PFD report

Sally Mills · Prevention of Future Deaths report

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Issued 14 Oct 2024•Berkshire

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
9

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 knowledge and embedding of the escalation policy
    Part of recurring concern: Unreliable escalation policy for care concerns
  2. Lack of understanding of first aid for unresponsive people
    Part of recurring concern: Inadequate staff competence to provide first aidPart of recurring concern: Unreliable emergency response to patient collapse
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

    Discuss the medication concerns policy and first aid procedures with staff at the scheduled December team meeting, including emergency scenarios and policy access.

    Stated by AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & ChilternStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.
  2. Action

    Extend induction with in-person walkthroughs of policies and procedures, questions, understanding assessments and support identification before new joiners begin caring.

    Stated by AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & ChilternStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.
  3. Action

    Emphasise contacting the office when in doubt during new-joiner induction and explore professional curiosity through full-team meetings.

    Stated by AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & ChilternStated plannedThe respondent said that this action was planned when they made their response on 16 October 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

Lack of knowledge and embedding of the escalation policy

Wider context from the report

“(2) Escalation of issues encountered by care assistants being appropriately escalated. Whilst the evidence demonstrated efforts have been made in this regard, such as a new checklist, and new policy dated September 2023; the evidence revealed lack of knowledge of the policy and embedding of it. ”

Is this part of a recurring concern?

Yes — Unreliable escalation policy for care concerns.

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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 understanding of first aid for unresponsive people

Wider context from the report

“(1) First Aid training. The evidence revealed there is still a lack of understanding of providing first aid to those becoming unresponsive. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid; Unreliable emergency response to patient collapse.

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

Discuss the medication concerns policy and first aid procedures with staff at the scheduled December team meeting, including emergency scenarios and policy access.

Verbatim wording from the response

“Concern 2 - Escalation of issues encountered by Care Assistants Evidence demonstrated efforts have been made in this regard, such as a new checklist and new policy dated September 2023; the evidence revealed a lack of knowledge of the policy and the embedding of it. The care team are the organisation’s eyes and ears on the ground and as such we are reliant on them to communicate their concerns to the office in a timely manner. It became apparent that further work should be undertaken to embed section 2.27 (Raising Concerns) of the Medication Procedures September 2023 (the ‘Policy’) and ensure staff are familiar with and understand its requirements. We have decided that the Policy will also be discussed with staff at the full team meetings held in December.”

Source location

Response from Caremark (Chiltern & Tree Rivers)
Page 2 · response
Published 16 October 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

Extend induction with in-person walkthroughs of policies and procedures, questions, understanding assessments and support identification before new joiners begin caring.

Verbatim wording from the response

“Caremark’s expectations We have decided to extend our induction programme to include an in person walk through of our policies and procedures, please see the programme attached. The walk through will facilitate discussion, allow time for questions and enable the team members delivering the session to assess the extent to which new joiners understand Caremark’s expectations. The sessions will also provide an opportunity to identify new joiners who may require additional support before they can commence caring for our clients. New joiners will not be placed on rotas until the team is satisfied, they understand the requirements of our policies.”

Source location

Response from Caremark (Chiltern & Tree Rivers)
Page 3 · response
Published 16 October 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

Emphasise contacting the office when in doubt during new-joiner induction and explore professional curiosity through full-team meetings.

Verbatim wording from the response

“The requirement to contact the office when in doubt will also be emphasised as part of our induction programme for new joiners. The scenarios listed in the Policy are not exhaustive, we recognise the need to encourage and empower our care team to exercise professional curiosity and that will also be explored in our full team meetings. We would be happy to share the minutes of the meetings if that would be helpful.”

Source location

Response from Caremark (Chiltern & Tree Rivers)
Page 3 · response
Published 16 October 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

Withhold new joiners from rotas until the team is satisfied they understand the organisation’s policy requirements.

Verbatim wording from the response

“Caremark’s expectations We have decided to extend our induction programme to include an in person walk through of our policies and procedures, please see the programme attached. The walk through will facilitate discussion, allow time for questions and enable the team members delivering the session to assess the extent to which new joiners understand Caremark’s expectations. The sessions will also provide an opportunity to identify new joiners who may require additional support before they can commence caring for our clients. New joiners will not be placed on rotas until the team is satisfied, they understand the requirements of our policies.”

