Recipient

Sycamore Horizon Ltd

First report 30 Apr 2014•Latest report 30 Apr 2014

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 100%
Concerns addressed: 2
Stated actions: 11

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.

100%published responses found

11stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Sycamore Horizon Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

30 Apr2014
Nottinghamshire
Concerns raised2
1. Insufficient end-of-life care planning to guide nursing and care staff
2. Lack of nursing staff understanding of DNACPR forms and required completion information
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Require a GP-signed DNAR form on a service user's file for the DNAR decision to be effective.
  Stated completed
2. Action
  Implement the signed-off End of Life care plan across the full portfolio of homes and train staff to use it.
  Stated planned
3. Action
  Complete Quality Assurance review and sign-off of the End of Life care plan.
  Stated in progress
1. Action
  Pilot the End of Life care plan in three homes.
  Status at response
2. Action
  Use multidisciplinary meetings involving all relevant care bodies to inform comprehensive End of Life care plans where appropriate.
  Stated planned
3. Action
  Review the resuscitation protocol and End of Life care plan at least every three years and earlier when legislation or incidents require review.
  Stated planned
4. Action
  Review newly admitted service users with existing DNAR decisions and obtain an appropriate GP-signed DNAR form where required.
  Stated completed
AI-generated summary

Beryl French · 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

Beryl French was a resident at Landmere Nursing Home who developed respiratory difficulties while receiving personal care. Nursing staff did not initiate active interventions because they believed a completed DNACPR form was in place, but no such form existed. The concerns included staff understanding of DNACPR forms and insufficient end-of-life care planning.

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 Sycamore Horizon Ltd; that does not assign responsibility.
PFD Monitor interpretation
Insufficient end-of-life care planning to guide nursing and care staff
Wider context from the report
“2. That End of Life Care planning was insufficient to guide nursing and care staff to help residents to die peacefully and with dignity in appropriate cases. ”
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 Sycamore Horizon Ltd; that does not assign responsibility.
PFD Monitor interpretation
Lack of nursing staff understanding of DNACPR forms and required completion information
Wider context from the report
“1. That there was a lack of understanding amongst nursing staff at Landmere about the nature of DNACPR forms and the information that should be provided for them to be complete and appropriate to be relied upon. Although the evidence disclosed that no active intervention would have saved Mrs French, and that in was in her best interests not to intervene, this might not be the case in other, similar circumstances. ”
Open source report
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
Require a GP-signed DNAR form on a service user's file for the DNAR decision to be effective.

Verbatim wording from the response
“Life Style Care Plc now require a DNAR form signed by a GP to be in place on a service user's file in order for it to be effective. Life Style Care Plc is not able to develop its own DNAR form because homes in different regions and boroughs are often required to use a particular DNAR form which is individual to that particular local health authority. With a DNAR form signed by a GP in place this provides clarity to both staff and paramedics about the status of the service user.”

Source location
2014-0198-Response-by-Life-Style-Care
Page 2 · response
Published 30 April 2014
Open published response
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
Implement the signed-off End of Life care plan across the full portfolio of homes and train staff to use it.

Verbatim wording from the response
“The End of Life care plan is currently being considered by the Quality Assurance team and we anticipate this will be signed off by the end of September 2014. Once the care plan is signed off it will be implemented into the full portfolio of Life Style Care Plc homes with appropriate training for staff being provided.”

Source location
2014-0198-Response-by-Life-Style-Care
Page 3 · response
Published 30 April 2014
Open published response
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
Complete Quality Assurance review and sign-off of the End of Life care plan.

Verbatim wording from the response
“The End of Life care plan is currently being considered by the Quality Assurance team and we anticipate this will be signed off by the end of September 2014. Once the care plan is signed off it will be implemented into the full portfolio of Life Style Care Plc homes with appropriate training for staff being provided.”

Source location
2014-0198-Response-by-Life-Style-Care
Page 3 · response
Published 30 April 2014
Open published response
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
Pilot the End of Life care plan in three homes.

Verbatim wording from the response
“The End of Life care plan has been piloted in 3 homes in different areas. In one home the pilot has been running for approximately 4 months and in the other 2 homes the pilot has been running for approximately 3 months. We have received regular positive feedback from the staff in the homes regarding the care plan. We have also received positive feedback from the CQC who had the view that the plan was clear and provided good guidance to staff.”

Source location
2014-0198-Response-by-Life-Style-Care
Page 3 · response
Published 30 April 2014
Open published response
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
Use multidisciplinary meetings involving all relevant care bodies to inform comprehensive End of Life care plans where appropriate.

Verbatim wording from the response
“The first stage in End of Life care planning now is that there will be a Multi-Disciplinary Team meeting which will include all bodies involved in the care of a service user. These meetings used to be fragmented with different parties meeting together but now the meeting will include all bodies. At the conclusion of the meeting an informed judgment will be made and a comprehensive End of Life care plan will be drafted if appropriate. The End of Life care plan provides clarity and clear guidance to staff.”

Source location
2014-0198-Response-by-Life-Style-Care
Page 3 · response
Published 30 April 2014
Open published response
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
Review the resuscitation protocol and End of Life care plan at least every three years and earlier when legislation or incidents require review.

Verbatim wording from the response
“Once implemented, both the protocol and care plan outlined above will be reviewed at least every 3 years as a minimum to identify whether any changes are required. The protocol and care plan will be reviewed before the end of the 3 year period if changes are required such as if new legislation is introduced or an incident occurs which triggers a review.”

Source location
2014-0198-Response-by-Life-Style-Care
Page 3 · response
Published 30 April 2014
Open published response
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
Review newly admitted service users with existing DNAR decisions and obtain an appropriate GP-signed DNAR form where required.

Verbatim wording from the response
“If a service user is admitted to a Life Style Care Plc home from hospital or another care setting with a DNAR in place then they are reviewed by a GP and a nurse and if appropriate a DNAR form is produced and signed by the GP.”

Source location
2014-0198-Response-by-Life-Style-Care
Page 2 · response
Published 30 April 2014
Open published response

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 raised2

Insufficient end-of-life care planning to guide nursing and care staff

Lack of nursing staff understanding of DNACPR forms and required completion information

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.7

Actions described in response 7