2 Dec 2019 Sidney Clarence Baker · Prevention of Future Deaths report Manchester West
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Concerns raised 2 Failure to maintain accurate and adequate care records View source Failure to maintain contemporaneous documentation of Dieticians or Falls Team referrals View source
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. 4
Action
Audit weight-loss records weekly and monthly, cross-reference them with care plans and record resulting actions.
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Action
Operate a weekly and monthly weight-monitoring and weight-loss escalation system linked to Caredocs and care plans, including dietetic, GP and SALT referrals.
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Action
Operate an accidents and incidents system linked to Caredocs and care plans, with falls triage, clinical referrals, family updates and required safeguarding or regulatory notifications.
View source
Action
Maintain person-centred Caredocs care plans identifying individual needs, with Home Manager and Regional Manager care-plan audits.
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AI-generated summary
Sidney Clarence Baker · 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
Sidney Clarence Baker, a frail elderly man with multiple co-morbidities, died at the Royal Albert Edward Infirmary in Wigan after a deterioration in health and treatment for acute kidney injury following a fall. The report raised concerns that required dietician and falls-team referrals were not documented, and that care-plan entries, including weight-monitoring information, were incorrect and record keeping was generally poor.
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× 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 Rosewood Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and adequate care records
Wider context from the report “2. There were concerns that entries contained in Mr Baker's care plan were incorrect , including vital information contained on his weight monitoring sheet . Furthermore, the general quality of record keeping was poor .
” 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 Rosewood Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous documentation of Dieticians or Falls Team referrals
Wider context from the report “1. There were no contemporaneous documents that a Dieticians or Falls Team referral had been made by the Care Home personnel in question
” Open source report
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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 Audit weight-loss records weekly and monthly, cross-reference them with care plans and record resulting actions.
Verbatim wording from the response “Point 2 – The home has in place Monthly Weights and Loss action file which identifies any residents currently on weekly weights, this system links in with the Caredocs and Care plans. Weights are done and recorded within a weights file which is kept up to date on a weekly/monthly basis by the Manager / Deputy Manager and if a resident starts to lose weight, it is immediately highlighted and actioned. The information from this file is then transferred over to the monthly audit file with Actions taken.
Referrals to Dietician and GP, and if necessary, SALT team. Families are notified and kept up to date with ongoing progress. All the information is updated within the care plans which also include fluid charts and food plans. Additionally, Anne-Marie Peters (Compliance officer for Wigan Council) undertakes rigorous checks on these areas on a monthly basis.” Source location 2019-0407-Response-by-Rosewood
Open published response
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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 Operate a weekly and monthly weight-monitoring and weight-loss escalation system linked to Caredocs and care plans, including dietetic, GP and SALT referrals.
Verbatim wording from the response “Point 2 – The home has in place Monthly Weights and Loss action file which identifies any residents currently on weekly weights, this system links in with the Caredocs and Care plans. Weights are done and recorded within a weights file which is kept up to date on a weekly/monthly basis by the Manager / Deputy Manager and if a resident starts to lose weight, it is immediately highlighted and actioned. The information from this file is then transferred over to the monthly audit file with Actions taken.
Referrals to Dietician and GP, and if necessary, SALT team. Families are notified and kept up to date with ongoing progress. All the information is updated within the care plans which also include fluid charts and food plans. Additionally, Anne-Marie Peters (Compliance officer for Wigan Council) undertakes rigorous checks on these areas on a monthly basis.” Source location 2019-0407-Response-by-Rosewood
Open published response
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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 Operate an accidents and incidents system linked to Caredocs and care plans, with falls triage, clinical referrals, family updates and required safeguarding or regulatory notifications.
Verbatim wording from the response “Point 1 – The home has in place Accidents and Incidents file which includes Falls and near misses. The file also has an Action and Review with specific outcomes. The information within the file links in with Caredocs and the individuals care plan.
Once a fall has been logged (depending on the severity), the home will follow the Local Authority Triage system (which notifications are located in the Manager’s office and the Communication Book); in other cases, symptoms of UTI are tested, a referral is done to the Physio and Moving and Handling team (Falls Team). In addition, families are contacted and kept up to date of the process.
In addition, the incidents are recorded within the file, and if necessary and where applicable notifications are done to both the Safeguarding team and the CQC.” Source location 2019-0407-Response-by-Rosewood
Open published response
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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 Maintain person-centred Caredocs care plans identifying individual needs, with Home Manager and Regional Manager care-plan audits.
Verbatim wording from the response “All staff within Barley Brook undertake both online and face to face training to ensure the safe delivery of care, which also includes the specific training on Manual Handling, Falls, and Person-centred Care.
There are Rigorous auditing systems in place which cover all areas of the home to ensure that residents are safe from Harm.
Care Plans on the Caredocs system are person centred and identify each individual need in order to meet the care delivered. Care Plan Audits are conducted by the Home Manager. In addition, during my Regional Managers visit on a monthly basis, I undertake care plan audits. As a Regional Manager I also have full access to the Caredocs cloud system which allows me to have access all residents care plans within each of the homes.
Resident Assessments are also done prior to admission by the trusted assessor to ensure the appropriateness of a placement.” Source location 2019-0407-Response-by-Rosewood
Open published response
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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 Existing falls, incident monitoring and referral procedures are considered sufficient to address concerns about dietician and falls-team referrals.
Verbatim wording from the response “Point 1 – The home has in place Accidents and Incidents file which includes Falls and near misses. The file also has an Action and Review with specific outcomes. The information within the file links in with Caredocs and the individuals care plan.
Once a fall has been logged (depending on the severity), the home will follow the Local Authority Triage system (which notifications are located in the Manager’s office and the Communication Book); in other cases, symptoms of UTI are tested, a referral is done to the Physio and Moving and Handling team (Falls Team). In addition, families are contacted and kept up to date of the process.
In addition, the incidents are recorded within the file, and if necessary and where applicable notifications are done to both the Safeguarding team and the CQC.” Source location 2019-0407-Response-by-Rosewood
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 Existing weight-monitoring, care-plan, auditing and staff-training arrangements are considered sufficient to address inaccurate records and poor record keeping.
Verbatim wording from the response “Point 2 – The home has in place Monthly Weights and Loss action file which identifies any residents currently on weekly weights, this system links in with the Caredocs and Care plans. Weights are done and recorded within a weights file which is kept up to date on a weekly/monthly basis by the Manager / Deputy Manager and if a resident starts to lose weight, it is immediately highlighted and actioned. The information from this file is then transferred over to the monthly audit file with Actions taken.
Referrals to Dietician and GP, and if necessary, SALT team. Families are notified and kept up to date with ongoing progress. All the information is updated within the care plans which also include fluid charts and food plans. Additionally, Anne-Marie Peters (Compliance officer for Wigan Council) undertakes rigorous checks on these areas on a monthly basis.” Source location 2019-0407-Response-by-Rosewood
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations