Red Oaks Care Community

Private and voluntary organisations · Nursing home

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First report 11 Jun 2025•Latest report 11 Jun 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: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

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

11 Jun2025
Nottinghamshire
Concerns raised12
1. Inaccurate reporting of incidents to regulators and social care
2. Failure to retain key records
3. Failure to update care plans regularly and when circumstances require
1. Delays in providing an appropriate bed surface
2. Incorrect adjustment of airflow mattresses
3. Failure to conduct and record daily skin inspections
4. Failure to keep family informed about wound deterioration
5. Failure to undertake internal investigations
6. Failure to consistently record repositioning
7. Failure to consistently implement repositioning
8. Lack of clear guidance to staff when pressure damage is identified
9. Delays in referral to tissue viability services
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Maureen POWELL · 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

Maureen Powell died from severe frailty after a prolonged period of ill health, hospitalisation and transfer to a nursing home. A serious pressure ulcer developed and worsened in the nursing home and contributed to her death. Concerns included inadequate recording and implementation of repositioning, failure to record skin inspections, delayed equipment and specialist referral, poor record-keeping, inaccurate reporting, and insufficient communication with her family.

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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate reporting of incidents to regulators and social care
Wider context from the report
“10. Inaccurate reports were made to the CQC and social care about the incidents; and ”
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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Failure to retain key records
Wider context from the report
“9. Key records were not kept or were lost or destroyed; ”
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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Failure to update care plans regularly and when circumstances require
Wider context from the report
“3. Care plans were not updated regularly in line with good practice and were not always updated when the circumstances 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Delays in providing an appropriate bed surface
Wider context from the report
“4. There was a delay in putting an appropriate bed surface 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Incorrect adjustment of airflow mattresses
Wider context from the report
“5. On at least one occasion the airflow mattress was incorrectly adjusted, reducing its efficacy; ”
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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct and record daily skin inspections
Wider context from the report
“2. There was widespread non-compliance with the regime of daily skin inspections in the period of time that Maureen was a resident at the Nursing Home. Not one skin inspection was recorded during Maureen’s stay; ”
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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Failure to keep family informed about wound deterioration
Wider context from the report
“6. The family were not kept up to date about deterioration in the wound; ”
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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake internal investigations
Wider context from the report
“8. No internal investigation was undertaken; ”
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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Failure to consistently record repositioning
Wider context from the report
“1. Repositioning was undertaken, but recording and implementation was, at times, patchy; ”
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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Failure to consistently implement repositioning
Wider context from the report
“1. Repositioning was undertaken, but recording and implementation was, at times, patchy; ”
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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear guidance to staff when pressure damage is identified
Wider context from the report
“11. There was an apparent lack of clear guidance to staff as to what to do if or when pressure damage was identified. ”
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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation
Delays in referral to tissue viability services
Wider context from the report
“7. The referral to tissue viability was made too late as it occurred after the wound had got beyond the ability of the in-house nursing staff to manage and treat the wound; ”
Open source report

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 raised12

Inaccurate reporting of incidents to regulators and social care

Failure to retain key records

Failure to update care plans regularly and when circumstances require

Delays in providing an appropriate bed surface

Incorrect adjustment of airflow mattresses

Failure to conduct and record daily skin inspections

Failure to keep family informed about wound deterioration

Failure to undertake internal investigations

Failure to consistently record repositioning

Failure to consistently implement repositioning

Lack of clear guidance to staff when pressure damage is identified

Delays in referral to tissue viability services