Ramona Doreen Harbott · Prevention of Future Deaths report

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Issued 19 Dec 2025•Surrey

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
6

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
32

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised6

  1. Failure to complete and audit improvements to pressure sore prevention and management
    Part of recurring concern: Inadequate management of pressure ulcers
  2. Failure to complete early and appropriate pressure sore risk assessment
    Part of recurring concern: Inadequate management of pressure ulcers
  3. Failure to provide appropriate pressure sore treatment
    Part of recurring concern: Inadequate management of pressure ulcersPart of recurring concern: Inadequate wound management for deteriorating wounds
Statements in published responses

Each statement is shown once, whether or not it is linked to an individual concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.32

  1. Action

    Review the post-incident investigation and resulting disciplinary actions and outcomes.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  2. Action

    Replace the Home’s General Manager.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  3. Action

    Appoint a Regional Manager to provide increased management oversight.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  4. Action

    Introduce and embed the Enable electronic records and case-management system for care documentation and oversight.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  5. Action

    Block the bank nurse involved in the incident from further work.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  6. Action

    Dismiss the Deputy Manager for gross misconduct and refer the matter to the NMC.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  7. Action

    Provide dedicated management and clinical support, daily meetings and escalation of changes in residents’ clinical status through electronic notifications.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  8. Action

    Operate daily, monthly and bi-monthly audits of care documentation, skin integrity, risk assessments, equipment, interventions and follow-up actions.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  9. Action

    Provide weekly Clinical Development Nurse reviews of skin-integrity risks, care plans, wound assessments, categorisation, referrals and clinical concerns.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  10. Action

    Conduct operational observations, monitoring visits and staff supervisions addressing equipment, moving and handling, and regular repositioning.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  11. Action

    Deliver staff training, supervision, knowledge checks and refresher sessions on pressure-area care, tissue-viability policy, risk assessment, prevention, skin monitoring, wound treatment and record keeping.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  12. Action

    Train staff on dynamic-air-mattress settings, regular equipment checks and obtaining replacement mattresses outside hours.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  13. Action

    Deliver reflective sessions and disseminate inquest learning to Home staff on pressure-injury risk, prevention, treatment and documentation.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  14. Action

    Hold bi-weekly clinical governance meetings to review high-risk residents, tissue-viability issues, referrals and clinical deterioration.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  15. Action

    Consider whether criminal enforcement is appropriate in this case.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.
  16. Action

    Continue monitoring the safety and quality of care at Windmill Manor.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.
  17. Action

    Train staff and maintenance personnel to set, check and replace dynamic air mattresses appropriately, including accessing out-of-hours replacements.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  18. Action

    Appoint a Regional Manager to provide increased management oversight.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  19. Action

    Review and update residents’ assessments, risk assessments and care plans monthly through the Resident of the Day process.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  20. Action

    Replace the Home’s General Manager.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  21. Action

    Provide enhanced dedicated support, regular staff meetings, daily clinical discussions and continuing knowledge checks to identify and address care-team gaps.

    Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.
  22. Action

    Implement and embed the Enable electronic records and case-management system.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  23. Action

    Conduct reflective staff sessions and disseminate hospital tissue-viability evidence and case-study learning on skin-integrity risk management.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  24. Action

    Maintain a robust admissions assessment and approval process to identify resident risks and arrange required staffing, training and equipment.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  25. Action

    Hold bi-weekly clinical governance meetings to review high-risk residents, tissue-viability issues, referrals and clinical deterioration.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  26. Action

    Block the bank nurse involved in the incident from working at the Home.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  27. Action

    Conduct observations, staff supervisions and equipment-use support covering repositioning, moving and handling, mattresses and pressure-relieving equipment.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  28. Action

    Carry out monthly skin-integrity audits and additional Regional Manager reviews of high-risk residents’ interventions, equipment, care plans and Waterlow scores.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  29. Action

    Deliver pressure-area, wound-management, tissue-viability, risk-assessment, prevention, skin-monitoring and record-keeping training with supervision and knowledge checks for staff.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  30. Action

    Maintain electronic notifications and management oversight of clinical-status changes, wound categorisation, care planning and treatment regimes.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  31. Action

    Carry out daily care-record sampling and monthly documentation audits, with management follow-up of identified actions.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
  32. Action

    Provide ongoing weekly Clinical Development Nurse reviews of skin-integrity risks, wound assessments, categorisation and care plans.

    Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The registered provider is legally responsible for ensuring service users receive safe care and treatment, including pressure wound care.

    Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete and audit improvements to pressure sore prevention and management

Wider context from the report

“a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week. b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete early and appropriate pressure sore risk assessment

Wider context from the report

“a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week. b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide appropriate pressure sore treatment

Wider context from the report

“a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week. b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers; Inadequate wound management for deteriorating wounds.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to use pressure sore preventative measures

Wider context from the report

“a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week. b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to monitor residents' skin condition for pressure sores

Wider context from the report

“a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week. b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to record pressure sore risk, skin monitoring and treatment information

Wider context from the report

“a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week. b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

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

Review the post-incident investigation and resulting disciplinary actions and outcomes.

Verbatim wording from the response

“• Review of investigation carried out post incident and subsequent disciplinary actions and outcomes.”

Source location

Response from Barchester Healthcare Ltd
Page 2 · response
Published 23 December 2025

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

Replace the Home’s General Manager.

Verbatim wording from the response

“Whilst some of the actions are completed such as replacement of the General Manager, appointment of a Regional Manager and dismissal of the Deputy Manager, other actions are necessarily part of day-to-day documentation and process which will remain embedded and ongoing to ensure a robust approach to the planning and management of the needs of our residents.”

Source location

Response from Barchester Healthcare Ltd
Page 2 · response
Published 23 December 2025

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

Appoint a Regional Manager to provide increased management oversight.

Verbatim wording from the response

“Whilst some of the actions are completed such as replacement of the General Manager, appointment of a Regional Manager and dismissal of the Deputy Manager, other actions are necessarily part of day-to-day documentation and process which will remain embedded and ongoing to ensure a robust approach to the planning and management of the needs of our residents.”

Source location

Response from Barchester Healthcare Ltd
Page 2 · response
Published 23 December 2025

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

Introduce and embed the Enable electronic records and case-management system for care documentation and oversight.

Verbatim wording from the response

“• Introduction and embedding of electronic records and case management system ‘Enable’.”

Source location

Response from Barchester Healthcare Ltd
Page 2 · response
Published 23 December 2025

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

Block the bank nurse involved in the incident from further work.

Verbatim wording from the response

“• Block of Bank Nurse involved in incident.”

Source location

Response from Barchester Healthcare Ltd
Page 2 · response
Published 23 December 2025

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

Dismiss the Deputy Manager for gross misconduct and refer the matter to the NMC.

Verbatim wording from the response

“• Dismissal of Deputy Manager due to gross misconduct and referral to the NMC.”

Source location

Response from Barchester Healthcare Ltd
Page 2 · response
Published 23 December 2025

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

Provide dedicated management and clinical support, daily meetings and escalation of changes in residents’ clinical status through electronic notifications.

Verbatim wording from the response

“(iii) The General Manager at Windmill Manor Care Home has been provided with dedicated support from the Managing and Regional Directors and the Clinical Development Nurse during the recent period of change at the home. When changes to a resident’s clinical status are identified, including deterioration to skin integrity, these are added to the online systems which immediately notifies the Clinical”

Source location

Response from Barchester Healthcare Ltd
Page 4 · response
Published 23 December 2025

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

Operate daily, monthly and bi-monthly audits of care documentation, skin integrity, risk assessments, equipment, interventions and follow-up actions.

Verbatim wording from the response

“iii. The General Manager daily walk around of the Home includes ad hoc sampling of resident care records and supporting documentation. This audit tool also directs the General Manager to approach and question both residents, families and staff to identify any concerns. Any actions identified are discussed at the daily stand-up meeting and then carried forward to the next meeting, to ensure review of completion.”

Source location

Response from Barchester Healthcare Ltd
Page 3 · response
Published 23 December 2025

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

Provide weekly Clinical Development Nurse reviews of skin-integrity risks, care plans, wound assessments, categorisation, referrals and clinical concerns.

Verbatim wording from the response

“• The Clinical Development Nurse now visits the Home on a weekly basis to review the approach to the management of risk to skin integrity and care and treatment plans in place where skin damage has been identified for any resident. She checks that wound assessment and categorisation is being completed correctly with review of wounds by staff in person supported by photographs. She attends the daily stand-up meeting during her visit to follow up on assessments and referrals and any clinical concerns. She is also available for advice and assistance to all staff outside these visits and can review concerns on an ‘as needed’ basis. She has reported an improvement overall in the approach of staff and their recognition of the importance of early interventions and comprehensive treatment plans.”

Source location

Response from Barchester Healthcare Ltd
Page 2 · response
Published 23 December 2025

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

Conduct operational observations, monitoring visits and staff supervisions addressing equipment, moving and handling, and regular repositioning.

