PFD report

Beryl ELLISON · Prevention of Future Deaths report

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Issued 3 Jan 2023•Sefton, St Helens and Knowsley

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
1

Raised in this report

Recipients
4

Named on the report

Responses found
1

Of 4 recipients

Stated actions
18

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 raised1

  1. Failure to supervise syringe medication
    Part of recurring concern: Failure to secure and control medicationPart of recurring concern: Unreliable medication management in care homesPart of recurring concern: Unsafe medication administration
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.2

  1. Action

    Conduct weekly observations of medicine rounds.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  2. Action

    Write and share a specific medication risk assessment when medication-management risk is identified, retaining it with medication records.

    Stated by Four Seasons Health Care GroupStated plannedThe respondent said that this action was planned when they made their response on 9 January 2023.

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 supervise syringe medication

Wider context from the report

“Mrs Ellison was resident at Alexandra Care Home and was found deceased on 28th June 2022 by staff. Her family expressed concern that she had been left with syringe medication unsupervised by staff and raised concerns about this with the care home both historically and four days prior to her death. A post mortem examination revealed Mrs Ellison to have an excessive concentration of oxycodone in her system which was likely to exceed any acquired tolerance level. The evidence heard at inquest revealed no explanation as to why Mrs Ellison was found to have taken the excessive quantity of oxycodone which contributed to her death. Furthermore, the systems at the care home were stated categorically to be the same as those that were in place prior to Mrs Ellison's death. ”

Is this part of a recurring concern?

Yes — Failure to secure and control medication; Unreliable medication management in care homes; Unsafe medication administration.

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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 weekly observations of medicine rounds.

Verbatim wording from the response

“• Weekly observations of drug rounds are now completed.”

Source location

Response from Four Seasons Health Care Group
Page 1 · response
Published 9 January 2023

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

Write and share a specific medication risk assessment when medication-management risk is identified, retaining it with medication records.

Verbatim wording from the response

“Where a risk to medication administration or management is identified for any resident, a specific medication risk assessment will be written and shared with the nursing and care team to ensure awareness of the specific risk and control measures in place. For ease of reference and to ensure that this potential risk is highlighted at each drug round to the member of staff administering medication, a copy of this risk assessment will be held alongside the medication administration records for the individual resident.”

Source location

Response from Four Seasons Health Care Group
Page 4 · response
Published 9 January 2023

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.16

  1. 1

    Discuss medication issues and learning during daily flash meetings.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  2. 2

    Monitor training compliance through learning platforms, management review, alerts and audits.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  3. 3

    Complete medication competency assessments for staff responsible for medicine administration.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  4. 4

    Refresh and reissue the Group medication competency assessment, requiring policy, e-learning and NICE-guideline preparation.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  5. 5

    Reissue the controlled-drug administration guide and require Home Managers to discuss it with relevant staff.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  6. 6

    Provide monthly medication-management learning surgeries for staff who administer medicines.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  7. 7

    Distribute monthly medication-management learning bulletins to every Group home.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  8. 8

    Develop and deliver national training on incident investigation, root-cause analysis and cascading lessons learned.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  9. 9

    Hold group supervisions and regular clinical meetings to reinforce timely reporting and escalation of incidents and near misses.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  10. 10

    Review incident workflows and improve root-cause-analysis guidance and prompts within RADAR.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  11. 11

    Improve controlled-drug competency assessment to test legal knowledge and witnessing, stock-count and register-signing procedures.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  12. 12

    Introduce a behavioural-management care-plan template addressing medication-hoarding, addiction and suicidal-ideation risks.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  13. 13

    Deploy the RADAR incident-reporting system across the Group.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  14. 14

    Hold monthly Nurse and Care Home Assistant Practitioner meetings to review incident-management and medication-audit outcomes.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  15. 15

    Display controlled-drug administration process warnings in treatment rooms.

    Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  16. 16

    Introduce and roll out the DepenSys dependency tool to assess resident needs and inform staffing and skill mix.

    Stated by Four Seasons Health Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.

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

Discuss medication issues and learning during daily flash meetings.

Verbatim wording from the response

“• Medication issues and areas of learning or development are discussed within daily flash meetings.”

