Care home incident, audit systems
Systems for audits, incidents, and accidents monitoring in care homes are not fully embedded or mature.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
86match
Roky Care Ltd
The provider must ensure effective auditing systems are in place to identify areas of improvement.
Matched on
terms: audit, care, system
PFD report
85match
Derrick Rivers
The coroner identified inadequacies in the care home's drug administration policy and audit processes, which were not fully noted by the Local Authority or CQC during inspections. Concerns were also raised about management's awareness of staff not following protocols and delayed action on recommendations.
Matched on
terms: audit, care, home
PFD report
81match
Peter Furness
The care home lacks a documented process for escalating incidents or concerns to trigger multi-disciplinary team meetings that review risk assessments and care plans for vulnerable residents.
Matched on
terms: care, home, incident
PFD report
81match
George Goldby
The coroner identified that care home staff were unaware of and did not follow SALT recommendations for resident supervision and dietary needs, leading to unsupervised mealtimes for those at high choking risk. Concerns also included inadequate incident reporting and disorganised care plan records.
Matched on
terms: care, home, incident
PFD report
81match
Ruth Gregory
The coroner noted that residents were regularly unsupervised in communal care home areas, creating a risk of resident-on-resident incidents leading to trauma. Information on risk management and supervision arrangements was absent.
Matched on
terms: care, home, incident
PFD report
81match
Arnold Ward
The care home's forms did not adequately capture pressure ulcer deterioration, leading to a delay in recognition and escalation to the Tissue Viability Nursing team, and there was no system to chase up referrals.
Matched on
terms: care, home, system
PFD report
81match
Edward Mallaby
The care home lacked a clear policy for handling residents' hazardous personal property, and a sensor mat failed to alert staff to the deceased being out of bed. There was no rapid learning exercise after the incident, and policy reviews lacked completion deadlines.
Matched on
terms: care, home, incident
PFD report
81match
Colm McCabe
The coroner identified gaps in policy adherence, staff recruitment, training, and appraisals at the care home. Concerns were also raised regarding the effectiveness of auditing processes and the candour of internal investigations.
Matched on
terms: audit, care, home
PFD report
81match
Margaret Greenacre
The coroner noted delays in statutory notifications of incidents to the CQC, including one that was never reported, potentially hindering investigations. Concerns were also raised regarding poor record-keeping at the care home, where care notes did not accurately reflect residents' needs and care plans were not updated.
Matched on
terms: care, home, incident
PFD report
81match
Beryl Ellison
The report raises concerns about Alexandra Care Home's medication management and supervision, with no explanation for the excessive oxycodone found in Mrs Ellison, and the systems remaining unchanged since her death.
Matched on
terms: care, home, system
Inquiry recommendation
81match
R45 - Incident trend analysis on board dashboards
Incident reports of any violent or aggressive behaviour by either people with learning disabilities and autistic people or staff should be analysed and trend data reported on every HSCT Board’s quality and safety dashboard. In private and third sector care a similar system must be in place.
Matched on
terms: care, incident, system
CQC action
81match
Copperfields Residential Home
There are audit processes and other systems in place but these are not robust enough to assess, monitor and continually improve the service.
Matched on
terms: audit, home, system
LGO / SPSO decision
74match
PSOW-202106081 - A Care Home
Mrs A complained about the actions of Aneurin Bevan University Health Board (“the Health Board”) in relation to the care provided to her late mother, Mrs B. Specifically, Mrs A complained that Mrs B’s needs (as set out in her Care Plan) were not met, there was a failure to ensure appropriate assessments were undertaken in a timely...
Matched on
terms: care, home
LGO / SPSO decision
74match
24-006-556 - Ideal Care Homes Ltd
Summary: Ms A and her sister Ms B complain that the care provider gave notice on their late father’s placement without due reason and they had to find another placement at short notice for their elderly father who has dementia. The care provider failed to meet Mr X’s needs and gave notice inappropriately; the care provider agrees to...
Matched on
terms: care, home
CQC action
73match
Orton Manor Nursing Home
Implement overall analysis of accidents and incidents to identify any trends or patterns.
Matched on
terms: home, incident
PHSO casework decision
73match
P-002447 - A care home in the Birmingham area
Mr O complained his mother suffered several unwitnessed falls at a care home in 2021 due to insufficient monitoring, leading to injuries and distress.
Matched on
terms: care, home
PFD report
69match
Jean Gillespie
The coroner identified that a senior care staff member administering medication was unaware of a resident's life-threatening condition and its urgency. Care home records lacked information on the condition, its symptoms, and the purpose of prescribed medication, presenting a risk if replicated.
Matched on
terms: care, home
PFD report
69match
Robert Davidson
Healthcare staff lacked training in basic emergency procedures, including 999 calls and CPR, and Health Care Assistants had insufficient foundational training for their role. The deceased's PICA behaviour was also not highlighted during care home transfer.
