Recipient

Riverside Rest Home, Lytham St Annes

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First report 8 Mar 2021•Latest report 8 Mar 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 Riverside Rest Home, Lytham St Annes linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Blackpool and the Fylde

    AI-generated summary

    Joan Elizabeth Rutter · 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

    Joan Elizabeth Rutter, aged 94, was found unresponsive after an unwitnessed fall beside her bed at the rest home on 23 October 2020; the fall resulted in a fatal spinal fracture. The report identified concerns about poor overnight record keeping, staffing and the delivery of night care, and an unplugged falls mat that did not alert staff to her movement.

    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 Riverside Rest Home, Lytham St Annes; that does not assign responsibility.

    PFD Monitor interpretation

    Poor overnight record keeping

    Wider context from the report

    “Record keeping. The standard of the records provided by the rest home were poor. There was a paucity of entries made during the night shift. For example, entries to reflect Joan had been found wandering in the rest home having left her own room were unrecorded. A member of the staff taking over the care of residents would have found it very difficult to review the records and have an accurate understanding of how the residents had presented overnight, thereby placing such day staff in a difficult position taking over the care of often elderly, vulnerable residents but potentially unaware of recent important events. Although the court received some evidence that changes have been made since Joan’s death, the court remains of the view that the standard of record keeping continues to pose a risk to residents and future deaths may occur. ”
    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 Riverside Rest Home, Lytham St Annes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of overnight care delivery to ensure staff awareness and availability to respond to residents needing assistance

    Wider context from the report

    “The delivery of care during the night shift. Joan was an elderly, vulnerable resident. She was known to be confused, and unlikely to utilize personal alarms, and had a tendency to leave her room. She may have left her room at times when staff were not available to respond to her movement because they were elsewhere in the building. The court is concerned that the night shift operated in a way that meant that staff could be unaware residents needed their assistance. Again, although the court heard that some changes have been made, the court remained of the view that the way care is delivered overnight to residents such as Joan poses a risk to their welfare and future deaths may occur. ”
    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