Recipient

The Holmes Care (Group) Limited

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First report 27 Jan 2022•Latest report 27 Jan 2022

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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 The Holmes Care (Group) Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Essex

    AI-generated summary

    Maria Howell · 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

    Maria Howell, a resident of Cranham Court Nursing Home, died in hospital on 28 September 2019 after her RIG tube fell out, reinsertion was delayed, and she later developed peritonitis. The concerns were that the care home lacked qualified nursing staff to reinsert a time-critical RIG tube and that staff did not recognise the need for urgent medical attention when she became critically ill.

    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 The Holmes Care (Group) Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of staff clinical judgement to recognise the need for urgent medical attention in critically ill people

    Wider context from the report

    “That the Care Home had a resident with specific complex needs, and they had no qualified nursing staff to reinsert a RIG tube which is time critical. That they employ staff whose clinical judgement on someone who is critically ill does not necessitate urgent medical attention. ”
    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 The Holmes Care (Group) Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of qualified nursing staff to reinsert time-critical RIG tubes

    Wider context from the report

    “That the Care Home had a resident with specific complex needs, and they had no qualified nursing staff to reinsert a RIG tube which is time critical. That they employ staff whose clinical judgement on someone who is critically ill does not necessitate urgent medical attention. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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