Matched on
terms: care, home
PFD report
69match
Mildred Griffiths
The care home's Braden Score for pressure sore risk may underestimate risk by not accounting for existing lesions and causes confusion due to its inverse calculation compared to the nationally recognised Walsall score.
Matched on
terms: care, home
PFD report
69match
Lea Hunsley
The EAM facility lacked a serious untoward incident protocol, and staff demonstrated insufficient ability to identify deteriorating patients, escalate medical reviews, or use care records effectively. Insufficient action had been taken on recommendations from a CQC inspection, without sustained improvement.
Matched on
terms: care, incident
PFD report
69match
Yong Hong
Concerns included the care home's failure to implement a GP-advised observation regime and to conduct a risk assessment before returning a call bell. There was also a lack of an interpreter for mental health assessment due to funding confusion, and staff lacked training.
Matched on
terms: care, home
PFD report
69match
Margaret Melia
Inadequate discharge and pre-assessment processes between two care homes meant that the patient's requirement for subcutaneous fluids was not properly managed.
Matched on
terms: care, home
PFD report
69match
Elaine Renshaw
The coroner noted insufficient processes for managing controlled drugs in care and nursing homes, leading to difficulties in accounting for medication and inaccurate stock sheets.
Matched on
terms: care, home
PFD report
69match
Marion Glover
The care home design allows residents with cognitive illnesses to freely leave the building unnoticed, as the main exit is unlocked during the day and there is no observation of the foyer area. This raises concerns about the suitability of the accommodation for individuals with such conditions.
Matched on
terms: care, home
PFD report
69match
Pauline Brumfitt
The care home did not apply its falls risk assessment and prevention policies, missing opportunities to reassess the resident's risks after three falls. There was a lack of timely reporting to regulatory bodies and delayed commencement of staff supervision regarding falls prevention.
Matched on
terms: care, home
PFD report
69match
Catherine Jux
A patient's risk assessment was not completed within 24 hours of admission to Elvy Court Nursing Home, and staff did not identify this oversight. The home lacked an adequate process for auditing the completion of such assessments according to its policy.
Matched on
terms: audit, home
PFD report
69match
Dorothy Spiby
The coroner noted an unclear account of a resident's fall at Tamworth Court Nursing Home, with no incident recorded in nursing notes, no incident form completed, and no investigation or evidence of learning from the event.
Matched on
terms: home, incident
PFD report
69match
Irene White
Frome Nursing Home staff did not adequately assess or manage the risk of deep vein thrombosis for an immobile patient, lacking a DVT policy and failing to inquire about care needs or implement preventative measures.
Matched on
terms: care, home
PFD report
69match
Sylvia Nash
The coroner notes a lack of clear understanding among agencies regarding the process for deciding on the removal of 1:1 patient observations, with disagreement between the Council and the care home on who holds responsibility. This indicates insufficient communication and understanding of the correct process between involved parties.
Matched on
terms: care, home
PFD report
69match
Sylvia Prichard
The coroner raised concerns about out-of-date mobility care plans, a lack of falls minimisation plans, and significant delays in call bell response times at the care home. The report also identified limited provision of emergency alert devices and insufficient corporate oversight.
Matched on
terms: care, home
PFD report
69match
June Phillips
The coroner identified concerns regarding inaccurate care home records not reflecting a patient's deterioration, the failure to update the falls risk assessment after a fall, and an inadequate post-falls investigation.
Matched on
terms: care, home
Inquiry recommendation
69match
R66 - Quarterly safeguarding file audit
A quarterly multidisciplinary audit of 10% of safeguarding files per ward or residential unit should be conducted. Findings must be integrated with incident data and reported to the Executive Team, NEDs and the Strategic Planning and Performance Group (SPPG).
Matched on
terms: audit, incident
CQC action
69match
Aaron Abbey Care Services Limited
The registered manager's systems and processes to monitor quality and safety in the service were not established and operated effectively to ensure compliance with their legal requirements. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Matched on
terms: care, system
LGO / SPSO decision
69match
22-000-526a - Akari Care (22 000 526a)
Summary: Mr B complained about the actions of a Care Provider because he says his late mother’s rings went missing in one of its nursing homes. He also said the Council did not do enough to investigate the matter. We did not find fault by the Council. The Care Provider failed to follow its procedures as it did...
Matched on
terms: care, home
PHSO casework decision
69match
P-001447 - A care home in the Warrington area
Mrs X complained that staff at her father's care home lost his dentures, causing her distress, anger, and upset.
Matched on
terms: care, home
LGO / SPSO decision
69match
24-018-019 - Barchester Healthcare Homes Limited
Summary: There was fault on the part of the care provider which led to suffering and distress for Mr X and distress for Mrs X. The care provider acknowledges fault in its record keeping and offers a goodwill payment. It should make a more significant payment to reflect the injustice caused by its actions.
