Care home alert systems
92 items
1 source
Failure of alert systems in care homes to effectively notify staff of residents requiring assistance or at risk.
Cross-Source Insight
Care home alert systems has been flagged across 1 independent accountability source:
92 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (92)
Pamela George
Concerns: The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical escalation, capacity assessment, and documentation, despite patient needs exceeding capacity.
Pending
George Ritchie
Concerns: The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.
Overdue
Peter Thompson
Concerns: Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents timely escalation of deteriorating conditions.
Response: Bank Close House has strengthened documentation expectations for handovers and instructed staff to immediately request blood glucose tests from external professionals for ill diabetic residents. Blood glucose monitoring equipment is …
Responded
Marc Davies
Concerns: Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely medical care.
Response: Monmouthshire County Council and MJ Events have implemented a new three-tier training program for all Safe Guards, covering first aid, safeguarding, drug and alcohol awareness, naloxone administration, mental health awareness, …
Overdue
Theo Treharne-Jones
Concerns: The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a vulnerable child.
Response: ABTA disputes the recommendation for additional security chains on hotel room doors, stating they could create fire safety risks and hinder evacuation, though their existing guidance allows for such measures …
Response: TUI has decided not to take any further action, disputing the recommendation for additional security measures like chains due to the unacceptable fire safety risks they believe such devices would …
Responded
Patricia Heaviside
Concerns: The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, and neglected to apply for Deprivation of Liberty Safeguards (DoLS) assessments for residents lacking mental capacity.
Overdue
Vera Fortey
Concerns: Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.
Responded
Hazel Gambles
Concerns: There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical reviews, and family communication following a patient fall.
Responded
Valerie Hill
Concerns: The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.
Responded
Ian Simpson
Concerns: The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading and unlabelled retrospective entries, compromising patient safety.
Responded
Raymond Jennings
Concerns: The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and could not demonstrate improved systems to prevent reoccurrence of this significant failing.
Responded
Isaiah Olugosi
Concerns: A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.
Responded
Sylvia Savage
Concerns: The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and poor, unsecured record-keeping, hindering proper resident care and risk assessment.
Responded
Susan Paley
Concerns: A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure essential safety aids are consistently in place for residents.
Responded
John Follon
Concerns: The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. This creates a significant risk of patients remaining unmonitored for extended periods.
Responded
Florence Stewart
Concerns: The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, an oxygen bottle ran out during resuscitation efforts.
Responded
Wendy Afford
Concerns: Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack of management oversight, and insufficient staff training on skin integrity.
Overdue
Rita Howells
Concerns: Hospital policy regarding bed rail erection before falls assessment is routinely ignored, and procedures for ensuring call bells are functional are inadequate.
Responded
Jeanine Huggins
Concerns: Hospitals lack formal risk assessments for patients in side rooms, failing to identify communication difficulties or call bell usage ability, hindering emergency alerts.
Responded
Jill Brice
Concerns: Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies like fires.
Responded
Norma Kyte
Concerns: Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small coverage area, risking undetected falls and potential non-compliance with manufacturer instructions.
Overdue
Sheila Johnson
Concerns: Inadequate falls prevention policy, unlocked doors, unlit common areas, missing signage, and insufficient nightly observations created an unsafe environment.
Responded
Linda Oldland
Concerns: Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a cardiac arrest, and incorrectly reported a DNAR, indicating policy and training deficiencies.
Responded
Eileen Walsh
Concerns: The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed faulty alarms, conflicting record-editing policies, and an internal investigation that missed key facts, mirroring CQC concerns.
Responded
Sharon Langley
Concerns: The Trust's emergency response was critically flawed, with delays and poor communication during an emergency. Known safety risks, including non-closing doors to high-risk areas, were inadequately mitigated, and the internal investigation was unreliable.
Responded
Brian Parry
Concerns: Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance calls were inefficiently routed, and no advanced first aider was on site.
