Pristine Care Group Limited

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
Published responses: 100%
Concerns addressed: 2
Stated actions: 3

Concerns and recipient responses

Statements from Pristine Care Group Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

3 Sep2024
South Yorkshire (Eastern)
Concerns raised4
1. Lack of formal systems for checking residents after fire alarm activations
2. Failure to effectively cascade care processes, protocols and expectations to staff providing care to residents
3. Failure to effectively cascade care processes, protocols and expectations to staff
1. Lack of formal systems for checking residents after fire alarm activations
Actions described in response 3
1. Action
  Cascade lessons learned to sister services across the organisation’s portfolio.
2. Action
  Implement revised care processes and protocols addressing identified shortfalls.
3. Action
  Conduct regular senior-management audits to identify discrepancies in care processes and protocols.
Respondent positions 1
1. Position
  Existing protocols, addressed shortfalls and regular senior-management audits are considered sufficient to identify and prevent future discrepancies.
  Existing arrangements considered sufficient
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 Pristine Care Group Limited; 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 Pristine Care Group Limited; 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 Pristine Care Group Limited; 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 Pristine Care Group Limited; 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 respondent action was interpreted

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

PFD Monitor interpretation
Cascade lessons learned to sister services across the organisation’s portfolio.

Verbatim wording from the response
“As always the ethos of the organisation is ensuring the safety of our residents is paramount and the lessons learnt have been cascaded to our sister services within the portfolio.”

Source location
Response from Pristine Care Group
Page 1 · response
Published 9 September 2024
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 revised care processes and protocols addressing identified shortfalls.

Verbatim wording from the response
“I can confirm and agree with the statement made by my colleague ████████ when she gave evidence that the processes and protocols put in place after reviewing the original items are definitely in place (some of which were with immediate effect) and as an organisation we are confident as we can be that any identified shortfalls have been addressed and the auditing duties carried out by the senior management team on a regular basis should highlight any discrepancies in the future. I can also confirm that a CQC inspector visited the care home only this week to review the protocols after receiving notification from your office and she was more than happy with improvements made.”

Source location
Response from Pristine Care Group
Page 1 · response
Published 9 September 2024
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 regular senior-management audits to identify discrepancies in care processes and protocols.

Verbatim wording from the response
“I can confirm and agree with the statement made by my colleague ████████ when she gave evidence that the processes and protocols put in place after reviewing the original items are definitely in place (some of which were with immediate effect) and as an organisation we are confident as we can be that any identified shortfalls have been addressed and the auditing duties carried out by the senior management team on a regular basis should highlight any discrepancies in the future. I can also confirm that a CQC inspector visited the care home only this week to review the protocols after receiving notification from your office and she was more than happy with improvements made.”

Source location
Response from Pristine Care Group
Page 1 · response
Published 9 September 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing protocols, addressed shortfalls and regular senior-management audits are considered sufficient to identify and prevent future discrepancies.

Verbatim wording from the response
“I can confirm and agree with the statement made by my colleague ████████ when she gave evidence that the processes and protocols put in place after reviewing the original items are definitely in place (some of which were with immediate effect) and as an organisation we are confident as we can be that any identified shortfalls have been addressed and the auditing duties carried out by the senior management team on a regular basis should highlight any discrepancies in the future. I can also confirm that a CQC inspector visited the care home only this week to review the protocols after receiving notification from your office and she was more than happy with improvements made.”

Source location
Response from Pristine Care Group
Page 1 · response
Published 9 September 2024
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 raised4

Lack of formal systems for checking residents after fire alarm activations

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

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

Lack of formal systems for checking residents after fire alarm activations

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.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 3

Respondent positions 1