Verbatim wording from the response

“• The Regional Operational Trainer and Clinical Development Nurse have attended the Home on several occasions to carry out observations and monitoring and to identify any further areas for improvement for the clinical team. Visits took place on 7, 10, 15 and 22 October. On 15 October 2025 the Clinical Development Nurse attended the Home to review equipment used by staff to support resident care needs. A group session with staff was held to discuss availability of equipment, appropriate use and processes and procedures to assess need and request equipment including pressure relieving mattresses. During an observation visit on 22 October 2025 there was a focus on Moving and Handling techniques used by staff at the Home. No concerns”

Source location

Response from Barchester Healthcare Ltd
Page 2 · response
Published 23 December 2025

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

Deliver staff training, supervision, knowledge checks and refresher sessions on pressure-area care, tissue-viability policy, risk assessment, prevention, skin monitoring, wound treatment and record keeping.

Verbatim wording from the response

“• Training and Supervision sessions took place with all staff at the Home on 22nd October 2025, and 18th December 2025 led by the Regional Operational Trainer and Clinical Development Nurse. As previously advised, the training focussed on pressure area care and management of pressure ulcer/wounds. During the training there were refresher sessions on the Barchester Tissue Viability and Skin Tear Policy and specific focus on early and appropriate management of risk, use of preventative measures, skin monitoring, pressure ulcer treatment and record keeping. The Clinical Development Nurse assigned to the Home uses the SSKIN bundle framework approach to promote comprehensive risk assessment, monitoring and care as a tool in pressure ulcer prevention. Early identification of skin compromise through regular checks is reinforced as part of daily care.”

Source location

Response from Barchester Healthcare Ltd
Page 2 · response
Published 23 December 2025

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

Train staff on dynamic-air-mattress settings, regular equipment checks and obtaining replacement mattresses outside hours.

Verbatim wording from the response

“• Advice has been provided by the Regional Operational Trainer and Clinical Development Nurse in respect of the use of beds and mattresses as vital equipment for the management of skin integrity and as an aid to prevention of damage to skin. Full staff training has been carried out with the Head of Maintenance at the Home in respect of the use of dynamic air mattress settings and how to use these appropriately and the importance of regular checks. Refresher training has also been provided to the Home team in respect of how to access mattress replacements in the event of a mattress failure occurring out of hours.”

Source location

Response from Barchester Healthcare Ltd
Page 3 · response
Published 23 December 2025

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

Deliver reflective sessions and disseminate inquest learning to Home staff on pressure-injury risk, prevention, treatment and documentation.

Verbatim wording from the response

“• Post inquest reflective sessions with staff carried out by Regional Manager with focus on the matters of concern raised by you during the inquest and in your findings and conclusion delivered on 8 December 2025.”

Source location

Response from Barchester Healthcare Ltd
Page 2 · response
Published 23 December 2025

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

Hold bi-weekly clinical governance meetings to review high-risk residents, tissue-viability issues, referrals and clinical deterioration.

Verbatim wording from the response

“vi. In accordance with Barchester procedures the Home holds a monthly clinical governance meeting. Following the appointment of a new General Manager at the”

Source location

Response from Barchester Healthcare Ltd
Page 3 · response
Published 23 December 2025

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

Consider whether criminal enforcement is appropriate in this case.

Verbatim wording from the response

“Whilst we have received assurances about the steps taken to address the concerns, we will continue to monitor the safety and quality of care at Windmill Manor and we are considering any criminal enforcement that may be appropriate in this case. If we identify safety concerns in relation to pressure wound care, we will consider whether an unannounced inspection and/or further regulatory action is required.”

Source location

2025-0637 - Response from Quality Care Commission
Page 3 · response
Published 23 December 2025

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

Continue monitoring the safety and quality of care at Windmill Manor.

Verbatim wording from the response

“Whilst we have received assurances about the steps taken to address the concerns, we will continue to monitor the safety and quality of care at Windmill Manor and we are considering any criminal enforcement that may be appropriate in this case. If we identify safety concerns in relation to pressure wound care, we will consider whether an unannounced inspection and/or further regulatory action is required.”

Source location

2025-0637 - Response from Quality Care Commission
Page 3 · response
Published 23 December 2025

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

Train staff and maintenance personnel to set, check and replace dynamic air mattresses appropriately, including accessing out-of-hours replacements.

Verbatim wording from the response

“• Advice has been provided by the Regional Operational Trainer and Clinical Development Nurse in respect of the use of beds and mattresses as vital equipment for the management of skin integrity and as an aid to prevention of damage to skin. Full staff training has been carried out with the Head of Maintenance at the Home in respect of the use of dynamic air mattress settings and how to use these appropriately and the importance of regular checks. Refresher training has also been provided to the Home team in respect of how to access mattress replacements in the event of a mattress failure occurring out of hours.”