Overdue
Margaret Stringer
Concerns: The care home lacked a documented system to restrict access to harmful items for at-risk residents and staff training on isolation's impact. Crucially, there were significant failures in transferring vital suicide risk information between agencies during patient handover.
Overdue
Sergio Dunkley
Concerns: Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance for anti-ligature fixtures, posing a significant safety risk.
Overdue
Reginald Weston
Concerns: The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely process for completing these critical safety evaluations.
Responded
Dilys Etchells
Concerns: The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual checks and handover, and deficient wound management protocols.
Responded
David O’Brien
Concerns: Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading to the deceased's excessive and unsafe use of the mobility aid.
Overdue
Stephen Verrall
Concerns: The CQC's failure to routinely check window restrictors, combined with a nursing home's un-manned weekend reception, allowed residents without capacity to leave unaccompanied, posing a significant risk.
Responded
Steven Kirkham
Concerns: A "blind spot" in door alarm systems for vulnerable people creates a potential danger, and other users may be unaware of this significant safety flaw.
Responded
Mary Lincoln
Concerns: The hospital lacked a policy for overnight checks on vulnerable fall-risk patients, causing delayed discovery of injury. Furthermore, the bedrails policy was not adequately circulated or understood by all relevant staff.
Responded
Stephen MAGUIRE
Concerns: A personal alarm failed due to not being charged, indicating a flaw in the alarm charging and checking system for staff, which poses a significant risk if alarms are unusable during emergencies.
Responded
Derek Russell
Concerns: A chronic and long-standing shortage of essential falls alarm equipment at the hospital significantly increases patient risk of falls and fatal injuries, compromising staff's ability to provide safety.
Responded
Amy Chiverall
Concerns: The care home's business decision not to use pendant call alarms meant fixed call bells were often out of reach for falls-risk residents, increasing their injury risk.
Responded
Shirley Froggett
Concerns: New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.
Overdue
Ruth Jones
Concerns: The care home could not adequately observe falls-risk residents during self-isolation due to staffing and lack of guidance. Vulnerable elderly patients sent to hospital alone faced significant communication barriers, hindering their care.
Responded
Eric Bird
Concerns: The care home failed to follow falls protocols, including not calling 999 after head injuries, delaying emergency services, and not updating care plans or identifying patterns in the deceased's repeated falls.
Responded
Elizabeth Pamment
Concerns: A care home failed to record and follow explicit instructions to contact a daughter during an emergency, leading to the resident being left unaided for hours after a fall.
Responded
Arthur Johnson
Concerns: Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff training on recognising intracranial injury was insufficient.
Responded
Edward Mallaby
Concerns: The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls detection. Observation protocols were unclear, and no rapid learning exercise followed the incident.
Responded
Anthony Slack
Concerns: The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.
Responded
Christine Neild
Concerns: The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, and lacked adequate night staff monitoring for wandering residents.
Responded
Dereck John Chapman
Concerns: Nursing home staff provided an insufficient response to a high-fall-risk dementia patient, failing to account for his communication difficulties. Additionally, poor and unreliable record-keeping compromised accurate care narrative and incident review.
Responded
Edna Davenport
Concerns: The care home failed to provide a disabled patient with a call alarm or adequate observations, lacked documentation for care plans, and did not properly assess or manage the risk posed by an aggressive resident, leading to an assault and neglect of head injury monitoring.
Overdue
Roy Campbell
Concerns: Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not properly implemented or enshrined in policy with mandatory staff training.
Responded
Eileen Pollard
Concerns: Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
Overdue
Kenneth Clarke
Concerns: The nursing home lacked formal policies for crucial areas including resident observation, food storage security, managing dementia residents, and caring for patients on liquid diets.
Overdue
Robert Lowe
Concerns: Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.
Overdue
Jeanette Robinson
Concerns: An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or warning system to alert the user or staff to the critical failure.
Responded
Gloria Mekins
Concerns: A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA CPR order caused delays. The care home also failed to investigate or identify these critical issues internally.
Overdue
Patrick Kelly
Concerns: Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care needs.
