PFD report

Maureen Alison Woollen · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 19 Jun 2024•South Yorkshire (Western)

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

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 raised4

  1. Failure to promptly seek medical attention for residents who require it
    Part of recurring concern: Failure to seek medical attention when a person's condition warrants itPart of recurring concern: Unreliable escalation by care staff for required medical attention
  2. Failure to conduct falls risk assessments on admission
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable safety assessment of new care-home residents on admission
  3. Failure to monitor the progression of resident injuries
    Part of recurring concern: Failure to assess and respond promptly to significant signs of injury
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.7

  1. Action

    Update admissions, falls prevention and risk-assessment policies to require timely assessment, injury monitoring and medical escalation.

    Stated by SheffcareStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
  2. Action

    Introduce management checks and sampling of the Person-Centred Care system and daily care notes to strengthen record-keeping oversight.

    Stated by SheffcareStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
  3. Action

    Roll out refresher training on pre-admission assessments, detailed care notes, falls documentation and escalation, using anonymised scenarios and monthly monitoring.

    Stated by SheffcareStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.

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 promptly seek medical attention for residents who require it

Wider context from the report

“The inquest found there were missed opportunities to conduct a falls risk assessment on Mrs Woollen's arrival to Deerlands Residential home, to seek medical attention when she was found on the floor on 3 October 2023, to seek medical attention when a bruise on her face was noted on 6 October 2023 and to monitor the progression of her bruise. I am concerned there is no process in place to ensure medical attention is promptly sought for residents who require it, that care notes are not fully utilised, especially for the recording of injury and incidents, and that falls risk assessments are not being conducted on admission. ”

Is this part of a recurring concern?

Yes — Failure to seek medical attention when a person's condition warrants it; Unreliable escalation by care staff for required medical attention.

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 conduct falls risk assessments on admission

Wider context from the report

“The inquest found there were missed opportunities to conduct a falls risk assessment on Mrs Woollen's arrival to Deerlands Residential home, to seek medical attention when she was found on the floor on 3 October 2023, to seek medical attention when a bruise on her face was noted on 6 October 2023 and to monitor the progression of her bruise. I am concerned there is no process in place to ensure medical attention is promptly sought for residents who require it, that care notes are not fully utilised, especially for the recording of injury and incidents, and that falls risk assessments are not being conducted on admission. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable safety assessment of new care-home residents on admission.

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 monitor the progression of resident injuries

Wider context from the report

“The inquest found there were missed opportunities to conduct a falls risk assessment on Mrs Woollen's arrival to Deerlands Residential home, to seek medical attention when she was found on the floor on 3 October 2023, to seek medical attention when a bruise on her face was noted on 6 October 2023 and to monitor the progression of her bruise. I am concerned there is no process in place to ensure medical attention is promptly sought for residents who require it, that care notes are not fully utilised, especially for the recording of injury and incidents, and that falls risk assessments are not being conducted on admission. ”

Is this part of a recurring concern?

Yes — Failure to assess and respond promptly to significant signs of injury.

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 fully utilise care notes for recording injuries and incidents

Wider context from the report

“The inquest found there were missed opportunities to conduct a falls risk assessment on Mrs Woollen's arrival to Deerlands Residential home, to seek medical attention when she was found on the floor on 3 October 2023, to seek medical attention when a bruise on her face was noted on 6 October 2023 and to monitor the progression of her bruise. I am concerned there is no process in place to ensure medical attention is promptly sought for residents who require it, that care notes are not fully utilised, especially for the recording of injury and incidents, and that falls risk assessments are not being conducted on admission. ”

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

Update admissions, falls prevention and risk-assessment policies to require timely assessment, injury monitoring and medical escalation.

Verbatim wording from the response

“The admissions policy was reviewed and updated on 1 July 2024 to further outline that falls risk assessment are to be completed prior to or on admission to Sheffcare homes. This will include a”

Source location

Reponse from Sheffcare
Page 4 · response
Published 27 June 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

Introduce management checks and sampling of the Person-Centred Care system and daily care notes to strengthen record-keeping oversight.

Verbatim wording from the response

“In addition, the Registered Manager and Deputy Manager QA now incorporate management checks on the Person-Centred Care system and daily care notes are sampled to promote good record-keeping principles. This gives further quality assurance and the end of the roll out of this new part of the services oversight will be completed by 31 August 2024.”

Source location

Reponse from Sheffcare
Page 4 · response
Published 27 June 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

Roll out refresher training on pre-admission assessments, detailed care notes, falls documentation and escalation, using anonymised scenarios and monthly monitoring.

Verbatim wording from the response

“The importance of maintaining care notes was discussed at the Deputy Managers’ meeting on 2 July 2024 [see document 9]. Sheffcare already have sophisticated Person–Centred Software, but this does not appear to have been used effectively at the time of Mrs Woollen’s care. Sheffcare has now improved the training sessions which already focus on the importance of keeping timely and accurate care notes by incorporating within the existing training real and anonymised scenarios to reinforce to staff understanding. The software includes training around ensuring a falls risk assessment is completed on admission. Falls (witnessed or otherwise) must be documented in the Person–Centred Care system and there is a monitoring and tracking section in the notes. This is audited.”

Source location

Reponse from Sheffcare
Page 3 · response
Published 27 June 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

Issue updated guidance and brief managers on completing body maps and photographing injuries or marks.

Verbatim wording from the response

“████████ held a Deputy Managers’ meeting on 2 July 2024 and issued notes for all the homes to ensure a generic approach and focus on, the process for completing body maps and taking photographs of any injuries or marks. Updated guidance on ensuring correct and robust use of body maps. This was completed on 12 July 2024 [see document 9].”