Matched on
terms: care, home
LGO / SPSO decision
69match
21-005-089 - Country Court Care Homes 3 OpCo Limited
Summary: Mrs X complained on behalf of Mrs Y, about the care she received at Tallington Care Home (the Care Provider). She says Mrs Y was put at risk and when family raised concerns, staff were aggressive. We found the Care Provider did cause injustice to Mrs Y and Mrs X because staff did not always follow care...
Matched on
terms: care, home
LGO / SPSO decision
69match
21-011-877 - Longfield (Care Homes) Limited
Summary: Ms Z complained about an inaccurate invoice for outstanding care fees. Based on the information available, I intend to find fault in the actions of the Care Provider for failing to identify and prevent an accumulation of arrears. This fault has caused an injustice to Ms X, and we have proposed recommendations to the Care Provider.
Matched on
terms: care, home
LGO / SPSO decision
69match
21-004-973 - Barchester Healthcare Homes Limited
Summary: Mrs D complains about the standard of care and support her father (Mr H) received while in residential care. Among other things, Mrs D says the Care Provider failed to meet Mr H’s health and care needs and provided him medication he was not prescribed. We found some fault by the Care Provider in relation to its...
Matched on
terms: care, home
LGO / SPSO decision
69match
23-011-659 - Barchester Healthcare Homes Limited
Summary: Mrs X complains, on behalf of her father, Mr Y, Barchester Healthcare Homes Limited mishandled the pre-admission process and failed to ask relevant questions before her father moved into in the home. She says the Care Provider failed to engage with her or social services to complete a re-assessment. Mrs X also complained the Care Provider took...
Matched on
terms: care, home
LGO / SPSO decision
69match
23-020-716 - Bupa Care Homes (AKW) Limited
Summary: We will not investigate this complaint about adult social care in a residential care home. The Care Provider has accepted failings in communication and record keeping, has apologised, and has spoken with staff to improve service. It is unlikely an Ombudsman investigation would add to this or lead to a different outcome.
Matched on
terms: care, home
LGO / SPSO decision
69match
23-020-500 - Heathfield Care Homes Limited
Summary: Mrs B complains about the care home’s delay in calling an ambulance for her mother and says her mother suffered dehydration and pressure sores because of the care home’s failures in care. We have not found fault in the way the care home decided to call an ambulance or its provision of liquids when Mrs B’s mother...
Matched on
terms: care, home
LGO / SPSO decision
69match
24-020-592 - Barchester Healthcare Homes Limited
Summary: We will not investigate this complaint about adult social care during a short respite break at a care home. The Care Provider accepted some fault, apologised, offered £200, and gave staff training to improve future service. We are satisfied with its actions in response to the complaint, and it is unlikely we would achieve anything further.
Matched on
terms: care, home
CQC action
65match
Northampton General Hospital
The trust should ensure systems were in place to ensure audits were consistently reviewed and actions taken to address any identified concerns.
Matched on
terms: audit, system
CQC action
65match
King's Mill Hospital
The trust should continue to implement their new electronic system. To support auditing the quality of the service.
Matched on
terms: audit, system
PHSO casework decision
65match
P-003058 - Care Quality Commission
Mr and Mrs B complained the CQC failed to properly inspect a nursing home, act on intelligence, communicate effectively, follow enforcement policy, and resolve their complaints, causing distress.
Matched on
terms: care, home
LGO / SPSO decision
65match
NIPSO-16874 - Belfast Health and Social Care Trust
The Ombudsman has found that the Belfast Health and Social Care Trust made a concerted attempt to resolve a complainant’s concerns about the care and treatment provided to her father while he was the resident of a Belfast nursing home.
Matched on
terms: care, home
LGO / SPSO decision
65match
21-018-569c - The Coach House Residential Home (21 018 569c)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or the Trust. The identified faults caused avoidable distress...
Matched on
terms: care, home
LGO / SPSO decision
65match
25-002-861 - Borough Care Ltd
Summary: The Care Provider was at fault for not maintaining Y’s personal hygiene and for delaying its response to Mr X’s concerns about the matter. The Care Provider further failed to keep adequate records about the issue. It also failed to record how it assessed Y’s capacity when obtaining consent to use Y’s photograph for promotional purposes. The...
Matched on
terms: care, system
CQC action
64match
Dorset County Hospital
Theservicemustensureaneffectiveandcomprehensive,rollingprogrammeofauditisinplace,andresultsare monitoredforusetoimproveservices.Thisincludesbutisnotlimitedtoeffectivemonitoringofwaittimesand appropriatecareinmaternitytriage,andthequalityofrecordkeeping.
Matched on
terms: audit, care