PFD report

Beryl French · Prevention of Future Deaths report

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Issued 30 Apr 2014•Nottinghamshire

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.

View original report
Concerns
2

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 raised2

  1. Insufficient end-of-life care planning to guide nursing and care staff
    Part of recurring concern: Unreliable care-planning processes
  2. Lack of nursing staff understanding of DNACPR forms and required completion information
    Part of recurring concern: Unreliable DNACPR decision-making, recording and communication
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.7

  1. Action

    Require a GP-signed DNAR form on a service user's file for the DNAR decision to be effective.

    Stated by Sycamore Horizon LtdStated completedThe respondent said that this action was complete when they made their response on 30 April 2014.
  2. Action

    Implement the signed-off End of Life care plan across the full portfolio of homes and train staff to use it.

    Stated by Sycamore Horizon LtdStated plannedThe respondent said that this action was planned when they made their response on 30 April 2014.
  3. Action

    Complete Quality Assurance review and sign-off of the End of Life care plan.

    Stated by Sycamore Horizon LtdStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2014.

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

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. ”

Is this part of a recurring concern?

Yes — Unreliable care-planning processes.

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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 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. ”

Is this part of a recurring concern?

Yes — Unreliable DNACPR decision-making, recording and communication.

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

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.4

  1. 1

    Sign off and implement the resuscitation-decision protocol across the full portfolio of homes.

    Stated by Sycamore Horizon LtdStated plannedThe respondent said that this action was planned when they made their response on 30 April 2014.
  2. 2

    Develop and consult on a company-wide protocol for decisions about whether service users should be resuscitated.

    Stated by Sycamore Horizon LtdStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2014.
  3. 3

    Improve auditing, staff support and training processes following the Landmere experience.

    Stated by Sycamore Horizon LtdStated completedThe respondent said that this action was complete when they made their response on 30 April 2014.
  4. 4

    Disseminate the resuscitation protocol through Regional Directors, home-manager training, staff meetings and handovers after sign-off.

    Stated by Sycamore Horizon LtdStated plannedThe respondent said that this action was planned when they made their response on 30 April 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Cannot develop its own DNAR form because homes must use forms prescribed by local health authorities.

    Stated by Sycamore Horizon LtdUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Sign off and implement the resuscitation-decision protocol across the full portfolio of homes.

Verbatim wording from the response

“The improvements since Landmere have included better staff training and the new attached protocol in respect of decisions as to whether a service user should be resuscitated. This protocol is being put through an extensive consultation process at Life Style Care Plc with input from staff at ground level in various homes and is currently at the stage of being reviewed by the Quality Assurance team in consultation with the Regional Directors. We anticipate that this protocol will be signed off and implemented in the full portfolio of homes by the end of September 2014.”

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

Develop and consult on a company-wide protocol for decisions about whether service users should be resuscitated.

Verbatim wording from the response

“The improvements since Landmere have included better staff training and the new attached protocol in respect of decisions as to whether a service user should be resuscitated. This protocol is being put through an extensive consultation process at Life Style Care Plc with input from staff at ground level in various homes and is currently at the stage of being reviewed by the Quality Assurance team in consultation with the Regional Directors. We anticipate that this protocol will be signed off and implemented in the full portfolio of homes by the end of September 2014.”

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

Improve auditing, staff support and training processes following the Landmere experience.

Verbatim wording from the response

“The experience with Landmere has resulted in huge improvements at Life Style Care Plc in particular with regards to assessing staff training and competencies. In approximately April 2013 Life Style Care Plc were way below the average standard for compliance when assessed by the CQC. In April 2014 Life Style Care Plc were assessed again by the CQC and have now been confirmed as higher than the national average in terms of compliance.”

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

Disseminate the resuscitation protocol through Regional Directors, home-manager training, staff meetings and handovers after sign-off.

Verbatim wording from the response

“Once the protocol has been signed off, this will be delegated down from senior management to the Regional Directors who will then provide appropriate training to the home managers. The home managers will then filter the information down to their staff by way of meetings and handovers and will also provide appropriate training.”

Source location

2014-0198-Response-by-Life-Style-Care
Page 2 · response
Published 30 April 2014

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

Cannot develop its own DNAR form because homes must use forms prescribed by local health authorities.

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
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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