Recipient

Gwern Alyn Care Home

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First report 26 Jul 2021•Latest report 26 Jul 2021

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Gwern Alyn Care Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. North Wales (East and Central)

    AI-generated summary

    Albert Rowlands · 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

    Albert Rowlands suffered serious injuries in an unwitnessed accidental fall at the residential care home where he lived and died in hospital on 25 November 2020. The principal concerns were inconsistent implementation of falls-prevention measures, possible staffing pressures affecting care, and the risks associated with the distance and obstacles between his room and the nearest toilet.

    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 Gwern Alyn Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Risky toilet access routes for vulnerable residents

    Wider context from the report

    “3. Given that he was found in a pool of urine, it is reasonable to infer that Mr Rowlands’ reason for getting out of bed was to use the toilet. The journey to the nearest toilet required him to walk through two heavy doors and along a corridor. This must have presented a risk to somebody with his background. Consideration should be given to whether residents generally are optimally located within the care home, having regard to their respective needs and risk profiles. ”
    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 Gwern Alyn Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to correctly position pressure mats and beds

    Wider context from the report

    “2. The indication that care staff felt pressured should be reflected upon, in the context of whether they are able to devote as much time to vulnerable residents as might be required. By inference, the errors made in respect of the mis-locating of the pressure mat and the incorrect position of the bed are likely to have occurred because the carer involved was rushing. The care home should consider whether its staffing levels are appropriate, both in this context and in terms of how quickly a member of staff might ordinarily be able to respond to a pressure mat alarm sounding. ”
    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 Gwern Alyn Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to implement falls risk measures consistently and effectively

    Wider context from the report

    “1. Despite the care home having identified the risks associated with Mr Rowlands wandering unsupervised and falling, the control measures put in place (including Zimmer frame use and the bedside pressure mat), these did not eliminate the risk. Mr Rowlands (on the occasion of this accident and at other times) was plainly able to get out of bed without his alarm sounding, and to move around without always using his Zimmer frame. I believe that care home should consider whether more can be done to ensure that falls risk measures are implemented consistently, as intended, and to identify additional steps that could be taken to reduce the risks to residents such as Mr Rowlands. ”
    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 Gwern Alyn Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate staffing capacity for vulnerable-resident care and alarm response

    Wider context from the report

    “2. The indication that care staff felt pressured should be reflected upon, in the context of whether they are able to devote as much time to vulnerable residents as might be required. By inference, the errors made in respect of the mis-locating of the pressure mat and the incorrect position of the bed are likely to have occurred because the carer involved was rushing. The care home should consider whether its staffing levels are appropriate, both in this context and in terms of how quickly a member of staff might ordinarily be able to respond to a pressure mat alarm sounding. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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