PFD report

Margaret AUSTIN · Prevention of Future Deaths report

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Issued 27 Nov 2023•County Durham and Darlington

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
3

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 raised3

  1. Lack of falls risk training for care home staff
    Part of recurring concern: Inadequate control of falls risks
  2. Inadequate and inconsistent documentation of falls risk management
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable documentation of falls-risk management
  3. Failure to review risk management plans when risks change or after falls
    Part of recurring concern: Failure to reliably develop and review risk-reduction plansPart of recurring concern: Inadequate control of falls risks
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.9

  1. Action

    Maintain improved falls-documentation standards through an ongoing audit programme.

    Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.
  2. Action

    Audit high-risk patients’ assessments and management-plan documentation to verify appropriate assessment and recording.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
  3. Action

    Have the Deputy Manager review assessments and plans to triangulate care and verify completion of assigned clinical-review actions.

    Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.

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

  1. Position

    The specific falls-prevention package was developmental rather than mandatory; all staff had completed mandatory training containing falls-risk elements.

    Stated by Care UKDisputes 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 falls risk training for care home staff

Wider context from the report

“3. Staff training in relation to falls risk remained outstanding at the date of the Inquest for the majority (3/4) of staff at the care home. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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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

Inadequate and inconsistent documentation of falls risk management

Wider context from the report

“1. The deceased was known to be at high risk of falls and the documentation in relation to how to manage that known high risk of falls was not comprehensive and contained significant discrepancies as to what should, in fact, be in place, and contained no rationale for why further measures which may have been considered appropriate were not in situ or considered appropriate or necessary. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable documentation of falls-risk management.

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 review risk management plans when risks change or after falls

Wider context from the report

“2. There was no evidence that the risk management plan was reviewed as the deceased's risks changed nor in the aftermath of documented falls. ”

Is this part of a recurring concern?

Yes — Failure to reliably develop and review risk-reduction plans; 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

Maintain improved falls-documentation standards through an ongoing audit programme.

Verbatim wording from the response

“To ensure that the learning from points (1) and (2) above has been fully embedded, an audit was carried out (starting first with high risk patients to ensure timely review) with the purpose of verifying that care needs have been appropriately assessed and that the assessment and subsequent management plan is properly documented. This audit was completed on 31 December 2023 and demonstrates that staff are compliant with the standards expected of them. There is a planned programme of ongoing audit to ensure that the improved standards are maintained.”

Source location

Response from Care UK
Page 2 · response
Published 14 February 2024

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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

Audit high-risk patients’ assessments and management-plan documentation to verify appropriate assessment and recording.

Verbatim wording from the response

“To ensure that the learning from points (1) and (2) above has been fully embedded, an audit was carried out (starting first with high risk patients to ensure timely review) with the purpose of verifying that care needs have been appropriately assessed and that the assessment and subsequent management plan is properly documented. This audit was completed on 31 December 2023 and demonstrates that staff are compliant with the standards expected of them. There is a planned programme of ongoing audit to ensure that the improved standards are maintained.”

Source location

Response from Care UK
Page 2 · response
Published 14 February 2024

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

Have the Deputy Manager review assessments and plans to triangulate care and verify completion of assigned clinical-review actions.

Verbatim wording from the response

“d. Assessments and plans are being reviewed by the Deputy Manager to ensure triangulation of care and to confirm that actions set in the clinical review meetings have been fully completed.”

Source location

Response from Care UK
Page 2 · response
Published 14 February 2024

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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

Review risk management plans and clarify documentation, review, updating and clinical-rationale expectations for staff.

Verbatim wording from the response

“Stanley Park has taken a number of steps to improve documentation around assessment and management of falls, including documentation to reflect the rationale sitting behind clinical decision making. The steps taken are as follows:”

Source location

Response from Care UK
Page 1 · response
Published 14 February 2024

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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

Make falls-documentation compliance and quality a continuing review point in annual appraisals.

Verbatim wording from the response

“December 2023. Compliance and quality in terms of falls documentation will remain a review point in annual appraisals going forward.”

Source location

Response from Care UK
Page 2 · response
Published 14 February 2024

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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

Discuss accidents and incidents in weekly clinical reviews and assign actions to update assessments and management plans.

Verbatim wording from the response

“c. Accidents and incidents are being discussed during the weekly clinical review meetings, with specific actions being assigned to staff members around ensuring that the individual's assessment and management plan is updated.”

Source location

Response from Care UK
Page 2 · response
Published 14 February 2024

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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

Include the falls-specific training package in mandatory induction and annual refresher training for staff.

Verbatim wording from the response

“Whilst at the time of inquest hearing the training numbers for the specific falls risk package were as stated, I wish to provide reassurance that all staff had undertaken their mandatory training both in terms of induction and annual refresher training. This includes elements of falls risk assessment and management as part of the moving and handling, emergency first aid at work and basic life support training. At the time, the falls prevention module was development training to enhance staff understanding rather than a mandatory requirement.”

Source location

Response from Care UK
Page 2 · response
Published 14 February 2024

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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

Review accident and incident reports to identify required responses and further falls-mitigation measures.

Verbatim wording from the response

“b. The management team are reviewing all accident and incident reports to ensure that appropriate actions in response have been identified, including any further mitigation steps such as sensory equipment, roll mats and requests to the GP for a secondary care falls referral.”

Source location

Response from Care UK
Page 2 · response
Published 14 February 2024

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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

Remind staff of reassessment triggers, including after hospital discharge and return to the home.

Verbatim wording from the response

“As part of the review and discussions outlined in respect of point (1) above, during these same processes the Home Manager has ensured that staff are appropriately recognising when falls/risks assessments and management plans need to be reviewed and updated and that the reviews are being carried out in a timely manner. The specific actions in relation to this point are as follows:”

Source location

Response from Care UK
Page 2 · response
Published 14 February 2024

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 specific falls-prevention package was developmental rather than mandatory; all staff had completed mandatory training containing falls-risk elements.

Verbatim wording from the response

“3. Staff training in relation to falls risk remained outstanding at the date of the Inquest for the majority (3/4) of staff at the care home.”

Source location

Response from Care UK
Page 2 · response
Published 14 February 2024

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

    Strengthen staff competence in bed-rails assessments and recording related clinical decision-making and rationale.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
  2. 2

    Share falls-management learning through leadership and senior-staff meetings, clinical-review cascades and individual performance-review discussions.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.

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

Strengthen staff competence in bed-rails assessments and recording related clinical decision-making and rationale.

Verbatim wording from the response

“b. Specific focus was given to bed rails assessments, ensuring that staff were competent in utilising bed rails assessments and that they were properly reflecting the decision making and clinical rationale in the care record.”

Source location

Response from Care UK
Page 1 · response
Published 14 February 2024

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

Share falls-management learning through leadership and senior-staff meetings, clinical-review cascades and individual performance-review discussions.

Verbatim wording from the response

“To ensure that the learning was appropriately shared, the following steps were taken:”

Source location

Response from Care UK
Page 1 · response
Published 14 February 2024

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