Concerns raised 2 Lack of instructions on the circumstances for using specific prescribed equipment View source Lack of monitoring of compliance with equipment-use instructions View source
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
Action
Record new mobility equipment, images and correct-use instructions in residents’ care plans, including instructions supplied by health professionals.
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Action
Conduct standardized service delivery audits comparing care delivered with care plans, and follow up deficiencies through supervision, retraining or closer performance monitoring.
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Action
Implement a process clarifying new equipment use, circumstances, staff accountability and competency checks for equipment introduced by health professionals.
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Action
Use the new care plan format to document mobility equipment, operating procedures and equipment changes, with monthly completeness and accuracy checks.
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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.
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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
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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
Open published response
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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
Open published response
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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
Open published response
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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
Open published response
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations