Passmonds House Care Home

Private and voluntary organisations · Residential care home

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First report 10 Mar 2014•Latest report 10 Mar 2014

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

  1. Manchester North

    AI-generated summary

    Derrick George RIVERS · 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

    Derrick George Rivers, who had been admitted to full-time care after becoming frail and falling, was mistakenly given a 150mg dose of Clozapine intended for another resident. He was admitted to hospital with altered consciousness and confusion, initially improved, then deteriorated and died on 11 July 2013; the inquest found that he died from natural causes to which the Clozapine may have contributed. Concerns included inadequate medication policies and administration protocols, insufficient auditing and inspection, and incomplete implementation of recommendations intended to reduce the risk of medication errors.

    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 Passmonds House Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the drugs administration policy to meet pharmacy requirements for patient and drug identification

    Wider context from the report

    “6) That the care home’s policy did not meet the pharmacy requirements in terms of patient and drug identification (pod system). ”
    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 Passmonds House Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of care home management to identify carers’ non-compliance with drugs administration protocols

    Wider context from the report

    “3) That the care home owner and/or manager were purportedly unaware of the fact that carers were not following drugs administration protocols. ”
    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 Passmonds House Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of inspections to identify inadequacies in the drugs policy and drug administration protocol

    Wider context from the report

    “1) That the Local Authority and/or CQC, following their recent inspections of the care home, had not noted the inadequacies of the care home’s drugs policy/drug administration protocol. ”
    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 Passmonds House Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to act upon all post-event recommendations in a timely manner

    Wider context from the report

    “7) That the care home owner and/or manager did not act upon all recommendations made by ████████ after the event, in a timely manner. Risks therefore remain. ”
    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 Passmonds House Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Incomplete inspection of CQC Outcomes and the drugs administration system

    Wider context from the report

    “2) That not all CQC Outcomes were considered at the last inspection, purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time. ”
    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 Passmonds House Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of care home audit processes

    Wider context from the report

    “4) That the care home had little, if any, audit processes in place. ”
    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 Passmonds House Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the drugs administration protocol to be fit for purpose and specific to the care home environment

    Wider context from the report

    “5) That the care home’s drugs administration protocol was not fit for purpose and was tantamount to a ‘hybrid’ of other policies i.e. it was not specific to the care home environment. ”
    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