PFD report

Irene Winifred BAKER · Prevention of Future Deaths report

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Issued 11 Dec 2017•Avon

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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 raised3

  1. Failure to escalate documented inability to weight-bear to the GP or ambulance service
    Part of recurring concern: Failure to seek medical attention when a person's condition warrants it
  2. Failure to undertake monthly mobility reviews
  3. Failure to revise the mobility care plan in response to documented deterioration in mobility
    Part of recurring concern: Unreliable care-planning processes
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

    Implement computerised person-centred care-plan software for live updates and incident, accident, mobility and other needs reporting.

    Stated by SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOMEStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  2. Action

    Raise requests for medical-professional support immediately when residents’ needs require it.

    Stated by SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOMEStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  3. Action

    Review care plans monthly or sooner after changes and update associated risk assessments.

    Stated by SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOMEStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.

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 escalate documented inability to weight-bear to the GP or ambulance service

Wider context from the report

“3. A failure to contact the GP or call an ambulance in response to a documented inability to weight-bear 12th - 23rd April 2017 ”

Is this part of a recurring concern?

Yes — Failure to seek medical attention when a person's condition warrants it.

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 undertake monthly mobility reviews

Wider context from the report

“2. No monthly mobility reviews were undertaken in January and February 2017; ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 revise the mobility care plan in response to documented deterioration in mobility

Wider context from the report

“1. No revision of the mobility care plan in response to monthly reviews documenting a deterioration in mobility in November and December 2016; ”

Is this part of a recurring concern?

Yes — Unreliable care-planning processes.

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

Implement computerised person-centred care-plan software for live updates and incident, accident, mobility and other needs reporting.

Verbatim wording from the response

“• From 31st January 2018, we have implemented a new computerised care plan software system, ‘Person Centred Software’ which allows care staff to update”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 1 · response
Published 11 February 2018

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

Raise requests for medical-professional support immediately when residents’ needs require it.

Verbatim wording from the response

“• Care plans are reviewed on a monthly basis or before if there are any changes, risk assessments are updated accordingly and support from medical professionals is raised immediately to ensure we are able to meet their needs at all times.”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 1 · response
Published 11 February 2018

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 care plans monthly or sooner after changes and update associated risk assessments.

Verbatim wording from the response

“• Care plans are reviewed on a monthly basis or before if there are any changes, risk assessments are updated accordingly and support from medical professionals is raised immediately to ensure we are able to meet their needs at all times.”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 1 · response
Published 11 February 2018

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

Overhaul and rewrite residents’ care plans.

Verbatim wording from the response

“• Care plans were completely overhauled and re-written by ████████ (this was evidenced at our North Somerset Council inspection on 14th September 2017)”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 1 · response
Published 11 February 2018

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.7

  1. 1

    Install sensor mats linked to call bells for residents at high risk of falls or unsteadiness.

    Stated by SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOMEStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  2. 2

    Establish a management structure comprising a Registered Manager, Deputy Manager and Head of Care.

    Stated by SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOMEStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  3. 3

    Provide a Head of Care, Deputy Manager or appointed Shift Leader on every shift to maintain continuity and care standards.

    Stated by SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOMEStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
  4. 4

    Provide further staff training.

    Stated by SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOMEStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  5. 5

    Inform families immediately when medical professionals are contacted and communicate the outcome.

    Stated by SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOMEStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  6. 6

    Create job descriptions specifying shift responsibilities and expected duties to residents.

    Stated by SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOMEStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  7. 7

    Receive monthly compliance-management support visits to oversee resident safety and wellbeing.

    Stated by SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOMEStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.

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

Install sensor mats linked to call bells for residents at high risk of falls or unsteadiness.

Verbatim wording from the response

“• Each resident who is high risk of falls or unsteady on their feet has a sensor mat in their rooms connected to their call bells to highlight the staff should they have a fall ensuring staff are able to contact the relevant medical support ie: GP, Ambulance etc.”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 2 · response
Published 11 February 2018

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

Establish a management structure comprising a Registered Manager, Deputy Manager and Head of Care.

Verbatim wording from the response

“• The management team structure now consists of myself, Registered Manager, Deputy Manager and Head of Care.”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 1 · response
Published 11 February 2018

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 a Head of Care, Deputy Manager or appointed Shift Leader on every shift to maintain continuity and care standards.

Verbatim wording from the response

“• Head of Care, Deputy Manager and appointed Shift Leader will cover every shift to ensure continuity of care and high standards are maintained.”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 1 · response
Published 11 February 2018

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 further staff training.

Verbatim wording from the response

“• Staff have received further training, and job descriptions outlining their responsibilities during a shift and the expectation of their duties to the residents.”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 1 · response
Published 11 February 2018

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

Inform families immediately when medical professionals are contacted and communicate the outcome.

Verbatim wording from the response

“• Families are informed immediately when a GP, Occupational Therapist or any other medical professional has been contacted and they are updated with an outcome.”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 1 · response
Published 11 February 2018

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

Create job descriptions specifying shift responsibilities and expected duties to residents.

Verbatim wording from the response

“• Staff have received further training, and job descriptions outlining their responsibilities during a shift and the expectation of their duties to the residents.”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 1 · response
Published 11 February 2018

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

Receive monthly compliance-management support visits to oversee resident safety and wellbeing.

Verbatim wording from the response

“Ongoing support is received from the Compliance Manager who visits on a monthly basis as well as the owner.”

Source location

2017-0362-Response-by-Rosewood-Lodge
Page 2 · response
Published 11 February 2018

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