds, and died in hospital on 18 May 2020. Concerns included failures to escalate her deterioration and pain, incomplete care planning and risk assessments, inadequate pressure-area care and documentation, and inadequate staff training and escalation procedures.

    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document, assess and manage pressure sores or tissue injuries

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of pressure-area care planning and risk assessment

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of falls assessment and care planning

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate escalation procedures for care staff

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to change incontinence pads regularly

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record skin integrity or breakdown in daily care records

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate patients’ deterioration and pain

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to inform appropriate clinical and social care services of pressure injuries

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate training and education of care staff

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate support and supervision of care staff

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    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 Litch Care Services Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of comprehensive care planning and general risk assessment

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
    Open source report
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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