Source location

Response from Barchester Healthcare
Page 3 · response
Published 23 December 2025

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

Appoint a Regional Manager to provide increased management oversight.

Verbatim wording from the response

“Whilst some of the actions are completed such as replacement of the General Manager, appointment of a Regional Manager and dismissal of the Deputy Manager, other actions are necessarily part of day-to-day documentation and processes which will remain embedded and ongoing to ensure a robust approach to the planning and management of the needs of our residents.”

Source location

Response from Barchester Healthcare
Page 2 · response
Published 23 December 2025

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 and update residents’ assessments, risk assessments and care plans monthly through the Resident of the Day process.

Verbatim wording from the response

“ii. All residents are part of the Resident of the Day process. As part of Resident of the Day process, all assessments, risk assessments and care plans are reviewed monthly and updated as required if needs change. This is completed by the Nurse leading the shift.”

Source location

Response from Barchester Healthcare
Page 3 · response
Published 23 December 2025

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

Replace the Home’s General Manager.

Verbatim wording from the response

“Whilst some of the actions are completed such as replacement of the General Manager, appointment of a Regional Manager and dismissal of the Deputy Manager, other actions are necessarily part of day-to-day documentation and processes which will remain embedded and ongoing to ensure a robust approach to the planning and management of the needs of our residents.”

Source location

Response from Barchester Healthcare
Page 2 · response
Published 23 December 2025

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

Provide enhanced dedicated support, regular staff meetings, daily clinical discussions and continuing knowledge checks to identify and address care-team gaps.

Verbatim wording from the response

“Development Nurse and Regional Director. This allows increased oversight and assessment of triangulation, including categorisation of wounds and associated care planning and treatment regimes. This increased oversight has demonstrated improvement in the detection of issues and prompt investigation of incidents. The General Manager has developed a strong relationship with the care team through regular staff meetings, daily ‘Pulse’ meetings and daily stand-up meetings to discuss events occurring within the service and any resident clinical concerns. The bi-weekly clinical governance meetings, address recent changes to resident’s skin integrity, safeguarding issues, weight loss or general clinical deterioration. This is attended monthly by the supporting Clinical Development Nurse who offers advice, clinical guidance and any further clinical training required for the care team.”

Source location

Response from Barchester Healthcare
Page 5 · response
Published 23 December 2025

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 and embed the Enable electronic records and case-management system.

Verbatim wording from the response

“• Introduction and embedding of electronic records and case management system ‘Enable’.”

Source location

Response from Barchester Healthcare
Page 2 · response
Published 23 December 2025

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

Conduct reflective staff sessions and disseminate hospital tissue-viability evidence and case-study learning on skin-integrity risk management.

Verbatim wording from the response

“• Post inquest reflective sessions with staff carried out by Regional Manager with focus on the matters of concern raised by you during the inquest and in your findings and conclusion delivered on 8 December 2025.”

Source location

Response from Barchester Healthcare
Page 2 · response
Published 23 December 2025

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

Maintain a robust admissions assessment and approval process to identify resident risks and arrange required staffing, training and equipment.

Verbatim wording from the response

“i. There is a robust admissions process in place which the General Manager controls and monitors throughout the stages from pre-admission to admission. This ensures that all prospective resident needs are identified prior to admission and appropriate training for staff and equipment for the individual is in place prior to and on admission. A robust pre-admission assessment is completed, both written and electronically. If there are any specific risks/complex care identified they would need the approval of the Regional Director before a place in the home would be offered. This ensures that an appropriate level of care is in place from the outset with a dedicated care plan to accommodate risks. The General Manager monitors changing needs and provides direction through the senior care team.”

Source location

Response from Barchester Healthcare
Page 3 · response
Published 23 December 2025

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

Hold bi-weekly clinical governance meetings to review high-risk residents, tissue-viability issues, referrals and clinical deterioration.

Verbatim wording from the response

“vi. In accordance with Barchester procedures the Home holds a monthly clinical governance meeting. Following the appointment of a new General Manager at the”

Source location

Response from Barchester Healthcare
Page 3 · response
Published 23 December 2025

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

Block the bank nurse involved in the incident from working at the Home.

Verbatim wording from the response

“• Block of Bank Nurse involved in incident.”

Source location

Response from Barchester Healthcare
Page 2 · response
Published 23 December 2025

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

Conduct observations, staff supervisions and equipment-use support covering repositioning, moving and handling, mattresses and pressure-relieving equipment.

