Sheila Rosamund JOHNSON · Prevention of Future Deaths report

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Issued 6 Sep 2023•Lincolnshire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

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 raised5

  1. Failure to keep doors to unoccupied rooms locked
  2. Failure to keep night lights on in common places
    Part of recurring concern: Failure to maintain adequate lighting in occupied premises
  3. Inadequacy of periodic nightly observations
    Part of recurring concern: Failure to carry out required overnight checks

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. Phoenix Care Centre

    Use an electronic care-planning system to record night checks and link them directly to residents’ care plans.

  2. Phoenix Care Centre

    Personalise generic care-home policies, including the falls prevention and management policy.

  3. Phoenix Care Centre

    Personalise generic care-home policies, including the falls prevention and management policy.

  4. Phoenix Care Centre

    Use an electronic care-planning system to record two-hourly night checks and link them directly to residents’ care plans.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.9

  1. Phoenix Care Centre

    The comprehensive falls prevention policy is legally and operationally adequate, although generic policies will be personalised for the home.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. Phoenix Care Centre

    Bedroom doors cannot remain locked at all times because residents must retain freedom to access their rooms; locking is limited to local safety decisions.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. Phoenix Care Centre

    Continuous lighting in common areas, resident choice for bedroom lighting, and care-plan documentation are considered sufficient arrangements.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  4. Phoenix Care Centre

    A 24-hour watch was not considered necessary because walking freedom was medically advised and staff regularly engaged with the resident.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  5. Phoenix Care Centre

    Two-hourly night checks, previously inspected records, and electronic recording are considered sufficient observation arrangements.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  6. Phoenix Care Centre

    The comprehensive falls prevention policy, supplied by a professional provider and accessible to staff, was considered sufficient despite its generic format.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  7. Phoenix Care Centre

    Bedroom doors cannot generally remain locked because residents have the freedom to enter their rooms; locking is only a local safety decision.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  8. Phoenix Care Centre

    Common areas and corridors were lit continuously; bedroom lighting was individually chosen by residents or documented in care plans when required.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  9. Phoenix Care Centre

    Night checks were conducted every two hours, recorded separately or electronically, and regarded as standard practice accepted during regulatory inspections.

    Existing 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 keep doors to unoccupied rooms locked

Wider context from the report

“2.Doors to unoccupied rooms were unlocked when they should have been locked. ”

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 keep night lights on in common places

Wider context from the report

“3.Night light in common places not on. ”

Is this part of a recurring concern?

Yes — Failure to maintain adequate lighting in occupied premises.

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

Inadequacy of periodic nightly observations

Wider context from the report

“5.Inadequate periodic nightly observations recorded at inquest. ”

Is this part of a recurring concern?

Yes — Failure to carry out required overnight checks.

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

Lack of signage for bell ringing

Wider context from the report

“4.No signage to bell ring in place. ”

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

Inadequacy of the generic falls prevention policy

Wider context from the report

“1.An inadequate generic falls prevention policy appeared to be in place. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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

Use an electronic care-planning system to record night checks and link them directly to residents’ care plans.

Verbatim wording from the response

“5. Inadequate periodic nightly observations recorded at inquest Our night checks are done every 2 hours and have always been done. We do not recall being asked about these records at the inquest. Care plans were submitted, but records of night checks are kept separate.”

Source location

Response from Phoenix Care Centre 2
Page 2 · response
Published 14 September 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

Personalise generic care-home policies, including the falls prevention and management policy.

Verbatim wording from the response

“Normally a Policy, when an update is sent to me, is forwarded to the Home. The Manager goes through it and personalises it for the Home. Depending on the policy, it generally requires the care home name added and small changes made where necessary.”

Source location

Response from Phoenix Care Centre 2
Page 1 · response
Published 14 September 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

Personalise generic care-home policies, including the falls prevention and management policy.

Verbatim wording from the response

“Normally a Policy, when an update is sent to me, is forwarded to the Home. The Manager goes through it and personalises it for the Home. Depending on the policy, it generally requires the care home name added and small changes made where necessary.”

Source location

Response from Phoenix Care Centre
Page 1 · response
Published 14 September 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

Use an electronic care-planning system to record two-hourly night checks and link them directly to residents’ care plans.

Verbatim wording from the response

“5. Inadequate periodic nightly observations recorded at inquest Our night checks are done every 2 hours and have always been done. We do not recall being asked about these records at the inquest. Care plans were submitted, but records of night checks are kept separate.”

Source location

Response from Phoenix Care Centre
Page 2 · response
Published 14 September 2023

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 comprehensive falls prevention policy is legally and operationally adequate, although generic policies will be personalised for the home.