Source location

Response from Four Seasons Health Care Group
Page 1 · response
Published 9 January 2023

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

Monitor training compliance through learning platforms, management review, alerts and audits.

Verbatim wording from the response

“Monitoring of compliance with training takes place regularly across all operational portfolios, reviewed by Managing Directors and Operational Managers to identify any corrective action where required. Compliance may be further assessed during internal and/or external audit. Group learning platforms continually monitor compliance data and alerts are issued to Managing Directors and Operational Managers on a monthly basis to ensure line of sight of all care team compliance.”

Source location

Response from Four Seasons Health Care Group
Page 3 · response
Published 9 January 2023

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 medication competency assessments for staff responsible for medicine administration.

Verbatim wording from the response

“• Team Members responsible for the administration of medicines completed medication competencies, irrespective of when these were last conducted.”

Source location

Response from Four Seasons Health Care Group
Page 1 · response
Published 9 January 2023

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

Refresh and reissue the Group medication competency assessment, requiring policy, e-learning and NICE-guideline preparation.

Verbatim wording from the response

“The Group’s medication competency assessment, which applies to all members of our care team was reviewed and refreshed in November 2022 and reissued to every care home. Prior to commencing this assessment, staff must complete the following:”

Source location

Response from Four Seasons Health Care Group
Page 2 · response
Published 9 January 2023

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

Reissue the controlled-drug administration guide and require Home Managers to discuss it with relevant staff.

Verbatim wording from the response

“The How to Guide for Administration of Controlled Drugs has been reissued across the Group. Home Managers were instructed to discuss this with all team members who are responsible for medication management during regular meetings held at the home.”

Source location

Response from Four Seasons Health Care Group
Page 2 · response
Published 9 January 2023

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 monthly medication-management learning surgeries for staff who administer medicines.

Verbatim wording from the response

“Further to the improvements made to medication competency assessments detailed above, the Group’s Heads of Care Quality and Care Support Managers have introduced medication management learning surgeries on the last two Thursdays of each month, where support, direction and discussion takes place under lessons learned following any incident of concern or more generally to ensure best practice in compliance with the Group’s policies is followed at all times. These surgeries are available for all staff who administer medications and allows for open discussion and lessons learned on a national scale across the Group.”

Source location

Response from Four Seasons Health Care Group
Page 3 · response
Published 9 January 2023

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

Distribute monthly medication-management learning bulletins to every Group home.

Verbatim wording from the response

“The Care Quality Team have further expanded upon the learning focus for medication management across the Group, with the introduction of medication management bulletins which are distributed to every home within the Group on a monthly basis. Edition 3: November 2022 Medicines Management Bulletin specifically discussed Controlled Drugs.”

Source location

Response from Four Seasons Health Care Group
Page 3 · response
Published 9 January 2023

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 deliver national training on incident investigation, root-cause analysis and cascading lessons learned.

Verbatim wording from the response

“Every incident reported has a designated workflow to guide and prompt team members as to the information required and notifications that may be required; these workflow steps are regularly reviewed to support improved reporting and investigation. A Root Cause Analysis function aligned to incident reporting has been simplified and improved with additional guidance and prompts to support team members. Furthermore, the Group has developed a bespoke training module to guide team members on how to conduct an investigation; this is directly aligned to the Incident Management System, workflow steps and effective completion of a Root Cause Analysis and is delivered nationally across the Group. The training has been developed using a ‘Lessons learned’ approach and guides managers through the process of completing a timely, thorough and effective investigation.”

Source location

Response from Four Seasons Health Care Group
Page 3 · response
Published 9 January 2023

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 group supervisions and regular clinical meetings to reinforce timely reporting and escalation of incidents and near misses.

Verbatim wording from the response

“The completion of the incident management process is reliant upon human elements, namely the importance of understanding the process, an honest and accurate approach to completion and the ability to execute this through comprehensive and open reporting. At Alexandra Care Home, group supervisions have”

Source location

Response from Four Seasons Health Care Group
Page 3 · response
Published 9 January 2023

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 incident workflows and improve root-cause-analysis guidance and prompts within RADAR.