Verbatim wording from the response

“• The Regional Operational Trainer and Clinical Development Nurse have attended the Home on several occasions to carry out observations and monitoring and to identify any further areas for improvement for the clinical team. Visits took place on 7, 10, 15 and 22 October. On 15 October 2025 the Clinical Development Nurse attended the Home to review equipment used by staff to support resident care needs. A group session with staff was held to discuss availability of equipment, appropriate use and processes and procedures to assess need and request equipment including pressure relieving mattresses. During an observation visit on 22 October 2025 there was a focus on Moving and Handling techniques used by staff at the Home. No concerns”

Source location

Response from Barchester Healthcare
Page 2 · response
Published 23 December 2025

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

Carry out monthly skin-integrity audits and additional Regional Manager reviews of high-risk residents’ interventions, equipment, care plans and Waterlow scores.

Verbatim wording from the response

“v. A monthly skin integrity audit is completed by the General Manager which reviews all residents deemed as ‘high’ or ‘very high’ risk of pressure damage. This looks at care interventions and equipment in place, including mattresses and chair cushions. The audit also reviews the care plans and the completion of Waterlow scores in line with the Resident of the Day process. The Regional Manager completes this audit bi-monthly to add increased oversight and safety netting and to identify any further interventions required for residents.”

Source location

Response from Barchester Healthcare
Page 3 · response
Published 23 December 2025

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

Deliver pressure-area, wound-management, tissue-viability, risk-assessment, prevention, skin-monitoring and record-keeping training with supervision and knowledge checks for staff.

Verbatim wording from the response

“• Training and Supervision sessions took place with all staff at the Home on 22nd October 2025, and 18th December 2025 led by the Regional Operational Trainer and Clinical Development Nurse. As previously advised, the training focussed on pressure area care and management of pressure ulcer/wounds. During the training there were refresher sessions on the Barchester Tissue Viability and Skin Tear Policy and specific focus on early and appropriate management of risk, use of preventative measures, skin monitoring, pressure ulcer treatment and record keeping. The Clinical Development Nurse assigned to the Home uses the SSKIN bundle framework approach to promote comprehensive risk assessment, monitoring and care as a tool in pressure ulcer prevention. Early identification of skin compromise through regular checks is reinforced as part of daily care.”

Source location

Response from Barchester Healthcare
Page 2 · response
Published 23 December 2025

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

Maintain electronic notifications and management oversight of clinical-status changes, wound categorisation, care planning and treatment regimes.

Verbatim wording from the response

“(iii) The General Manager at Windmill Manor Care Home has been provided with dedicated support from the Managing and Regional Directors and the Clinical Development Nurse during the recent period of change at the home. When changes to a resident’s clinical status are identified, including deterioration to skin integrity, these are added to the online systems which immediately notifies the Clinical”

Source location

Response from Barchester Healthcare
Page 4 · response
Published 23 December 2025

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

Carry out daily care-record sampling and monthly documentation audits, with management follow-up of identified actions.

Verbatim wording from the response

“iii. The General Manager daily walk around of the Home includes ad hoc sampling of resident care records and supporting documentation. This audit tool also directs the General Manager to approach and question both residents, families and staff to identify any concerns. Any actions identified are discussed at the daily stand-up meeting and then carried forward to the next meeting, to ensure review of completion.”

Source location

Response from Barchester Healthcare
Page 3 · response
Published 23 December 2025

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

Provide ongoing weekly Clinical Development Nurse reviews of skin-integrity risks, wound assessments, categorisation and care plans.

Verbatim wording from the response

“• The Clinical Development Nurse now visits the Home on a weekly basis to review the approach to the management of risk to skin integrity and care and treatment plans in place where skin damage has been identified for any resident. She checks that wound assessment and categorisation is being completed correctly with review of wounds by staff in person supported by photographs. She attends the daily stand-up meeting during her visit to follow up on assessments and referrals and any clinical concerns. She is also available for advice and assistance to all staff outside these visits and can review concerns on an ‘as needed’ basis. She has reported an improvement overall in the approach of staff and their recognition of the importance of early interventions and comprehensive treatment plans.”

Source location

Response from Barchester Healthcare
Page 2 · response
Published 23 December 2025

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

The registered provider is legally responsible for ensuring service users receive safe care and treatment, including pressure wound care.

Verbatim wording from the response

“Barchester Healthcare Homes Limited have advised us the above actions are now in place at Windmill Manor. As a CQC registered provider Barchester Healthcare Homes Limited is legally responsible for ensuring that all service users receive safe care and treatment.”

Source location

2025-0637 - Response from Quality Care Commission
Page 3 · response
Published 23 December 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026