Verbatim wording from the response

“1. An inadequate generic falls prevention policy appeared to be in place Our Policies are supplied by a professional company that takes into account latest legislations in terms of Legal, Health & Safety, CQC, Safeguarding, etc. They are specifically written for care homes. We use them as it ensures we are compliant with these different areas.”

Source location

Response from Phoenix Care Centre 2
Page 1 · response
Published 14 September 2023

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

Bedroom doors cannot remain locked at all times because residents must retain freedom to access their rooms; locking is limited to local safety decisions.

Verbatim wording from the response

“2. Doors to unoccupied rooms were unlocked when they should have been locked Bedroom doors in a care home cannot be kept locked at all times. Phoenix Care Centre is a Residential Home and most of the residents there go in and out of their rooms whenever they wish to. They have the choice and freedom to do so. We even ‘personalise’ doors with their names, photographs of either themselves or items they recognise/associate with.”

Source location

Response from Phoenix Care Centre 2
Page 1 · response
Published 14 September 2023

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

Continuous lighting in common areas, resident choice for bedroom lighting, and care-plan documentation are considered sufficient arrangements.

Verbatim wording from the response

“3. Night light in common places not on No idea as to how this has been brought up. All common areas, particularly corridors, have lights on 24/7. Bedroom lights are not always kept on – the decision for that is usually up to the resident as most of them do have the capacity to make that choice.”

Source location

Response from Phoenix Care Centre 2
Page 1 · response
Published 14 September 2023

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

A 24-hour watch was not considered necessary because walking freedom was medically advised and staff regularly engaged with the resident.

Verbatim wording from the response

“It is very unfortunate for this incident to have happened to SJ. She was well settled in the Home and her daughter, who worked as an independent hairdresser at the Home, witnessed this on the days she was there. She regularly commented that her mum was well and liked being in the Home. SJ had been assessed several times for her risk of falls and the assessment came to Medium Risk each time. The electronic care planning does an objective assessment which is discussed with her Social Worker and Medical Professionals. SJ had Dementia and what she really liked was to walk around the Home. She was in a secure environment and every day (and for most part of the day) she would walk up and down the corridors and around the lounges.”

Source location

Response from Phoenix Care Centre 2
Page 2 · response
Published 14 September 2023

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

Two-hourly night checks, previously inspected records, and electronic recording are considered sufficient observation arrangements.

Verbatim wording from the response

“5. Inadequate periodic nightly observations recorded at inquest Our night checks are done every 2 hours and have always been done. We do not recall being asked about these records at the inquest. Care plans were submitted, but records of night checks are kept separate.”

Source location

Response from Phoenix Care Centre 2
Page 2 · response
Published 14 September 2023

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 comprehensive falls prevention policy, supplied by a professional provider and accessible to staff, was considered sufficient despite its generic format.

Verbatim wording from the response

“1. An inadequate generic falls prevention policy appeared to be in place Our Policies are supplied by a professional company that takes into account latest legislations in terms of Legal, Health & Safety, CQC, Safeguarding, etc. They are specifically written for care homes. We use them as it ensures we are compliant with these different areas.”

Source location

Response from Phoenix Care Centre
Page 1 · response
Published 14 September 2023

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

Bedroom doors cannot generally remain locked because residents have the freedom to enter their rooms; locking is only a local safety decision.

Verbatim wording from the response

“2. Doors to unoccupied rooms were unlocked when they should have been locked Bedroom doors in a care home cannot be kept locked at all times. Phoenix Care Centre is a Residential Home and most of the residents there go in and out of their rooms whenever they wish to. They have the choice and freedom to do so. We even ‘personalise’ doors with their names, photographs of either themselves or items they recognise/associate with.”

Source location

Response from Phoenix Care Centre
Page 1 · response
Published 14 September 2023

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

Common areas and corridors were lit continuously; bedroom lighting was individually chosen by residents or documented in care plans when required.

Verbatim wording from the response

“3. Night light in common places not on No idea as to how this has been brought up. All common areas, particularly corridors, have lights on 24/7. Bedroom lights are not always kept on – the decision for that is usually up to the resident as most of them do have the capacity to make that choice.”

Source location

Response from Phoenix Care Centre
Page 1 · response
Published 14 September 2023

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

Night checks were conducted every two hours, recorded separately or electronically, and regarded as standard practice accepted during regulatory inspections.

Verbatim wording from the response

“5. Inadequate periodic nightly observations recorded at inquest Our night checks are done every 2 hours and have always been done. We do not recall being asked about these records at the inquest. Care plans were submitted, but records of night checks are kept separate.”

Source location

Response from Phoenix Care Centre
Page 2 · response
Published 14 September 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