A) Circumstances at Chilton Care Centre are such that the placing of pressure mats (intended to detect residents leaving their beds unaided) is such that residents may bypass those mats; B) The use and operation of audible signals is such that important audible alarms may not come to the attention of staff. Mr LOWE left his bed and fell unwitnessed and then lay undetected by his bed for up to two hours until a scheduled welfare check. The pressure mat may not have been triggered. The basis for my concern is as follows: (A) , Chilton Home Manager said that when she investigated this matter (by which time the mat had been removed) “…there could have been a possibility that Mr LOWE, may have bypassed the mat when getting out at the top of his bed…”(witness statement dated 11th August 2019); and (B) In the same statement, stated: “Then… when staff carried out another welfare check, they found Mr Lowe on the floor. Three out of 4 staff on duty and only one believes that the mat had not activated and the other 3 could not remember if the sensor mat was making a sound or not, as the emergency buzzer was pressed and other buzzers around the home were also going at the same time, and their priority was Mr Lowe…”