Care plan failures
Care plans not accurately reflecting individual needs or care provided, and ineffective systems for quality assurance and continuous improvement.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
LGO / SPSO decision
90match
24-022-879 - Barchester Healthcare Homes Limited
Summary: The Care Provider failed to update Mrs Y’s care plan to reflect a change in her care needs around continence. There was also a failure to ensure Mrs Y saw a chiropodist regularly. This caused avoidable distress for which the Care Provider has apologised, completed staff training and introduced a new policy around continence care. This action...
Matched on
terms: care, failure, plan
Inquiry recommendation
87match
R5 - Named person for care plans
Any service user with a learning disability should have a named person (a key individual) responsible for their care plans and this person should be involved in and record the discussion with the family and the discussion with any relevant MDT and sign off the final decision. (And see Recommendation 99).
Matched on
terms: care, plan
Inquiry recommendation
83match
WATE-(33) - Base care plans on comprehensive assessment, prepared with child consultation
The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Matched on
terms: care, plan
Inquiry recommendation
83match
LAMI-64 - Ensure nursing care plans account for suspected deliberate harm in hospitalised children.
When a child is admitted to hospital and deliberate harm is suspected, the nursing care plan must take full account of this diagnosis.
Matched on
terms: care, plan
Inquiry recommendation
82match
R12 - Person-centred care plans with family involvement
Care plans must be live, person-centred documents. This requires joint ownership with people with learning disabilities and their families rather than simply professional records. While professionals necessarily lead assessments, families should be actively involved in identifying needs. Resulting care plans should be shared with the service user themselves (where appropriate) and families, who should be able to challenge...
Matched on
terms: care, plan
Inquiry recommendation
82match
COVID-M3.9 - Standardised Advance Care Planning
The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for clinicians to ascertain and record their patients' wishes and preferences for future care and treatment in order to...
Matched on
terms: care, plan
Inquiry recommendation
82match
R18 - Care planning system
Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff. Where appropriate they should introduce pro forma care plans to assist nurses with care planning. Health Boards should ensure that there is a system of audit of care planning in place.
Matched on
terms: care, plan
GIRFT recommendation
82match
Adult Critical Care
Put Advance Care Planning and shared decision-making protocols in place, in order to know patient and families' wishes and help to inform appropriate referrals to critical care. a All trusts should review, update and implement their protocols and referrals so they are following end of life guidance. b GIRFT will work with NHS England and NHS Improvement (NHSE/I)...
Matched on
terms: care, plan
PFD report
81match
Michael Uriely
The care management for chronic asthma lacked coordination, long-term planning, and adherence to clinical guidelines. Concerns also included insufficient communication between primary and secondary care, and a failure to refer to a tertiary respiratory service.
Matched on
terms: care, failure, plan
GIRFT recommendation
81match
Mental Health – Adult Crisis and Acute Care
Trusts need to ensure that person-centred care and co-production of care plans is standard (including to the maximum extent feasible within the law for those detained under the MHA). For people who lack capacity, care planning should follow the principles and rules set out in the Mental Capacity Act. a Trusts to ensure the electronic health record clearly...
Matched on
terms: care, plan
Scottish FAI
81match
Hamish Adamson
The management of the Trust and the senior medical and midwifery management at Cresswell should carry out an urgent and thorough review of the practices and procedures at Cresswell in relation to a trial of labour by induction by prostaglandin gel by a woman who has previously undergone a caesarean section operation with particular reference to • The...
Matched on
terms: care, plan
Inquiry recommendation
78match
R15 - Independent care plan reviews
Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and should include formal, documented input from the service user themselves (where appropriate) and families. Additionally, there should be regular independent reviews overseen by the Public Health Agency (PHA) to assess any deviation from best practice, both...
Matched on
terms: care, plan
Inquiry recommendation
78match
WATE-(37) - Prepare and periodically review leaving care plans for all looked after children
A leaving care plan should be prepared for each looked after child, in consultation with that child, a year in advance of the event and should be reviewed periodically thereafter until the child ceases to require or be eligible for further support.
Matched on
terms: care, plan
Inquiry recommendation
78match
WATE-(34) - Designate social worker responsible for care plan implementation and child supervision
An appropriate social worker should be designated as the person responsible for the implementation of the care plan and supervision of the looked after child.
Matched on
terms: care, plan
HSSIB recommendation
78match
Medication not given: discharge from an acute hospital to the community
How to adjust the insulin dose was discussed, as well as injection technique. The patient was given leaflets which detailed injection technique and what to do in the event of illness, and type 2 diabetes and healthy eating booklets were also provided. 2.3 The patient was advised that the diabetes specialist nursing team would follow up during the...
Matched on
terms: care, plan
LGO / SPSO decision
77match
23-020-972 - London Borough of Merton
Summary: There was delay by the Council in reviewing Ms Y’s care and support plan causing avoidable uncertainty. There was delay in complaint handling and a failure to provide a response, causing avoidable distress and time and trouble. The Council will make a payment, apologise, make a decision on funding and review procedures to minimise the risk of...
Matched on
terms: care, failure, plan
CQC enforcement action
77match
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an inspection of their community-based mental health services for people of working age in October. Inspectors found safety concerns still needed addressing across the service, including understaffing, postponed routine appointments, and issues with care plans, risk assessments, and medication storage....
Matched on
terms: care, plan
CQC enforcement action
77match
Warning Notice: East Sussex Hospitals NHS Trust
The Care Quality Commission (CQC) issued a warning notice to East Sussex Hospitals NHS Trust, requiring urgent improvements to patient care. Inspectors found insufficient staff to support proper patient care in some areas, and that care plans and risk assessments were not completed or were inaccurate. Additionally, patients did not always receive the help they needed to eat...
Matched on
terms: care, plan
LGO / SPSO decision
76match
21-006-581 - London Borough of Richmond upon Thames
Summary: Mrs D complains about the Council’s handling of her son F’s Education, Health and Care plan. She says it did not adhere to the Special Educational Needs and Disabilities Code of Practice. Mrs D says she had to pay for privately arranged therapy and F missed education due to the Council’s failures. We find fault by the...
Matched on
terms: care, failure, plan
GIRFT recommendation
74match
Paediatric Critical Care
Ensure that L3 beds are used efficiently, with alternative pathways in place to minimise the use of L3 beds by patients who do not require L3 care. a Level 3 providers should develop a PCC system that enhances step-up and step-down pathways beyond PICU, thereby reducing the proportion of L0/1/2 activity delivered in designated L3 beds. b Monitor...
Matched on
terms: care
PFD report
73match
John Davies
There was no process for completing risk assessment plans when a resident's needs changed from care to nursing, leading to communication gaps between the care home and District Nursing Team. Patient records lacked detail and the correct procedure for pressure relieving strategies was not consistently followed.
Matched on
terms: care, plan
Inquiry recommendation
73match
R16 - Missed care incident reporting
If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using the Trust’s or organisation’s incident reporting system.
Matched on
terms: care, plan
PPO recommendation
73match
The Head of Healthcare at Parc
The Head of Healthcare at Parc should ensure that CVOP meetings are clinically multidisciplinary, that effective care plans are created and implemented, and that the meetings are accurately minuted.
Matched on
terms: care, plan
Committee recommendation
73match
#14 - 1st Report - Think Work First: the transition from education to work for young disabled people
Education, Health and Care Plans help young disabled people receive essential educational support and are fundamental to enabling many young disabled people to access employment programmes such as supported internships or more accessible apprenticeships. However, the current system does not deliver the vital support that many young disabled people need, nor does it adequately support the councils and...
Matched on
terms: care, plan
GIRFT recommendation
73match
Mental Health Rehabilitation
4.1 Trusts and health commissioners should develop standardised care pathways and service frameworks in line with NHS Digital definitions from the service framework of community rehabilitation teams and typology of different inpatient rehabilitation services from RCPsych Rehab Faculty. Provider collaboratives will come into play. a Trusts to use these definitions to develop a whole system rehabilitation pathway. b...
Matched on
terms: care, plan
CQC action
73match
Sunderland Royal Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Matched on
terms: care, plan
CQC action
73match
South Tyneside District Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Matched on
terms: care, plan
CQC action
73match
Clatterbridge Hospital
The services should ensure patients care plans reflect individual needs and preferences.
Matched on
terms: care, plan
CQC enforcement action
73match
Warning Notice: United Lincolnshire NHS Trust
Following a visit to Pilgrim Hospital, the Care Quality Commission found United Lincolnshire NHS Trust was not taking appropriate steps to ensure people receive effective, safe and appropriate care. Inspectors noted that care plans did not always reflect patient needs, and risk assessments lacked sufficient detail or clear actions to minimise risk. CQC has demanded the trust take...
Matched on
terms: care, plan
LGO / SPSO decision
72match
20-001-927 - London Borough of Redbridge
Summary: Miss X complains that the Council failed to provide special educational provision for her daughter in line with her Education, Health and Care plan. She also complains that the Council ignored her request for a personal budget and failed to respond to her complaint. Miss X says her daughter lost out on provision she was entitled to...
Matched on
terms: care, failure, plan
Scottish FAI
72match
Erin Casey and Christina Fiorre Ilia
I recommend the following:- (1) The vast majority of patients with epilepsy, or their parents or carers where appropriate, should be advised of the risk of SUDEP on first diagnosis or if , in the particular circumstances of that patient, there are exceptional circumstances for delaying immediate provision of the information, then within a very short time thereafter....
Matched on
terms: care, plan
CQC action
71match
Ashbourne House - Torquay
People's care plans did not meet their needs and were not reflective of their wishes and preferences. People's care plans were not always effectively reviewed to ensure they were reflective of the care being delivered.
Matched on
terms: care, plan
Committee recommendation
70match
#8 - 2nd Report - Human Rights of Children in the Social Care System in England
Assessments of children’s needs must also effectively identify neurodivergence, and must lead to the provision of adequate support to meet the needs of neurodivergent children. (Recommendation, Paragraph 59)
Matched on
terms: care
PFD report
69match
Sybil Roberts
The coroner noted no referral to a GP for a falls risk assessment upon admission, despite Mrs. Roberts' declining condition. Additionally, her care plan and falls risk were not reassessed or updated after her return from hospital following a first fall.
Matched on
terms: care, plan
PFD report
69match
Leonard Hudson
The coroner identified a failure to follow the Trust's pressure ulcer policy, including inadequate incident reporting and risk identification. Further concerns related to insufficient record-keeping, confusion in patient care arrangements, and a lack of contingency for physiotherapy provision.
Matched on
terms: care, failure
PFD report
69match
John Bird
The care home manager did not provide the falls risk assessment at the inquest. The coroner also noted that a carer was unfamiliar with a resident's high falls assessment and care plan, which the manager acknowledged was their responsibility to ensure staff knew.
Matched on
terms: care, plan
PFD report
69match
Michael Lyons
The Care Agency did not determine the outcome of a swallowing assessment or implement steps to protect Mr Lyons from choking, and the care plan lacked a management strategy including supervision and specific food preparation instructions for carers.
Matched on
terms: care, plan
PFD report
69match
Maurice Camfield
The coroner noted that Mr. Camfield's agreed care plan, which stipulated one-to-one nursing care at all times, was not strictly followed by those involved in his treatment.
Matched on
terms: care, plan
PFD report
69match
Rasharn Williams
Rasharn's care plan lacked clarity regarding when to call an ambulance for breathlessness, potentially creating ambiguity for staff. A medical notice with his photograph and instructions was also not displayed at the time of his death.
Matched on
terms: care, plan
PFD report
69match
Walter Willows
Care plans for clients with swallowing difficulties, specifically their feeding regimes, were reviewed quarterly, which was insufficient to adjust diets to changing abilities. More frequent examination of these plans was required.
Matched on
terms: care, plan
PFD report
69match
Joanna Bowring
The patient and carer left an initial assessment without a clear understanding of the service or a care plan. Carers were not routinely included in risk assessments, their views were not actively sought, and they were not advised about behaviours indicating an increased risk of suicide.
Matched on
terms: care, plan
PFD report
69match
Clifford Crofts
The coroner identified issues with staff not following care plans or being aware of policies, difficulties escalating patient care and obtaining urgent CT scans, and insufficient weekend staffing levels.
Matched on
terms: care, plan
PFD report
69match
Pamela Thurston
The coroner identified insufficient direct supervision during mealtimes for a resident with dementia, who choked after being given toast following a 17-hour period without food. Her care plan was also not updated despite a prior related incident.
Matched on
terms: care, plan
PFD report
69match
Dorothy Imisson
The coroner identified that the District Nursing Service did not develop an appropriate care plan and did not adhere to NMC guidance on record-keeping or NICE clinical guidelines.
Matched on
terms: care, plan
PFD report
69match
Malcolm Bennett
The coroner noted a three-hour delay in calling an ambulance for a person who had been hit, despite the care plan indicating immediate transfer to the emergency department for significant injury. This delay might have been contributory to the cause of death.
Matched on
terms: care, plan
PFD report
69match
Etheline De-Gale
The care plan was too vague to guide carers, who also lacked training on how to undertake risk assessments. Insufficient staffing levels compromised resident safety, potentially leading to paramedic recommendations being ignored.
Matched on
terms: care, plan
PFD report
69match
Janet Williams
Inadequate recording of Ms Williams' care plan led to missed reviews and delayed medical appointments. Additionally, the care coordinator did not address family concerns and made undeclared retrospective entries in medical records.
Matched on
terms: care, plan
HSSIB recommendation
69match
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
HSSIB recommends that the Department of Health and Social Care works with NHS England and other stakeholders, to develop a strategy that ensures that all diseases are given parity and that all people with a long-term condition in primary, secondary, tertiary and community or social care have their care effectively co-ordinated across multiple agencies. This is to ensure...
Matched on
terms: care, plan
PPO recommendation
69match
The Head of Healthcare at HMP Buckley Hall
The Head of Healthcare at HMP Buckley Hall should ensure that all prisoners identified as having a severe and enduring mental illness have comprehensive care plans.
Matched on
terms: care, plan
PPO recommendation
69match
The Head of Healthcare
The Head of Healthcare should ensure that care plans are created for all patients with suspected coronary heart disease.
Matched on
terms: care, plan