PFD report

John Patrick MacGREGOR · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 6 Mar 2024•Herefordshire

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
8

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. Deficiencies in procedures for escalation or non-escalation after a fall and subsequent medical intervention
    Part of recurring concern: Unreliable post-fall assessment and clinical response
  2. Deficiencies in the quality and completion of residence care documentation
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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.6

  1. Action

    Review the falls protocol and maintain monthly falls audits, professional escalation, post-fall reviews, and 24–48-hour monitoring.

    Stated by Credenhill Court Rest HomeStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.
  2. Action

    Carry out daily audits of written daily notes and continue supporting staff to maintain documentation quality.

    Stated by Credenhill Court Rest HomeStated plannedThe respondent said that this action was planned when they made their response on 14 March 2024.
  3. Action

    Advance-email weekly ward-round resident lists to the GP surgery and record visiting clinicians’ actions in care plans.

    Stated by Credenhill Court Rest HomeStated completedThe respondent said that this action was complete when they made their response on 14 March 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 existing falls protocol is considered effective, with concerns outside its parameters referred to appropriate health professionals.

    Stated by Credenhill Court Rest HomeExisting 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

Deficiencies in procedures for escalation or non-escalation after a fall and subsequent medical intervention

Wider context from the report

“Evidence was heard regarding: (a) The quality of residence care documentation and its completion. (b) Procedures regarding escalation or non-escalation following a fall and subsequent medical intervention ”

Is this part of a recurring concern?

Yes — Unreliable post-fall assessment and clinical response.

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

Deficiencies in the quality and completion of residence care documentation

Wider context from the report

“Evidence was heard regarding: (a) The quality of residence care documentation and its completion. (b) Procedures regarding escalation or non-escalation following a fall and subsequent medical intervention ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Review the falls protocol and maintain monthly falls audits, professional escalation, post-fall reviews, and 24–48-hour monitoring.

Verbatim wording from the response

“• The falls protocol has been reviewed and we believe it is affective and each fall is taken on its own merit, any concerns beyond the parameter of the protocol we seek support and guidance from the appropriate health professionals i.e. doctors or paramedics and this documented. The falls continue to be audited each month to highlight any trends and to ensure the correct professional has been contacted. Any minor fall that takes place at Credenhill Court Rest Home the senior on duty emails the GP care home admin group and this resident is then reviewed on the weekly ward round and notes are added to their individual patient records. Each resident regardless of the severity of the fall and their capacity have 24-48 hour monitoring in the form of blood pressure, pulse and body map notes.”

Source location

Response from Credenhill Court
Page 1 · response
Published 14 March 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

Carry out daily audits of written daily notes and continue supporting staff to maintain documentation quality.

Verbatim wording from the response

“• I will carry out daily audits of the daily notes that have been written and continue to support staff to ensure that the quality of our written documentation is upheld.”

Source location

Response from Credenhill Court
Page 2 · response
Published 14 March 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

Advance-email weekly ward-round resident lists to the GP surgery and record visiting clinicians’ actions in care plans.

Verbatim wording from the response

“• I have reviewed our weekly ward round and a list of residents that need to be seen are emailed to the GP surgery 24 hours in advance. Once the residents have been seen we now receive a record of actions taken by the GP/ECP that visited. These actions are then added to the individual resident’s health notes within their care plan and any omissions can be identified.”

Source location

Response from Credenhill Court
Page 1 · response
Published 14 March 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

Implement written daily handover sheets and add completed handovers to residents’ daily records.

Verbatim wording from the response

“• In addition to our verbal handover and residents information board on display to all care staff in the office, to facilitate and capture more extensive notes for the daily records we have implemented a written daily handover sheet that care staff will complete and this will then be added to each residents daily records.”

Source location

Response from Credenhill Court
Page 2 · response
Published 14 March 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

Support senior care staff through weekly documentation discussions and regularly review and audit resident notes.

Verbatim wording from the response

“• Senior care staff have been supported through weekly discussions to ensure they are confident in documenting the needs of each resident, they are able to capture everything on a day to day basis and any concerns raised are being addressed and documented. The notes are being regularly reviewed and audited.”

Source location

Response from Credenhill Court
Page 1 · response
Published 14 March 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

Review and audit care plans monthly or when required.

Verbatim wording from the response

“• Care plans continue to be regularly reviewed and audited monthly or when required.”

Source location

Response from Credenhill Court
Page 2 · response
Published 14 March 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 existing falls protocol is considered effective, with concerns outside its parameters referred to appropriate health professionals.

Verbatim wording from the response

“• The falls protocol has been reviewed and we believe it is affective and each fall is taken on its own merit, any concerns beyond the parameter of the protocol we seek support and guidance from the appropriate health professionals i.e. doctors or paramedics and this documented. The falls continue to be audited each month to highlight any trends and to ensure the correct professional has been contacted. Any minor fall that takes place at Credenhill Court Rest Home the senior on duty emails the GP care home admin group and this resident is then reviewed on the weekly ward round and notes are added to their individual patient records. Each resident regardless of the severity of the fall and their capacity have 24-48 hour monitoring in the form of blood pressure, pulse and body map notes.”

Source location

Response from Credenhill Court
Page 1 · response
Published 14 March 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

    Add an alert sheet to medication administration records for residents taking blood thinners.

    Stated by Credenhill Court Rest HomeStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.
  2. 2

    Discontinue facilitating respite residents after reviewing the respite care plan.

    Stated by Credenhill Court Rest HomeStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.

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

  1. 1

    The medication process for residents taking blood thinners was reviewed by the GP surgery and is considered adequate, with no concerns identified.

    Stated by Credenhill Court Rest HomeExisting 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

Add an alert sheet to medication administration records for residents taking blood thinners.

Verbatim wording from the response

“• The medication processes for residents taking blood thinners has been reviewed by the GP surgery and there are no concerns with the process we have in place although we ourselves have added an additional safeguard by including an alert sheet that can be found within the medication administration sheet.”

Source location

Response from Credenhill Court
Page 1 · response
Published 14 March 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

Discontinue facilitating respite residents after reviewing the respite care plan.

Verbatim wording from the response

“• Credenhill Court Rest Home no longer facilitates respite residents. After reviewing the respite care plan we feel, although effective in its short term use it is not as robust as our caredocs care planning system.”

Source location

Response from Credenhill Court
Page 1 · response
Published 14 March 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 medication process for residents taking blood thinners was reviewed by the GP surgery and is considered adequate, with no concerns identified.

Verbatim wording from the response

“• The medication processes for residents taking blood thinners has been reviewed by the GP surgery and there are no concerns with the process we have in place although we ourselves have added an additional safeguard by including an alert sheet that can be found within the medication administration sheet.”

Source location

Response from Credenhill Court
Page 1 · response
Published 14 March 2024

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