Source location

Response from Caremark (Chiltern & Tree Rivers)
Page 3 · response
Published 16 October 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

Add first aid as a standing agenda item at full-team meetings and regular supervision sessions to discuss incidents, best practice and staff concerns.

Verbatim wording from the response

“At this stage, we confirm that our basic life support training will be delivered in person from now on both in terms of the induction programme and the refresher sessions. Given the importance of the issue, we have decided to add first aid as an agenda item to all of our full team meetings or regular supervision sessions. We will discuss any issues encountered and talk about the best practices which should be followed. As well as giving care assistants an opportunity to raise any concerns or seek any further clarifications.”

Source location

Response from Caremark (Chiltern & Tree Rivers)
Page 2 · response
Published 16 October 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

Deliver extended three-and-a-half-hour in-person basic life support and manual handling refresher training to care staff.

Verbatim wording from the response

“This was extended to a 3 and a half hour session from 31st October 2024 and also covered manual handling techniques. At present, all members of our care team are in date with their mandatory training which includes refresher training sessions in basic life support. ████████ is responsible for ensuring that all care team members complete the required training within the relevant time frame, and this is managed via People Planner. There”

Source location

Response from Caremark (Chiltern & Tree Rivers)
Page 1 · response
Published 16 October 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

Deliver externally provided in-person basic life support training with practical demonstrations, practice and mandatory competency assessments across four staff sessions.

Verbatim wording from the response

“In person Basic Life Support training from January 2025 We have now engaged the support of an external provider, The Training Centre (London) Ltd to deliver in person Basic Life Support training to our staff. The first session will take place on 21st January 2025. The session will train up to 12 members of staff and as such 4 sessions in total will be arranged at the beginning of 2025. The session will comprise demonstrations, practice of practical skills and a competency assessment at the end. All staff will be required to pass the competency assessment. This session will cover attending to a person who is unresponsive (and breathing, unresponsive and not breathing) and where choking is suspected. Our intention is to seek feedback from the provider as to the frequency of refresher training and format to be adopted moving forwards.”

Source location

Response from Caremark (Chiltern & Tree Rivers)
Page 2 · response
Published 16 October 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

    Seek provider feedback on the appropriate frequency and format of future basic life support refresher training.

    Stated by AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & ChilternStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.
  2. 2

    Amend medication-recording practical mandatory training to reference the medication concerns policy and provide consistent guidance on recording and identifying incidents.

    Stated by AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & ChilternStated completedThe respondent said that this action was complete when they made their response on 16 October 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

Seek provider feedback on the appropriate frequency and format of future basic life support refresher training.

Verbatim wording from the response

“In person Basic Life Support training from January 2025 We have now engaged the support of an external provider, The Training Centre (London) Ltd to deliver in person Basic Life Support training to our staff. The first session will take place on 21st January 2025. The session will train up to 12 members of staff and as such 4 sessions in total will be arranged at the beginning of 2025. The session will comprise demonstrations, practice of practical skills and a competency assessment at the end. All staff will be required to pass the competency assessment. This session will cover attending to a person who is unresponsive (and breathing, unresponsive and not breathing) and where choking is suspected. Our intention is to seek feedback from the provider as to the frequency of refresher training and format to be adopted moving forwards.”

Source location

Response from Caremark (Chiltern & Tree Rivers)
Page 2 · response
Published 16 October 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

Amend medication-recording practical mandatory training to reference the medication concerns policy and provide consistent guidance on recording and identifying incidents.

Verbatim wording from the response

“Finally, our induction session Care Mark Assistant Practical Mandatory Training regarding ‘Golden Rules’ in relation to medication recording has also been amended to refer to the Policy to ensure there is consistent and clear messaging throughout our suite of guidance in relation to recording and identification of ‘medication incidents’.”

Source location

Response from Caremark (Chiltern & Tree Rivers)
Page 3 · response
Published 16 October 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