Recurring concern
Unreliable fall-mat safety controls
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Request correctionFirst reported 15 Dec 2014•Latest report 3 Jun 2025
What this concern includes
Includes failures of dedicated fall-mat systems, including crash mats, sensor mats and comparable bedside fall mats, where provision, suitability, coverage, positioning, wireless activation, alerting or associated operating instructions do not reliably support falls prevention or detection.
Not included
- Excludes general falls-risk assessment, supervision, staffing or post-fall response failures where no fall-mat control is deficient.
- Excludes pressure-relief mats, pressure mats used for purposes other than falls detection, mattresses and other equipment unless the assertion specifically concerns a fall-mat system.
- Excludes generic wireless, WiFi, alarm or equipment failures not directly tied to the safe operation of fall mats.
- Excludes the underlying occurrence of a fall where no failure of a dedicated fall-mat control is identified.
- Reports
- 14
- Individual concerns
- 18
- Date range
- 2014–2025
- Stated actions
- 20
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Lack of crash mats at the side of the bed
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to use sensory mats in accordance with manufacturers instructions
Insufficient coverage of bedside sensory mats
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
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Action
Test sensor mats and establish daily care-plan checks plus manager walkaround checks of their operation and placement.
Stated by Bupa Care Services UK -
Action
Remind Bupa Care Homes to order equipment through the Clinical Equipment Guide.
Stated by Bupa Care Services UK -
Action
Record sensor-mat need, type and required position in every high-fall-risk resident’s additional care plan.
Stated by Bupa Care Services UK
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Action
Complete one-to-one sessions with all staff on sensor-mat equipment and correct use.
Stated by Bupa Care Services UK -
Action
Provide appropriate sensor mats for chair, seat, floor and crash-mat use.
Stated by Bupa Care Services UK -
Action
Review residents’ care plans to allocate correct sensor mats and continue monthly or post-fall reviews.
Stated by Bupa Care Services UK
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Concerns raised1
Failure to address falls risks and faulty sensor mats
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Install and operate a monitoring system linking room-entry records, sensor mats, audible alarms and response-time reporting.
Stated by Broadland View Care Home -
Action
Increase maintenance alarm checks from monthly to weekly and replace faulty sensor mats immediately, with additional resident observations until repairs are completed.
Stated by Broadland View Care Home -
Action
Check sensor mats three times daily and record testing, faults, replacements and handover information.
Stated by Broadland View Care Home
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Sensor-mat risks are addressed through checks three times daily, immediate replacement, increased observations and maintenance arrangements.
Stated by Broadland View Care Home
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Concerns raised2
Insufficient sensor mat provision for a high-falls-risk resident
Failure to position a high-falls-risk resident’s bed appropriately
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inadequate provision of crash and sensor mats
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Assess equipment needs before admission, provide required mats and other equipment before admission, and maintain urgent access to additional stock.
Stated by Hill Care Group
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Concerns raised2
Failure to correctly position pressure mats and beds
Failure to implement falls risk measures consistently and effectively
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Continue using the North Wales falls pathway with GPs and health professionals for residents with a history of falls or new falls.
Stated by Hillbury & Gwern Alyn -
Action
Maintain relevant falls management documents within residents’ care plans, including risk assessments, accident records and post-fall reports.
Stated by Hillbury & Gwern Alyn
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing falls assessments, reviews, clinical input and the falls pathway were considered sufficient; no additional mobility or falls-management support was identified.
Stated by Hillbury & Gwern Alyn
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Position
Completely eliminating falls risk was considered unrealistic and unachievable for an older person with capacity and freedom to choose movement.
Stated by Hillbury & Gwern Alyn
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Concerns raised1
Failure of fitted sensor mats to activate an alert when a resident is out of bed
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Introduce an Observation and Monitoring form, update the Falls Risk Assessment, and require at least hourly sensor-mat checks throughout each shift with daily senior-management monitoring at Alexandra View.
Stated by Roseberry Care Centres GB Limited
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Concerns raised1
Unavailability of required falls prevention equipment
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Floor-based sensor mats and staff monitoring are considered sufficient; bed sensors offer no additional advantage and communal-area sensors are unsafe.
Stated by Avenue House Nursing and Care Home
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Concerns raised1
Removal and unplugging of falls mat and sensor for high-falls-risk residents
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Create precise care plans for residents using crash mats or sensor mats, including placement, equipment condition and safe-use guidance.
Stated by BIOcareM -
Action
Highlight crash-mat and sensor-mat use in bold on daily handover sheets to alert new and agency staff.
Stated by BIOcareM -
Action
Add daily mattress-check documentation requiring staff to confirm equipment placement, settings and working condition.
Stated by BIOcareM
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Action
Include the risks of unplugging sensor mats or moving crash mats in in-house moving and handling training for staff.
Stated by BIOcareM
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Concerns raised1
Unavailability of observable beds and crash mats for patients requiring them
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026