Recipient

Sunflower House, Partington

First report 10 Apr 2018•Latest report 10 Apr 2018

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Sunflower House, Partington linked to the concerns in each report. Select any concern, action or position to view the source wording.

10 Apr2018
Manchester North
Concerns raised6
1. Failure to identify, recognise and act upon deteriorating patients
2. Poor standard of basic physiological observation and monitoring
3. Failure to escalate deteriorating patients for medical review
1. Lack of a serious untoward incident protocol
2. Failure to read and use care records appropriately
3. Failure to implement CQC inspection recommendations and achieve sustained improvement
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Miss Lea Louise Hunsley · 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

Lea Hunsley, who had profound cerebral palsy and complex healthcare needs, became increasingly unwell while in respite care on 9 July 2016 and died after cardio-respiratory arrest at Wythenshawe Hospital Emergency Department shortly after midnight on 10 July 2016. The report identified missed opportunities to assess, escalate and intervene, and raised concerns about the facility’s lack of protocols, staff’s ability to recognise deterioration, inadequate observations and monitoring, failure to use care records appropriately, and insufficient action following a CQC inspection.

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 Sunflower House, Partington; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify, recognise and act upon deteriorating patients
Wider context from the report
“2. Registered Nurse/s and Carers at EAM: i) lack the ability to identify, recognise and act upon the deteriorating patient; ii) in this case, did not escalate for medical review (no policy/protocol exists for the same); iii) demonstrated a poor standard of basic (physiological) observation and monitoring & iv) failed to read and use the care records appropriately (in particular, the RN did not read important/critical entries on the 9th at all). ”
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 Sunflower House, Partington; that does not assign responsibility.
PFD Monitor interpretation
Poor standard of basic physiological observation and monitoring
Wider context from the report
“2. Registered Nurse/s and Carers at EAM: i) lack the ability to identify, recognise and act upon the deteriorating patient; ii) in this case, did not escalate for medical review (no policy/protocol exists for the same); iii) demonstrated a poor standard of basic (physiological) observation and monitoring & iv) failed to read and use the care records appropriately (in particular, the RN did not read important/critical entries on the 9th at all). ”
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 Sunflower House, Partington; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate deteriorating patients for medical review
Wider context from the report
“2. Registered Nurse/s and Carers at EAM: i) lack the ability to identify, recognise and act upon the deteriorating patient; ii) in this case, did not escalate for medical review (no policy/protocol exists for the same); iii) demonstrated a poor standard of basic (physiological) observation and monitoring & iv) failed to read and use the care records appropriately (in particular, the RN did not read important/critical entries on the 9th at all). ”
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 Sunflower House, Partington; that does not assign responsibility.
PFD Monitor interpretation
Lack of a serious untoward incident protocol
Wider context from the report
“1. EAM (a medical/nursing care facility) does not have a serious untoward incident (SUI) protocol. Responding appropriately when things go wrong in the healthcare setting is critical to improving patient/service user safety, identifying individual and systemic weaknesses, reducing avoidable harm and thus, preventing future deaths. ”
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 Sunflower House, Partington; that does not assign responsibility.
PFD Monitor interpretation
Failure to read and use care records appropriately
Wider context from the report
“2. Registered Nurse/s and Carers at EAM: i) lack the ability to identify, recognise and act upon the deteriorating patient; ii) in this case, did not escalate for medical review (no policy/protocol exists for the same); iii) demonstrated a poor standard of basic (physiological) observation and monitoring & iv) failed to read and use the care records appropriately (in particular, the RN did not read important/critical entries on the 9th at all). ”
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 Sunflower House, Partington; that does not assign responsibility.
PFD Monitor interpretation
Failure to implement CQC inspection recommendations and achieve sustained improvement
Wider context from the report
“3. CQC Inspection - insufficient action has been taken with regard to the recommendations made within the last CQC inspection. During the course of the evidence heard at inquest, EAM accepted: i) that the most recent inspection report had found the home to be inadequate on safety and requiring improvement in all other categories (effective, caring, responsive and well-led) ii) that meeting the recommendations had proved challenging but that the organisation was working with the CQC on improvements. However the Home did not demonstrate any marked or sustained improvement in any of the aforementioned areas of concern. This gives cause for concern in terms of the safety of other residents in EAM's care, whether children or adults and the prevention of serious harm/death. ”
Open source report