Responded
Joan Wright
Concerns: Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a lack of statutory definition for "regular" medication checks in care homes.
Responded
Ronald Houchin
Concerns: Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.
Overdue
Beryl Walsh
Concerns: There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the falls team, or implement falls prevention equipment and assessments.
Responded
Anne Roberts
Concerns: Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties managing choking risks alongside self-harm concerns for patients eating in bedrooms were identified.
Overdue
Doris Douthwaite
Concerns: Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and a lack of investigation into multiple falls, missing learning opportunities.
Overdue
Phylliss Letcher
Concerns: The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm if the stairgate was left open, creating unrestricted access to dangerous areas.
Responded
Doris McCarthy
Concerns: Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone to sliding in chairs.
Overdue
Sheila Ross
Concerns: The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor communication with the family.
Overdue
Mavis Reeves
Concerns: The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, and key safe access issues, potentially unknown to residents.
Responded
John Edwards
Concerns: The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed medication or seek timely medical assistance for deterioration.
Overdue
Ronald Farrington
Concerns: The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.
Overdue
Kathleen Devine
Concerns: A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information for agency staff regarding critical safety measures.
Responded
Joseph Tarnowski
Concerns: A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for alternative wearable alarm systems.
Responded
Michael Bingham
Concerns: Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC must review regulations and inspection procedures for door safety, and Stockport NHS guidelines lack clarity on CT scan requirements.
Overdue
Daphne Cherry
Concerns: Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Responded
Roger Tombs
Concerns: Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.
Responded
Terence Hawkins
Concerns: There was no system for regular medical monitoring of care home residents, with one not seen by a GP for months. Difficulties in arranging assessments for non-attending residents highlighted the need for regular, on-site GP reviews.
Responded
Doris Clarkson
Responded
Norman Beard
Concerns: Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.
Overdue
Stanley Sampey
Concerns: The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing a risk to patient airway management.
Overdue
Jacqueline Scott
Concerns: The BIPAP machine's battery alarm is visually obscured and lacks a distinct sound, hindering staff recognition of critical power loss due to inadequate training. The ward lacked isolated power supply, and there was no system to detect mains power failure.
Overdue
Margaret Metcalfe
Concerns: Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.
Responded
David Hughes
Concerns: Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of physical illness signs.
Responded
Norman Dorn
Concerns: Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.
Overdue
Connor Sparrowhawk
Concerns: The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring and potential staff distraction. The RIO system also lacks sufficient fields for comprehensive epilepsy information, hindering staff access.
Responded
Jean Gillespie
Concerns: Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.
Responded
Carl Foot
Concerns: Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's death.
Overdue
Davin Short
Concerns: The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare staff create risks of medical emergencies being overlooked or delayed, endangering prisoners.
Responded
Sidney Barnett
Concerns: The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was flawed, relying too heavily on unverified staff statements.
Overdue
Olive Nugent
Concerns: Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.
Overdue
George Hulme
Concerns: Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to confusion during emergencies and incorrect patient file retrieval for treatment.
Overdue
Hilda Cole
Concerns: The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link to fire alarms, creating an unaddressed fire risk for vulnerable users.
Overdue
James McArdle
Concerns: The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.
Responded
Margaret Connor
Concerns: Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family concerns.
Responded
Joseph Godfrey
Concerns: Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed to follow observation protocols, document checks, or access medical history, and BUPA's investigation was insufficient.
Overdue
Sandra Wordingham
Concerns: A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if early intervention was possible.
Response: Springbank Nursing Home has developed and implemented new policies and protocols for managing residents who become unconscious, including a strict protocol for summoning emergency services and clear guidance for staff, …
Responded
Jane Dyson Gabbitas
Concerns: An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's prolonged disappearance until her body was discovered.
Overdue
Volodymyr Korol
Concerns: The care provider failed to investigate causative failures in mental capacity assessments, information sharing, and vital sign escalation. Similar deficient practices may pose a risk at their other operational nursing home.
Pending