PFD report

Barbara PROUDLOVE · Prevention of Future Deaths report

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Issued 12 Jul 2022•Hampshire, Portsmouth and Southampton

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Source document

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 raised2

  1. Lack of training and skills to respond to a medical emergency
    Part of recurring concern: Inadequate training and competence assurance for carers providing care
  2. Lack of training and skills to identify a medical emergency
    Part of recurring concern: Inadequate training and competence assurance for carers providing care
Responses linked to these concerns

Each statement is shown once, even when linked to more than one 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.4

  1. Action

    Send carers guidance on when to call emergency and non-emergency health services.

    Stated by Trinity Homecare Group LtdStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
  2. Action

    Incorporate emergency-call examples into induction and refresher training.

    Stated by Trinity Homecare Group LtdStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
  3. Action

    Introduce an emergency and unexpected death of a client policy for the care delivery team.

    Stated by Trinity Homecare Group LtdStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.

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

  1. Position

    The incident is considered isolated, limiting the basis for further responsive safety work.

    Stated by Trinity Homecare Group LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Lack of training and skills to respond to a medical emergency

Wider context from the report

“The Berkeley Home Health carer did not identify that the deceased was unconscious in good time; there was delay by the carer in summoning medical assistance. The evidence of the carer demonstrated a lack of training, skills and understanding in being able to reasonably identify a medical emergency and how to respond to a medical emergency. My concern is that such carers lack the necessary training and skills when tasked with caring for others in the same position as the deceased. ”

Is this part of a recurring concern?

Yes — Inadequate training and competence assurance for carers providing care.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of training and skills to identify a medical emergency

Wider context from the report

“The Berkeley Home Health carer did not identify that the deceased was unconscious in good time; there was delay by the carer in summoning medical assistance. The evidence of the carer demonstrated a lack of training, skills and understanding in being able to reasonably identify a medical emergency and how to respond to a medical emergency. My concern is that such carers lack the necessary training and skills when tasked with caring for others in the same position as the deceased. ”

Is this part of a recurring concern?

Yes — Inadequate training and competence assurance for carers providing care.

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

Send carers guidance on when to call emergency and non-emergency health services.

Verbatim wording from the response

“Carer Communication Due to the nature of the concerns within the Regulation 28 all carers have been sent communications and guidance on when to call 999 in emergency situations and when to contact 111. Examples of these will be incorporated in our induction and refresher training and delivered by our in-house training team, who have been briefed on the incident to ensure the topic is trained and discussed to a point where all new starters are clear on the procedure. We have enhanced our spot check process and monitoring in the field will take place by our Field Care Supervisors and Care Managers to continue testing knowledge outside of a training room environment. An emergency and unexpected death of a client policy has been introduced to the care delivery team.”

Source location

Response from Berkeley Home Health
Page 2 · response
Published 27 September 2022

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

Incorporate emergency-call examples into induction and refresher training.

Verbatim wording from the response

“Carer Communication Due to the nature of the concerns within the Regulation 28 all carers have been sent communications and guidance on when to call 999 in emergency situations and when to contact 111. Examples of these will be incorporated in our induction and refresher training and delivered by our in-house training team, who have been briefed on the incident to ensure the topic is trained and discussed to a point where all new starters are clear on the procedure. We have enhanced our spot check process and monitoring in the field will take place by our Field Care Supervisors and Care Managers to continue testing knowledge outside of a training room environment. An emergency and unexpected death of a client policy has been introduced to the care delivery team.”

Source location

Response from Berkeley Home Health
Page 2 · response
Published 27 September 2022

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 an emergency and unexpected death of a client policy for the care delivery team.

Verbatim wording from the response

“Carer Communication Due to the nature of the concerns within the Regulation 28 all carers have been sent communications and guidance on when to call 999 in emergency situations and when to contact 111. Examples of these will be incorporated in our induction and refresher training and delivered by our in-house training team, who have been briefed on the incident to ensure the topic is trained and discussed to a point where all new starters are clear on the procedure. We have enhanced our spot check process and monitoring in the field will take place by our Field Care Supervisors and Care Managers to continue testing knowledge outside of a training room environment. An emergency and unexpected death of a client policy has been introduced to the care delivery team.”

Source location

Response from Berkeley Home Health
Page 2 · response
Published 27 September 2022

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

Enhance spot checks and conduct field monitoring to test carers’ knowledge of emergency procedures.

Verbatim wording from the response

“Carer Communication Due to the nature of the concerns within the Regulation 28 all carers have been sent communications and guidance on when to call 999 in emergency situations and when to contact 111. Examples of these will be incorporated in our induction and refresher training and delivered by our in-house training team, who have been briefed on the incident to ensure the topic is trained and discussed to a point where all new starters are clear on the procedure. We have enhanced our spot check process and monitoring in the field will take place by our Field Care Supervisors and Care Managers to continue testing knowledge outside of a training room environment. An emergency and unexpected death of a client policy has been introduced to the care delivery team.”

Source location

Response from Berkeley Home Health
Page 2 · response
Published 27 September 2022

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 incident is considered isolated, limiting the basis for further responsive safety work.

Verbatim wording from the response

“The Trinity Group is committed to ensuring the health and safety of employees and clients and by continuous improvement in our health and safety and environment standards. I hope you find our actions satisfactory; we strongly believe this is an isolated incident and we have taken relevant action.”

Source location

Response from Berkeley Home Health
Page 2 · response
Published 27 September 2022

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Implement a digital care system for real-time alerts, incident reporting, investigation, escalation and governance review.

    Stated by Trinity Homecare Group LtdStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
  2. 2

    Appoint and provide support through a new Registered Manager for Berkeley Southeast.

    Stated by Trinity Homecare Group LtdStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.

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 a digital care system for real-time alerts, incident reporting, investigation, escalation and governance review.

Verbatim wording from the response

“New System To improve visibility of the activity taking place in the service, we have introduced a new digital care system (Access Care Planning) into Berkeley Southeast. The system allows carers to report information or concerns via an Alert in real time, this is monitored by our Care Managers and actioned upon receipt. Access Care Compliance allows any incidents and accidents to be logged and investigated, any high level concerns the system will automatically sends an alert to our Group Director of Care Services and our Group Compliance Officer. Monthly Risk Committee meetings take place to discuss areas of improvement, lessons learnt, process, and policy changes as well as positive feedback and compliments.”

Source location

Response from Berkeley Home Health
Page 1 · response
Published 27 September 2022

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 and provide support through a new Registered Manager for Berkeley Southeast.

Verbatim wording from the response

“The care services across the group pride themselves on Good and Outstanding ratings by the Care Quality Commission. Berkeley Southeast since the acquisition now has a new Registered Manager in place working alongside our Group Director of Care Services and Regional Care Director to support the delivery of care.”

Source location

Response from Berkeley Home Health
Page 1 · response
Published 27 September 2022

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