Unsupervised High-Risk Residents
23 items
2 sources
High-risk residents being left unsupervised, potentially due to insufficient staffing or inadequate alert systems, increasing the risk of harm.
Cross-Source Insight
Unsupervised High-Risk Residents has been flagged across 2 independent accountability sources:
1 inquiry rec
22 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (22)
Evelyn Chancellor
Concerns: Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
Responded
Paul Reeves
Concerns: Supported accommodation staff had unclear medication supervision roles and failed to communicate critical welfare concerns about a deteriorating resident to the mental health team, hindering proper assessment.
Responded
Diane Poole
Concerns: A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks 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
Edith Alden
Concerns: Inconsistent fall risk assessments and care plans, coupled with staff lacking clarity on mitigation, meant high-risk residents were often unsupervised in communal areas or bedrooms, leading to preventable falls.
Responded
Janet Smith
Concerns: Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to a preventable fall and death.
Responded
Tarik Drakes
Concerns: Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating an environment where drug use and safeguarding risks are prevalent.
Responded
Susan Perry
Concerns: Medication cupboard keys were left in easily accessible, unlocked locations nearby, compromising medication security and creating a significant risk of service users accessing and misusing drugs.
Responded
Thomas Smith
Concerns: Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant escorts were unaware of recent drug-related risks or patient care plans, compromising safety.
Overdue
Philip Ellis
Concerns: The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision failures.
Responded
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
Marion Glover
Concerns: Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was unsuitable for confused residents, posing a wandering risk.
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
Ruth Gregory
Concerns: Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.
Responded
Ryan Williams
Concerns: Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any oversight or means of intervention.
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
John Wherlock
Concerns: Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe staffing practice was still ongoing despite being criticised.
Overdue
Jane Bell
Concerns: Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff who are also busy with other tasks, creating a risk of future deaths.
Responded
Lee Rigby
Concerns: Systemic failures in care provision include support workers lacking keys, leaving residents unsupervised, and inadequate staffing levels, training, and procedural adherence regarding care plans and risk management.
Overdue
Alois Piska
Concerns: The care home suffered from inadequate staffing levels, leading to insufficient supervision of residents in communal areas.
Overdue
Amar Majid
Concerns: Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering a person in distress.
Overdue
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