National Care Consortium Ltd

Private and voluntary organisations · Private limited company

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First report 3 Sep 2024•Latest report 3 Sep 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Concerns and recipient responses

Statements from National Care Consortium Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South Yorkshire (Eastern)

    AI-generated summary

    Margaret Aitchison · 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

    Margaret Aitchison, a resident of Broom Lane Care home, accessed a fire door and fell down an unheated stairwell after a fire alarm activation, sustaining traumatic injuries and being found hypothermic; she died from her injuries. The report raised concerns about inadequate resident and fire-exit checks after alarm activations and whether updated procedures had been effectively communicated and implemented.

    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 National Care Consortium Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of formal systems for checking residents after fire alarm activations

    Wider context from the report

    “The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations, is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes. Accordingly, I invite you to consider the following and in particular whether there is a need for: 1. Further training of senior staff. 2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations. 3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits. ”
    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 National Care Consortium Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to effectively cascade care processes, protocols and expectations to staff providing care to residents

    Wider context from the report

    “The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations, is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes. Accordingly, I invite you to consider the following and in particular whether there is a need for: 1. Further training of senior staff. 2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations. 3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits. ”
    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 National Care Consortium Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to effectively cascade care processes, protocols and expectations to staff

    Wider context from the report

    “The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations, is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes. Accordingly, I invite you to consider the following and in particular whether there is a need for: 1. Further training of senior staff. 2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations. 3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits. ”
    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 National Care Consortium Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of formal systems for checking residents after fire alarm activations

    Wider context from the report

    “The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations, is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes. Accordingly, I invite you to consider the following and in particular whether there is a need for: 1. Further training of senior staff. 2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations. 3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits. ”
    Open source report
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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