Concerns raised7
Insufficient alarm audibility in the clinician’s room
Lack of Agency staff training in documentation, record keeping and risk assessment procedures
Reliance on Agency staff as the sole trained nurse and senior member of staff during night incidents
Omissions in documentation and record keeping of falls and changes in residents’ condition
Failure to review falls risk assessments and refer recurrent falls back to the Falls Service
Lack of procedures for reviewing risk assessments after falls or significant changes in residents’ condition
Failure of alarm signals to distinguish falls-sensor activation from handheld-buzzer requests for assistance
No linked response statementsNo action or position from this recipient is clearly linked to the concerns in this report.