Verbatim wording from the response

“Every incident reported has a designated workflow to guide and prompt team members as to the information required and notifications that may be required; these workflow steps are regularly reviewed to support improved reporting and investigation. A Root Cause Analysis function aligned to incident reporting has been simplified and improved with additional guidance and prompts to support team members. Furthermore, the Group has developed a bespoke training module to guide team members on how to conduct an investigation; this is directly aligned to the Incident Management System, workflow steps and effective completion of a Root Cause Analysis and is delivered nationally across the Group. The training has been developed using a ‘Lessons learned’ approach and guides managers through the process of completing a timely, thorough and effective investigation.”

Source location

Response from Four Seasons Health Care Group
Page 3 · response
Published 9 January 2023

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 controlled-drug competency assessment to test legal knowledge and witnessing, stock-count and register-signing procedures.

Verbatim wording from the response

“The Group have further reviewed and improved the competency assessment for Care Assistants who witness Controlled Drugs (CD) administration, stock counts and signing the CD register. This assessment now validates staff knowledge on Controlled Drugs and the Misuse of Drugs Act 1971 alongside practical assessment on the process of witnessing the correct administration of Controlled Drugs.”

Source location

Response from Four Seasons Health Care Group
Page 2 · response
Published 9 January 2023

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 a behavioural-management care-plan template addressing medication-hoarding, addiction and suicidal-ideation risks.

Verbatim wording from the response

“DepenSys, in conjunction with our comprehensive pre-admission assessment process covering all activities of daily living, ensures a clear record of any area of risk that may be associated with medication management or the behaviour of a resident, for the attention of the Home Manager and so such risk can be supported by the team working at the home. Alongside the rollout of DepenSys, the Group has recently introduced a new behavioural management care plan template, which allows team members to create personalised plans for any resident that may experience a behaviour that could result in risk and the necessary management of that risk; specifically this would include any known issues with hoarding of medication, addiction to medication or suicidal ideation.”

Source location

Response from Four Seasons Health Care Group
Page 2 · response
Published 9 January 2023

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

Deploy the RADAR incident-reporting system across the Group.

Verbatim wording from the response

“Through reflection and review, it has been recognised that the Group Incident Reporting System, RADAR was not utilised at the Alexandra Care Home in the way for which it was intended.”

Source location

Response from Four Seasons Health Care Group
Page 3 · response
Published 9 January 2023

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 monthly Nurse and Care Home Assistant Practitioner meetings to review incident-management and medication-audit outcomes.

Verbatim wording from the response

“been held concerning the importance and requirement to report any concern, incident or near miss in a timely manner and ensure effective use of the Group RADAR system, to allow management to be notified immediately of any incident, allowing for timely action. Across the Group, regular clinical meetings attended by Home Managers and team members are reminded of the importance of escalating any concern reported or issue identified to management within a timely manner. Monthly Nurse and Care Home Assistant Practitioner (CHAP) meetings are held at all homes with the purpose to review the previous month’s incident management system and medication audit, which provides further assurance that incidents are escalated accordingly and appropriate action is taken.”

Source location

Response from Four Seasons Health Care Group
Page 4 · response
Published 9 January 2023

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

Display controlled-drug administration process warnings in treatment rooms.

Verbatim wording from the response

“• A Warning Notice is displayed within treatment rooms, advising staff of the correct process to follow when administering Controlled Drugs.”

Source location

Response from Four Seasons Health Care Group
Page 1 · response
Published 9 January 2023

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 roll out the DepenSys dependency tool to assess resident needs and inform staffing and skill mix.

Verbatim wording from the response

“More generally, as part of our efforts on continuous quality improvement for the benefit of our residents, the Group has invested in a new dependency tool called DepenSys, a proven, effective and researched methodology for assessing the holistic care needs of residents, from the point of pre-assessment, while supporting the professional judgement of the Home Manager. DepenSys assists Home Managers to successfully calculate the care and clinical team requirements, their deployment and required skill mix, to meet the needs of all residents in the home.”

Source location

Response from Four Seasons Health Care Group
Page 2 · response
Published 9 January 2023

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