Recipient

Abbeyfield The Dales Limited

First report 22 Oct 2021•Latest report 22 Oct 2021

Recipient record

Reports, concerns and published responses

Housing · Registered provider of social housing. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 2
Stated actions: 5

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Abbeyfield The Dales Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

22 Oct2021
North Yorkshire (Western)
Concerns raised2
1. Lack of instructions on the circumstances for using specific prescribed equipment
2. Lack of monitoring of compliance with equipment-use instructions
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Record new mobility equipment, images and correct-use instructions in residents’ care plans, including instructions supplied by health professionals.
  Stated completed
2. Action
  Conduct standardized service delivery audits comparing care delivered with care plans, and follow up deficiencies through supervision, retraining or closer performance monitoring.
  Stated completed
3. Action
  Implement a process clarifying new equipment use, circumstances, staff accountability and competency checks for equipment introduced by health professionals.
  Stated planned
1. Action
  Use the new care plan format to document mobility equipment, operating procedures and equipment changes, with monthly completeness and accuracy checks.
  Stated completed
2. Action
  Conduct unannounced Quality Manager spot-check audits of care plans and observed care practice to verify compliance with equipment-use instructions and address improvements.
  Stated completed
AI-generated summary

Dorothy Pegg · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Dorothy Pegg slipped from a shower chair while sitting on a sling and suffered bilateral leg fractures, which contributed to her death. The report identified concerns about the absence of monitoring for compliance with equipment-use instructions and the lack of instructions about when specific prescribed equipment should be used.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbeyfield The Dales Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of instructions on the circumstances for using specific prescribed equipment
Wider context from the report
“2. There were no instructions as to the circumstances in which it is appropriate that specific prescribed equipment is used. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbeyfield The Dales Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of monitoring of compliance with equipment-use instructions
Wider context from the report
“1. There was no system of monitoring the compliance with instructions as to how equipment should be used. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Record new mobility equipment, images and correct-use instructions in residents’ care plans, including instructions supplied by health professionals.

Verbatim wording from the response
“New Equipment (already introduced) A record of new equipment delivered to support a resident’s mobility (a delivery note) is held in a resident’s care plan (where one is received). The care plan is updated with an image of the equipment, so it is clear what equipment must be used when supporting a resident with their mobility and clear instructions are set out in the care plan regarding the correct use of the equipment.”

Source location
2021-0358-Response-from-Abbeyfield-The-Dales-Ltd_Published
Page 2 · response
Published 1 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct standardized service delivery audits comparing care delivered with care plans, and follow up deficiencies through supervision, retraining or closer performance monitoring.

Verbatim wording from the response
“Service Delivery Audit (launched with Managers in September 2021) The service delivery audit has recently been introduced and standardises a variety of formats and content of similar audits that have been in use up until recently. The audit checks that the service delivered by a member of the care team is in line with what is required in the care plan, and expected from an Abbeyfield The Dales employee. Please see a blank version of the form at appendix 3.”

Source location
2021-0358-Response-from-Abbeyfield-The-Dales-Ltd_Published
Page 2 · response
Published 1 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a process clarifying new equipment use, circumstances, staff accountability and competency checks for equipment introduced by health professionals.

Verbatim wording from the response
“New Equipment Process (to be implemented in January 2022) We have developed a process to ensure staff are clear of the correct use for and operation of a new piece of equipment that is introduced by an Occupational Therapist or other Health Professional to support the safe transfer and movement of a resident. This process is intended to ensure there is no ambiguity in how and in what circumstances a piece of equipment is used, and also there is clear accountability and checking that staff are knowledgeable and confident in the use of the equipment to support that resident. Please see a blank version of the process at appendix 4.”

Source location
2021-0358-Response-from-Abbeyfield-The-Dales-Ltd_Published
Page 2 · response
Published 1 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use the new care plan format to document mobility equipment, operating procedures and equipment changes, with monthly completeness and accuracy checks.

Verbatim wording from the response
“New Care Plan Format (already introduced) The statement I provided to the coroner contained details of the new care plan format introduced across all sites during 2020. In the new care plan format (section 6 – Mobility, Fitness and Falls Prevention) the documentation contains an image of all equipment used to support a resident’s mobility. This section is updated by either the Senior Carer, Assistant Manager of Registered Manager if the equipment used is changed or discontinued. The mobility section of a resident’s care plan also documents systems of work (a standard operating procedure) for all equipment used.”

Source location
2021-0358-Response-from-Abbeyfield-The-Dales-Ltd_Published
Page 1 · response
Published 1 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct unannounced Quality Manager spot-check audits of care plans and observed care practice to verify compliance with equipment-use instructions and address improvements.

Verbatim wording from the response
“Quality Manager Spot Check Audits (re-introduced in 2021) Part of the Quality Manager’s role is to provide audit assurance to the Registered Manager and Senior Leaders of Abbeyfield The Dales that care delivery and record keeping is in line with policy and best practice. This includes ensuring carers comply with instructions as to how/what”

Source location
2021-0358-Response-from-Abbeyfield-The-Dales-Ltd_Published
Page 1 · response
Published 1 November 2021
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Lack of instructions on the circumstances for using specific prescribed equipment

Lack of monitoring of compliance with equipment-use instructions

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.5

Actions described in response 5