PFD report

Terence James White · Prevention of Future Deaths report

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Issued 16 Mar 2017•Gloucestershire

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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. Lack of documentation recording pressure-sore treatment measures
    Part of recurring concern: Inadequate management of pressure ulcers
  2. Lack of turning charts for pressure-sore care
    Part of recurring concern: Failure to reliably reposition patients at required intervalsPart of recurring concern: Inadequate management of pressure ulcers
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

    Maintain individual resident folders containing daily care records, including repositioning charts.

    Stated by The Grange Care Centre CheltenhamStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  2. Action

    Require the responsible nurse to sign off each chart before evening handover and record additional notes.

    Stated by The Grange Care Centre CheltenhamStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.

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

  1. Position

    Although a robust system was not then in place, relevant records for Mr White existed, qualifying the concern about missing documentation.

    Stated by The Grange Care Centre CheltenhamDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 documentation recording pressure-sore treatment measures

Wider context from the report

“The Care Centre records documented the presence of the pressure sore appropriately but there was a very substantial absence of documentation recording measures in place to treat the pressure sore and in particular a very substantial absence of turning charts making it impossible for Senior Staff to know if the condition was being treated properly. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

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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 turning charts for pressure-sore care

Wider context from the report

“The Care Centre records documented the presence of the pressure sore appropriately but there was a very substantial absence of documentation recording measures in place to treat the pressure sore and in particular a very substantial absence of turning charts making it impossible for Senior Staff to know if the condition was being treated properly. ”

Is this part of a recurring concern?

Yes — Failure to reliably reposition patients at required intervals; Inadequate management of pressure ulcers.

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

Maintain individual resident folders containing daily care records, including repositioning charts.

Verbatim wording from the response

“The Home has made several changes to ensure that record keeping for resident’s care plans are more thorough and staff are accountable for the records produced during their shift:-”

Source location

James-white-Response
Page 1 · response
Published 24 March 2017

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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

Require the responsible nurse to sign off each chart before evening handover and record additional notes.

Verbatim wording from the response

“• Every chart contained within the individual folders is then signed off by the nurse responsible for the shift before the evening handover. This sign off is recorded and signed for with any additional notes on the Daily Allocation sheet for each unit. We enclose a copy by way of demonstration.”

Source location

James-white-Response
Page 1 · response
Published 24 March 2017

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

Although a robust system was not then in place, relevant records for Mr White existed, qualifying the concern about missing documentation.

Verbatim wording from the response

“Notwithstanding the improvements to the archiving system, we have been carrying out further searches and have located further records for Mr White. I have attached these records to confirm that although a robust system was not in place at that time, the relevant records were in existence. On behalf of the Company I would like to apologise for the delay in providing the additional records.”

Source location

James-white-Response
Page 2 · response
Published 24 March 2017

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.6

  1. 1

    Implement orderly documentation archiving using appropriately marked boxes and retrieval arrangements.

    Stated by The Grange Care Centre CheltenhamStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  2. 2

    Check unit allocation sheets each morning for completeness and appropriate standards.

    Stated by The Grange Care Centre CheltenhamStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  3. 3

    Provide staff supervision and refresher training on skin integrity.

    Stated by The Grange Care Centre CheltenhamStated in progressThe respondent said that this action was in progress when they made their response on 24 March 2017.
  4. 4

    Reorganize older archives to make them orderly and readily accessible.

    Stated by The Grange Care Centre CheltenhamStated in progressThe respondent said that this action was in progress when they made their response on 24 March 2017.
  5. 5

    Create unit-based Skin Integrity Boards with pressure-sore grading guidance, images and causes.

    Stated by The Grange Care Centre CheltenhamStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  6. 6

    Appoint a Home Administrator to support documentation archiving.

    Stated by The Grange Care Centre CheltenhamStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.

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 orderly documentation archiving using appropriately marked boxes and retrieval arrangements.

Verbatim wording from the response

“• He now ensures that all relevant documentation is archived correctly in a neat and orderly manner which can then be retrieved as and when required.”

Source location

James-white-Response
Page 2 · response
Published 24 March 2017

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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

Check unit allocation sheets each morning for completeness and appropriate standards.

Verbatim wording from the response

“• The Allocation sheets are then checked the following morning by either the Manager or Deputy Manager to ensure that all documents are duly completed and to an appropriate standard.”

Source location

James-white-Response
Page 1 · response
Published 24 March 2017

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 staff supervision and refresher training on skin integrity.

Verbatim wording from the response

“• Staff have been undergoing supervision and refresher training in respect of skin integrity with the Home Manager who is a qualified Tissue Viability Link Nurse.”

Source location

James-white-Response
Page 2 · response
Published 24 March 2017

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

Reorganize older archives to make them orderly and readily accessible.

Verbatim wording from the response

“• We are currently working through the old archives to put it in order and easily accessible should they need to be accessed.”

Source location

James-white-Response
Page 2 · response
Published 24 March 2017

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 unit-based Skin Integrity Boards with pressure-sore grading guidance, images and causes.

Verbatim wording from the response

“In addition to the changes in relation to the documentation we have also introduced further measures to ensure pressure sores are suitably identified:”

Source location

James-white-Response
Page 2 · response
Published 24 March 2017

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

Appoint a Home Administrator to support documentation archiving.

Verbatim wording from the response

“There have also been changes with regards to archiving documentation:-”

Source location

James-white-Response
Page 2 · response
Published 24 March 2017

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