PFD report

Donald George ELLIOTT · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 12 Feb 2020•Lincolnshire

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
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised2

  1. Failure to provide staff with necessary support, training, professional development, supervision and appraisals
    Part of recurring concern: Unreliable staff appraisal and performance-review processes
  2. Failure to deploy enough suitably qualified, competent and experienced staff
    Part of recurring concern: Insufficient care-home staffing capacity for residents’ required care
Responses linked to these concerns

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

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

  1. Position

    Existing staffing levels were considered sufficient and suitably qualified to meet residents’ needs on the relevant dates.

    Stated by Holdingham GrangeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 staff with necessary support, training, professional development, supervision and appraisals

Wider context from the report

“2. Is the Care Home able to evidence and demonstrate on both dates they complied with Regulation 18 Health and Social Care Act 2008 as to: a) Deploying enough suitably qualified competent and experienced staff and, b) That those staff received the support, training, professional development, supervision and appraisals that are necessary for them to carry out their role and responsibilities. ”

Is this part of a recurring concern?

Yes — Unreliable staff appraisal and performance-review processes.

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 deploy enough suitably qualified, competent and experienced staff

Wider context from the report

“2. Is the Care Home able to evidence and demonstrate on both dates they complied with Regulation 18 Health and Social Care Act 2008 as to: a) Deploying enough suitably qualified competent and experienced staff and, b) That those staff received the support, training, professional development, supervision and appraisals that are necessary for them to carry out their role and responsibilities. ”

Is this part of a recurring concern?

Yes — Insufficient care-home staffing capacity for residents’ required care.

Open source report

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

Existing staffing levels were considered sufficient and suitably qualified to meet residents’ needs on the relevant dates.

Verbatim wording from the response

“The investigation has demonstrated that there were sufficient, suitably qualified, staff on duty on 24.01.19 and 31.01.19 to meet the needs of the residents occupying the home at the time.”

Source location

2020-0109-Response-from-Holdingham-Grange-Nursing-Home_Redacted.pdf
Page 2 · response
Published 8 June 2020

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

    Work with occupational therapists to discuss suitable falls-prevention equipment.

    Stated by Holdingham GrangeStated in progressThe respondent said that this action was in progress when they made their response on 8 June 2020.
  2. 2

    Review all falls risk assessments.

    Stated by Holdingham GrangeStated completedThe respondent said that this action was complete when they made their response on 8 June 2020.

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

  1. 1

    Because the resident was not assessed as requiring one-to-one care, usual observations and checks were considered sufficient.

    Stated by Holdingham GrangeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Work with occupational therapists to discuss suitable falls-prevention equipment.

Verbatim wording from the response

“We have reviewed all our falls risk assessments we work in partnership with OTs to discuss suitable equipment and this is ongoing and falls training is available for all staff.”

Source location

2020-0109-Response-from-Holdingham-Grange-Nursing-Home_Redacted.pdf
Page 2 · response
Published 8 June 2020

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 all falls risk assessments.

Verbatim wording from the response

“We have reviewed all our falls risk assessments we work in partnership with OTs to discuss suitable equipment and this is ongoing and falls training is available for all staff.”

Source location

2020-0109-Response-from-Holdingham-Grange-Nursing-Home_Redacted.pdf
Page 2 · response
Published 8 June 2020

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

Because the resident was not assessed as requiring one-to-one care, usual observations and checks were considered sufficient.

Verbatim wording from the response

“DE had not been assessed as requiring 1-1 care therefore usual observations and checks were undertaken.”

Source location

2020-0109-Response-from-Holdingham-Grange-Nursing-Home_Redacted.pdf
Page 2 · response
Published 8 June 2020

Open published response
Back to top

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