Source location

Reponse from Sheffcare
Page 4 · response
Published 27 June 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

Discuss falls, documentation and escalation requirements with staff through huddles, supervision and management briefings.

Verbatim wording from the response

“Directly after the incident with Mrs Woollen, the service met with staff at Deerland and what is known as “huddles” were carried out [see document 7]. A huddle is an informal meeting at which matters to celebrate as well as concerns are raised directly with staff. The incident with Mrs Woollen was discussed and staff were reminded of the policies in relation to falls risk, documentation, and escalation it has also been part of their mandatory training and discussed in supervisions. [see document 8].”

Source location

Reponse from Sheffcare
Page 3 · response
Published 27 June 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

Complete a quality-assurance systems review for linked care plans, risk assessments, falls escalation and care-note updating.

Verbatim wording from the response

“Subsequent to Mrs Woollen’s fall, there has also been a complete review spearheaded by Louise of the Quality Assurance Systems for the Person-Centred Care systems which links care plans and risk assessments automatically; this is audited [see document 3]. There is a three-tier approach to quality auditing headed by the Team Leader, Deputy Manager and Registered Manager who undertake quality audits which then inform the monthly quality dashboard report. [see document 4]. There has been further focus on the process at Team Leader level to capture whether falls and requirement for medical attention is being escalated appropriately. The auditing also includes analysis of whether care notes are properly updated. This review was completed on 8 July 2024.”

Source location

Reponse from Sheffcare
Page 4 · response
Published 27 June 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

Analyse Person-Centred Care falls-assessment data and present findings to the Quality Committee.

Verbatim wording from the response

“████████ met with Care Plan Coordinators on 16 July 2024. The Care Plan Coordinator role and remit is to upload the PCS notes from assessment and ensure that all assessments are undertaken. They support the operational management team in building care plans on PCS and ensure care plans are kept under close review. The meeting focussed on ensuring that falls risk assessments are in place prior to admission or on admission day, along with care plan review processes. ████████ is undertaking an analysis of PCS falls assessment data, which will provide additional reassurances that all residents have falls risk assessments in place and any additional information around the management of falls is appropriately reviewed. The initial findings will be presented at the 22 August 2024 Quality Committee meeting, and this will be completed by 31 August 2024.”

Source location

Reponse from Sheffcare
Page 4 · response
Published 27 June 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.6

  1. 1

    Issue a service-wide lessons-learned briefing on the incident and associated prevention measures.

    Stated by SheffcareStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
  2. 2

    Provide executive oversight of inquests and conduct thematic reviews requiring additional quality, safety or investment action.

    Stated by SheffcareStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
  3. 3

    Introduce Director home quality-assurance visits.

    Stated by SheffcareStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
  4. 4

    Undertake unannounced service visits and review resulting observations and learning.

    Stated by SheffcareStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
  5. 5

    Implement service-wide quality and care improvements under the new Director of Quality and Care.

    Stated by SheffcareStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
  6. 6

    Implement increased due diligence for referrals containing limited information or indicators of risk.

    Stated by SheffcareStated completedThe respondent said that this action was complete when they made their response on 27 June 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

Issue a service-wide lessons-learned briefing on the incident and associated prevention measures.

Verbatim wording from the response

“A Lessons learned briefing was issued on 21 June 2024 to all homes to ensure that this matter was discussed across all the teams [see document 10].”

Source location

Reponse from Sheffcare
Page 4 · response
Published 27 June 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

Provide executive oversight of inquests and conduct thematic reviews requiring additional quality, safety or investment action.

Verbatim wording from the response

“There is now oversight by the Executive team of any inquests providing further opportunity to undertake thematic reviews that may require additional oversight or action, including any relating to HR, health and safety or financial investment.”

Source location

Reponse from Sheffcare
Page 5 · response
Published 27 June 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

Introduce Director home quality-assurance visits.

Verbatim wording from the response

“The governance of Quality Assurance processes is kept under review by the Executive team and Quality Committee. Reporting at Director level to the Board is in place and includes all areas of risk management. Director home Quality Assurance visits were introduced in May 2024.”

Source location

Reponse from Sheffcare
Page 4 · response
Published 27 June 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

Undertake unannounced service visits and review resulting observations and learning.

Verbatim wording from the response

“Unannounced visits have been undertaken by the Head of Quality and Improvement and the Director of Quality and Care provide additional assurances and visibility to the team. Following these visits, a review is being undertaken to include any observations and learning arising.”

Source location

Reponse from Sheffcare
Page 5 · response
Published 27 June 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 service-wide quality and care improvements under the new Director of Quality and Care.

Verbatim wording from the response

“████████ is the new Director of Quality and Care for SheffCare. ████████ was not in post at the time of Mrs Woollen’s fall, but since she took on the role of Director of Quality and Care, has been implementing changes and improvements at the service. She is a senior and very experienced member of the management team at Sheffcare having over 30 years’ experience in the private care sector. The service through ████████ has taken the opportunity to consider wider matters arising from the inquest and although strictly not part of the PFD request, Sheffcare wish to document reassurance that it has”

Source location

Reponse from Sheffcare
Page 1 · response
Published 27 June 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 increased due diligence for referrals containing limited information or indicators of risk.

Verbatim wording from the response

“Increased due diligence of referrals was discussed with managers on 24 July 2024 at the managers’ meeting and a frank discussion regarding referrals which arise, with limited information, or areas of assessment which identify possible areas of risk a new due diligence process has been implemented (see comments regarding the Local Authority involvement above).”

Source location

Reponse from Sheffcare
Page 5 · response
Published 27 June 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